Historical view of medical Spanish instruction in a medical school at the US–Mexico border region
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* Jorge Cervantes
* Mark L Francis
* Kirsten F Nigro
* Lucía Sánchez-Llorente
* Gilberto Garcia
* Daniel Rios
* Arely Munoz
* Jose Manuel Delarosa

## Abstract

With a growing speaking Spanish population in the USA, it is necessary to help meet their healthcare needs. The Paul L. Foster School of Medicine is located in El Paso at the US–Mexico border. The medical Spanish curriculum is required for all medical students and begins on their first day of medical school, with conversational Spanish and medical Spanish through the preclerkship years. One of the key elements to the success of this course is the use of instructors with expertise in language instruction with an emphasis on task-based instruction. In addition to language instruction, this course also emphasizes instruction and experience in the culture of the US–Mexico border region. While taught medical Spanish, students are also prompted to understand when their skills are not adequate for the situation, in which case they need to enlist a skilled translator. Students report that, on a daily basis, they productively use what they learned in this preclerkship curriculum.

*   Education, Medical
*   Language

## Need for Spanish language skills

Spanish is the most common non-English language spoken in the USA.1 The USA also has the second largest population of Spanish speakers in the world after Mexico.2 Native Spanish speakers experience barriers to healthcare and are known to be medically underserved.3 Clinical outcomes and patient satisfaction are better when physicians and patients speak the same language.4–10 The US Latino population is projected to double over the next 50 years,11 while the proportion of Latino physicians is expected to decrease over the same interval,12 with the need exceeding their supply. Medical schools, thus, face the challenge of training physicians who can provide care for predominately or solely Spanish-speaking patients. The need for Spanish competency extends beyond Latino physicians. In California, most current physicians who provide same language care for Spanish-speaking patients are non-native Spanish speakers.13 While there is an obvious need in the Southwest, the need for Spanish-speaking physicians is present throughout the country.1

By 2005, less than half of medical schools were providing any instruction on medical Spanish.14 A survey published last year showed that among medical schools participating in the survey, 78% offered medical Spanish.15 Most of these medical schools provide medical Spanish instruction as an elective, with just a third providing course credit.15 Only a few provide extensive early instruction on not only medical Spanish but also on cultural issues through elective programs.16 17 Furthermore, most of these programs use clinical faculty as Spanish educators.15

## Forging a medical Spanish program

Necessity was the prime impetus to develop an aggressive Spanish language curriculum at the Paul L. Foster School of Medicine (PLFSOM) since the school is located in El Paso, Texas, where approximately 70% of the residents speak Spanish.18 Before the inaugural class matriculated in 2009, it served as a regional campus for Texas Tech University Health Sciences Center in Lubbock and served as a training site for third and fourth year medical students. These students were offered a Spanish elective before coming to the El Paso campus.

In reviewing this experience, the Founding Dean, Dr Jose Manuel Delarosa, and his team concluded that this level of preparation was not sufficient. During their clerkship rotations, student efficiency was hampered by their need to find and often wait for translation support. On ward rounds with patients who did not speak English, for instance, non-Spanish speaking students were inherently disadvantaged and prone to experience a constricted understanding of how these conversations affected patient–provider relationships and clinical decisions. This seemed to be the case even if students were provided a synopsis, particularly for those on the team not specifically assigned to the patient being interviewed.

Making Spanish-speaking ability a prerequisite for admission to our medical school was rejected as a solution, as it could potentially be considered discriminatory and would critically limit the application pool. Alternatively, the leadership team decided to begin Spanish instruction for all students during their first and second year. In addition to providing language skills, another goal was to train students in cultural issues that are highly prevalent in a medical center located on the border with another country.

One of the first decisions for the Spanish curriculum was to use instructors with expertise in language teaching. Prior to the inaugural class, third year medical students who came to us from the Lubbock campus received instruction from bilingual members of the College of Health Sciences and then by teachers from the Department of Languages and Linguistics at the University of Texas at El Paso. To enhance teaching competency, we required instructors to have a master’s degree in Spanish or linguistics and a minimum of 5 years of teaching Spanish or linguistics or a PhD in Spanish or linguistics. Currently, almost all instructors are native Spanish speakers with long-standing ties to the US–Mexico border in El Paso.

## Program immersed into clinical skills at the US border

Prior to starting their scientific principles of medicine course, medical students take a placement test. They then begin a 3-week course of language foundations and conversational Spanish instruction, along with activities (such as visits to local restaurant, markets, and museum) that aim to integrate the students into our community. The primary goal is conversational Spanish, and the prime mode of instruction is classroom conversation.

After this 3 week course, medical Spanish instruction is delivered weekly in parallel with the medical skills course, with required attendance. Through this integration with the school’s clinical presentation-based preclerkship curriculum, medical skills and medical Spanish reinforce each other. For example, when students are learning history and physical exam skills in conjunction with patients presenting with chest pain, they will also learn how to approach a Spanish-speaking patient with the same clinical problem. Thus, for many students, doing these activities in Spanish will enhance their long-term knowledge of the medical skills in both English and Spanish. Instructions use task-based instruction, an approach that considers language to be an activity: language is doing something, for some reason and in a particular context, to achieve an outcome. The medical Spanish course is not simply a language course; it is as much a course about cultural and socioeconomic issues along the US–Mexico border. It emphasizes real-life situations that students must actively negotiate, as opposed to exercise-based instruction in which drills and learned patterns make students a passive rather than active learner.

## Improving language skills with caution

Our students express high satisfaction with the Spanish curriculum, reporting that they have not only enhanced their Spanish skills but also can now ask basic medical information in Spanish. Regardless of Spanish-speaking proficiency, students felt that their use of Spanish enhanced their rapport with their Spanish-speaking patients. Through student self-assessment, most novice students rise to the ability to converse well enough to obtain basic medical information, and the advanced students who uniformly have this level of ability are able to enhance this skill.

Patients with limited English may be at risk for medical errors and worse health outcomes.19 While it is desirable for physicians to speak the language of the patient, physicians need to be alert to situations in which their Spanish-speaking skills are not adequate, as it could lead to a detrimental outcome.20 21 Thus, at all levels, students are taught to recognize when their proficiency level constitutes a limitation to patient care and, thus, to seek professional interpretation. While the largely Spanish-speaking clinical staff has always been helpful, the pragmatic need to serve as interpreters may place an informal or ‘hidden’ burden on nurses, medical assistants, and others with distinctly different primary functions in the hospital and clinics. Thus, reducing this burden from other healthcare providers could potentially improve patient outcomes. For medical Spanish education to improve patient outcomes, it should be linked to improvement in language concordance with Spanish-speaking patients and should include safety measures to prevent inadvertent communication errors.22

## Model to share

The PLFSOM undertook a novel approach to teach Spanish as a curricular requirement during the preclerkship years and judges its curriculum as a success. Our impetus to do so was driven by the practical need of our sizeable Spanish-only speaking population that we serve. Thus, our experience should be readily transferable to medical schools that serve a population in which there are a large percentage of patients that speak more than one language. A required Spanish program, however, could easily be considered in all medical schools to give students the ability and flexibility to work with the sizeable and growing Spanish-speaking population in the USA. In this case, schools will need to weigh the local needs of their students as well as the expense and logistics of providing such a program with the long-term benefit they will provide their students and their eventual patients. It is also possible that some of our methods could be used to enhance an elective foreign language curriculum in a medical school.

One of our current challenges is to determine whether we can extend our curriculum into their clerkship years to enhance the ability of our students to communicate effectively with their Spanish-speaking patients. We are currently putting our efforts on designing objective assessment of the effectiveness of our curriculum and the proficiency of our students.

We hope that other medical schools will find our experience valuable and will share their own experiences so that future directions on the evolution of the medical Spanish curriculum across medical schools could be discussed and enhanced.

## Ethics statements

### Patient consent for publication

Not applicable.

### Ethics approval

Not applicable.

## Acknowledgments

The authors wish to thank the many instructors and administrators involved with the Spanish Curriculum.

## Footnotes

*   Contributors JC, MLF, KFN, LS-L, GG, DR, AM, and JMD contributed to the conception of the work, drafting of the article and its intellectual content; and approved the final version of the manuscript.

*   Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

*   Competing interests None declared.

*   Provenance and peer review Commissioned; externally peer reviewed.

## References

1.  Annual estimates of the residential population by sex, age, race, and Hispanic origin for the United States and states, 2000
    
    

2.  Thompson S. Has the second-largest population of Spanish Speakers—How to Equip your brand to serve them. Forbes, 2021.
    
    

3.  Gene Hallford H, Coffman MA, Obregon-Tito AJ, et al. Access barriers to genetic services for Spanish-speaking families in states with rapidly growing migrant populations. J Genet Couns 2020;29:365–80.[doi:10.1002/jgc4.1195](http://dx.doi.org/10.1002/jgc4.1195)pmid:http://www.ncbi.nlm.nih.gov/pubmed/31828856
    
    [PubMed](/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fjim%2Fearly%2F2022%2F09%2F05%2Fjim-2022-002519.atom) 

4.  Fernandez A, Schillinger D, Warton EM, et al. Language barriers, physician-patient language concordance, and glycemic control among insured Latinos with diabetes: the diabetes study of northern California (distance). J Gen Intern Med 2011;26:170–6.[doi:10.1007/s11606-010-1507-6](http://dx.doi.org/10.1007/s11606-010-1507-6)pmid:http://www.ncbi.nlm.nih.gov/pubmed/20878497
    
    [CrossRef](/lookup/external-ref?access_num=10.1007/s11606-010-1507-6&link_type=DOI) 
    
    [PubMed](/lookup/external-ref?access_num=20878497&link_type=MED&atom=%2Fjim%2Fearly%2F2022%2F09%2F05%2Fjim-2022-002519.atom) 

5.  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 2:324–30.[doi:10.1007/s11606-007-0340-z](http://dx.doi.org/10.1007/s11606-007-0340-z)pmid:http://www.ncbi.nlm.nih.gov/pubmed/17957419
    
    [PubMed](/lookup/external-ref?access_num=17957419&link_type=MED&atom=%2Fjim%2Fearly%2F2022%2F09%2F05%2Fjim-2022-002519.atom) 

6.  González HM, Vega WA, Tarraf W. Health care quality perceptions among foreign-born Latinos and the importance of speaking the same language. J Am Board Fam Med 2010;23:745–52.[doi:10.3122/jabfm.2010.06.090264](http://dx.doi.org/10.3122/jabfm.2010.06.090264)pmid:http://www.ncbi.nlm.nih.gov/pubmed/21057070
    
    [Abstract/FREE Full Text](/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NToiamFiZnAiO3M6NToicmVzaWQiO3M6ODoiMjMvNi83NDUiO3M6NDoiYXRvbSI7czo0MjoiL2ppbS9lYXJseS8yMDIyLzA5LzA1L2ppbS0yMDIyLTAwMjUxOS5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

7.  Wilson E, Chen AHM, Grumbach K, et al. Effects of limited English proficiency and physician language on health care comprehension. J Gen Intern Med 2005;20:800–6.[doi:10.1111/j.1525-1497.2005.0174.x](http://dx.doi.org/10.1111/j.1525-1497.2005.0174.x)pmid:http://www.ncbi.nlm.nih.gov/pubmed/16117746
    
    [CrossRef](/lookup/external-ref?access_num=10.1111/j.1525-1497.2005.0174.x&link_type=DOI) 
    
    [PubMed](/lookup/external-ref?access_num=16117746&link_type=MED&atom=%2Fjim%2Fearly%2F2022%2F09%2F05%2Fjim-2022-002519.atom) 
    
    [Web of Science](/lookup/external-ref?access_num=000231596400002&link_type=ISI) 

8.  Gany F, Leng J, Shapiro E, et al. Patient satisfaction with different interpreting methods: a randomized controlled trial. J Gen Intern Med 2007;22 Suppl 2:312–8.[doi:10.1007/s11606-007-0360-8](http://dx.doi.org/10.1007/s11606-007-0360-8)pmid:http://www.ncbi.nlm.nih.gov/pubmed/17957417
    
    [PubMed](/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fjim%2Fearly%2F2022%2F09%2F05%2Fjim-2022-002519.atom) 

9.  Cheng EM, Chen A, Cunningham W. Primary language and receipt of recommended health care among Hispanics in the United States. J Gen Intern Med 2007;22 Suppl 2:283–8.[doi:10.1007/s11606-007-0346-6](http://dx.doi.org/10.1007/s11606-007-0346-6)pmid:http://www.ncbi.nlm.nih.gov/pubmed/17957412
    
    [PubMed](/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fjim%2Fearly%2F2022%2F09%2F05%2Fjim-2022-002519.atom) 

10. Diamond LC, Reuland DS. Describing physician language fluency: deconstructing medical Spanish. JAMA 2009;301:426–8.[doi:10.1001/jama.2009.6](http://dx.doi.org/10.1001/jama.2009.6)pmid:http://www.ncbi.nlm.nih.gov/pubmed/19176445
    
    [CrossRef](/lookup/external-ref?access_num=10.1001/jama.2009.6&link_type=DOI) 
    
    [PubMed](/lookup/external-ref?access_num=19176445&link_type=MED&atom=%2Fjim%2Fearly%2F2022%2F09%2F05%2Fjim-2022-002519.atom) 
    
    [Web of Science](/lookup/external-ref?access_num=000262777200023&link_type=ISI) 

11. Sadanand A, Ryan MH, Cohen S, et al. Development of a medical Spanish curriculum for fourth-year medical students. PRiMER 2018;2:17.[doi:10.22454/PRiMER.2018.738688](http://dx.doi.org/10.22454/PRiMER.2018.738688)pmid:http://www.ncbi.nlm.nih.gov/pubmed/32818189
    
    [PubMed](/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fjim%2Fearly%2F2022%2F09%2F05%2Fjim-2022-002519.atom) 

12. Sánchez G, Nevarez T, Schink W, et al. Latino physicians in the United States, 1980-2010: a thirty-year overview from the Censuses. Acad Med 2015;90:906–12.[doi:10.1097/ACM.0000000000000619](http://dx.doi.org/10.1097/ACM.0000000000000619)pmid:http://www.ncbi.nlm.nih.gov/pubmed/25629948
    
    [CrossRef](/lookup/external-ref?access_num=10.1097/ACM.0000000000000619&link_type=DOI) 
    
    [PubMed](/lookup/external-ref?access_num=25629948&link_type=MED&atom=%2Fjim%2Fearly%2F2022%2F09%2F05%2Fjim-2022-002519.atom) 

13. Yoon J, Grumbach K, Bindman AB. Access to Spanish-speaking physicians in California: supply, insurance, or both. J Am Board Fam Pract 2004;17:165–72.[doi:10.3122/jabfm.17.3.165](http://dx.doi.org/10.3122/jabfm.17.3.165)pmid:http://www.ncbi.nlm.nih.gov/pubmed/15226280
    
    [Abstract/FREE Full Text](/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NToiamFiZnAiO3M6NToicmVzaWQiO3M6ODoiMTcvMy8xNjUiO3M6NDoiYXRvbSI7czo0MjoiL2ppbS9lYXJseS8yMDIyLzA5LzA1L2ppbS0yMDIyLTAwMjUxOS5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

14. Maben K, Dobbie A. Current practices in medical Spanish teaching in US medical schools. Fam Med 2005;37:613–4.pmid:http://www.ncbi.nlm.nih.gov/pubmed/16193412
    
    [PubMed](/lookup/external-ref?access_num=16193412&link_type=MED&atom=%2Fjim%2Fearly%2F2022%2F09%2F05%2Fjim-2022-002519.atom) 

15. Ortega P, Francone NO, Santos MP, et al. Medical Spanish in US medical schools: a national survey to examine existing programs. J Gen Intern Med 2021;36:2724–30.[doi:10.1007/s11606-021-06735-3](http://dx.doi.org/10.1007/s11606-021-06735-3)pmid:http://www.ncbi.nlm.nih.gov/pubmed/33782890
    
    [PubMed](/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fjim%2Fearly%2F2022%2F09%2F05%2Fjim-2022-002519.atom) 

16. Manetta A, Stephens F, Rea J, et al. Addressing health care needs of the Latino community: one medical school's approach. Acad Med 2007;82:1145–51.[doi:10.1097/ACM.0b013e318159cccf](http://dx.doi.org/10.1097/ACM.0b013e318159cccf)pmid:http://www.ncbi.nlm.nih.gov/pubmed/18046116
    
    [CrossRef](/lookup/external-ref?access_num=10.1097/ACM.0b013e318159cccf&link_type=DOI) 
    
    [PubMed](/lookup/external-ref?access_num=18046116&link_type=MED&atom=%2Fjim%2Fearly%2F2022%2F09%2F05%2Fjim-2022-002519.atom) 
    
    [Web of Science](/lookup/external-ref?access_num=000251383700005&link_type=ISI) 

17. Nora LM, Daugherty SR, Mattis-Peterson A, et al. Improving cross-cultural skills of medical students through medical school-community partnerships. West J Med 1994;161:144–7.pmid:http://www.ncbi.nlm.nih.gov/pubmed/7941532
    
    [PubMed](/lookup/external-ref?access_num=7941532&link_type=MED&atom=%2Fjim%2Fearly%2F2022%2F09%2F05%2Fjim-2022-002519.atom) 
    
    [Web of Science](/lookup/external-ref?access_num=A1994PC71000003&link_type=ISI) 

18. Akhtar A. El Paso, where a gunman reportedly worried about a 'Hispanic invasion of Texas' shot up a Walmart, is one of the country’s largest Latino cities. Business Insider, 2019.
    
    

19. Tseng CW, Schriger D, Usatine R, et al. The need for Spanish-language training at UCLA. Acad Med 1998;73:222–3.[doi:10.1097/00001888-199803000-00004](http://dx.doi.org/10.1097/00001888-199803000-00004)pmid:http://www.ncbi.nlm.nih.gov/pubmed/9526443
    
    [PubMed](/lookup/external-ref?access_num=9526442&link_type=MED&atom=%2Fjim%2Fearly%2F2022%2F09%2F05%2Fjim-2022-002519.atom) 

20. Diamond LC, Schenker Y, Curry L, et al. Getting by: underuse of interpreters by resident physicians. J Gen Intern Med 2009;24:256–62.[doi:10.1007/s11606-008-0875-7](http://dx.doi.org/10.1007/s11606-008-0875-7)pmid:http://www.ncbi.nlm.nih.gov/pubmed/19089503
    
    [CrossRef](/lookup/external-ref?access_num=10.1007/s11606-008-0875-7&link_type=DOI) 
    
    [PubMed](/lookup/external-ref?access_num=19089503&link_type=MED&atom=%2Fjim%2Fearly%2F2022%2F09%2F05%2Fjim-2022-002519.atom) 
    
    [Web of Science](/lookup/external-ref?access_num=000262651100017&link_type=ISI) 

21. Prince D, Nelson M. Teaching Spanish to emergency medicine residents. Acad Emerg Med 1995;2:32–6.[doi:10.1111/j.1553-2712.1995.tb03076.x](http://dx.doi.org/10.1111/j.1553-2712.1995.tb03076.x)pmid:http://www.ncbi.nlm.nih.gov/pubmed/7606608
    
    [CrossRef](/lookup/external-ref?access_num=10.1111/j.1553-2712.1995.tb03076.x&link_type=DOI) 
    
    [PubMed](/lookup/external-ref?access_num=7606608&link_type=MED&atom=%2Fjim%2Fearly%2F2022%2F09%2F05%2Fjim-2022-002519.atom) 
    
    [Web of Science](/lookup/external-ref?access_num=A1995RA29600008&link_type=ISI) 

22. Ortega P, Pérez N, Robles B, et al. Teaching medical Spanish to improve population health: evidence for incorporating language education and assessment in U.S. medical schools. Health Equity 2019;3:557–66.[doi:10.1089/heq.2019.0028](http://dx.doi.org/10.1089/heq.2019.0028)pmid:http://www.ncbi.nlm.nih.gov/pubmed/31701080
    
    [PubMed](/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fjim%2Fearly%2F2022%2F09%2F05%2Fjim-2022-002519.atom)