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Journal of Spanish Language Teaching
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Improving linguistic and cultural
competence in the health sector:
a medical Spanish curriculum for
resident physicians
Avik Chatterjeeab, Li Qinc, María de la Paz Garcíad & Jaideep S.
Talwalkare
a Harvard Medical School
b Harvard Pilgrim Health Care Institute
c Yale School of Public Health
d Yale University
e Yale School of Medicine
Published online: 08 May 2015.
To cite this article: Avik Chatterjee, Li Qin, María de la Paz García & Jaideep S. Talwalkar (2015):
Improving linguistic and cultural competence in the health sector: a medical Spanish curriculum for
resident physicians, Journal of Spanish Language Teaching, DOI: 10.1080/23247797.2015.1019288
To link to this article: http://dx.doi.org/10.1080/23247797.2015.1019288
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Improving linguistic and cultural competence in the health sector:
a medical Spanish curriculum for resident physicians
Avik Chatterjee
a,b
*, Li Qin
c
, María de la Paz García
d
and Jaideep S. Talwalkar
e
a
Harvard Medical School;
b
Harvard Pilgrim Health Care Institute;
c
Yale School of Public
Health;
d
Yale University;
e
Yale School of Medicine
(Received 12 July 2014; accepted 27 January 2015)
Existing medical Spanish curricula have improved language skills, but are
incompatible with resident-physician schedules, and do not always integrate cultural
education. A 2009 survey at our institution revealed that residents saw Spanish-
speaking patients regularly and wanted a medical Spanish curriculum designed for
them. Our objective was to improve medical Spanish and cultural competency
among resident physicians at our institution. Kramsch’s (1998) principle of
combining language and cultural instruction, Gardner’s (1983) theory of multiple
intelligences, and the American Council for the Teaching of Foreign Languages 5Cs
provided a framework for the self-directed curriculum, which consisted of nine-
month long modules with online and in-person grammar, vocabulary, listening
comprehension and conversation practice. We conducted pre-intervention, midterm
and final assessments of language and cultural competency. We found moderate
correlations between the number of modules completed and self-reported fluency,
understanding of health-related cultural beliefs, and change in receptive language.
While revisions are necessary, we found a self-directed resident medical Spanish
curriculum, combining language and cultural instruction, to be feasible.
Keywords: curriculum development; non-traditional language learning environ-
ments; medical Spanish; cultural competence; resident physicians; health sector
Los planes actuales de estudio de español para médicos que existen han contribuido
a mejorar las habilidades lingüísticas del personal sanitario. Sin embargo, son en su
mayor parte incompatibles con los horarios de los médicos residentes y frecuente-
mente no incluyen formación cultural. En 2009, una encuesta realizada en nuestra
institución mostró que los médicos veían a pacientes hispanohablantes regular-
mente y deseaban un plan de estudio de español diseñado para ellos. Nuestro
objetivo era mejorar el español médico y el entendimiento cultural de este grupo. El
principio de Kramsch (1998) de combinar instrucción lingüística y formación
cultural, la teoría de Gardner (1983) de las inteligencias múltiples, y las 5C del
American Council for the Teaching of Foreign Languages nos guiaron para formar
el plan de estudio, que consistía en nueve módulos de gramática, vocabulario y
práctica de conversación en línea y en persona. Se llevaron a cabo evaluaciones de
competencia lingüística y cultural preliminares, a mitad de programa y finales.
Encontramos correlaciones moderadas entre el número de módulos completados y
el nivel de fluidez reportado, la comprensión de las creencias culturales relaciona-
das con la salud, y la capacidad de entendimiento del lenguaje. Aunque el curso
amerita revisiones, constatamos que el desarrollo de un currículum autogestionado
de español para médicos residentes es factible.
*Corresponding author. Email: avc031@mail.harvard.edu
Journal of Spanish Language Teaching, 2015
http://dx.doi.org/10.1080/23247797.2015.1019288
© 2015 Taylor & Francis
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Palabras clave: desarrollo curricular; entornos no tradicionales de aprendizaje de
idiomas; español médico; competencia cultural; médicos residentes; sector sanitario
1. Introduction
Spanish speakers with limited English proficiency (LEP) represent a large and
growing part of the population in the United States (US) (“CDC Minority Health
Page: Hispanic and Latino Populations”2012). The growing number of LEP
patients has impacted the health care system, with 80% of hospitals providing care to
LEP patients regularly (Ulmer, McFadden, and Nerenz 2012). Yet communication
between English-speaking providers and Spanish-speaking patients, even when using
a phone or in-person interpreter, can result in clinically significant communication
errors (Flores et al. 2003), and in a lesser degree of effective communication on
preventative health topics (Eamranond et al. 2009). LEP patients also seem to prefer
language-concordant providers or interpreters (Ngo-Metzger et al. 2007). Given the
benefits of language concordance and the lack of Spanish-speaking physicians
relative to the surge in Spanish-speaking patients (Jordan 2007), some argue that all
physicians in the US should learn Spanish (Clarridge et al. 2008).
Previously described medical Spanish curricula designed for medical students
(Reuland et al. 2008) and attending physicians (Barkin et al. 2003) have resulted in
improved communication and patient satisfaction scores, though these studies did
not involve resident physicians. At the University of North Carolina, investigators
created a curriculum for medical students –the Comprehensive Advanced Medical
Program of Spanish (CAMPOS) –that combined didactic work, cultural seminars,
and a community service project in a Latino community, and found that the 42
medical student participants had improved Spanish-language proficiency and
listening comprehension scores by the end of the year-long curriculum (Reuland
et al. 2008). In a study with pediatric faculty, investigators measured Spanish
proficiency before and after a two-week immersion program in Guatemala and
monthly Spanish classes, and found improved language proficiency that persisted
over the course of 12 months (Barkin et al. 2003).
None of these interventions, however, included resident physicians, who have
very different schedules from medical students or members of a medical faculty.
Resident physicians in the US have multiple demands on their time, and can work
up to 80 hours a week and 16 to 24 hours per shift, including nights and weekends
(Peets and Ayas 2012). Thus, the above-described medical Spanish curricula, which
utilize regularly scheduled class time and practice sessions or trips abroad, are not
compatible with the inflexibility of resident schedules. Some training programs
have attempted to find time for learning Spanish by adding an immersion
experience prior to the start of residency. The Lawrence Family Medicine program
took three successive classes of eight residents to a 10-day immersion program at a
nearby language program, while also providing weekly classes and individual
instruction, and found an improvement in language scores (Valdini et al. 2009).
This approach, however, is not feasible for most residency programs given the cost
and the time necessary to cover numerous other orientation topics prior to the start
of residency.
A recent review examined the literature for medical Spanish offerings (Hardin
and Hardin 2013). In appraising the curricula, these reviewers pre-specified five
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criteria used elsewhere in second language acquisition (SLA) research, that is, the
curricula should describe the methods of assessment, have a pre- and post-
intervention evaluation, have an independent evaluator, use a longitudinal study
design, and measure oral proficiency. They found 23 medical Spanish curricula, 5 of
which were geared toward resident physicians. Only one of those met all one of the
reviewers’criteria. Thus there seems to be a need both for more medical Spanish
offerings, and more rigorous study design and evaluation of such curricula.
Working with Spanish-speaking patients requires language skills but also cultural
competency, the ability to deliver “the highest quality care to every patient regardless
of race, ethnicity, culture, or language proficiency”(Betancourt et al. 2005). Indeed,
Kramsch argues that language and culture are tightly linked, and provide a
framework for teaching both together (Kramsch 1998). In a medical context,
investigators have found some success in teaching cultural competency to physicians.
In a recent systematic review, a majority of the 34 studies looking at interventions to
improve cultural competency showed a positive impact on physician knowledge and
attitudes, though patient outcomes were either not assessed in these studies, or there
was no benefit found (Beach et al. 2005). To our knowledge, no interventions in the
medical context seek to improve both medical Spanish and cultural competency, and
measure both as outcomes.
Given resident interest but the lack of Spanish course offerings for residents,
in 2009, the investigators from the internal medicine and pediatrics program, in
conjunction with faculty from the Yale Department of Spanish, designed the Yale
Resident Spanish Initiative (YRSI), a pilot medical Spanish curriculum for residents
(Chatterjee and Talwalkar 2012). In developing the curriculum, we followed a widely
employed model for medical curriculum development (Kern, Thomas, and Hughes
2010). Curriculum development in the Kern model follows six steps: (1) problem
identification and general needs assessment, (2) needs assessment for targeted
learners, (3) goals and objectives, (4) educational strategies, (5) implementation
and (6) evaluation and feedback.
Investigators were aware of the large number of LEP Spanish-speaking patients
in our hospital and clinics and anecdotal evidence that communication with those
patients needed improvement (step 1 of the Kern model). These observations
triggered an initial needs assessment of resident physicians at our institution in 2009
(step 2 of the Kern model), in which 35 of 38 (92%) respondents reported seeing
Spanish-speaking patients at least weekly, and 33 of 38 (87%) felt that communica-
tion with those patients was not as good as communication with English-speaking
patients. Residents also expressed interest in a medical Spanish curriculum designed
for residents.
In 2010–2011 we created and implemented a medical Spanish curriculum with
the goal of determining the feasibility of a rigorous medical Spanish curriculum for
resident physicians (step 3 of the Kern model). We discuss the educational strategies
behind the curriculum below in the methods section (step 4 of the Kern model).
Twenty residents from three residency programs (internal medicine, pediatrics, and
combined internal medicine-pediatrics) participated (step 5 of the Kern model), and
in our evaluation, we found it to be feasible to implement but also challenging
for residents (Chatterjee and Talwalkar 2012). We provided the opportunity for
participants to give us feedback to help us improve the curriculum (step 6 of the
Journal of Spanish Language Teaching 3
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Kern model) and in the 2011–2012 academic year we used the feedback to refine the
YRSI curriculum and program evaluation, with help from a hospital grant.
For our revamped curriculum, we had the goal of offering a medical Spanish
curriculum that would be compatible with a traditional resident schedule and
increase resident physicians’abilities to take excellent care of Spanish-speaking
patients, with the specific objectives of:
(1) Improving medical Spanish-language skills among resident physicians with
at least basic Spanish-language skills.
(2) Improving cultural competency among these resident physicians.
To our knowledge there are no previous descriptions of medical Spanish curricula
for residents within a traditional training schedule (i.e., not compartmentalized to
orientation, a specific protected block of time, or during international electives).
Furthermore, as mentioned above, to our knowledge, no interventions have
combined language skill intervention and cultural competency skill building among
medical trainees.
2. Methods
2.1. Population and setting
Our institution is a 1,541 bed tertiary-care hospital in a city of 129,585 people, of
whom 27.4% self-identify as Hispanic (“Get the Facts: Yale-New Haven Hospital”
2013;“New Haven, Connecticut Population: Census 2010 and 2000 Interactive Map,
Demographics, Statistics, Quick Facts”2011).
Professional interpreter services are available 24 hours a day and 7 days a week
at our institution. However, outside of business hours and on weekends, interpreters
are often available only by phone. Additionally, at busy times, given the potential for
delay before the arrival of an interpreter, and despite hospital policy discouraging it,
medical teams were known to have used ad hoc interpreters, such as family members,
or not use interpreters at all. Given some of these practices, as noted above, 33 of
38 (87%) resident respondents to our initial survey felt that communication with
Spanish-speaking LEP patients was worse than with English-speaking patients.
2.2. Curriculum
The American Council on the Teaching of Foreign Languages (ACTFL) has
published the National Standards for Foreign Language Education, which outlines
the 5Cs of foreign language teaching Communication, Culture, Connections,
Comparisons and Communities (National Standards 1996/2006). As we developed
the curriculum, we had the goal of integrating each of these pieces. Furthermore, we
followed the principle that utilizing multiple learning modalities would be superior in
teaching medical Spanish (Arnold and Fonseca 1999). Incorporating the two
frameworks, we designed the YRSI curriculum as a year-long, nine-module, self-
directed curriculum that included practice with a variety of skills including grammar,
vocabulary, reading, writing, listening comprehension, speaking, and cultural
competency (Figure 1) (Chatterjee and Talwalkar 2012). We created each systems-
based module to include four activities:
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(1) Grammar and vocabulary practice: We included grammar and vocabulary
practice in each module of the curriculum, considering such practice to be a
necessary basis for the Communication part of the 5Cs (National Standards
1996/2006). We worked with the faculty for Spanish teaching at our
university to design systems-based vocabulary and grammar activities, often
using existing, free, internet-based materials that allowed residents to practice
grammar, reading and writing to build vocabulary. An answer key was
provided online. This section was designed to take about one hour per
module.
(2) DVD telenovela chapter: Ljubojevic and colleagues have described how
video and multimedia instruction improve learning efficiency and accepta‐
bility of language curricula (Ljubojevic et al. 2014). The online multimedia A
Su Salud medical Spanish teaching program, based on a series of telenovela
videos, lets students practice listening comprehension, including the oppor-
tunity to listen to a variety of accents from Mexico, Central America, the
Caribbean, and South America (Bender et al. 2006). The lessons also teach
medically-specific vocabulary and lessons about culture that are relevant to
the health care setting. This portion of each module was designed to take
about 1 hour per module.
Figure 1. Organizational structure of the Yale Resident Spanish Initiative medical Spanish
curriculum. GI, gastrointestinal; HEENT, head, eyes, ear, nose and throat.
Journal of Spanish Language Teaching 5
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(3) Simulated patient cases with a medical Spanish tutor: Simulated patient cases
are used widely in medical education (Nagoshi 2001) and other interventions
have used Spanish-speaking simulated patients to assess cultural competency
(Juarez et al. 2006) and Spanish-language ability (Pfeiffer 2010). We felt that
a simulated patient case with immediate feedback added value beyond that
of a purely summative assessment, and would be an effective learning tool.
We recruited native Spanish-speaking interpreters, medical students and
physicians at our institution by email and paired them to work one-on-one,
once a month with residents to go through practice cases, working on
listening comprehension and speaking skills, as well as applying the
vocabulary and grammar they learned. The simulated cases included aspects
of cultural and social history that helped residents build cultural competency
skills, such as the need to ask about herbal and traditional medicines. The
learner and the tutor scheduled a time that worked for both of their
schedules. Tutors read the cases beforehand and became familiar with the
important parts of the patient history. During the session, the learner
practiced asking questions as if the tutor were a real patient, and the tutor
took on the role of the patient (or patient’s parent). Generally, three cases
were provided, covering a variety of common patient presentations (such as
diabetes and obesity in the endocrine system module), and we suggested that
tutors and learners pick two to work through in 1 hour per module
(Appendix 1). We suggested that tutors stayed in the role of the patient
until the end of the case, and provided relevant feedback on vocabulary,
grammar and accent at that time.
(4) Community practice session: As outlined previously, Kramsch has written
about the centrality of culture in teaching language (Kramsch 1998). Like
Reuland and colleagues in their CAMPOS curriculum (Reuland et al. 2008),
we included a community component in our curriculum in order to integrate
cultural and language education. Our institution has a long-standing relation-
ship with the Junta for Progressive Action, a local non-profit organization
that, among other things, provides English as a Second Language (ESL)
classes to mostly Spanish-speaking immigrants (“Junta for Progressive Action”
2011). We created language exchange sessions for our residents, having them
prepare health education talks on various topics (cancer screening, physical
activity, nutrition, and sexual health), to practice with ESL students, getting
the chance to practice vocabulary, speaking and listening comprehension
skills, while also allowing the ESL students to practice English. Particularly
useful from these sessions was the ability to hear regional accents and
vocabulary, as well as cultural concerns that would arise from the patient
population that our residents serve. Some of the sessions were held on-site at
Yale-New Haven Hospital and some were held at Junta for Progressive
Action’s offices in the heavily Latino Fair Haven neighborhood of New
Haven. This part of the curriculum usually took 1–2 hours per module.
To participate in the above activities, residents would need at least a basic ability to
read, write, speak, and understand spoken Spanish. Furthermore, in conversations
with faculty members from the Spanish-language teaching faculty at our institution,
teaching medical Spanish from the basic level would take a significant amount of
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face-to-face time that we felt would be very difficult to fit into a traditional resident
schedule. Therefore, we offered an intermediate and advanced curriculum. Partici-
pants were allowed to self-select a level, with the guidance that intermediate-level
participants should be able to hold a basic, non-medical conversation in the present
and simple past tenses, and that advanced curriculum participants be comfortable
with additional tenses including the conditional tense and subjunctive mood. Given
prior literature indicating the accuracy of physician self-report in Spanish-language
ability (Rosenthal et al. 2011), we felt comfortable with participants self-selecting the
difficulty level of their curriculum. The intermediate curriculum covered basic
system-specific vocabulary and reviewed the present, past, and future tenses as well
as the subjunctive mood, while the advanced curriculum covered more advanced
grammar and technical vocabulary.
At the start of the 2011–2012 academic year, all residents at our institution in at
least their second year of training were sent an email notifying them of the YRSI and
inviting them to participate. First-year residents were not invited to participate
because of the concern that they would not be as familiar with the rigors and time
constraints of residency and thus would not be able to make a well-informed decision
about participating. The application also stated that only residents with an
intermediate level of Spanish or better should apply. The application included
demographic and pre-intervention survey questions, as described below. All residents
in their second post-graduate year or higher who submitted an application were
accepted; no one who completed the application was excluded. Sixty-three residents
self-selected to participate, completing the initial application and survey, and giving
consent to participate in a study of the effects of YRSI on their ability to
communicate with Spanish-speaking patients and on cultural competency scores.
2.3. Program evaluation
The Yale University Human Subjects Committee granted the project (IRB Protocol
#1007007055) exempt status under 45 CFR 46.101(b)(1) for evaluation of the
curriculum. Program evaluation was done in multiple phases, including a pre-
intervention, midterm, and post-intervention evaluation.
The pre-intervention evaluation consisted of survey questions including language
assessment and assessment of cultural competency skills. The survey was embedded
within the application material submitted by all participants. The survey itself
consisted of demographic questions, a 14-point Likert scale, and multiple-choice
items. Survey items related to prior Spanish exposure and included previously
validated measures of physicians’Spanish-language ability (Rosenthal et al. 2011)
and cultural competency (Fernandez et al. 2004). In the Rosenthal study of 110
physicians and 46 Spanish-speaking patients, physicians’self-reported general
Spanish fluency was well-correlated with patients’assessment of their ability to
speak Spanish, with a positive predictive value of 99%. In the Fernandez study, 46
physicians rated their own cultural competence, and the ratings were compared to
ratings of interpersonal processes of care completed by independent observers during
visits with Spanish-speaking patients; higher self-rated cultural competence was
associated with more optimal interpersonal processes of care scores. Given resource
and time constraints, and literature showing the utility of self-report of Spanish-
language and cultural competence, we used self-report questions in our evaluations.
Journal of Spanish Language Teaching 7
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A midterm intervention measured how much of the curriculum had been
completed to that point by self-report. The mid-intervention survey also included
questions about satisfaction with the curriculum, repeated the self-rating of Spanish-
language ability and cultural competence, and elicited open-ended feedback.
The post-intervention evaluation consisted of a survey including self-report
measures of completion of the curriculum, the self-report questions relating to
Spanish-language ability, and the questions eliciting open-ended feedback.
Ongoing evaluation consisted of informal feedback from participants, the
community non-profit partner, and volunteer tutors.
For self-reported language ability and cultural competency questions, we
compared the pre-intervention, midterm and post-intervention Likert scale score,
presenting medians, and minimum and maximum values for non-normally distri‐
buted data, and using the Wilcoxon rank sum test to determine significance of
differences. We also planned to look for the Spearman correlation coefficient for the
relationship between number of modules completed and post-intervention self-report
score, as well as for the relationship between modules completed and change in self-
report score. Similar analyses were performed for the language assessment pre-, mid-
and post-intervention scores.
We also performed secondary analysis of the relationship between participant
characteristics and completion of the curriculum.
3. Results
Of the 63 participants, a majority (65%) was female and a plurality (44%) was in the
second post-graduate year. More than half of participants (51%) were in procedural
specialties, which we defined as general surgery and surgical sub-specialties such as
orthopedics and ophthalmology, and emergency medicine. The rest of the partici-
pants were in cognitive sub-specialties –internal medicine, pediatrics, neurology and
dermatology. Participants self-selected to complete either intermediate- or advanced-
level grammar activities based on self-perceived Spanish-language ability. Forty-nine
participants (78%) chose to participate in the intermediate level of the curriculum
and 9 (16%) in the advanced curriculum (5 expressed no choice in the initial survey)
(Table 1).
Fourteen (22%) participants completed the midterm survey. Of those, 10 (72%)
were satisfied with the curriculum, while 4 (28%) felt neutral toward it. At that point,
61% of respondents had completed enough modules to be on track to complete the
entire curriculum. All but one respondent cited time as a barrier; a few cited the
length of the modules and one cited “laziness.”There were no statistically significant
changes in self-report language or cultural competency scores at the midterm
evaluation (Tables 2,3).
Thirteen (21%) participants responded to the final survey (Table 2). Of those,
9 (71%) were satisfied or very satisfied with the curriculum, but only 5 (38%) were
able to complete a majority of the modules. Lack of time was by far the most
commonly cited barrier, with every respondent citing time as a barrier (Table 4).
There were moderate correlations between number of modules completed by the
end of the intervention and self-report of fluency scores (Spearman correlation
γ= 0.62, Pvalue = 0.025), self-report of understanding of the health-related
cultural beliefs of Spanish-speaking patients (γ= 0.56, Pvalue = 0.047), and
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Table 2. Responses to key items on pre-, mid-, and post-course surveys for the YRSI medical
Spanish curriculum.
Item
Pre-course
median
(min, max)
n=63
Midterm
median
(min, max)
n=14
Pvalue
(pre-course
vs.
midterm)
a
Post-course
median
(min, max)
n=13
Pvalue
(pre-course
vs. post-
course)
a
How would you rate
your level of fluency in
Spanish?
b
3 (1, 5) 3.5 (2, 5) 0.63 3 (2, 5) 0.50
How would you rate
your receptive
language ability in
Spanish?
c
3 (1, 4) 3 (2, 4) 1.0 3 (1, 4) 1.0
How well do you
understand the health-
related cultural beliefs
of your Spanish-
speaking patients?
c
3 (1, 4) 3 (2, 4) 0.63 3 (2, 4) 1.0
How effective are you in
caring for Latino/
Hispanic patients?
d
3 (1, 4) 2.5 (2, 4) 1.0 3 (2, 3) 0.69
a
Wilcoxon signed rank sum tests are used to calculate pvalues
b
Responses based on 5-point Likert scale (1, none; 2, poor; 3, fairly poor; 4, good; and 5, excellent)
c
Responses based on 4-point Likert scale (1, Not at all well; 2, Not very well; 3, Somewhat well; 4, Very
well)
d
Responses based on 4-point Likert scale (1, Not at all effective; 2, Somewhat effective; 3, Very effective;
4, Extremely effective).
Table 1. Characteristics as indicated the on curriculum application of the participants (n= 63)
in the YRSI medical Spanish curriculum.
Item n(%)
Gender female 41 (65)
Post-graduate level of training
Year 2 28 (44)
Year 3 17 (27)
Year 4 11 (18)
Year 5+ 7 (11)
Procedural specialty
a
32 (51)
Course level selected
Intermediate 9 (16)
Advanced 49 (85)
a
Procedural specialties included general surgery, surgical specialties, emergency medicine, and dermato-
logy. Cognitive specialties included internal medicine, pediatrics, combined internal medicine/pediatrics,
and psychiatry.
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self-reported receptive language ability (γ= 0.56, Pvalue = 0.025) (Table 3).
Secondary analysis revealed that residents in cognitive specialties were more likely
than residents in procedural specialties to complete the post-course evaluation (γ=
0.64, Pvalue = 0.03).
4. Discussion
We developed and implemented a novel medical Spanish curriculum for residents
in order to address the prevalent health disparities issue of communicating with
Spanish-speaking LEP patients. The curriculum was feasible to complete, and
those who completed more of the curriculum had better self-reported language
proficiency and cultural competency. Kramsch’s principles of combining culture and
language instruction, Gardner’s theory of multiple intelligences, and the ACTFL
5C’s provided a theoretical framework for our curriculum (Kramsch 1998; Arnold
and Fonseca 1999; National Standards 1996/2006).
We sought to design a curriculum evaluation that had significant rigor to answer
the question of whether the curriculum improved linguistic ability in our partici-
pants, as suggested by Hardin and colleagues (Hardin and Hardin 2013). We feel
that we were moderately successful in that we described the methods of assessment,
had a pre- and post-intervention evaluation, and used a longitudinal study design,
though in the end we lacked the numbers to have an independent evaluator and did
not have the number of respondents to pursue a rigorous evaluation of oral
proficiency.
Table 3. Pre-specified Spearman correlations between number of modules completed and
midterm and final self-report scores, as well as changes in those scores.
Spearman correlation
between number of
modules finished and
response (Pvalue)
Spearman correlation
between number of
modules completed and
change in response from
pre-course survey
(Pvalue)
Item Mid-term Post-course Mid-term Post-course
How would you rate your level of
fluency in Spanish?
a
0.53 (0.053) 0.62 (0.025) 0.24 (0.43) 0.36 (0.25)
How would you rate your receptive
language ability in Spanish?
b
0.11 (0.72) 0.50 (0.08) 0.35 (0.24) 0.64 (0.025)
How well do you understand the
health-related cultural beliefs of
your Spanish-speaking patients?
b
0.44 (0.12) 0.56 (0.047) 0.35 (0.25) 0.53 (0.077)
How effective are you in caring for
Latino/Hispanic patients?
c
0.42 (0.13) 0.27 (0.37) 0.21 (0.49) 0.07 (0.84)
a
Responses based on 5-point Likert scale (1, none; 2, poor; 3, fairly poor; 4, good; and 5, excellent)
b
Responses based on 4-point Likert scale (1, Not at all well; 2, Not very well; 3, Somewhat well; 4, Very well)
c
Responses based on 4-point Likert scale (1, Not at all effective; 2, Somewhat effective; 3, Very effective; 4,
Extremely effective).
10 A. Chatterjee et al.
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In keeping with our objectives, our study demonstrated that residents who
completed more of the curriculum had better self-reported fluency scores and
cultural competency skills. However, while residents from multiple specialties were
initially enthusiastic about the availability of the Yale Resident Spanish Initiative,
they ultimately found it difficult to participate due to time constraints. The majority
of residents who provided feedback via the midterm and final surveys were
satisfied with the YRSI and several were able to complete significant parts of the
curriculum.
Our curriculum is the first description of a medical Spanish-language and
cultural competency program for residents within a traditional training schedule.
Our findings support those of educators for other groups of medical personnel, such
as medical students (Reuland et al. 2008) and attending physicians (Jordan 2007).
Applying the research of Howard Gardner into multiple intelligences, education
experts have argued that acquisition of second-language skills in adults is best
accomplished through multiple learning modalities (Arnold and Fonseca 1999), and
previously successful medical Spanish curricula, such as CAMPOS for medical
students at the University of North Carolina, have utilized this approach (Reuland
et al. 2008). Thus, the curriculum we designed included reading, writing, listening,
speaking, video programs, and interactive scenarios in a way that optimized adult
learning. Additionally, self-directed online learning modules have long been used
for adult medical education (Herrick, Jenkins, and Carlson 1998), and fit in well
Table 4. Representative participant and tutor comments after the YRSI medical Spanish
curriculum.
Overall comments “I appreciate all your work on this. I’m sorry that I didn’t complete it, it
was hard to push myself sometimes to sit down and do it solo. I do think
I definitely learned from the modules that I did, particularly new medical
words. I think [the curriculum] has a lot of potential.”
“Not to say that this is AT ALL your responsibility, but creating more
deadlines and rigorous follow up will make the program FEEL more like
an obligation, which will in the end make more people complete more
parts of it …Monthly quizzes (even if they aren’t graded) or more
regular contact might create more accountability which will overall
improve the program.”
Barriers to
completion?
“Time. [W]orking as a 3rd year resident with the duty hour changes made
it impossible to have extra time to do the modules limited by fatigue and
need for sleep.”
“The community-based practice sessions were a larger burden on time.”
“I think [the barrier] was just finding the motivation to do it and staying
engaged with the curriculum. Because it was in so many pieces it didn’t
feel quite as coherent to me …Also something involving my writing
down more things, rather than looking at something on a webpage.”
Tutor comments “[The challenge] was the busy schedule of residents and mine. They were
often too tired to learn, but I still appreciate their effort to learn”.
“Only 1 resident which was assigned to me met regularly to go over cases
(which worked out well b/c developed a great mentor/mentee relationship
and was more manageable for my busy schedule)”.
Journal of Spanish Language Teaching 11
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with traditional resident schedules to optimize learning (Sisson, Hill-Briggs, and
Levine 2010).
There are a variety of possible reasons for the suboptimal completion rate of the
midterm and final surveys, and the curricular modules in general. The major barrier
cited by residents was time. Despite our efforts to create a flexible curriculum, the
baseline demands of residency training were time-prohibitive for most participants.
Residents found it especially challenging to make time for the less-flexible parts of
the curriculum (meetings with Spanish tutors and community volunteers), which
required advance planning and coordination. Additionally, several participants felt
that more robust methods for holding residents accountable would have helped with
completion rates. The multiple and varied curricular activities, while important to
the theory of improving adult learning, may have made completion of all curricular
activities more difficult.
Next, given the lower completion rate among residents from procedural
specialties, it is possible that curricular content (which was chosen by internists
and pediatricians) did not adequately fit the needs of all participants. Finally, guilt
may have played a role in poor survey response. On the final survey, one resident
requested that we not use her data because she had not completed the modules and
did not want her lack of follow-through to reflect poorly on the curriculum. It might
be inferred that guilt at not completing the curriculum kept participants from
completing the post-course evaluation.
There is room to improve based on feedback received. Participants suggested
shorter modules, options to work together on curricular materials, improvements to
the community-based portion of the curriculum, and more frequent reminders and
encouragement. For future participants in the YRSI, we plan greater clarity about
the amount of time required for the curriculum, more rigorous and objective
documentation (aside from self-report) of completion of curricular materials,
frequent reminders, and large-group events to encourage a sense of team among
learners. We will also include more surgery-specific simulated cases and vocabulary
to ensure relevance to a broader group of disciplines within medicine. Given the
demand among residents who have no background in Spanish, we also plan to work
with the Yale Department of Spanish to design a beginner-level medical Spanish
course. Ultimately, as completion rates improve with curricular revision, measure-
ment of the YRSI’s impact on patient outcomes will be important.
In conclusion, our novel Spanish-language curriculum was well received by
trainees and our institution, and resulted in better perceived fluency and cultural
competency scores among participants who were able to complete more educational
modules. While curricular revision is necessary to improve completion rates, we
believe that the implementation of a flexible, self-directed curriculum is a feasible
way to incorporate Spanish-language education into a traditional residency schedule.
Acknowledgements
The authors wish to thank Rosemarie Fisher, MD, Associate Dean of Graduate Medical
Education at Yale School of Medicine; Alan Friedman, MD, President, Yale-New Haven
Hospital Medical Staff; Celia Carvalho, Junta for Progressive Action, New Haven; Angela
Frentress, Director, and Isabel Pachiarotti, Yale-New Haven Hospital Office of Interpreter
Services; Constanza Bustamente; Ricardo Pérez-Truglia, PhD; and Sarah Gottfried, MD,
12 A. Chatterjee et al.
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MPH, Director, Yale Resident Spanish Initiative for their assistance with the design and
implementation of the YRSI curriculum.
Disclosure statement
No potential conflict of interest was reported by the authors.
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Appendix 1. Sample simulated patient cases from the Yale Resident Spanish curriculum
Simulated patient module 4: Endocrine/diabetes
In this module, intermediate and advanced learners studied nutrition and endocrine system vocabulary.
The simulated patient experience should last about 1 hour and the experience should be structured as
follows:
(1) 40 minutes –simulated cases. Brief case outlines are given. Please read the bold case stem to the
learner. Feel free to make up any details they ask about but that are not explicitly listed. If you
have time, go onto case two and/or three. You will be working with medicine, pediatrics, and
med-peds residents, so feel free to choose whichever cases you feel are the most appropriate.
(2) 10–20 minutes –case feedback. Please begin with what they did well and then cover areas for
improvement. Focus on grammar issues for the month (see above for what was covered), but
anything is fair game. This would be a helpful time to work on pronunciation/accent as well.
Case 1: Patricia is an obese 19 year old girl presenting to the clinic with several weeks of increased thirst
and urination.
HPI: Over the past three weeks, Patricia has noted increasing thirst, increasing urinary frequency during
the day and a few times at night. She denies dysuria, vaginal discharge or rash. She denies fever or chills,
14 A. Chatterjee et al.
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but does think that she has lost a few pounds over the past few weeks. She has had some blurry vision. She
drinks two liters of regular soda a day to keep up with her thirst. Otherwise she eats a “normal”diet,
including burgers, fries, chips, chicken nuggets, and cookies.
PMH/PSH: Appendicitis in 1999. Morbid obesity (BMI 40).
Meds: Prenatal vitamins.
Allergies: Amoxicillin.
Family history: Her mother and her aunt are obese and have type 2 diabetes mellitus. Her mother has
hypertension. Her father had a heart attack in his early 50s.
Social History: Lives with mother, father, and younger brother (7) and sister (5). She is sexually active with
her boyfriend but does not use condoms. Smokes occasionally, uses alcohol occasionally (once a week, 2–3
drinks) and uses marijuana once a month or so.
[Once the learner has gotten most of this information, tell her that your blood sugar in the office was 313;
ask the provider what that means.]
Case 2: Cristián is a 5-year-old boy here for well child check; his mother is worried about his diet.
HPI: Cristián is a 5-year-old boy here for maternal concerns for diet. He does not like fruits or vegetables,
other than an occasional apple. He eats cereal with whole milk in the morning, snacks on cheese sticks or
cookies during the day, eats chicken nuggets or peanut butter sandwiches for lunch, and pizza or some sort
of meat and rice for dinner. He drinks 16 ounces of juice a day. He plays video games and stays inside
most of the day; he does not know how to ride a bike. Heavy exercise gives him asthma symptoms.
PMH/SH: Born at full term, no complications, his immunizations are up to date. No childhood illnesses or
surgeries. Last time, you told mom he was 90
th
% for weight and 50
th
% for height, BMI 85th%.
Meds: Albuterol 2 puffs inhaled every 4 hours as needed for wheeze, uses once a month or so after
exercise.
Allergies: None
Family History: Mom and dad are both obese. Sister has asthma.
Social History: Lives with his mom and dad. Goes to kindergarten.
[Have the provider counsel you on diet and exercise tips]
Case 3: Iris is a 60-year-old woman with diabetes presenting with hypoglycemia.
HPI: Iris is a 60-year-old woman with type 2 DM presenting for ED follow up for hypoglycemia. She was
in her usual state of health until two days ago when she went to a family reunion and had some homemade
coleslaw. She started throwing up that night and had some diarrhea. She took her regular insulin doses the
next day, but had very little appetite. That night, she began feeling dizzy, confused and almost passed out;
her husband brought her to the ED where her glucose was 41; it improved to 108 with juice and crackers.
She comes to you this morning for counseling. Nothing like this has ever happened before. Denies fever,
chills, URI symptoms, and her abdominal discomfort, and vomiting/diarrhea have resolved.
PMH/SH: Type 2 DM ×5 years. No complications.
Meds: Insulin glargine 25 units at bedtime, Insulin aspart 5 units with meals.
Allergies: No allergies.
Family History: Mom has a history of DM. Dad died of a heart attack in his 60s.
Social History: Lives with husband in Waterbury. Denies alcohol, tobacco, or drugs.
Journal of Spanish Language Teaching 15
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