Enhancing Clinical Spanish Proficiency through Standardized Patient Interactions: A Case Study of Medical Students' Performance

doi:10.21203/rs.3.rs-4156037/v1

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Enhancing Clinical Spanish Proficiency through Standardized Patient Interactions: A Case Study of Medical Students' Performance

https://doi.org/10.21203/rs.3.rs-4156037/v1

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Background

With the anticipated growth of the Hispanic population in the United States to 30% by 2050, there is an urgent demand for Spanish-speaking healthcare professionals. The California University of Science and Medicine School of Medicine has addressed this need by introducing a medical Spanish curriculum that includes Spanish-speaking Standardized Patients. This innovative educational approach is designed to improve students' communication skills and enhance their ability to take medical histories, preparing them for effective clinical interactions as evaluated through the Objective Structured Clinical Examination.

Methods

This study assesses the impact of the medical Spanish curriculum, with a focus on the role of Standardized Patients in role-playing scenarios that simulate real clinical experiences. A regression analysis was conducted to examine the relationship between students’ attendance in medical Spanish classes and their performance in the Objective Structured Clinical Examination, highlighting the value of experiential learning in developing clinical skills.

Results

The findings indicate a significant positive relationship between consistent participation in medical Spanish courses, which feature Standardized Patient interactions, and higher scores in the Objective Structured Clinical Examination. This relationship emphasizes the importance of regular engagement in these interactive educational settings to improve clinical assessment capabilities.

Conclusions

The inclusion of Standardized Patients in the medical Spanish curriculum plays a critical role in enhancing students’ clinical performance, validating the importance of experiential learning in medical education. This approach confirms the effectiveness of practical, interaction-based language instruction in producing competent, culturally adept healthcare providers ready to serve an increasingly diverse patient demographic.

Medical Spanish

Clinical skills

Clinical Spanish

Standardized patients

Due to recent advancements in healthcare, there is an increasing emphasis on educating students and trainees to embrace a more patient-centered approach (1). Patient-centered care emphasizes the need for healthcare organizations and professionals to actively understand patients' priorities, which can differ across various regions. With the Hispanic population in the United States projected to reach 30% by 2050, there is a corresponding growth in demand for Medical Spanish education among medical students to address the shortage of skilled Spanish-speaking healthcare professionals (2). Consequently, medical schools are urged to integrate compulsory Medical Spanish courses that not only enhance students' confidence in using the language but also significantly improve their linguistic competencies (3).

Medical Spanish courses aim to improve language concordance and enable learners to recognize their limitations in the target language (4). These programs frequently involve the utilization of Spanish-speaking Standardized Patients (SPs) to evaluate communication skills in Spanish, providing a controlled environment for students to practice and refine their abilities in real-world patient scenarios (5). The engagement with Spanish-speaking SPs aims to improve communication between physicians and the growing Spanish-speaking demographic, thus addressing the critical need for enhanced language proficiency in healthcare (3).

There is evidence on the significant role of SPs in enhancing students' competencies in medical history-taking, with a notable improvement in their ability to accurately collect medical histories. This enhancement is evident not only in educational contexts but also in its practical application within real-world clinical settings (6). Indeed, integrating SPs into assessment methods has been shown to improve students' proficiency in taking medical histories in practice, surpassing the outcomes achieved through exclusive reliance on virtual patient simulation programs.

In response to the medical requirements of the Hispanic community in the Inland Empire region, the California University of Science and Medicine School of Medicine (CUSM-SOM) has initiated a focused initiative to enrich its medical Spanish curriculum, known as the Vida program (7). Vida incorporates large group lessons, hands-on experiences with proficient SPs, collaborative small group sessions, and comprehensive post-course assessments. Students engage in 18 months of on-site instruction, which is scheduled to become a mandatory component of the MD curriculum starting the 2024–2025 academic year.

The Vida curriculum has been evaluated using the Kirkpatrick Model (8), and the results were promising across all three levels of assessment. Student experience was positive, with feedback indicating that the curriculum aligned well with their expectations and educational needs. The knowledge component, assessed through Objective Structured Clinical Examination (OSCE), revealed that students attained a robust proficiency in medical Spanish, effectively applying their linguistic skills in simulated clinical scenarios. Behaviorally, the program’s impact was evident in the students' ability to integrate their Spanish communication skills into clinical practice, demonstrating enhanced competencies in interacting with Spanish-speaking patients (7).

Furthermore, Vida is strategically formulated to involve Spanish-speaking SPs with a specific emphasis on enhancing students' proficiency in oral communication in Spanish. The consciously trained Spanish-speaking SPs participate in role-playing scenarios that mirror actual patient cases, thereby positively impacting students' communication abilities. Additionally, the Vida curriculum incorporates diverse interventions dedicated to fostering cultural sensitivity and addressing implicit biases. These interventions encompass extensive training sessions focused on cultural competence, the cultivation of awareness regarding biases, and the provision of effective cross-cultural communication techniques (3). Notably, the curriculum emphasizes the utilization of gender-affirming language, which is reinforced through SP practice. These measures are intricately designed to augment students' capacity to navigate varied patient populations and promote equitable healthcare outcomes.

When engaging in medical scenario rehearsals with SPs, medical students express reduced anxiety and discomfort, which allows them to experience an enhanced sense of preparedness for skill execution in live patient settings. This heightened readiness contributes to improved performance in clinical tests (9) and a decreased likelihood of errors during patient interactions (10). Additionally, medical students highlight the alleviation of distress associated with the performance of intimate examination skills when utilizing SPs, and, therefore, they perform better in clinical examinations (11).

During each session of the medical Spanish curriculum, the instructor systematically introduced grammar and vocabulary directly tied to the patient scenarios previously explored in the Clinical Skills courses at CUSM-SOM. This approach ensured a comprehensive integration of language with clinical context and emphasized relevant cultural nuances. Interactive role-playing exercises with trained SPs followed, designed to replicate the actual patient cases accurately. The SP scripts, crafted by the course director and aligned with educational objectives, were then taught to the SPs by the SP Educator, ensuring accuracy and consistency in the simulated clinical encounters. Three SP script samples are included in Additional file 1.

Every student enrolled in the Vida curriculum was required to complete the post-course assessments, including the medical Spanish OSCE. This OSCE was designed to assess the integration of Spanish language skills in clinical interactions, mirroring the structure of the Clinical Skills courses at CUSM-SOM (12), and involved trained SPs. The assessment featured three stations: neurological examination, comprehensive history-taking, and diabetes counseling. The neurological examination was selected for its demand for diverse Spanish language structures applicable to various physical examinations, necessitating the use of formal commands and enabling students to communicate effectively in Spanish during procedural tasks. The history-taking station aimed to evaluate students’ proficiency in conducting thorough patient exams, with an emphasis on respectful, sensitive, and inclusive Spanish communication. The diabetes counseling station was included due to the high prevalence and impact of diabetes among Hispanic populations in the United States, highlighting the need for culturally competent communication in managing this condition (7).

In addition to fulfilling the post-course OSCE assessments, students in the Vida curriculum were required to participate in weekly medical Spanish small group sessions. While attendance at large group sessions was not mandatory, it was highly recommended to enrich the learning experience. These large group sessions typically comprised a lecture presentation followed by interactive practice with SPs (7). Consequently, the level of engagement with SPs varied among students, with some attending several of these sessions to practice their skills, while others participated less frequently. The value of working with SPs is highlighted by the fact that it allows students to apply clinical medicine principles in a safe, controlled environment, without risking the health or welfare of real patients. This method extends learning beyond textbook knowledge, offering students hands-on experience with responsive human beings, thus moving away from the traditional reliance on paper and pencil tests (12).

Over 18 months, the Vida course aimed to enhance students' communication skills with Spanish-speaking patients, thereby strengthening their residency applications and preparing them for their roles as future medical providers (3). In the class of 2026, out of 112 students, 56 completed the post-course assessments for medical Spanish in November 2023.

The medical Spanish OSCE evaluation employed a two-level approach. Initially, graders used standardized checklists derived from Bates’ Guide to Physical Examination and History-Taking (13), with the specifics provided in Additional file 2. The checklist's scoring system awarded 0 points for actions not performed, 1 point for actions executed with errors, and 2 points for actions completed with minimal errors (7). To ensure consistency in grading, an interrater reliability assessment was carried out. The medical Spanish program's course director reviewed each encounter. Specifically for the neurological encounter, students could refer to the grading checklist without penalty, a flexibility not extended to other encounters.

The analysis focused on evaluating the impact that attending medical Spanish lessons with SPs has on medical Spanish OSCE scores. This evaluation aimed to uncover the significance of these educational methods and their potential to revolutionize medical Spanish education by enhancing linguistic skills in clinical environments

Table 1

Regression Statistics Summary
Regression Statistics
Multiple R	0.74011921
R Square	0.54777645
Adjusted R Square	0.53940194
Standard Error	6.36087549
Observations	56

The regression analysis, as presented in Table 1, revealed that the coefficient of determination (R²) was 0.5478. This indicates that approximately 54.78% of the variation in OSCE grades can be attributed to participation in the Spanish medical courses. This substantial percentage underscores the strong association between course attendance and OSCE performance among medical students. The R² value quantifies the extent to which changes in medical Spanish OSCE scores are due to class attendance, offering insights into the predictive effectiveness of attendance on practical clinical evaluation outcomes. While causation cannot be inferred from correlation alone, the notable size and significance of the correlation coefficient suggest that attendance in Spanish medical classes plays a crucial role in enhancing students’ clinical assessment capabilities, highlighting the importance of active participation in these courses for improving clinical skills proficiency.

Table 2

ANOVA Table for Regression Analysis
ANOVA
	df	SS	MS	F	Significance F
Regression	1	2646.53553	2646.53553	65.4099683	7.124863870817E-11
Residual	54	2184.8798	40.460737
Total	55	4831.41532

The regression analysis shown in Table 2 indicates that attendance is a significant predictor of OSCE grades for medical students, with a notable Fisher's F-statistic of 65.41 and a p-value of less than 0.001. These results confirm that the model accounts for a considerable portion of the variability in medical Spanish OSCE scores, emphasizing the crucial role of class participation in students' academic success. The significant explanatory power of the model, with attendance as a key predictor, is further highlighted by the exceptionally low p-value (7.1248638708166E-11). This statistically significant outcome strongly indicates that the observed relationship between attendance and OSCE grades is not due to random chance, underscoring the importance of consistent class attendance for achieving successful outcomes in clinical assessments.

Table 3

Regression Coefficients and Statistical Significance
	Coefficients	Standard Error	t Stat	P-value	Lower 95%	Upper 95%
Grade	72.9025675	1.55118884	46.9978675	1.7297E-45	69.79262116	76.0125139
Attendance	0.87713038	0.10845315	8.08764294	7.1249E-11	0.659694897	1.09456586

The analysis, as detailed in Table 3 and illustrated in Fig. 1, reveals a significant positive correlation between class attendance and OSCE scores. Specifically, for each additional unit of attendance, medical Spanish OSCE grades increase by 0.8771 units (Attendance: Coefficient = 0.8771, Standard Error = 0.1085, t-statistic = 8.09, P-value < 0.001). This finding underscores the vital role that consistent class participation plays in the development of clinical skills. The identified positive relationship suggests that regular attendance in Spanish medical courses leads to better outcomes in practical clinical evaluations. Students who consistently attend classes have increased opportunities to improve both their language skills and clinical competencies, which are reflected in higher proficiency levels in OSCE settings.

The intercept term in the model (Grade: Coefficient = 72.90, Standard Error = 1.55, t-statistic = 47.00, P-value < 0.001) provides a theoretical insight into the expected medical Spanish OSCE grade without any class attendance. Though this scenario is hypothetical and lacks practical relevance, it sets a baseline for medical Spanish OSCE performance independent of attendance. This baseline, as indicated by the intercept, aids in understanding the intrinsic variability in OSCE grades not explained by attendance. Although the intercept might not have a direct practical interpretation, it significantly contributes to the regression model's overall accuracy by accounting for the systematic variability in OSCE grades beyond that which is explained by class attendance.

The analysis yielded 95% confidence intervals for both the intercept and the attendance coefficient. The confidence interval for the intercept, which ranges from 69.79 to 76.01, indicates that the true average OSCE grade, in the theoretical scenario of zero attendance, would likely fall within this range. Similarly, the confidence interval for the attendance coefficient, extending from 0.66 to 1.09, delineates the range within which the actual impact of attendance on OSCE grades can be confidently estimated. These intervals provide essential insights into the precision of the estimates, clearly contextualizing the statistical significance of the findings.

Addressing Multicollinearity:

Table 4

Pearson Correlation Data
Pearson Correlation Test
Coefficient (r)	Observations	t Stat	df	P-value
0.740119212	56	8.087642939	54	7.12486E-11

The Pearson correlation analysis presented in Table 4 shows a strong and statistically significant positive correlation (r = 0.740) between participation in Spanish medical classes and medical Spanish OSCE scores. This finding substantiates the hypothesis that increased attendance is associated with improved outcomes in practical clinical assessments. However, the strong correlation between attendance and OSCE grades raises concerns about multicollinearity, which could affect the stability and interpretability of the regression model, making the analysis of individual predictors challenging. Despite these concerns, the analysis is committed to understanding how attendance affects medical Spanish OSCE scores, providing important insights into the factors that contribute to clinical skill proficiency in medical students. Future efforts will aim to address the effects of multicollinearity to ensure the model's validity and the reliability of the findings.

The study's exploration of the link between SP session attendance and medical Spanish OSCE performance sheds light on the benefits of experiential learning in medical education, particularly in acquiring clinical Spanish skills. The findings confirm that active engagement in SP sessions significantly boosts students' clinical abilities, mirrored in their OSCE scores. A positive correlation between session attendance and assessment outcomes accentuates the essential role of practical, interactive learning in medical curricula.

Analyzing the methodological framework of the study, the accuracy in monitoring student attendance and the implementation of a blind grading system lend credibility to the results. Nonetheless, the study faces limitations such as the elective nature of SP session participation and the lack of initial Spanish proficiency assessment among participants. Despite these challenges, the data reaffirm the educational value of SP interventions within the framework of medical Spanish education.

With the demographic shifts in the United States pointing towards an increasing need for bilingual healthcare professionals, the relevance of this study becomes even more pronounced. There is clear empirical support for broadening experiential learning approaches across medical education to prepare students more effectively for treating a diverse patient populace.

The analysis further indicates that regular attendance in medical Spanish lessons has a positive impact on students' clinical assessment performances, suggesting that active participation in such specialized educational settings is vital for developing necessary clinical skills. Attendance stands out as a significant predictor of success in clinical evaluations, emphasizing the need to promote consistent engagement to better prepare future healthcare professionals.

The study also navigates through potential methodological pitfalls, such as multicollinearity, indicated by the strong correlation between attendance and OSCE grades. This factor could potentially compromise the stability and interpretability of the regression model, adding complexity to the analysis of individual predictors. However, the research still provides substantial insights into the factors that influence clinical skill development among medical students. Future studies should aim to overcome these limitations, seeking strategies to diminish the effects of multicollinearity and maintain the robustness of the analysis.

Future research directions include broadening the diversity and size of the participant sample and conducting longitudinal studies to assess the enduring impact of attendance on clinical skills development. Utilizing advanced statistical methods to tackle multicollinearity will be pivotal in ensuring the accuracy of regression models. Additionally, exploring other determinants of OSCE grades through a mix of quantitative and qualitative approaches could yield more comprehensive insights into the educational dynamics. Adopting experimental designs might help elucidate the cause-and-effect relationship between class attendance and clinical performance. Collaborative efforts across various academic disciplines will offer a more holistic view of how medical Spanish training shapes proficient healthcare providers. Further investigations should also delve into the long-lasting effects of SP engagement on clinical competencies and the quality of patient care, evaluating the potential to extend these educational methods to bolster linguistic and cultural competencies in healthcare training programs

This study has emphasized the impact of integrating SPs into the medical Spanish curriculum, demonstrating a clear link between SP session attendance and improved OSCE grades in medical Spanish. Despite challenges such as inconsistent attendance and varied baseline Spanish proficiency among participants, the findings strongly support the implementation of experiential learning models throughout medical education. Future research should continue to explore the long-term effects of these educational strategies on patient care, with a goal to further integrate cultural and linguistic competence into medical training. Advancing these inclusive educational approaches is essential for progressing toward a healthcare system that can fully address the needs of all patients. This aligns with the broader objectives of inclusivity, equity, and improved healthcare delivery, underlining the critical role of comprehensive and culturally aware medical education in fostering a more effective and empathetic healthcare environment.

SPs, Standardized Patients

CUSM-SOM, California University of Science and Medicine School of Medicine

OSCE, Objective Structured Clinical Examinations

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants and/or their legal guardian(s) involved in the study.

Ethics approval: The California University of Science and Medicine Institutional Review Board approved this study on (protocol # HS-2024-16).

Consent for publication: Not applicable.

Availability of data: Data supporting the findings of this study are available from the corresponding author upon reasonable request.

Competing interest: None.

Funding: None.

Authors’ contributions: ALV led the project’s conceptualization, investigation, and led the writing of the original draft, review, and editing. JA led the formal analysis and participated in manuscript draft preparation, review, and editing. CR participated in manuscript draft preparation, review, and editing. All authors read and approved the final manuscript.

Acknowledgments: The authors thank the Clinical Skills team at CUSM-SOM and express deep appreciation for the SPs, and especially for Maria Luna, the SP Educator.

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No competing interests reported.

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You are reading this latest preprint version

Enhancing Clinical Spanish Proficiency through Standardized Patient Interactions: A Case Study of Medical Students' Performance

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Background

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Background

Methods

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Addressing Multicollinearity:

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