LatinX individuals comprise 18.3% of the United States population, of which approximately 40% have limited English proficiency. Medical Spanish programs are emerging to bridge language barriers with these patients, but more data are needed to determine the most effective teaching practices. In this paper, we evaluate the efficacy of a decade-old Peer Led Medical Spanish Program (PLMSP) that reaches over 50% of first-year medical students at Stritch School of Medicine. Students were placed into levels based on a pre-test that assessed comfort with Spanish, cultural competency, and reading/audio comprehension. After the completion of twenty classes taught by fluent peers that aligned with components of the medical history students were learning in English at that time, students were re-evaluated using the same exam. Intermediate and above students also completed an Objective Structured Clinical Examination (OSCE) in which their performance in medical history taking was evaluated by standardized patients. We found significant improvement in Spanish comfort for novice, beginner, and advanced students. Cultural competency growth was noteworthy amongst the novice and intermediate students. Nearly all levels showed statistically significant improvements in Spanish comprehension. For all levels participating in the OSCE, >90% of the history was discussed with standardized patients either agreeing or strongly agreeing that students had appropriate pronunciation, medical vocabulary, conversational fluidity, and cultural awareness. Further development of the program should focus on incorporating culture more effectively into the curriculum.
LatinX Americans comprise the second largest ethnic group in the United States, consisting of nearly 60 million individuals (18.3% of the population) according to the U.S. Census Bureau (2018). Nearly 40% of LatinX individuals in the United States have limited English proficiency (1). Language discordance in a healthcare setting is associated with increased health disparities and more negative health outcomes (2), including lower patient satisfaction, less access to preventive care, increased risk of medical errors/adverse events, longer hospital stays, and increased cost of care (3, 4). Because language-concordant care is associated with enhanced patient care, there is a growing need for effective Medical Spanish education efforts.
In 2012, the National Latino Medical Student Association (LMSA) assessed Medical Spanish curricula in 132 U.S. medical schools in a nationwide survey (1). Eighty-three percent of schools completed the survey, of which 66% reported offering a Medical Spanish curriculum; 32% reported an intention to initiate one in the near future. These data show that medical schools recognize the importance of Medical Spanish education in training future physicians. However, there are currently no widely accepted guidelines on how to structure a Medical Spanish curriculum or how to evaluate such programs. Education efforts are not consistently linked to learner assessments, and when they are, there is much variability in design and limited use of reliable outcome measures (5). Some programs use speaking proficiency interviews (6), while others rely on standardized patient exams or oral proficiency interviews (2, 7).
To address the lack of standardization, a 2018 multidisciplinary expert panel convened by the University of Illinois College of Medicine and the National Hispanic Health Foundation proposed goals for standardizing Medical Spanish learner competencies and promoting evidence-based assessment methods (8). Despite this important step, more research is needed on effective teaching practices. This prompted our evaluation of the Loyola University Chicago Stritch School of Medicine (SSOM) Peer Led Medical Spanish Program (PLMSP), a large and long-standing program that is fully peer-taught and peer-managed, and whose history-oriented curriculum parallels the Stritch Patient Centered Medicine course throughout the academic year.
SSOM's PLMSP began in 2009 and provides elective credit to medical students during their first two years of medical school. SSOM is one of only six medical schools to maintain a peer-led teaching model out of 62 schools surveyed by LMSA (1). Medical students not only teach the course but also develop and update the curriculum, gather data on effectiveness, recruit and train new teachers, manage placement, and oversee student progress. This model promotes leadership and academic skills across multiple competencies, including professionalism and practice-based learning and improvement. For participants, the model offers flexibility and responsiveness to learner needs. The curriculum is focused on taking the medical history in Spanish and is taught concurrently with the English patient interview curriculum for first-year students. More than 50% of Stritch's first-year class typically completes the program for credit.
In response to the need for rigorous evaluation of Medical Spanish education, we assessed the PLMSP's impact on Spanish comfort, cultural competency, and comprehension before and after the course, and on clinical performance in an OSCE for intermediate and above students. We hypothesized that PLMSP participation would improve students' performance in these areas and better prepare intermediate, advanced, and proficient students to obtain and understand medical histories in Spanish.
Program structure and placement: Students interested in the 2020–2021 PLMSP took an electronic placement exam assessing comfort with Spanish, cultural competency, and written and auditory Spanish comprehension (Appendix A, online). The exam served as a pre-test and placed students into five levels: novice, beginner, intermediate, advanced, or proficient. Rather than hard score cutoffs, students were grouped with peers at similar proficiency levels while aiming to keep teacher–student ratios < 12:1, to maximize speaking opportunities and feedback. Students could request to move up or down a level within the first three classes. Analyses used each student's final level assignment.
Teachers and training: Nineteen teachers (14 first-year medical students, 3 nursing students, 2 graduate students) were selected through an interview process based on language ability, cultural awareness, and teaching experience. Classes with >12 students had two teachers. Teachers received training in teaching theory and strategies from a local college's Chair of World Languages, used standardized lesson materials (Appendix B, on request), and had ongoing mentorship from prior PLMSP leaders.
Curriculum and delivery: Due to the COVID-19 pandemic, all sessions were held via Zoom. Students attended 20 classes from September to May. Each class used a standardized set of daily objectives aligned with components of the medical history and the concurrent English Patient Centered Medicine curriculum. Lessons incorporated interactive listening and reading tasks, role-plays, games, and extended breakout room speaking practice. Toward the end of the year, more time was dedicated to full simulated patient encounters to prepare for the OSCE.
Beyond class attendance, students were required to complete: (1) four cultural competency events (e.g., online seminars on health disparities, film screenings of immigrant experiences, panels with DACA recipients); (2) one practical experience using Spanish or engaging LatinX communities (e.g., voter registration drives, LatinX health symposium, language exchange programs); and (3) for intermediate, advanced, and proficient levels, an OSCE encounter with a Spanish-speaking standardized patient.
Assessment tools: The post-test, administered at the final class, was identical to the pre-test and measured:
OSCE: Intermediate and higher students completed an OSCE modeled on the SSOM clinical skills course. Spanish-speaking standardized patients used one of two scripts mapped to a 43-item history checklist (Appendix C–D, online). Students then completed a 10-item English quiz on the case (Appendix E). Standardized patients rated students on pronunciation, vocabulary, conversational ability, and cultural knowledge on a 0–9 scale (Appendix F).
Analysis: Using Excel, we calculated means, standard deviations, and interquartile ranges for ILR comfort scores, cultural competency ratings, comprehension scores (total, audio, reading), OSCE history items completed, quiz scores, and OSCE ratings. Paired t-tests compared pre- and post-test scores (α = 0.05). Cohen's d effect sizes were calculated for pre–post changes.
The 2020–2021 PLMSP cohort included 100 medical students who completed all course requirements and both pre- and post-tests: 26 novice, 27 beginner, 28 intermediate, 16 advanced, and 3 proficient. All were first- or second-year SSOM students. Figure 1 (in the original article) depicts participant flow and exclusions.
| Level | Pre-test Mean (SD/IQR) | Post-test Mean (SD/IQR) | Cohen's d | p-value |
|---|---|---|---|---|
| Novice | 0.15 (0.37 / 0.00) | 1.03 (0.60 / 0.00) | 0.37 | <0.001 |
| Beginner | 1.26 (0.59 / 1.00) | 1.81 (0.62 / 1.00) | 0.90 | 0.001 |
| Intermediate | 2.14 (0.71 / 1.00) | 2.33 (0.68 / 1.00) | 0.27 | 0.06 |
| Advanced | 2.60 (0.51 / 1.00) | 3.13 (0.52 / 0.00) | 1.04 | 0.001 |
| Proficient | 4.33 (0.58) | 4.33 (0.58) | 0.00 | 1.00 |
All levels except proficient increased their ILR-rated comfort with Spanish by the end of the elective. Increases were statistically significant for novice, beginner, and advanced groups.
| Level | Pre-test Mean (SD/IQR) | Post-test Mean (SD/IQR) | Cohen's d | p-value |
|---|---|---|---|---|
| Novice | 3.40 (1.13 / 1.00) | 3.92 (1.24 / 2.00) | 0.44 | 0.006 |
| Beginner | 4.30 (0.81 / 1.00) | 3.96 (0.88 / 1.00) | 0.40 | 0.01 |
| Intermediate | 3.89 (0.86 / 1.00) | 4.13 (1.05 / 2.00) | 0.25 | 0.045 |
| Advanced | 4.27 (0.73 / 1.00) | 4.27 (0.70 / 1.00) | 0.00 | 0.50 |
| Proficient | 4.67 (0.41) | 5.00 (0.41) | 0.80 | 0.09 |
Cultural competency ratings improved significantly for novice and intermediate levels, decreased slightly for beginners, and were unchanged or nonsignificantly improved for advanced and proficient students.
| Level | Pre-test Mean (SD/IQR) | Post-test Mean (SD/IQR) | Cohen's d | p-value |
|---|---|---|---|---|
| Novice | 3.81 (3.78 / 5.00) Audio: 2.23 (2.30 / 3.00) Reading: 1.50 (1.70 / 2.00) |
14.88 (2.64 / 4.00) Audio: 8.42 (1.36 / 3.00) Reading: 6.54 (1.88 / 3.00) |
3.40 Audio: 3.28 Reading: 2.81 |
<0.001 Audio: <0.0001 Reading: <0.001 |
| Beginner | 12.74 (2.64 / 3.00) Audio: 7.19 (1.30 / 2.00) Reading: 5.56 (1.83 / 3.00) |
17.56 (1.85 / 2.00) Audio: 8.93 (0.92 / 2.00) Reading: 8.63 (1.42 / 2.00) |
2.12 Audio: 1.55 Reading: 1.87 |
<0.001 Audio: <0.001 Reading: <0.001 |
| Intermediate | 16.61 (0.92 / 1.00) Audio: 8.56 (0.74 / 1.00) Reading: 8.07 (0.96 / 1.50) |
18.59 (1.76 / 2.00) Audio: 9.15 (1.75 / 1.00) Reading: 9.44 (0.64 / 1.00) |
1.41 Audio: 0.44 Reading: 1.68 |
<0.001 Audio: 0.06 Reading: <0.001 |
| Advanced | 18.33 (0.82 / 1.00) Audio: 9.40 (0.51 / 1.00) Reading: 8.93 (0.80 / 2.00) |
19.40 (0.51 / 1.00) Audio: 9.67 (0.48 / 1.00) Reading: 9.73 (0.46 / 1.00) |
1.57 Audio: 0.55 Reading: 1.23 |
<0.001 Audio: 0.02 Reading: 0.001 |
| Proficient | 19.66 (0.58) Audio: 10.00 (0.00) Reading: 9.66 (0.58) |
19.66 (0.58) Audio: 10.00 (0.00) Reading: 9.66 (0.58) |
0.00 Audio: 0.00 Reading: 0.00 |
1.00 Audio: 1.00 Reading: 1.00 |
Total comprehension scores improved significantly at all levels except proficient, with substantial gains in both audio and reading components for most groups.
| Level | Interview Questions Discussed (SD/IQR) | Quiz Score (SD/IQR) | Pronunciation (SD/IQR) | Vocabulary (SD/IQR) | Conversational Fluidity (SD/IQR) | Cultural Competency (SD/IQR) |
|---|---|---|---|---|---|---|
| Intermediate | 38.96 (4.61 / 4.50) | 9.14 (1.43 / 1.50) | 7.79 (1.13 / 2.00) | 8.18 (0.94 / 1.00) | 7.89 (1.20 / 2.00) | 8.61 (0.88 / 0.50) |
| Advanced | 40.33 (3.52 / 4.00) | 9.40 (0.83 / 1.00) | 8.60 (0.63 / 1.00) | 8.73 (0.46 / 1.00) | 8.53 (0.74 / 1.00) | 8.87 (0.35 / 0.00) |
| Proficient | 40.33 (1.53 / n/a) | 9.66 (0.58 / n/a) | 9.00 (0) | 9.00 (0) | 9.00 (0) | 9.00 (0) |
Intermediate students addressed on average 38.96 of 43 history items (∼91%), and advanced and proficient students ∼94%. Comprehension quiz scores were high across levels. Standardized patients generally agreed or strongly agreed that students spoke with appropriate pronunciation, vocabulary, conversational fluency, and cultural sensitivity.
The PLMSP demonstrated promising effects across a range of competencies, including self-rated comfort, objective comprehension, and OSCE-based communication performance. Notable strengths include statistically and educationally meaningful gains in comprehension across most levels and strong OSCE performance with high percentages of complete histories in Spanish.
Cultural competency scores improved at some levels but not uniformly, suggesting that cultural content may require further strengthening and more nuanced assessment. Proficient students did not show measurable improvement, likely due to ceiling effects, underscoring the need for advanced metrics tailored to high-level learners.
This work contributes to the limited literature linking Medical Spanish education to multiple outcome domains (comfort, comprehension, and clinical performance). The peer-led structure appears to offer advantages in scalability, responsiveness, and leadership development, particularly for institutions lacking dedicated faculty or resources for faculty-led language training.
Limitations include reliance on non-validated, program-specific instruments (especially for cultural competency and comfort), potential subjectivity in standardized patient ratings, lack of a control group, and the online-only delivery during the COVID-19 pandemic, which may have constrained cultural immersion experiences. Future work should investigate reasons for attrition, validate assessment tools, and compare peer-led models with alternative formats.
Overall, the SSOM PLMSP improved Spanish language competency among medical students, particularly in comfort and comprehension, and supported strong performance in simulated clinical encounters. Future iterations should focus on more robust integration and assessment of cultural competence and on advanced evaluation methods for proficient learners. The program provides a replicable model for other schools seeking to build sustainable, student-driven Medical Spanish curricula that complement core communication training.
The authors acknowledge the peer teachers who developed content throughout the program's history, including founders Erin Stratta, MD; the late Jason Howell, MD; Katherine O'Rourke, MD; and medical students Nicholas Sasso and Jaquelin Solis Solis. They also thank the staff of the Center for Simulation Education, especially Donna Quinones, and all OSCE volunteers.
Funding: No funding was received to assist with the preparation of this manuscript.
Conflicts of interest: The authors declare no financial or non-financial conflicts of interest.
Availability of data and material: Included in the manuscript as relevant; further details available upon request.
Code availability: Not applicable.
Authors' contributions: All authors contributed according to journal authorship guidelines.
Ethics approval: The questionnaire and methodology were approved by the Human Research Ethics Committee of Loyola University Chicago (212132).
Consent to participate: Informed consent and consent to publish were obtained from all participants.