Perspective
Medical Spanish Standardization in U.S.
Medical Schools: Consensus Statement From a
Multidisciplinary Expert Panel
Pilar Ortega, MD, Lisa Diamond, MD, MPH, Marco A. Alemán, MD,
Jaime Fatás-Cabeza, MMA, USCCI, CHI, Dalia Magaña, PhD, Valeria Pazo, MD,
Norma Pérez, MD, DrPH, Jorge A. Girotti, PhD, MHA, and Elena Ríos, MD, MSPH,
on behalf of the Medical Spanish Summit
Abstract
Downloaded from http://journals.lww.com/academicmedicine by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 12/31/2020
Medical Spanish (MS) education is in
growing demand from U.S. medical
students, providers, and health
systems, but there are no standard
recommendations for how to structure
the curricula, evaluate programs,
or assess provider performance or
linguistic competence. This gap in
medical education and assessment
jeopardizes health care communication
with Hispanic/Latino patients and poses
significant quality and safety risks. The
National Hispanic Health Foundation
and University of Illinois College of
Medicine convened a multidisciplinary
expert panel in March 2018 to define
national standards for the teaching
P
atient–physician communication is a
critical element in health care provision,
and the increasing number of Spanishspeaking patients in the United States1
presents a growing challenge for health
systems tasked with providing equitable
care. According to the 2015 American
Community Survey, there are 40 million
Spanish-speaking Hispanic/Latino* U.S.
residents, representing a rise of 131.2%
since the prior survey in 1990; of these,
43% (17.2 million) are monolingual
Spanish speakers.1 The Latino population
is not only underserved but also
underrepresented in the health care
workforce in general and in the physician
workforce specifically.2,3 As a result,
medical Spanish education is in growing
Please see the end of this article for information
about the authors.
Correspondence should be addressed to Pilar Ortega,
University of Illinois at Chicago, College of Medicine,
808 South Wood St., Suite 990, Chicago, IL 60612;
email: POrtega1@uic.edu; Twitter: @pilarortegamd.
Acad Med. 2020;95:22–31.
First published online July 30, 2019
doi: 10.1097/ACM.0000000000002917
Copyright © 2019 by the Association of American
Medical Colleges
Supplemental digital content for this article is
available at http://links.lww.com/ACADMED/A724.
22
and application of MS skills in patient–
physician communication, establish
curricular and competency guidelines for
MS courses in medical schools, propose
best practices for MS skill assessment
and certification, and identify next
steps needed for the implementation
of the proposed national standards.
Experts agreed on the following
consensus recommendations: (1)
create a Medical Spanish Taskforce
to, among other things, define
educational standards; (2) integrate MS
educational initiatives with governmentfunded research and training efforts
as a strategy to improve Hispanic/
Latino health; (3) standardize core MS
learner competencies; (4) propose a
consensus core curricular structure
for MS courses in medical schools;
(5) assess MS learner skills through
standardized patient encounters
and develop a national certification
exam; and (6) develop standardized
evaluation and data collection processes
for MS programs. MS education and
assessment should be standardized and
evaluated with a robust interinstitutional
medical education research strategy
that includes collaboration with
multidisciplinary stakeholders to
ensure linguistically appropriate care
for the growing Spanish-speaking U.S.
population.
demand from U.S. medical students,
providers, and health systems. Many
medical schools have taken on the task
of providing medical Spanish education
to their students but have identified
significant barriers in designing,
implementing, evaluating, and sustaining
quality programs.4
each other to share resources or data on
medical Spanish educational techniques
or evaluation processes. Further, existing
medical education curriculum inventory
processes do not capture data on elective
medical Spanish courses.6
Some of the barriers to medical Spanish
courses include the time needed to
develop new courses, limited space within
the curriculum to insert courses, limited
availability of faculty with the expertise
to teach such a course, and limited funds
to compensate these faculty for their
time.4 In addition, important elements
of medical Spanish courses have been
proposed, but their implementation
has not been evaluated.5 The most
complete survey available of existing
medical Spanish courses was completed
in 20124 and showed that a majority of
MD-granting medical schools (55%)
had a medical Spanish course. However,
no formal follow-up has been done to
date, and no current mechanism exists
for programs to communicate with
*Hereafter, the term Latino is used throughout the
text to refer to individuals of Hispanic/Latino origin.
Several medical Spanish programs have
been reported in the literature, but few
meet best practice criteria, including a
reliable method of individual student
and overall program assessment and
evaluation.7 Lack of assessment results in
medical students and physicians, without
confirmation of proficiency, using
variable language skills with patients
out of perceived necessity, which can
jeopardize health care communication
with Latino patients and pose significant
quality and safety risks to an already
vulnerable population.8,9 The current
approach to medical Spanish education
has relied on each medical school
developing its own educational materials,
clinical cases, scripts, and scoring
rubrics for complex standardized patient
(SP) encounters and other curricular
components, missing an opportunity
for peer review and interdisciplinary
and interinstitutional collaboration.
Confounding the problem, language
Academic Medicine, Vol. 95, No. 1 / January 2020
Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
Perspective
training requires longitudinal efforts
across the full medical education
curriculum and instructors with
specialized skills.10 Prior work has
proposed a collaborative effort and a
multidisciplinary approach to address
linguistic issues, including medical
Spanish education, in health care.11
Relatedly, medical Spanish educational
efforts should be viewed in the context
of the U.S. health system’s commitment
to provide linguistically appropriate
care to all patients. The advancement
of health-related diversity, inclusion,
and equity is a recognized priority area
of U.S. governmental and researchfocused institutions, such as the
National Institutes of Health, the U.S.
Department of Health and Human
Services’ Office of Minority Health,
and the Patient-Centered Outcomes
Research Institute. Federal guidelines
mandate nondiscrimination in health
care based on language12; however, there
are few government-funded programs
that directly promote increasing the
number of bilingual physicians who
can provide language-concordant care.
Similarly, academic institutions—such
as the Association of American
Medical Colleges (AAMC), a national
organization that has standardized the
curriculum development process for
U.S. medical schools—prioritize the
advancement of diversity, inclusion, and
equity in medical education but do not
currently have a standardized curriculum
to address medical language proficiencies
in non-English languages. The AAMC’s
existing curriculum development process
presents an opportunity for medical
Spanish education, which could follow a
similar path to national standardization.
In this context, leaders from the National
Hispanic Health Foundation (NHHF)
and University of Illinois College
of Medicine (UI-COM) convened a
multidisciplinary expert panel called
the Medical Spanish Summit in March
2018 to address the following objectives:
to define national standards for the
teaching and application of medical
Spanish skills in physician–patient
communication, to establish curricular
and competency guidelines for medical
Spanish courses in medical schools,
to propose best practices for medical
Spanish skill assessment and certification,
and to identify next steps needed for
the implementation of the proposed
Academic Medicine, Vol. 95, No. 1 / January 2020
national standards. For the purposes of
the summit, the expert panelists agreed
on a definition of medical Spanish as “the
use of Spanish in the practice of medicine
for communication with patients.” The
panelists defined the scope of the summit
as being to advise on medical Spanish
education for U.S. medical students to
make actionable recommendations,
which could later be adapted and applied
as a model for other health professions,
multiple stages of physician training and
practice, and other languages.
Description of the Summit
The Medical Spanish Summit was
convened in Fort Washington, Maryland.
A national representation of experts who
were identified as key stakeholders in
medical Spanish education and language
concordance were invited to the summit.
Invitations were sent by the summit
directors, leaders from UI-COM (P.O.)
and NHHF (E.R.), to individuals who
had participated in the Debate Forum on
Medical Spanish at Harvard University
in 2017,13 had previously published on
the topic of medical Spanish education,
or had been involved in organizations
engaged in linguistic components of
health services for Latino patients. The
summit directors were attentive to
including representation of experts from
all regions of the United States where
Latino patient nationality and linguistic
variants may influence medical Spanish
needs. Twenty-seven experts attended
the Medical Spanish Summit, and an
additional 8 experts were unable to attend
but participated in post hoc discussions.
Participants included physicians, medical
educators, academic deans, language
researchers, residency leadership,
members of private industry, government
employees, medical interpreters, and
nonprofit organization leadership. A
full list of expert panelists is available
in Supplemental Digital Appendix 1 (at
http://links.lww.com/ACADMED/A724).
Speakers from the expert panel gave
presentations on preidentified topics,
reviewed existing literature, and discussed
current practice pertaining to medical
Spanish education. All attendees were
then divided into breakout working
groups corresponding to 4 components
of medical Spanish standardization:
curriculum and resources, competencies,
provider assessment and certification,
and program evaluation. The summit
directors had previously identified
specific objectives, based on gaps in the
literature pertaining to each component
of medical Spanish standardization,
for each working group to address
(Figure 1). The curriculum and
resources working group was tasked with
determining whether there is a need for
a medical Spanish network and, if so, to
propose a method of implementation,
identifying the recommended resources
for medical Spanish education and
generating a consensus course syllabus
to facilitate curricular implementation.
The competencies working group was
asked to propose a list of target medical
Spanish learner competencies, including
recognition of limitations; to propose
the recommended qualifications for
educators; and to recommend the
prerequisite proficiency level for students
before enrolling in medical Spanish
Figure 1 The 4 components of medical Spanish standardization and the objectives for the
corresponding working group, Medical Spanish Summit, Fort Washington, Maryland, March 2018.
23
Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
Perspective
courses. The provider assessment and
certification working group objectives
were to recommend assessment processes
for medical Spanish learners at course
completion and to determine whether a
certification exam is needed and, if so,
to propose methods of development.
Finally, the program evaluation working
group was asked to identify next steps in
research and for implementation of the
summit recommendations and to identify
potential collaborators and partnerships.
A leader was preidentified for each of
the working groups by the summit
directors and was responsible for directing
the group’s 2-hour discussion and
consolidating their recommendations
pertaining to the proposed objectives.
A final 2-hour plenary session with all
attendees reviewed the key findings and
recommendations of each group and
allowed for additional contributions to
the working group consensus from the
summit participants in other working
groups. Using notes taken during the
event, a draft document was generated
and shared with all attendees and post hoc
participants for their review and feedback.
The recommendations presented in this
Perspective are outcomes on which each
member of the expert panel agreed after
discussion. Areas in which a consensus
could not be reached were determined to
need additional research to evaluate best
practice guidelines.
Final Consensus
Recommendations
The final consensus recommendations
of the Medical Spanish Summit are
summarized in List 1 and discussed in
more detail below.
Consensus recommendation 1: The
panel recommends the creation of a
U.S. Medical Spanish Taskforce to define
educational standards, provide academic
peer review, implement a pilot program,
and create partnerships with national
and international organizations
Medical Spanish educational
development to date has involved the
unintentional duplication of work and a
lack of uniform guidelines for teaching
or assessing medical Spanish skills. In
addition, concerns about unintended
consequences of medical Spanish
programs leading to inappropriate use of
limited Spanish skills in patient care or
24
an inability to recognize self-limitations
in Spanish abilities are valid in the
high-stakes health care environment.14
A Medical Spanish Taskforce should be
created to define and evaluate standards
for the teaching and application of
medical Spanish in physician–patient
communication.
Although the United States is 1 of the top
2 countries in the world in terms of having
the greatest number of Spanish speakers,15
additional research is needed to better
define medical Spanish language usage
in the United States, including linguistic
variations and colloquialisms16,17 as well as
the extent to which health-related language
is understood by Spanish-speaking patients
of varied literacy and socioeconomic
backgrounds. Through the Real Academia
Nacional de Medicina de España and the
Asociación Latinoamericana de Academias
Nacionales de Medicina, the academies
of multiple Spanish-speaking countries
are collaborating in the creation of a free
online medical Spanish resource known as
the Diccionario Panhispánico de Términos
Médicos (DPTM)18 to define and centralize
medical terminology and usage among
patients, communities, and providers in
medical settings. Future medical Spanish
efforts should evaluate the DPTM’s
potential use and applicability in U.S.
medical Spanish educational and patient
care settings, which may differ from the
use and applicability in other countries
with large Spanish-speaking populations.
A Medical Spanish Taskforce could serve to
represent the linguistic repertoires of U.S.
Spanish speakers in the development of
educational resources, such as the DPTM,
to foster interdisciplinary international
collaborations and to critically evaluate
progress.
Consensus recommendation 1 was
drafted by the curriculum and resources
working group and confirmed by
consensus.
Consensus recommendation 2: The panel
recommends integration of medical
Spanish educational initiatives with
government-funded research and training
efforts to advance physician linguistic
diversification and skills building as a
strategy to improve Latino health
It has been established that the lack of
data regarding patient language preference
hinders the health system’s ability to
address resulting health disparities,19
though this has been improved by recent
efforts (e.g., federal mandates for the
collection of race, ethnicity, ancestry,
and language preference—or R/E/A/L
—data).20 However, a persistent lack of
documentation of physician language
proficiency limits the capacity to conduct
patient-centered research of language
concordance.11 Further, most research
and implementation efforts to date have
focused on bridging language barriers
almost exclusively through medical
interpretation, which is necessary but
not superior to high-quality languageconcordant care.21
For example, the national Culturally
and Linguistically Appropriate Services
(CLAS) standards22 do not specifically
List 1
Summary of the Final Consensus Recommendations of the Medical Spanish
Summit, Fort Washington, Maryland, March 2018
The medical Spanish expert panel:
1. Recommends the creation of a U.S. Medical Spanish Taskforce to define educational
standards, provide academic peer review, implement a pilot program, and create
partnerships with national and international organizations.
2. Recommends integration of medical Spanish educational initiatives with government-funded
research and training efforts to advance physician linguistic diversification and skills building
as a strategy to improve Latino health.
3. Provides a consensus list of core medical Spanish learner competencies to standardize
the learning objectives and student performance expectations, targeting learners with
intermediate Spanish proficiency.
4. Provides a consensus core curriculum as a recommended structure for medical Spanish
courses in U.S. medical schools.
5. Recommends assessment of medical Spanish learner skills through standardized patient
encounters that incorporate interactive communication and interpersonal skills and proposes
development of a national certification exam.
6. Recommends development of standardized evaluation and data collection processes for
medical Spanish programs.
Academic Medicine, Vol. 95, No. 1 / January 2020
Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
Perspective
address bilingual provider language
usage, training, or certification
recommendations or requirements and
have historically had low rates of hospital
compliance.23 In the implementation of
the Affordable Care Act, Section 1557,
the Office of Civil Rights (OCR) has
defined the term language assistance as
including not only qualified interpreters
but also qualified bilingual providers.24
This definition implies that those who
are in need of assistance are solely the
non-English-speaking patients and not
the non-Spanish-speaking staff. Further,
the OCR does not clarify how complex
bilingual provider skills ought to be
tested, demonstrated, or verified.
The expert panelists propose using
CLAS as an existing framework when
implementing pilot programs with the
goal of identifying areas that need to
be further defined and updated. The
ultimate objective of standardized
national medical Spanish education is
to increase patient–physician language
concordance to improve access and
quality of care for Spanish-speaking
U.S. patients on a population health
level.25–27 As such, medical education
research on medical Spanish skills
should be linked with long-term
outcomes for both learners and patients.
Relatedly, medical research should
develop strategies to intentionally and
safely include non-English speakers as
research subjects rather than excluding
such populations because of the added
challenges of informed consent.28 Such
complex research requires national
networks, assessment tool testing in an
interinstitutional fashion, and funding
support. Therefore, medical Spanish
educational research should be linked
to and supported by agencies that are
dedicated to improving population health
for vulnerable populations, reducing
health disparities resulting from social
risk factors, and developing long-term
data collection practices.
Consensus recommendation 2 was
developed by the program evaluation
working group and confirmed by
consensus. Figure 2 depicts the potential
roles and partner organizations of a
proposed multidisciplinary collaborative
network for the Medical Spanish Taskforce.
Consensus recommendation 3: The
panel provides a consensus list of core
medical Spanish learner competencies
Academic Medicine, Vol. 95, No. 1 / January 2020
to standardize the learning objectives
and student performance expectations,
targeting learners with intermediate
Spanish proficiency
Medical Spanish courses should be
directed toward students with some prior
Spanish knowledge.5,29 After comparing
multiple existing proficiency assessment
methods, the expert panel consensus
recommends using the validated selfassessment tool of the Interagency
Language Roundtable (ILR)30 modified
scale for physicians31 as part of precourse
evaluations to characterize the starting
proficiency levels of medical Spanish
students and to require a minimum
self-rating of fair as a prerequisite.
The ILR scale has been shown to be
comparable in accuracy to a validated
oral proficiency interview for the lower
and higher ends of the scale, though it is
less accurate in the intermediate range.31
It is important to emphasize that the
recommendation is to use the ILR as a
precourse screening mechanism—not as
a postcourse competency examination
or certification. A rating of fair
approximately corresponds to the low to
mid-intermediate level in the American
Council on the Teaching of Foreign
Languages proficiency guidelines,32 which,
though more comprehensive in evaluating
functional general language proficiency,
are not as rapid for self-assessment and
do not have direct applicability to medical
settings. As opposed to courses that target
more rigorous written and academic
proficiency, in a clinically focused course,
the priority is having the language fluency
and health-relevant cultural knowledge
to enable direct patient–physician verbal
communication. This is an objective
that experts agree can be achieved with
students at varying proficiency levels,
including fair or above, although it may
require personalizing the learner’s study
plan, target areas, and timeline depending
on that individual’s starting proficiency,
strengths, and weaknesses. Within the
acceptable proficiency range, students
who enroll in a medical Spanish course at
a lower proficiency level may be expected
to require additional study to achieve
all competencies than those who start at
higher proficiency, though this has not
been studied.
After a literature review of existing
medical Spanish programs, expert panel
discussion, and application of the AAMC
existing framework for competency
development,33 a consensus emerged on
learner competency recommendations
(Chart 1). Although the focus of
the medical Spanish competencies
is verbal communication, it should
be noted that cultural elements are
incorporated as critical components of
patient–physician communication and
should be included in medical Spanish
courses. Cultural elements should
include culturally acceptable health
beliefs or practices, patient expectations
and comfort regarding provider and
family roles in health care, nonverbal
cues and interpersonal skills that can
affect communication (e.g., politeness
norms), and the recognition of the
heterogeneity of Latino cultural beliefs
among individual patients to avoid
inappropriate stereotyping. Recognition
of the effect of socioeconomic status
and public policy on access to care for
the Latino community should also be
considered as part of the social context of
health addressed during medical Spanish
courses. For example, patient cases used
in medical Spanish courses (e.g., class
presentations, simulated encounters, role
plays) should reflect relevant, realistic
sociocultural context pertaining to the
target community (e.g., issues related
to immigration, deportation, financial
hardship, transportation, fresh food
access) so that learners may recognize
and learn to address the multitude of
challenges to health care access that nonEnglish-speaking patients may encounter
in addition to language discordance.
Moreover, specific training on
working with certified interpreters34,35
should be addressed as a corollary
part of a linguistic curriculum both
within medical Spanish courses and
longitudinally throughout medical
education, with the goal of teaching
medical students to work with, not
as, interpreters. Although competent
use of medical Spanish would obviate
the need for medical interpreting, it is
essential to acknowledge that medical
language competence may be gradually
acquired and may vary from individual
to individual; thus, providers must
be empowered to self-assess their
limitations on an ongoing basis to
ensure patient safety and to learn to
work with professional interpreters
when necessary.
Consensus recommendation 3 was
drafted by the competencies working
group and confirmed by consensus.
25
Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
Perspective
Figure 2 The potential roles and partner organizations of a multidisciplinary collaborative network for the Medical Spanish Taskforce, as proposed
by the Medical Spanish Summit, Fort Washington, Maryland, March 2018. Abbreviations: AAMC indicates Association of American Medical Colleges;
ACGME, Accreditation Council for Graduate Medical Education; ACTFL, American Council on the Teaching of Foreign Languages; ALANAM,
Asociación Latinoamericana de Academias Nacionales de Medicina; CCHI, Certification Commission for Healthcare Interpreters; CDC, Centers for
Disease Control and Prevention; CLAS, Culturally and Linguistically Appropriate Services; COERLL, Center for Open Education Resources and Language
Learning; HHS OMH, U.S. Department of Health and Human Services’ Office of Minority Health; HSI, Hispanic-serving institution; ILR, Interagency
Language Roundtable; JMJF, Josiah Macy Jr. Foundation; LCME, Liaison Committee on Medical Education; MOLA, Medical Organization for Latino
Advancement; NBME, National Board of Medical Examiners; NCIHC, National Council on Interpreting in Health Care; NHHF, National Hispanic Health
Foundation; NHMA, National Hispanic Medical Association; NIH, National Institutes of Health; NIMHD, National Institute of Minority Health and Health
Disparities; NPA, National Partnerships for Action to End Health Disparities; PCORI, Patient-Centered Outcomes Research Institute; RANME, Real
Academia Nacional de Medicina de España; RWJF, Robert Wood Johnson Foundation; USMLE, United States Medical Licensing Examination.
Consensus recommendation 4: The panel
provides a consensus core curriculum
as a recommended structure for medical
Spanish courses in U.S. medical schools
Proposed standard medical Spanish
course curricula should be flexible
26
enough to allow course integration at
different points in the medical student
cycle, depending on the curricular
nuances of individual medical
schools,36 and should be acknowledged
institutionally via course credits for
completion.5 Based on data from
published courses29,37–41 as well as expert
panel discussion, the panel has generated
a consensus curricular structure for
medical Spanish courses, which is
summarized in Table 1.
Academic Medicine, Vol. 95, No. 1 / January 2020
Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
Perspective
Chart 1
Core Competencies and the Corresponding Performance Objectives for Medical Spanish,
as Proposed by the Medical Spanish Summit, Fort Washington, Maryland, March 2018
Core competencies
Corresponding performance objectives
Upon conclusion of the course, the learner should demonstrate:
Upon completion of the course, the learner should be able to perform
the following elements in Spanish, using appropriate register given the
context of the interview (e.g., adult, child, family) and incorporating
patient-centered and culturally responsive language and manner:
A. Obtain an accurate, age-appropriate complete medical history
B. Obtain an accurate, age-appropriate focused medical history
C. Engage and instruct the patient during a complete physical examination
D. Engage and instruct the patient during a focused physical examination
1. Medical Spanish knowledge regarding organ systems and medical
interviewing, including
- Anatomical components and functions from head to toe
- Complete medical interview script
- Complete physical examination instructions
2. Medical Spanish knowledge regarding common disease entities,
including
- Basic illness scripts and symptoms
- Common descriptors of psychological distress and physical
discomfort such as pain, itching, dizziness, etc.
- Comprehension of information provided in Spanish by the patient
- Recognition of cultural nuances/colloquialisms in various Spanishspeaking populations
- Synthesis of information gathered into a working assessment/plan
A. Successfully conduct the medical interview by asking appropriate
questions that demonstrate evaluation of pertinent positives/
negatives that sufficiently address differential diagnostic
considerations for a given chief complaint
B. Explain a diagnosis or differential diagnoses appropriate to the chief
complaint and clinical history
C. Document the visit accurately according to standard documentation
practice (e.g., electronic medical record charting) to demonstrate
comprehension of the patient interview and systems-based practice
3. Patient-centered explanation of medical diagnoses/assessment,
including
- Common medical diagnoses
- Ability to explain medical diagnoses in colloquially understandable
language
- Understand cultural health concepts that may play a role in Spanishspeaking patients’ understanding of diagnoses
A. Orally communicate findings of the medical evaluation to the
patient, adjusted for cultural, emotional, and literacy needs
B. Assess patient comprehension of the information provided and
address gaps in patient’s knowledge
4. Patient-centered explanation of treatment/evaluation plan, including
- Testing (blood, imaging, urine, etc.)
- Medication management/instructions
- Therapeutic interventions and procedural discussions
- Referrals/follow-up care
- Emergency precautions
- Relevant sociocultural context
A. Orally communicate the treatment plan to the patient, adjusted for
cultural, emotional, and literacy needs
B. Explicitly consider patient’s cultural conceptualization of wellness
and illness during the discussion as means of providing culturally
sensitive care to diverse Spanish-speaking populations
C. Explicitly consider patient’s access to care and sociocultural context to
check accessibility and appropriateness of the proposed plan of care
D. Assess patient comprehension of the information provided and
address gaps in patient’s knowledge
5. Determination of self-assessed confidence and limitations, including
- Self-assessment of language skills
- Assessment of patient’s understanding
- Skill in working with an interpreter
- Knowledge of how to access supplemental language services and
resources
A. Recognize and interpret nonverbal communication cues offered by
the patient
B. Demonstrate proper techniques for inquiring about and answering
patient’s questions regarding his/her medical care
C. Demonstrate ability to seek a medical interpreter or languageassistance resources when limitations are reached
D. Demonstrate proper use of an interpreter
The medical Spanish course syllabus
can be organized according to 1 of the
following 3 patterns:
1. An organ system–based syllabus
is recommended for medical
students who have had prior clinical
experiences and already have some
knowledge of interviewing skills. This
method may also be suited to teaching
in conjunction with preclinical
coursework that is organ system
based if the course can correspond
temporally with the material being
Academic Medicine, Vol. 95, No. 1 / January 2020
covered in English. Suggested topics
for lectures include cardiovascular,
endocrine, gastrointestinal,
genitourinary, hematologic/oncologic,
musculoskeletal, neurologic,
otolaryngologic/ophthalmologic,
pediatric, psychiatric, and pulmonary
systems.
2. An interview-based syllabus is
recommended for preclinical
medical students who have little
to no experience with general
medical interviewing skills. This
type of syllabus can be scheduled
to correspond longitudinally with
medical school coursework. Suggested
topics for lectures include chief
complaint/history of present illness,
past medical and surgical histories,
review of systems, family history,
social/sexual histories, psychiatric
history and mental status examination,
physical examination, assessment/
diagnosis, management/treatment
plan, and procedures/consent.
3. A problem-based syllabus is
recommended for courses with an
interdisciplinary audience (i.e., an
27
Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
Perspective
Table 1
Consensus Curricular Structure for Medical Spanish Courses, as Proposed by the
Medical Spanish Summit, Fort Washington, Maryland, March 2018
Curricular component
Recommended structure
Syllabus
Organ system, interview, or problem based (see main text for
recommendations)
80–120 hours for official university credit; distribution of hours/dates
of elective per institutional preference
Credit hours
Placement in curriculum
Per institutional preference
Hour distribution
• Minimum of 25% faculty-supervised hours
• 25%–50% self-study or self-learning modules
• 25% patient interviews (e.g., simulated, role-play, SP, or live
patient interviews)
• Culturally focused activities should be integrated into every
aspect of the course
Prerequisites for students
Self-assessment rating of fair or above on the ILR modified scale for
physicians28
Number of students
Maximum of 20–25 students per faculty per course
Faculty hours
Faculty hours spent teaching a course may vary by institutional
curricular structure and may be divided among 2 or more educators
but are estimated as a total of 5%–10% FTE per course
Learning objectives
Core competencies and corresponding performance objectives as
described in Chart 1
Learner assessment
Interactive patient interview-based assessment (e.g., SP encounter)
that addresses performance objectives as described in Chart 1
Abbreviations: FTE indicates full-time equivalent; ILR, Interagency Language Roundtable; SP, standardized patient.
audience that is not exclusively made
up of medical students) because the
material can be tailored to the medical
content needed for each profession.
Suggested topics for lectures include
introduction to the general medical
setting, pain relief and history of
illness, diet and nutrition, fitness
and physical therapy, breathing
and circulatory issues, emergency
evaluations (e.g., stroke, acute
coronary syndrome, trauma, sepsis),
social and sexual health, mental and
behavioral health, family life and
history, medication management, and
hospital medicine.
Regardless of the syllabus selected,
self-study assignments—such as written
or audio- or video-recorded case
reports, dialogues, patient medication
or discharge instructions, student
assignments on cultural topics, and
simulated encounters—can be tailored
to allow feedback from faculty. Course
time and instructor feedback should
incorporate role-play opportunities;
effective communication skills;
appropriate usage of terminology
that can be understood by patients;
grammar improvements if they affect
communication; culturally appropriate
28
health explanations; and special
attention to challenging but common
circumstances where increased need
for professional interpreting should be
considered, such as procedural consent,
decision-making capacity, and delivering
bad news. The curriculum structure
(e.g., an intensive course, a global health
immersion course, a longitudinal course
spread over multiple months) may
vary by institution. Additional study is
needed to evaluate effectiveness of varied
applications of medical Spanish curricula
in medical schools.
As next steps in facilitating the creation
and sustainability of high-quality
medical Spanish courses, the expert panel
proposes updating existing reviews of
resources for medical Spanish education
to identify recommended print and/or
online educational materials for courses42
as well as to standardize training for
medical Spanish instructors. Providing
a train-the-trainer experience as a
professional development tool could
increase the pool of candidates who are
able to teach medical Spanish courses.
Specific tracks in the train-the-trainer
experience should address areas in which
specific educators would need more
training (e.g., a physician educator may
need to dedicate more time to proficiency
assessment training, whereas an educator
with an interpreter background may need
more training in teaching and medical
components). University language
departments, hospital interpreter services,
or community health worker programs
may represent pools of educators who
can be trained to teach medical Spanish
courses, particularly in partnership with
clinician educators, such as physicians.
Consensus recommendation 4 was
presented by the curriculum and
resources working group and confirmed
by consensus.
Consensus recommendation 5: The panel
recommends assessment of medical
Spanish learner skills through SP
encounters that incorporate interactive
communication and interpersonal skills
and proposes development of a national
certification exam
Provider certification in medical Spanish
is needed to deliver accountability and
quality assurance for physicians wishing
to use bilingual skills in clinical practice.
A prior call to action has urged for the
consideration of an examination similar
to the United States Medical Licensing
Examination Step 2 Clinical Skills exam
that would be given in Spanish for U.S.
physicians who wish to use Spanish skills
in patient care.11
Although some individual schools
include SP examinations in Spanish
as part of medical Spanish courses,
the process for case development and
approval varies by institution and is
often solely determined by the course
instructor. There are also significant
challenges in identifying, recruiting,
and training SPs who are native Spanish
speakers, although opportunities exist
for community partnerships that can
assist medical schools with this. Use
of clinical performance centers and
SPs also carries a cost that needs to be
factored into medical school budgets
but is already routinely included as
part of standard English medical skills
evaluations for medical students. The
medical education literature has long
established the utility of SP examinations
in providing realistic settings in which
to practice high-stakes skills in a safe
environment.43 The expert panelists agree
that while other assessments such as
written, phone, or oral examinations may
Academic Medicine, Vol. 95, No. 1 / January 2020
Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
Perspective
address components of medical Spanish
skills, the type of examination that best
addresses a comprehensive assessment
of the physician’s ability to use medical
Spanish in patient settings, including
the evaluation of interpersonal and
communication skills, would be an SP
examination.
The assessment should be tailored to
address the domains of general oral
Spanish proficiency (e.g., fluency,
pronunciation, grammar), listening
comprehension (e.g., ability to
understand the patient), oral medical
Spanish proficiency (e.g., contentspecific vocabulary, ability to explain
medical concepts in patient-centered
language), and communication and
interpersonal skills (e.g., building
rapport, verbal and nonverbal culturally
appropriate communication skills)
and should be directly linked to the
course’s target core competencies (Chart
1). Further, the medical Spanish cases
used for these examinations should not
simply be translations of existing English
SP cases but rather cases that reflect
the appropriate sociocultural context
of U.S. Spanish-speaking patients and
so reflect the literacy levels, language
use, and cultural norms that these
patients may have. Given the diversity
of nationalities, cultural beliefs, and
social contexts of Latinos, a single case
or encounter is unlikely to appropriately
assess a provider’s competence. A series
of virtual SP encounters or scenarios is
a potential future strategy that would
assess patient–physician communication
skills while reducing barriers, such as
cost or lack of native-speaking SPs,
imposed by in-person clinical skills
testing.
The Medical Spanish Taskforce
should establish a shared repository
of simulation-based cases and
examination strategies and engage with
organizations with prior experience in
testing physician communication skills,
such as the National Board of Medical
Examiners (NBME). Further research and
development are needed for a sustainable,
validated, and reliable standardized
certification process, including
recertification guidelines and continuing
medical education opportunities as well
as incorporation and credentialing for
providers who are currently practicing as
bilingual physicians.
Academic Medicine, Vol. 95, No. 1 / January 2020
A certification process for practicing
medicine in Spanish has the potential
to be perceived as a burden or obstacle
to caring for Spanish-speaking patients.
The certification process should aim
to empower and validate physicians’
bilingual skills and to protect vulnerable
patients from well-meaning physicians
who use limited skills to “get by,” while
avoiding inappropriately overburdening
physicians intending to care for
underserved patients. For this reason,
partnerships between medical institutions
and certification authorities are expected
to play a critical role in increasing
accessibility of medical Spanish
educational and assessment opportunities
for physicians and students. For example,
institutions may choose to cover costs
for students or clinicians who want to
take a medical Spanish course and/or
certification examination.
Consensus recommendation 5 was
proposed by the provider assessment
and certification working group and
confirmed by consensus.
Consensus recommendation 6: The
panel recommends development of
standardized evaluation and data
collection processes for medical Spanish
programs
While some courses are individually
collecting data and show student
satisfaction through comfort and
knowledge self-assessments and
qualitative data,29,37 implementation
of a standardized curriculum should
be coupled with a uniform process of
data collection to evaluate the progress,
impact, and quality improvement of
national course development. Specifically,
pre- and postcourse data should be
collected, including learner proficiency
assessments and evaluation of course
components. Program and learner
evaluations should include questions
about unintended consequences of
second-language acquisition, such as
erroneous usage of language stemming
from insufficient recognition of selflimitations. Standardizing the evaluation
tools used across institutions would
enable the merging of data for multiinstitution analyses and for evaluation
of course effectiveness across diverse
settings.
Available data demonstrate that
multiple elements of medical care
are improved with patient–physician
language concordance.44 It follows that
medical education efforts to improve
physician language skills and achieve
patient–physician language concordance
for Spanish-speaking patients may
improve clinical outcomes and quality
of care. Therefore, a research plan and
data collection process that can evaluate
long-term outcomes of learners and
potentially link these to clinical outcomes
for their Spanish-speaking patients
should be considered. Organizations
that already collect trainee and physician
performance and skill data, such as the
AAMC, NBME, Accreditation Council
for Graduate Medical Education, and
American Medical Association, would
be impactful partners in effectively
collecting physician language data across
institutions.
Consensus recommendation 6 was
developed by the program evaluation
working group and confirmed by
consensus.
Next Steps and Conclusions
The Medical Spanish Summit convened a
group of experts in U.S. medical Spanish
education and created a list of critical
recommendations for future work,
recognizing the emerging field as one
that requires multidisciplinary attention.
The expert panelists will be the initial
invited members of the proposed Medical
Spanish Taskforce and will continue
to apply the working group structure
that was implemented at the summit
(Figure 1). The goals of the working
groups will be to develop and finalize the
educational elements of a standardized
pilot program to be implemented and
evaluated at a nationally representative
sample of U.S. medical schools. Pending
research to be conducted includes a
systematic review of materials available
for medical Spanish education, a survey
on the current status of medical Spanish
courses in U.S. medical schools, and
the development of an assessment
examination that, if validated, can
be used as a certification method for
medical students and providers. We
will seek to develop a consortium that
includes a nationally representative
sample of U.S. medical schools that will
comply with the consensus curricular
guidelines, learner competencies, and
assessment methodology so we can
29
Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
Perspective
compare methods of implementation,
evaluate their effectiveness, and improve
the quality and precision of future
recommendations.
We propose the establishment of
partnerships with key stakeholders from
the government, academic institutions,
business, and the community (Figure 2)
who can help link to existing work,
provide interdisciplinary perspectives
in the working groups, and secure
funding. For example, federal agencies
that establish standards of care with
regard to language assistance22,24 and
medical education organizations
that establish competencies for
undergraduate and graduate medical
education programs have existing
policies pertaining to communication
skills, cultural competence, and health
disparities45,46 that are well aligned
with increasing access to and research
on medical Spanish education and
assessment. Such collaborations can be
the catalyst needed to launch muchneeded medical education research
to establish best practices for medical
Spanish course design and learner
assessment. Future work should include
an additional dimension of patient
outcomes research to evaluate the
connections between medical Spanish
education, patient–physician language
concordance, and clinical outcomes. If
successful, this process could lead to
replication in other health care fields,
including nursing, pharmacy, dentistry,
and physical and occupational therapy
training programs as well as replication
for other languages and cultural groups
with the goal of ensuring quality health
care for all.
Funding/Support: The Medical Spanish Summit
was funded in part by the National Hispanic
Health Foundation, the Josiah Macy Jr.
Foundation, Baylor University, the University
of Illinois Hospital & Health Sciences System,
the Certification Commission for Healthcare
Interpreters, and the Research Institute of United
States Spanish.
Other disclosures: P. Ortega receives author
royalties from Saunders (an imprint of Elsevier)
for a textbook. N. Pérez receives author royalties
from University of Texas Medical Branch.
Ethical approval: Reported as not applicable.
Disclaimer: The contents of this article are
solely the responsibility of the authors and
do not necessarily represent the official views
of the authors’ or expert panelists’ respective
institutions.
30
P. Ortega is clinical assistant professor, Departments
of Emergency Medicine and Medical Education,
University of Illinois College of Medicine, Chicago,
Illinois; ORCID: http://orcid.org/0000-0002-5136-1805.
L. Diamond is assistant attending, Department of
Psychiatry and Behavioral Sciences, Immigrant Health
and Cancer Disparities Service, Hospital Medicine
Service, Memorial Sloan Kettering Cancer Center,
New York, New York.
M.A. Alemán is professor, Department of
Medicine, University of North Carolina School of
Medicine, and director, Comprehensive Advanced
Medical Program of Spanish, Chapel Hill, North
Carolina.
J. Fatás-Cabeza is associate professor, Department
of Spanish and Portuguese, and director,
Undergraduate Translation and Interpretation
Program, University of Arizona, Tucson, Arizona.
D. Magaña is assistant professor, Department of
Literature, Languages and Cultures, University of
California, Merced, Merced, California.
V. Pazo is instructor, Department of Medicine,
Brigham and Women’s Hospital, Harvard Medical
School, and course director, Medical Spanish,
Harvard University, Boston, Massachusetts.
N. Pérez is director, School of Medicine Special
Programs and Hispanic Center of Excellence,
University of Texas Medical Branch, Galveston, Texas.
J.A. Girotti is assistant professor, Department of
Medical Education, and director, Hispanic Center of
Excellence, University of Illinois College of Medicine,
Chicago, Illinois.
E. Ríos is president, National Hispanic Health
Foundation, Washington, DC.
References
1 U.S. Census Bureau. Profile America facts
for features: Hispanic Heritage Month
2016. https://www.census.gov/content/dam/
Census/newsroom/facts-for-features/2016/
cb16-ff16.pdf. Accessed June 11, 2019.
2 Deville C, Hwang WT, Burgos R, Chapman
CH, Both S, Thomas CR Jr. Diversity in
graduate medical education in the United
States by race, ethnicity, and sex, 2012. JAMA
Intern Med. 2015;175:1706–1708.
3 Association of American Medical Colleges.
Table B-4: Total U.S. medical school
graduates by race/ethnicity and sex, 2013–
2014 through 2017–2018. https://www.aamc.
org/download/321536/data/factstableb4.pdf.
Accessed June 11, 2019.
4 Morales R, Rodriguez L, Singh A, et
al. National survey of medical Spanish
curriculum in U.S. medical schools. J Gen
Intern Med. 2015;30:1434–1439.
5 Reuland DS, Frasier PY, Slatt LM, Alemán
MA. A longitudinal medical Spanish program
at one US medical school. J Gen Intern Med.
2008;23:1033–1037.
6 Association of American Medical Colleges.
Curriculum Inventory: Coverage of Medical
Spanish Education Content 2016–2017.
Washington, DC: Association of American
Medical Colleges; 2017.
7 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.
8 Vela MB, Fritz C, Press VG, Girotti J. Medical
students’ experiences and perspectives
on interpreting for LEP patients at two
US medical schools. J Racial Ethn Health
Disparities. 2016;3:245–249.
9 Flores G, Mendoza FS. Dolor aquí? Fiebre?:
A little knowledge requires caution. Arch
Pediatr Adolesc Med. 2002;156:638–640.
10 Ortega L, Iberri-Shea G. Longitudinal
research in second language acquisition:
Recent trends and future directions. Annu
Rev Appl Linguist. 2005;25:26–45.
11 Ortega P. Spanish language concordance in
U.S. medical care: A multifaceted challenge and
call to action. Acad Med. 2018;93:1276–1280.
12 Improving access to services for persons with
limited English proficiency. Executive Order
13166. Fed Regist. 2000;65:50119–50122.
13 Díaz-Rubio E. Suplemento Monográfico,
Actualidad de la Real Academia Nacional
de Medicina de España: Diccionario
Panhispánico de Términos Médicos y Foro
Español Médico en Harvard. Madrid, Spain:
Real Academia Nacional de Medicina; 2017.
14 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.
15 Instituto Cervantes. El español: Una lengua
viva—Informe 2018. https://cvc.cervantes.
es/lengua/espanol_lengua_viva/pdf/espanol_
lengua_viva_2018.pdf. Accessed June 11,
2019.
16 Escobar AM, Potowski K. El Espanol de los
Estados Unidos. Cambridge, UK: Cambridge
University Press; 2015.
17 Ortega P. Spanish and the Medical Interview:
A Textbook for Clinically Relevant Medical
Spanish. 2nd ed. Philadelphia, PA: Saunders;
2015.
18 Diccionario Panhispánico de Términos
Médicos. https://dptm.ranm.es. Accessed
June 11, 2019.
19 Ulmer C, McFadden B, Nerenz DR;
Institute of Medicine Subcommittee on
Standardized Collection of Race/Ethnicity
Data for Healthcare Quality Improvement.
Race, Ethnicity, and Language Data:
Standardization for Health Care Quality
Improvement. Washington, DC: National
Academies Press; 2009.
20 Azar KM, Moreno MR, Wong EC, Shin JJ,
Soto C, Palaniappan LP. Accuracy of data
entry of patient race/ethnicity/ancestry and
preferred spoken language in an ambulatory
care setting. Health Serv Res. 2012;47(1 pt
1):228–240.
21 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.
22 U.S. Department of Health and Human
Services Office of Minority Health.
National Standards for Culturally and
Linguistically Appropriate Services (CLAS)
in Health and Health Care. https://www.
thinkculturalhealth.hhs.gov/assets/pdfs/
EnhancedNationalCLASStandards.pdf.
Accessed June 11, 2019.
23 Diamond LC, Wilson-Stronks A, Jacobs EA.
Do hospitals measure up to the national
culturally and linguistically appropriate
services standards? Med Care. 2010;48:1080–
1087.
Academic Medicine, Vol. 95, No. 1 / January 2020
Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
Perspective
24 Nondiscrimination in health programs
and activities. Final rule. Fed Regist.
2016;81:31376–31473.
25 Jaramillo J, Snyder E, Dunlap JL, Wright
R, Mendoza F, Bruzoni M. The Hispanic
clinic for pediatric surgery: A model to
improve parent-provider communication for
Hispanic pediatric surgery patients. J Pediatr
Surg. 2016;51:670–674.
26 Parker MM, Fernández A, Moffet HH, Grant
RW, Torreblanca A, Karter AJ. 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.
27 Fernández A, Quan J, Moffet H, Parker MM,
Schillinger D, Karter AJ. Adherence to newly
prescribed diabetes medications among
insured Latino and white patients with
diabetes. JAMA Intern Med. 2017;177:371–379.
28 Ortega P. Physicians interrupting
patients [published online ahead of
print July 3, 2019]. J Gen Intern Med.
doi:10.1007/s11606-019-05139-8
29 Ortega P, Park YS, Girotti JA. Evaluation
of a medical Spanish elective for senior
medical students: Improving outcomes
through OSCE assessments. Med Sci Educ.
2017;27:329–337.
30 Interagency Language Roundtable. http://
www.govtilr.org. Accessed June 11, 2019.
31 Diamond L, Chung S, Ferguson W, Gonzalez
J, Jacobs EA, Gany F. Relationship between
self-assessed and tested non-Englishlanguage proficiency among primary care
providers. Med Care. 2014;52:435–438.
32 American Council on the Teaching of
Foreign Languages. ACTFL proficiency
Academic Medicine, Vol. 95, No. 1 / January 2020
guidelines 2012. https://www.actfl.
org/sites/default/files/pdfs/public/
ACTFLProficiencyGuidelines2012_FINAL.
pdf. Accessed June 11, 2019.
33 Englander R, Cameron T, Ballard AJ, Dodge J,
Bull J, Aschenbrener CA. Toward a common
taxonomy of competency domains for the
health professions and competencies for
physicians. Acad Med. 2013;88:1088–1094.
34 Certification Commission for Healthcare
Interpreters. http://www.cchicertification.org.
Accessed June 11, 2019.
35 The National Board of Certification
for Medical Interpreters. http://www.
certifiedmedicalinterpreters.org. Accessed
June 11, 2019.
36 Ortega P, Pérez N, Robles B, Turmelle Y,
Acosta D. Strategies for teaching linguistic
preparedness for physicians: Medical
Spanish and global linguistic competence in
undergraduate medical education. Health
Equity. 2019;3:312–318.
37 Pérez NA. Student acceptance of clinical
conversational Spanish in medical
curriculum. Cogent Med. 2018;5:1475691.
38 Cesari WA, Brescia WF, Harricharan Singh
K, et al. Medical Spanish. MedEdPORTAL.
https://www.mededportal.org/
publication/9171. Published May 8, 2012.
Accessed June 11, 2019.
39 Rampal A, Wang C, Kalisvaart J. Pediatric
medical Spanish vignettes. MedEdPORTAL.
https://www.mededportal.org/
publication/5110. Published July 29, 2009.
Accessed June 11, 2019.
40 Dawson AL, Patti B. Spanish Acquisition
Begets Enhanced Service (S.A.B.E.S.): A
beginning-level medical Spanish curriculum.
MedEdPORTAL. https://www.mededportal.
org/publication/9057. Published December 7,
2011. Accessed June 11, 2019.
41 O’Rourke K, Gruener G, Quinones D, Stratta
E, Howell J. Spanish bilingual medical
student certification. MedEdPORTAL.
https://www.mededportal.org/
publication/9400. Published April 24, 2013.
Accessed June 11, 2019.
42 Hardin K. Targeting oral and cultural
proficiency for medical personnel: An
examination of current medical Spanish
textbooks. Hispania. 2012;95:698–713.
43 Chalabian J, Dunnington G. Standardized
patients: A new method to assess the clinical
skills of physicians. Best Pract Benchmarking
Healthc. 1997;2:174–177.
44 Diamond L, Izquierdo K, Canfield D,
Matsoukas K, Gany F. A systematic review of
the impact of patient-physician non-English
languag e concordance on quality of care and
outcomes. J Gen Intern Med. 2019;34:1591–
1606.
45 Accreditation Council for Graduate
Medical Education. ACGME common
program requirements (residency). https://
www.acgme.org/Portals/0/PFAssets/
ProgramRequirements/CPRResidency2019.
pdf. Revised June 10, 2018. Accessed July 4,
2019.
46 Liaison Committee on Medical Education.
Functions and structure of a medical
school: Standards for accreditation of
medical education programs leading to
the MD degree. Effective academic year
2019–20. http://lcme.org/publications.
Published March 2018. Accessed June 11,
2019.
31
Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.