Teaching Medical Spanish to Improve Population Health: Evidence for Incorporating Language Education and Assessment in U.S. Medical Schools

Abstract

Introduction: Language concordance between patients and physicians is an important factor in providing safe and effective health care, with Spanish as the predominant and fastest growing non-English language in the United Sates. However, despite increasing demand for medical Spanish education, valid concerns about inadvertently increasing provider use of limited Spanish with patients, lack of knowledge of best practice in education and assessment, and lack of institutional support still present barriers to medical Spanish education in medical schools.
Methods: The authors conducted a narrative review of existing literature that evaluates the link between medical Spanish education of physicians and language concordance.
Results: Medical Spanish educational efforts, although increasing, are not consistently linked to learner assessment. The literature to date supports that for medical Spanish education to improve patient outcomes, it should be linked to assessment methodology that demonstrates improvement in language concordance with Spanish-speaking patients, and should include safety measures to prevent inadvertent communication errors. The authors review data for published medical Spanish postcourse language assessment strategies and provide recommendations to ensure responsible and competent use of medical Spanish skills.
Conclusion: The authors propose three structural elements that should be considered when incorporating or enhancing medical Spanish education in medical schools: institutional endorsement of the role of medical Spanish education within a national health disparities context; precourse proficiency testing to establish student starting level; and learner postcourse communications skills and limitations assessment to provide individualized recommendations and assure patient safety.

Full text

NARRATIVE REVIEW Open Access
Teaching Medical Spanish to Improve Population Health:
Evidence for Incorporating Language Education and
Assessment in U.S. Medical Schools
Pilar Ortega,
1,2,
*Norma Pe
´rez,
3
Brenda Robles,
4
Yumirle Turmelle,
5
and David Acosta
6
Abstract
Introduction: Language concordance between patients and physicians is an important factor in providing safe
and effective health care, with Spanish as the predominant and fastest growing non-English language in the
United Sates. However, despite increasing demand for medical Spanish education, valid concerns about inadver-
tently increasing provider use of limited Spanish with patients, lack of knowledge of best practice in education
and assessment, and lack of institutional support still present barriers to medical Spanish education in medical
schools.
Methods: The authors conducted a narrative review of existing literature that evaluates the link between med-
ical Spanish education of physicians and language concordance.
Results: Medical Spanish educational efforts, although increasing, are not consistently linked to learner assess-
ment. The literature to date supports that for medical Spanish education to improve patient outcomes, it should
be linked to assessment methodology that demonstrates improvement in language concordance with Spanish-
speaking patients, and should include safety measures to prevent inadvertent communication errors. The
authors review data for published medical Spanish postcourse language assessment strategies and provide rec-
ommendations to ensure responsible and competent use of medical Spanish skills.
Conclusion: The authors propose three structural elements that should be considered when incorporating or
enhancing medical Spanish education in medical schools: institutional endorsement of the role of medical Span-
ish education within a national health disparities context; precourse proficiency testing to establish student start-
ing level; and learner postcourse communications skills and limitations assessment to provide individualized
recommendations and assure patient safety.
Keywords: language concordance; medical Spanish; limited English proficiency; patient/physician communica-
tion; Hispanic/Latino health; population health
Introduction
The question of whether and how to initiate medical
Spanish courses in medical school programs is an in-
creasingly common medical education scenario with
few evidence-based answers. Students asking the ques-
tion may be eager to use any pre-existing Spanish skills
Departments of
1
Emergency Medicine and
2
Medical Education, College of Medicine, University of Illinois at Chicago, Chicago, Illinois.
3
Hispanic Center of Excellence, School of Medicine Special Programs, University of Texas Medical Branch, Galveston, Texas.
4
Language Interpreters Program, National Institutes of Health Clinical Center, Bethesda, Maryland.
5
Department of Pediatrics, Washington University St Louis School of Medicine, St Louis, Missouri.
6
Association of American Medical Colleges, Washington, District of Columbia.
Information on the relevance of medical Spanish education to public health and medical education was discussed by the authors during an AAMC-CDC Diversity 360
Webinar on February 22, 2018, titled ‘‘Teaching Medical Spanish to Improve Population Health.’’
*Address correspondence to: Pilar Ortega, MD, Department of Medical Education, College of Medicine, University of Illinois at Chicago, 808 S Wood Street, Suite 990,
Chicago, IL 60612, E-mail: portega1@uic.edu
ªPilar Ortega et al. 2019 Published by Mary Ann Liebert, Inc. This Open Access article is distributed under the terms of the Creative Commons License
(http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work
is properly cited.
Health Equity
Volume 3.1, 2019
DOI: 10.1089/heq.2019.0028 Health Equity
557

with patients with the goal to help the underserved.
1
Medical educators asking the question may be plagued
by the uncertainty of their own skills in teaching or
assessing medical non-English language skills.
2
Medi-
cal school administrators may wonder how to justify
including Spanish language skills in a time-scarce cur-
riculum. All stakeholders are further faced with the
question of how to offer medical Spanish education
in a way that appropriately considers the quality and
patient safety concerns that can arise with partial lan-
guage knowledge acquisition.
3
Although medical Span-
ish courses are increasingly requested in U.S. medical
schools,
4
dataaresparseregardingmethodsofimple-
mentation, learner assessment, and confirmation of
course effectiveness and sustainability. Therefore, an
updated review of existing evidence may facilitate
high-quality medical Spanish program implementa-
tion and help identify next steps in related educational
research.
Language concordance between patients and physi-
cians is an important factor in providing safe and effec-
tive health care. Language has been identified as a
major contributor to health disparities for patients
who prefer languages besides English, and may result
in increased risk of medical errors and poor health out-
comes.
5
Prior research and policy efforts to address the
need for Spanish language health services have primar-
ily focused on language assistance by means of inter-
pretation services, as federally mandated
6
and guided
through the national standards for culturally and lin-
guistically appropriate services.
7
However, it has been
suggested that overcoming this challenge will also re-
quire augmenting the Spanish language competency
of physicians themselves through the recruitment of
Spanish-speaking physicians and increased training of
the physician workforce in conversational and medical
Spanish.
3,8,9
This latter approach has been supported
by evidence that demonstrates that physician/patient
language concordance is associated with improved
quality in health care delivery and health outcomes.
10
Furthermore, preparing physicians to appropriately
communicate with and care for vulnerable linguistic
minority patients fits within the existing communica-
tion skills and cultural competence standards of the
Liaison Committee on Medical Education.
11,12
Providing medical Spanish educational opportuni-
ties for physicians should be approached thoughtfully
and should incorporate validated tools for careful as-
sessment of provider skill set. Medical Spanish educa-
tion should improve quality of care and patient safety
without overburdening bilingual physicians or in-
creasing the risk that medical Spanish learners will
overestimate their competence in using Spanish skills
in patient care without recognizing limitations—a
concept known as false fluency.
3,13
Existing guidelines
for medical school medical Spanish courses were estab-
lished in the medical literature by Reuland et al. in
2008
14
and other guidelines for medical Spanish courses
(including undergraduate and graduate programs) were
presented in the language literature by Hardin in 2015.
2
Recent research shows that there are still significant
barriers to establishing courses that meet these criteria,
4
and that demonstrating course effectiveness and learner
competency achievement remains a significant concern.
In particular, stakeholders in medical Spanish educa-
tion, such as medical students and faculty who wish
to enhance medical Spanish opportunities at their in-
stitutions, may be unequipped with the data and/or
strategies to gain institutional support for the initia-
tion of new medical Spanish courses or to improve
existing ones.
A recent systematic review highlights the patient
outcome benefits of language concordance.
15
It follows
that efforts to improve physician language abilities in a
target language, if effective, may also enhance language
concordance with the given linguistic minority popula-
tion and may therefore improve patient outcomes for
that population. The purpose of conducting this nar-
rative review was (1) to review existing literature that
evaluates the link between medical Spanish education
of physicians and language concordance or patient
outcomes (i.e., the effectiveness of medical Spanish
courses) and (2) to identify existing gaps in knowledge
regarding medical Spanish education and assessment.
Methods
To describe existing knowledge or gaps in knowledge of
medical Spanish course effectiveness in the context of
population health, we conducted a review of literature.
We performed the search through Medline, PubMed,
and Google Scholar using the following keywords:
medical education, medical Spanish, medical Spanish
education, medical Spanish assessment, clinical Span-
ish, language in health, language concordance, limited
English proficiency, public health, population health,
and patient outcomes. The review was initially con-
ducted as background information for the Association
of American Medical Colleges (AAMC)—Centers for
Disease Control Diversity 360 Webinar titled ‘‘Teach-
ing Medical Spanish to Improve Population Health,’’
16
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558

and was later expanded and reformatted into this
article. Opinions expressed in the review are also
based on the authors’ professional experience as bilin-
gual physicians, medical interpreters, and medical
Spanish educators.
Results
Medical Spanish education within a national health
disparities context
According to the 2016 U.S. census, the Hispanic/Lati-
no* population is the nation’s largest and fastest grow-
ing ethnic or racial minority, constituting 17.8% of the
total population, and Spanish represents the most
widely spoken non-English language.
17
Of the U.S.
population determined by census criteria to have lim-
ited English proficiency, 64% are Spanish speaking,
and this percentage is expected to rise. It is estimated
that the U.S. Latino population will increase by 115%
over the next 50 years, and by 2060 will compromise
119 million people, or 29% of the U.S. population.
17
Even though Latinos make up the largest minority
population in the United Sates, they only represent a
small fraction (5.2%) of the physician workforce,
18
and recent national data of medical school graduation
rates show that these numbers are not improving,
with Latino students representing only 4.6% of U.S.
medical school graduates in 2015.
19
Furthermore, al-
though Latino physician candidates are considerably
more likely to report Spanish skills compared with
non-Latinos,
20
they may have never been exposed to
medical vocabulary or complex communication sce-
narios such as procedural consent, delivering bad
news, or psychiatric interviewing skills and may be un-
prepared to provide equivalent quality of care in Span-
ish as they would in English without specialized
training (i.e., medical Spanish).
21
Even without skills
verification, Latino medical students with some Span-
ish skills report being called upon to interpret or care
for patients in Spanish.
1
Despite federal mandates for provision of health care
services in a patient’s language by means of qualified
professionals, the use of family members or untrained
staff, including medical students, as ad hoc interpreters
remains in widespread unsupervised use and presents
serious patient safety risks.
1,22,23
Most studies regarding
linguistically appropriate access to care have focused on
interpreter use rather than provider language skills.
Although training in use of interpreters remains a crit-
ical communication skill for physicians,
24,25
language
concordant care is known to be superior with regard
to patient satisfaction and quality measures.
26,27
Language discordance has been associated with mul-
tiple health disparities, including decreased patient sat-
isfaction,
28
less access to preventive health services,
29,30
increased risk of medical errors and misdiagnoses,
31
longer hospital stays, and increased care cost.
5,31,32
A
recent systematic review of 33 available studies that
compared language concordant medical care with
language discordant medical care with the interven-
tion of trained or ad hoc interpreters shows that in
the majority of cases, language concordance im-
proves outcomes.
15
Recent data from the state of California demonstrate
that the deficit in the number of language concordant
primary care physicians relative to the number of mi-
nority language speakers in the population is most sig-
nificant for the Spanish-speaking population compared
with any other linguistic minority group.
33,34
Equiva-
lent analyses have not been completed for the rest of
the United Sates but are expected to demonstrate sim-
ilar results, given the Spanish-speaking population
growth nationwide. Moreover, since physician lan-
guage proficiency information, when available, mostly
consists of self-assessed binary data (e.g., physicians
may be asked to report what languages they speak
but are not asked to describe proficiency level or take
an assessment), the accuracy of existing data may be
limited and may underestimate the deficit in the num-
ber of physicians competent in independently caring
for linguistic minority patients.
8
In addition to the lack and poor quality of physician
language data, patients with non-English language
preferences are often excluded from research due to
difficulties with informed consent.
35,36
The current sys-
temic lack of accountability for physician non-English
language skills is coupled with the increasingly com-
mon reality of the urgent communication needs in pa-
tient settings, with the outcome that medical students
and physicians may already rely on limited Spanish
skills to convey or obtain critical information during
patient care.
1,37
The literature to date supports that
for medical Spanish education to improve patient out-
comes, it should be linked to assessment methodology
that demonstrates improvement in language concor-
dance with Spanish-speaking patients, and should
include safety measures to prevent inadvertent com-
munication errors resulting from false fluency.
*Hereafter, the term Latino is used to refer to individuals who identify as Hispanic/
Latino.
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Current state of medical Spanish education in U.S.
medical schools
The most comprehensive overview regarding existing
U.S. medical school medical Spanish courses to date
comes from a study by Morales et al. that published
the results of their national survey of U.S. medical
school deans regarding the availability, characteristics
of, and obstacles to establishing medical school medical
Spanish courses.
4
This e-mail-based survey included 39
questions developed based on Reuland’s principles.
14
Over a period of 2 years from 2012 to 2014, 83%
(110/130) of institutions responded, with the number
of participating medical schools well-represented
across the four AAMC-designated geographic regions
(northeastern, central, southern, and western).
Seventy-three medical schools reported having a med-
ical Spanish curriculum (66%), representing an in-
crease from 48% identified by a prior study in 2005.
38
Of note, of the 37 schools that reported not having
medical Spanish courses, 27% reported having had
one previously. The most common barriers cited by
medical schools as reasons for not having or discontin-
uing medical Spanish courses included lack of time in
the overall curriculum (51%), cost (28%), overly het-
erogeneous Spanish-speaking skill level (25%), and in-
sufficient faculty support (20%). Teaching modalities
used in the courses were variable (e.g., didactic, role
play, standardized patients [SPs], immersion experi-
ences, or online modules), as well as the qualifications
of the instructors (e.g., medical faculty students, inter-
preters, or language instructors).
4
The finding that
medical Spanish courses vary considerably regarding
teaching modalities and instructor qualifications is
consistent with a review by Hardin and Hardin in
2013, in which the authors reviewed 23 published stud-
ies of medical Spanish curricula.
39
Importantly, most schools that offer medical Spanish
education report not having a method to determine
students’ proficiency before enrolling in the course,
nor an assessment method at course completion,
4
even though both elements have been recommended
by experts as critical to best practice in physician lan-
guage education.
14,39
Furthermore, 75% of medical
schools in the most recent national survey reported
allowing their students to perform patient interviews
in Spanish, and 57% stated that they did not require
any proof of language proficiency.
4
The lack of assess-
ment of medical Spanish skills before their use in pa-
tient care is a major concern that threatens to
exacerbate communication errors endangering patient
safety.
5,9,20,21,23,40
Some literature reports use of a com-
mercially available phone-based oral examination to
certify physician non-English language abilities before
patient care,
41
but this assessment has not been evalu-
ated for alignment with medical Spanish curricular ob-
jectives or learner target competencies, and so, its
relevance in examining postcourse outcomes is un-
known. Few studies have evaluated physician language
assessment in relation to medical Spanish educational
interventions.
The lack of knowledge of how to properly assess lan-
guage proficiency of physicians is a significant reason
that medical Spanish educators may not formally assess
proficiency. Clinician-educators—the most common
teachers of medical Spanish in medical schools
4
—
may benefit from combining their clinical expertise in
communicating with Spanish-speaking patients with
the experience of language educators in addressing
learner proficiency assessment.
2,42
Some medical Span-
ish experts have published their strategies regarding
postcourse proficiency assessment of medical Spanish
learners. Of the six publications describing outcomes
of medical Spanish courses in medical school or similar
settings since 2012, four describe learner assessment via
SP objective structured clinical examinations,
43–46
two
of which are medical Spanish courses in medical school
programs
43,44
and two in other health professions grad-
uate programs (pharmacy and physician assistant pro-
grams).
45,46
Two other studies describe use of an oral
proficiency interview as a learner assessment tool.
47,48
A seventh publication that describes medical Spanish
curricula and assessment at three medical schools reports
use of SP examinations in all three programs and an oral
proficiency interview in one of the programs.
11
Since many medical Spanish learning experiences in
medical school are peer-led extracurricular activities
rather than formal courses,
4
it is possible that a signif-
icant portion of the existing educational efforts are not
being reported, supervised, evaluated for effectiveness,
or acknowledged either by individual institutions or in-
terinstitutional curricular surveys.
8
For example,
AAMC’s Curriculum Inventory
49
captured few medical
Spanish courses compared with the survey by Morales
et al.
4
since it did not directly inquire about elective
courses.
While most studies report improvement in medical
Spanish skills following educational interventions,
11,43–48
not all programs routinely evaluate unintended out-
comes—such as false fluency—or train students strat-
egies to recognize and address language discordance if
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present—such as interpreter use. Such communica-
tion skills have been referred to as global linguistic
competence due to their relevance in communicating
with patients of any language preference, whether a
patient/physician language discordance is present or
not.
11
Some medical Spanish courses in graduate med-
ical education programs have reported that some global
linguistic learner skill usage may be worsened after
courses, specifically noting reduced use of interpreters
by learners despite still demonstrating skill limitations,
including medical communication errors in Span-
ish.
50,51
These findings should alert educators to the
potential risks of partial language knowledge acquisi-
tion. Of note, these concerning outcomes were both
identified following short-duration courses taking
place in residency programs. Other residency programs
with large Spanish-speaking patient populations have
successfully implemented longitudinal medical Spanish
educational interventions that integrate intensive medi-
cal Spanish classroom learning and daily Spanish use in
clinical settings with interpreter support and progressive
resident independence.
52
Furthermore, due to the resi-
dent physician’s clinical responsibilities, resident physi-
cians may perceive increased urgency to use skills with
patients compared with medical students, although ad-
ditional study is needed to evaluate the potential differ-
ences between language education in undergraduate and
graduate medical education settings and among inten-
sive, longitudinal, and mixed-structure courses.
Discussion
Unless the number of competent Spanish-speaking
physicians increases over time and all providers are
educated on global linguistic skills, the language discor-
dance gap is likely to lead to more health disparities for
the U.S. Latino patient population and other linguistic
minorities. A vast majority of hospitals nationwide
are encountering patients with language preferences
besides English on a regular basis,
22
suggesting that
even medical schools and hospitals in cities without
large urban populations need to address language dis-
cordance. In addition, a medical school’s goal should
not be solely to prepare their students for the practice
of medicine in the particular hospital where they
train, but rather to serve the increasingly global popu-
lation of patients in the United Sates. One potential so-
lution would be to recruit more bilingual students into
medical school
3
; however, the number of Latino candi-
dates applying to and graduating from medical schools
has remained constant over the last 20 years.
53
Further-
more, even physician heritage Spanish speakers—indi-
viduals who were exposed to or learned Spanish at
home but whose proficiency level may significantly
vary—may lack the necessary language skills to practice
medicine in Spanish.
54
Therefore, medical schools
should focus on teaching medical Spanish to selected
candidates and global linguistic competence to all stu-
dents as part of the medical school curriculum to better
prepare future physicians to provide quality care to all
patients.
11
Although student demand is most often the inciting
reason for initiating medical Spanish courses at indi-
vidual medical schools,
4
the burden of ensuring lin-
guistic competence and patient communication skills
should not fall on students. Moreover, the evidence
of need is a national population health issue and should
not have to be redemonstrated at individual medical
schools to warrant resource allocation for course devel-
opment. Similarly, heritage Spanish-speaking medical
school faculty and even medical students are often re-
lied upon to develop and teach medical Spanish courses
because they are assumed to have the necessary skills to
do so, but this group may feel unprepared, overbur-
dened, and unsupported in this specialized task.
Resource allocation required for course implementa-
tion may include SP or other assessment costs, faculty
training, and faculty percentage time for course devel-
opment and implementation. Other needs that would
require institutional commitment involve providing
student course credit, integration into existing commu-
nication skills portions of the curriculum, and support
of interdisciplinary partnerships with language instruc-
tors who can help inform the pedagogy of language ed-
ucation with which clinicians may be unfamiliar.
42
Given population trends and patient outcomes data,
issues of linguistic and cultural competency have been
cited by experts as an urgent call to action for educa-
tional institutions nationwide.
8,55
Some experts have
cautioned that teaching medical Spanish may increase
a sense of false fluency among providers and thus cre-
ate patient safety concerns that may worsen health dis-
parities.
5,9,20,21,23,40
We consider that the risk of false
fluency may be higher for providers with some basic
Spanish who have never taken a medical Spanish
course and have never been taught to assess their skills
or limitations, a concept supported by the finding that
pediatric residents overestimated their medical Spanish
proficiency before formal testing.
48
We argue that the
best approach is not to discourage medical Spanish
courses altogether but rather (1) to support replication
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of high-quality medical Spanish educational and as-
sessment methodology in medical schools and (2)
to encourage inclusion of training for physicians on
recognizing self-limitations and on appropriately
accessing and working with professional interpreters
when their personal skills are insufficient. This type
of training has been termed global linguistic compe-
tence and defined as the skills needed to effectively
communicate with patients of any language prefer-
ences or needs.
11
The practice of medicine in English is no longer suf-
ficient to ensure health equity for the U.S. population,
so medical education institutions should develop strat-
egies to address language discordance, including med-
ical Spanish courses and assessment. Specifically, we
propose three step-by-step recommendations for stake-
holders to initiate new or improve existing medical
Spanish courses, summarized in Table 1: First, we rec-
ommend to seek institutional endorsement of the role
of medical Spanish education within a national health
disparities context. This step is critical to ensure that
medical Spanish efforts are not isolated to work done
by a single educator, that they are connected to other
institutional efforts to improve communication skills
and care for vulnerable populations, and that they are
sustainable. Second, we recommend that medical Span-
ish educators include precourse proficiency testing to
establish a starting level for students. Precourse profi-
ciency testing can be used to determine course eligibil-
ity and to formulate individualized student goals.
Finally, we recommend that educators implement a
postcourse learner examination that includes a commu-
nications skills assessment. The postcourse assessment
should be nuanced enough to provide individualized
recommendations regarding learner skills and limita-
tions. By following these steps, medical educators can
approach medical Spanish education as a long-term sus-
tainable institutional effort to improve physician skills
that safely and directly address population health for
vulnerable linguistic minority groups in an evidence-
based manner.
Precourse language proficiency assessment
Although the terms competence and proficiency are
often used interchangeably, we first want to establish
that what is meant by proficiency is often unclear
and generally should be divided in two distinct catego-
ries: (1) the assessment of precourse language profi-
ciency, and (2) the assessment of postcourse
communication skills. The purpose of the former is
to determine student appropriateness to enroll in a
medical Spanish course, and, as such, is a lower stakes
evaluation, whereas the purpose of the latter is to deter-
mine readiness for independent direct patient care in a
given language. Given these important differences, the
purpose of the assessment should drive the cost and
complexity of the type of testing that is recommended
for each phase of the learner process. Establishing a
standardized prerequisite proficiency assessment for
medical Spanish courses and providing transparency
as to how the Spanish postcourse proficiency will be
evaluated may also serve to encourage premedical un-
dergraduates to pursue bilingualism. For example, par-
ticipating in conversational Spanish courses, seeking a
Spanish minor, or pursuing other opportunities to im-
prove general Spanish skills may enhance candidates’
qualifications in later caring for Spanish-speaking pop-
ulations before applying to medical school or enrolling
in medical Spanish courses.
Given that medical Spanish is a complex skill that re-
quires building upon pre-existing Spanish conversa-
tional skills, most authors agree that medical Spanish
courses should focus on the advanced skill develop-
ment rather than on the basic general Spanish skill
acquisition.
11,14,42
Although most medical Spanish pro-
grams rely on student self-report, and some literature
supports that self-assessment may be sufficiently reli-
able as a way to determine starting proficiency,
56
others
Table 1. Recommended Structural Elements for Medical Spanish Program Implementation or Enhancement
Structural elements Recommended examples for implementation
1. Institutional endorsement of the role of medical Spanish education
within a national health disparities context
a. Dedicated medical Spanish course for intermediate Spanish students
or above (elective)
b. Global linguistic skills training to understand self-limitations in any
language, cultural context, and work with interpreters (all students)
2. Precourse language proficiency assessment to establish a basic fluency
level for students and ensure eligibility for dedicated medical Spanish
course
ILR modified scale for physicians
41
3. Postcourse communication skills assessment SP encounter, OSCE
ILR, Interagency Language Roundtable; OSCE, objective structured clinical examination; SP, standardized patient.
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have questioned its utility based on data that students
may overestimate their level.
48
A validated example of a precourse proficiency as-
sessment that may be applied to medical Spanish
courses may include the Interagency Language Round-
table (ILR) modified scale for physicians, a rapid self-
assessment tool that describes proficiency categories
as related to conversational health care skills in catego-
ries of ‘‘poor,’’ ‘‘fair,’’ ‘‘good,’’ ‘‘very good,’’ and ‘‘excel-
lent.’’ The modified ILR scale has demonstrated
accuracy at the lower and higher ends of the scale
equivalent to more formal but also more costly oral
language testing methodology, such as existing
phone-based examinations.
41
The American Council
on the Teaching of Foreign Languages proficiency
guidelines provide another scale for proficiency-level
assessment for student placement, but it is not specific
for health care use.
57
It is important to emphasize that
the purpose of the proficiency preassessment would be
to evaluate readiness for a medical Spanish course,
rather than postcourse competency or certification
for clinical Spanish usage. While oral examinations or
patient encounter-focused examinations to test medical
language proficiency may be more reliable to provide a
nuanced understanding of personal abilities, particu-
larly for speakers in the intermediate range, these
tools represent a significant time, labor, and expense,
and may not be necessary for precourse assessment.
A recent medical Spanish expert panel’s consensus re-
port recommends a minimum self-assessed level of
‘‘fair’’ or above on the modified ILR scale as a student
prerequisite to enroll in a medical Spanish course in
medical school.
42
Precourse assessment, such as the modified ILR
scale, can be helpful not only to determine course eligi-
bility but also to help guide personalized learner com-
petency goals for students at different starting levels.
For example, a student at the intermediate starting
level may have the goal to increase vocabulary, identify
individual deficits, and complete a simple patient inter-
view, whereas advanced students may additionally
work on more complex communication skills such as
informed consent discussions or delivering bad news.
If an objective measure is desired that does not rely
on self-assessment, a brief instructor-directed written
or oral examination to evaluate general Spanish profi-
ciency may be sufficient to establish that a student
meets the course prerequisite level, although to the au-
thors’ knowledge, no specific tools have been validated
for this purpose.
Postcourse communication skills assessment
Upon completion of a medical Spanish course, a more
detailed understanding of a learner’s skills is necessary,
including ability to self-assess language limitations and
to seek help when needed. In addition, some centers
are seeking to certify bilingual providers to allow
them to use languages other than English in patient
care, and as such are interested in a standardized cer-
tification examination that can adequately assess
medical communication skills in languages besides
English. Although written examinations can theoreti-
cally be used to evaluate knowledge of terminology
and grammar, they do not address listening compre-
hension, oral communication, or interpersonal skills,
which are among the most critical educational objec-
tives of medical Spanish for physicians. Therefore, a
more comprehensive and time-consuming evaluation
addressing face-to-face communication skills and com-
prehension would be best suited for postcourse testing
or certification.
Language literature supports that best practice in
medical Spanish assessment should focus on oral pro-
ficiency,
39
and medical literature provides examples
of SP clinical encounters as an evaluation mechanism
for clinical skills in Spanish.
43–46
Simulation-based ex-
aminations are already the primary standard formative
and summative assessment tool in U.S. medical educa-
tion
58
and are utilized with validated scales such as the
Communication and Interpersonal Skills (CIS) scale in
graduate competency evaluations to test U.S. medical
students and residents before graduation
59
and for li-
censing examinations.
60
Similarly, in medical Spanish
courses, the goal of the postcourse examination
would not be focused on language proficiency alone,
but rather on the provider’s competence in using med-
ical Spanish skills for patient care.
Relatedly, SP encounters can be designed appropri-
ately for specific learners depending on skill level and
course goals. Since medical Spanish proficiency level
can vary depending on the complexity of the subject
matter being discussed during a particular encounter
and the frequency of use for a given provider, SP en-
counters can be used to target specific competencies
in a realistic but low-stakes environment and to evalu-
ate provider performance in various clinical situations,
including difficult or high-risk patient scenarios. By
contrast, a one-size-fits-all written or oral examination
may not sufficiently define true competency for medical
Spanish usage in clinical settings or provide sufficient
guidance for providers to recognize their limitations.
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Interdisciplinary partnerships with professionals in
other areas of language such as medical interpreters
or Spanish language educators can potentially work
with clinician-educators on collaboratively developing
more nuanced assessments.
11
In addition, assessment of physician language skills
should acknowledge that patient-centered medical
communication in a non-English language may not
necessarily (and not likely) be acquired in a single
course, but rather should be acquired as a longitudinal
process with ‘‘graduated measures of proficiency’’
21
that physicians can develop over time. There is a
need for standardization of such Spanish communica-
tion assessment examinations in connection with med-
ical Spanish educational efforts and course objectives.
In parallel, medical Spanish educators to be able should
be trained to appropriately teach and assess student
competencies and limitations in interviewing and car-
ing for Spanish-speaking patients.
Conclusions
Given that the demographics of the United Sates have
continued to change substantially since the most re-
cent national survey
4
and that the number of U.S.
medical schools has increased (154 institutions in
2019 vs. 130 in 2012), a reassessment of medical
Spanish programs should be conducted. In addition,
the prior survey did not query whether cultural com-
petency or other elements of global linguistic compe-
tence (e.g., use of interpreters and understanding of
basic skills in cross-linguistic communication)
11
were included in the course instruction. Given the
recognized call to action to promote adopting stan-
dardized language proficiency testing for clinicians
to ensure health equity across language preferences,
8
it would be important to assess if there has been any
progress.
To facilitate new medical Spanish program imple-
mentation or improvement of existing programs, indi-
viduals who champion these efforts should consider the
proposed three structural elements (Table 1) in a step-
wise approach. Contextualizing medical Spanish edu-
cation within larger institutional efforts to reduce
population health disparities and increase physician
global linguistic preparedness may facilitate inclusion
of educational efforts within existing curricula and
provide justification for using institutional resources.
Furthemore, implementation of precourse language
proficiency assessment, coupled with a comprehensive
postcourse communication skills assessment, will help
ensure that quality and safety measures are prioritized
when teaching medical students to care for vulnerable
linguistic minority patients. Importantly, attention
should be given to recruitment and preparation of
medical school faculty to teach and assess medical
Spanish skills—a unique skill set that involves language
and clinical knowledge and requires training. Addi-
tional study is needed to evaluate best practices with
regard to each of the elements above including effective
curricular models for medical Spanish courses, integra-
tion of global linguistic skills in existing CIS education,
and development and assessment methodology of
medical Spanish competencies.
The time has come to take a comprehensive ap-
proach to medical Spanish programming with the
goals of making it easier for medical schools to institute
effective courses for their students, to assess student
communication skills with patients who prefer lan-
guages besides English, to verify effectiveness of medical
Spanish programming on learner competencies, and to
provide reliable and effective options for physicians to
become bilingual clinicians who can offer high-quality
services to the linguistically diverse U.S. population.
Disclaimer
The contents of this article are solely the responsibility
of the authors and do not necessarily represent the of-
ficial views of the Association of American Medical
Colleges, the University of Illinois at Chicago College
of Medicine, the Washington University in St. Louis,
the University of Texas Medical Branch, or the
National Institutes of Health.
Author Disclosure Statement
Dr. Ortega receives author royalties from Saunders
Elsevier. Dr. Pe
´rez receives author royalties from the
University of Texas Medical Branch. Dr. Acosta, Dr.
Turmelle, and Ms. Robles have no competing financial
interests.
Funding Information
No funding was received for this article.
References
1. Vela MB, Fritz C, Girotti J. Medical students’ experiences and perspec-
tives on interpreting for LEP patients at two U.S. medical schools. J Racial
Ethn Health Disparities. 2016;3:245–249.
2. Hardin K. An overview of medical Spanish curricula in the United States.
Hispania. 2015;98:640–661.
3. Ferna
´ndez A, Pe
´rez-Stable EJ. ¿Doctor, habla espan
˜ol? Increasing the
supply and quality of language-concordant physicians for spanish-
speaking patients. J Gen Int Med. 2015;30:1394–1396.
Ortega, et al.; Health Equity 2019, 3.1
http://online.liebertpub.com/doi/10.1089/heq.2019.0028
564

4. Morales R, Rodrı
´guez L, Singh A, et al. National survey of medical
Spanish curriculum in U.S. medical schools. J Gen Intern Med. 2015;30:
434–439.
5. Divi C, Koss RJ, Schmaltz SP, et al. Language proficiency and adverse
events in U.S. hospitals: a pilot study. Int J Qual Health Care. 2007;19:
60–67.
6. Improving access to services for persons with limited English proficiency.
Executive Order 13166. Fed Regist. 2000;65:50119–50122.
7. Office of Minority Health, U.S. Department of Health and Human Services.
National standards for culturally and linguistically appropriate services
in health and health care: A blueprint for advancing and sustaining
CLAS—Policy and practice. Published April 2013. https://www
.thinkculturalhealth.hhs.gov/pdfs/EnhancedCLASStandardsBlueprint.pdf
Accessed August 27, 2018.
8. Ortega P. Spanish language concordance in medical care: a multifaceted
challenge and call to action. Acad Med. 2018;93:1276–1280.
9. Flores G, Mendoza FS. ¿Dolor aquı
´? ¿Fiebre?: a little knowledge requires
caution. Arch Ped Adolesc Med. 2002;156:638–640.
10. Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic
Disparities in Health Care. Washington, DC: The National Academies Press,
2003. Available at https://www.nap.edu/resource/10260/
disparities_providers.pdf Accessed April 5, 2018.
11. Ortega P, Pe
´rez N, Robles B, et al. Strategies for teaching linguistic
preparedness for physicians: medical Spanish and global linguistic
competence in undergraduate medical education. Health Equity. 2019;3:
312–318.
12. Liaison Committee on Medical Education. Functions and structure of a
medical school: standards for accreditation of medical education pro-
grams leading to the MD Degree. Effective academic year: 2019–20.
Published March 2018. Available at http://lcme.org/publications
Accessed August 27, 2018.
13. Diamond LC, Jacobs EA. Let’s not contribute to disparities: the best
methods for teaching clinicians how to overcome language barriers to
health care. J Gen Intern Med. 2010;25 Suppl 2:S189–S193.
14. Reuland DS, Frasier PY, Slatt LM, et al. A longitudinal medical Spanish
program at one U.S. medical school. J Gen Intern Med. 2008;23:1033–
1037.
15. Diamond L, Izquierdo K, Canfield D, et al. A systematic review of the
impact of patient-physician non-English language concordance on
quality of care and outcomes. J Gen Intern Med. 2019;34:1591–1606.
16. Ortega P, Pe
´rez N, Robles B, et al. Teaching medical Spanish to improve
population health [webinar]. Available at https://www.aamc.org/
initiatives/diversity/portfolios/485628/medicalspanishwebinar.html
Accessed June 11, 2019.
17. U.S. Census Bureau. Profile America facts for features: Hispanic heritage
month 2016. Available at https://www.census.gov/content/dam/Census/
newsroom/facts-for-features/2016/cb16-ff16.pdf Accessed February 14,
2019.
18. Deville C, Hwang W, Burgos R, et al. Diversity in graduate medical edu-
cation in the United States by race, ethnicity, and sex, 2012. JAMA Intern
Med. 2015;175:1706–1708.
19. Association of American Medical Colleges. Table B-4: total U.S. medical
school graduates by race/ethnicity and sex, 2013–2014 through 2017–
2018. Available at https://www.aamc.org/download/321536/data/
factstableb4.pdf Accessed July 19, 2019.
20. Diamond LC, Tuot DS, Karliner LS. The use of Spanish language skills by
physicians and nurses: policy implications for teaching and testing. J Gen
Intern Med. 2012;27:117–123.
21. Regenstein M, Andres E, Wynia MK. Appropriate use of non-English-
language skills in clinical care. JAMA. 2013;309:145–146.
22. Huang J, Jones K, Regenstein M, et al. Talking with Patients: How
Hospitals use Bilingual Clinicians and Staff to Care for Patients with
Language Needs (Issue brief: Survey findings). Washington, DC:
Department of Health Policy, School of Public Health and Health Services,
The George Washington University, 2009.
23. Jacobs EA, Diamond LC, Stevak L. The importance of teaching clinicians
when and how to work with interpreters. Patient Educ Counts. 2010;78:
149–153.
24. Jacobs EA, Sadowski LS, Rathouz PJ. The impact of an enhanced inter-
preter service intervention on hospital costs and patient satisfaction.
J Gen Intern Med. 2007;22 Suppl 2:306–311.
25. Karliner LS, Pe
´rez-Stable EJ, Gildengorin G. The language divide: the im-
portance of training in the use of interpreters for outpatient practice. J
Gen Intern Med. 2004;19:175–183.
26. Ngo-Metzger Q, Sorkin DH, Phillips RS, et al. Providing high-quality
care for limited English proficient patients: the importance of language
concordance and interpreter use. J Gen Intern Med. 2007;22 Suppl 2:324–
330.
27. Allison A, Hardin K. Missed opportunities to build rapport: a pragmalin-
guistic analysis of interpreted medical conversations with Spanish-
speaking patients. Health Commun 2019. [Epub ahead of print]; DOI:
10.1080/10410236.2019.1567446.
28. Jaramillo J, Snyder E, Dunlap JL, et al. The Hispanic Clinic for Pediatric
Surgery: a model to improve parent-provider communication for His-
panic pediatric surgery patients. J Pediatr Surg. 2016;51:670–674.
29. DuBard CA, Gizlice Z. Language spoken and differences in health status,
access to care, and receipt of preventive services among US Hispanics.
Am J Public Health. 2008;98:2021–2028.
30. Pe
´rez-Stable EJ, Na
´poles-Springer A, Miramontes JM. The effects of eth-
nicity and language on medical outcomes of patients with hypertension
or diabetes. Med Care. 1997;35:1212–1219.
31. Parker MM, Ferna
´ndez A, Moffet HH, et al. Association of patient-
physician language concordance and glycemic control for limited-English
proficiency Latinos with type 2 diabetes. JAMA Intern Med. 2017;177:380–
387.
32. Ferna
´ndez A, Quan J, Moffet H, et al. Adherence to newly prescribed
diabetes medications among insured Latino and white patients with
diabetes. JAMA Intern Med. 2017;177:371–379.
33. Hsu P, Balderas-Medina Anaya Y, Anglin L, et al. California’s language
concordance mismatch: clear evidence for increasing physician diver-
sity. September 2018. Available at http://latino.ucla.edu/wp-content/
uploads/2018/09/UCLA-AltaMed-Language-Concordance-Brief-2018.pdf
Accessed March 4, 2019.
34. Garcı
´a ME, Bindman AB, Coffman J. Language-concordant primary care
physicians for a diverse population: the view from California. Health
Equity. 2019;3: 343–349.
35. Schenker Y, Wang F, Selig SJ, et al. The impact of language barriers on
documentation of informed consent at a hospital with on-site interpreter
services. J Gen Intern Med. 2007;22(Suppl 2):294–299.
36. Ortega P. Physicians interrupting patients. J Gen Intern Med. 2019 [Epub
ahead of print]; DOI: 10.1007/s11606-019-05139-8.
37. Diamond LC, Schenker Y, Curry L, et al. Getting by: under-use of inter-
preters by resident physicians. J Gen Intern Med. 2009;24:256–262.
38. Maben K, Dobbie A. Current practices in medical Spanish teaching in US
medical schools. Fam Med. 2005;37:613–614.
39. Hardin KJ, Hardin DM. Medical Spanish programs in the United States:
a critical review of published studies and a proposal of best practices.
Teach Learn Med. 2013;25:306–311.
40. Diamond LC, Reuland DS. Describing physician language fluency:
deconstructing medical Spanish. JAMA. 2009;301:426–428.
41. Diamond L, Chung S, Ferguson W, et al. Relationship between self-
assessed and tested non-English-language proficiency among primary
care providers. Med Care. 2014;52:435–438.
42. Ortega P, Diamond L, Alema
´n M, et al. Medical Spanish standardization
in U.S. Medical Schools: consensus statement from a multidisciplinary
expert panel. Acad Med. 2019 [Epub ahead of print]; DOI: 10.1097/
ACM.0000000000002917.
43. Ortega P, Park YS, Girotti JA. Evaluation of a medical Spanish elective
for senior medical students: improving outcomes through OSCE assess-
ments. Med Sci Educ. 2017;27:329–337.
44. O’Rourke K, Gruener G, Quinones D, et al. Spanish bilingual medical
student certification. MedEdPORTAL. 2013;9:9400.
45. Lie DA, Forest CP, Richter-Lagha R. Evaluating medical Spanish profi-
ciency: a comparison of physician assistant student self-assessment to
standardized patient and expert faculty member ratings. J Physician
Assist Educ. 2018;29:162–166.
46. Mueller R. Development and evaluation of an intermediate-level elective
course on medical Spanish for pharmacy students. Curr Pharm Teach
Learn. 2017;9:288–295.
47. Reuland DS, Slatt LM, Alema
´n MA, et al. Effect of spanish language
immersion rotations on medical student Spanish fluency. Fam Med. 2012;
44:110–116.
Ortega, et al.; Health Equity 2019, 3.1
http://online.liebertpub.com/doi/10.1089/heq.2019.0028
565

48. Lion KC, Thompson DA, Cowden JD, et al. Impact of language proficiency
testing on provider use of Spanish for clinical care. Pediatrics. 2012;130:
e80–e87.
49. Association of American Medical Colleges. Curriculum Inventory: Cover-
age of Medical Spanish Education Content 2016–2017. Generated De-
cember 5, 2017.
50. Mazor S, Hampers L, Chande V, et al. Teaching Spanish to pediatric
emergency physicians: effects on patient satisfaction. Arch Pediatr Ado-
lesc Med. 2002;156:693–695.
51. Prince D, Nelson M. Teaching Spanish to emergency medicine residents.
Acad Emerg Med. 1995;2:32–36.
52. Barr WB, Valdini A, Louis JS, et al. Sı
´,tu
´puedes: an integrated Spanish
language acquisition in residency utilizing personal instruction. J Grad
Med Educ. 2018;10:343–344.
53. Association of American Medical Colleges (AAMC), Diversity in Medical
Education: Facts & Figures 2016. Available at http://
aamcdiversityfactsandfigures2016.org Accessed April 5, 2018.
54. Martı
´nez G, Rivera-Mills S, Trujillo JA. Medical Spanish for heritage learners:
A prescription to improve the health of Spanish speaking communities.
Building Communities and Making Connections. Newcastle upon Tyne,
United Kingdom: Cambridge Scholars Publishing, 2010, pp. 2–15.
55. Ghaddar S, Ronnau J, Saladin SP, et al. Innovative approaches to promote
a culturally competent, diverse health care workforce in an institution
serving hispanic students. Acad Med. 2013;88:1870–1876.
56. Reuland DS, Frasier PY, Olson MD, et al. Accuracy of self-assessed Spanish
fluency in medical students. Teach Learn Med. 2009;21:305–309.
57. American Council on the Teaching of Foreign Languages Proficiency 2012
Guidelines. Available at https://www.actfl.org/sites/default/files/pdfs/public/
ACTFLProficiencyGuidelines2012_FINAL.pdf Accessed April 30, 2018.
58. Karkowsky CE, Chazotte C. Simulation: improving communication with
patients. Semin Perinatol. 2013;37:157–160.
59. Iramaneerat C, Myford CM, Yudkows ky R, et al. Evaluating the effec-
tiveness of rating instruments for a communication skills assessm ent
of medical residents. Adv Health Sci Educ Theory Pract. 2009;14:
575–594.
60. Federation of State Medical Boards of the United States, Inc., and the
National Board of Medical Examiners. USMLE step 2 clinical skills content
description and general information. Revised October 2017. Available at
www.usmle.org/pdfs/step-2-cs/cs-info-manual.pdf Accessed August 28,
2018.
Cite this article as: Ortega P, Pe
´rez N, Robles B, Turmelle Y, Acosta D
(2019) Teaching medical Spanish to improve population health: evi-
dence for incorporating language education and assessment in U.S.
medical schools, Health Equity 3:1, 557–566, DOI: 10.1089/
heq.2019.0028.
Abbreviations Used
AAMC ¼Association of American Medical Colleges
CIS ¼Communication and Interpersonal Skills
ILR ¼Interagency Language Roundtable
SP ¼standardized patient
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