Enhancing Clinical Spanish Proficiency Through Standardized Patient Interactions: A Case Study on Medical Students’ Performance

Abstract

Background

The growing Hispanic population in the United States highlights the urgent need for Spanish-speaking healthcare professionals to address clinical language barriers. In response, the California University of Science and Medicine introduced the Vida Medical Spanish curriculum to equip medical students with linguistic and cultural skills for effective communication with Spanish-speaking patients. A key component of this program is the use of Spanish-speaking Standardized Patients in role-playing scenarios that simulate real clinical encounters.

Methods

This prospective cohort study, conducted between 2022 and 2023, assessed the relationship between student attendance at Standardized Patient sessions within the Vida Medical Spanish curriculum and their performance in the Medical Spanish Objective Structured Clinical Examination. Over an 18-month period, data were collected for 56 medical students in the pre-clerkship curriculum. A multiple regression analysis was conducted to evaluate the impact of class participation on clinical Spanish competency.

Results

The findings indicate a statistically significant positive correlation between consistent interactions with Standardized Patients and higher scores in the Medical Spanish Objective Structured Clinical Examination (r = 0.74, p < 0.001). These results underscore the critical role of regular participation in interactive educational settings in enhancing clinical assessment skills.

Discussion

The inclusion of Standardized Patients in the medical Spanish curriculum plays an important role in improving students’ clinical communication skills. This study highlights the significance of integrating interactive patient encounters into language-specific medical training to enhance physicians’ preparedness for culturally and linguistically concordant care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-025-06966-6.

Background

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 [2], there is a corresponding growth in demand for Medical Spanish education among medical students to address the shortage of skilled Spanish-speaking healthcare professionals. Consequently, medical schools are urged to integrate required Medical Spanish courses that not only enhance students' confidence in using the language but also significantly improve their linguistic competencies [3].

Medical Spanish education is increasingly sought after by U.S. medical students, healthcare providers, and health systems. However, the lack of standardized evaluation and assessment methods remains a challenge [4]. These curricula frequently incorporate Spanish-speaking Standardized Patients (SPs) to assess communication skills in Spanish, offering a controlled environment for students to practice and refine their competencies in realistic 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.

To address the medical needs of the Spanish-speaking community in the Inland Empire region of Southern California, the California University of Science and Medicine School of Medicine (CUSM-SOM) launched the Vida program, a targeted initiative aimed at enhancing its medical Spanish curriculum [7]. CUSM-SOM serves a diverse population, including a significant proportion of Spanish-speaking patients with limited English proficiency, highlighting the need for structured language training in medical education. Vida is designed to bridge the gap between the growing Spanish-speaking patient population and the physician workforce by providing comprehensive medical Spanish education to medical students in the pre-clerkship curriculum. The program aims to enhance students' linguistic competencies and cultural sensitivity, thereby promoting more effective patient-centered care. Initially offered as an optional elective, Vida became a mandatory component of the MD curriculum starting in the 2024–2025 academic year. By integrating language training with clinical practice, Vida addresses the critical need for skilled Spanish-speaking healthcare professionals, thereby improving healthcare outcomes for Spanish-speaking communities.

The design of the Vida program was informed by educational best practices and evidence-based frameworks aimed at optimizing language acquisition and clinical application [5]. Curriculum development included a comprehensive needs assessment to identify the specific linguistic and cultural competencies essential for effectively serving the Spanish-speaking patient population. This process involved collaboration with language experts, clinical educators, and members of the Hispanic community [8]. The Vida curriculum was structured to include large group lessons, hands-on experiences with proficient SPs, collaborative small group sessions, and comprehensive post-course assessments. Each component was meticulously designed to align with the Clinical Skills courses at CUSM-SOM, ensuring that language training was contextually relevant and directly applicable to real-world patient interactions. Key educational content areas included medical terminology, patient history-taking, physical examination techniques, and culturally competent communication strategies.

The Vida curriculum has been evaluated using the Kirkpatrick Model [9], 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 [10], 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, allowing them to feel more prepared for skill execution in live patient settings. This heightened readiness contributes to improved performance in clinical assessments [11] and reduces the likelihood of errors during patient interactions [12]. Additionally, medical students report less distress when performing intimate examination skills with SPs, leading to improved outcomes in clinical evaluations [13].

While prior research has demonstrated the benefits of SPs in general clinical training, limited empirical evidence exists on their role in developing medical Spanish proficiency. This study aims to address that gap by evaluating whether participation in Standardized Patient sessions within the Vida Medical Spanish curriculum enhances students' ability to conduct clinical encounters in Spanish, as measured by their performance in the OSCE.

Methods

Study design and setting

The study sample consisted of medical students enrolled in the optional Vida Medical Spanish Curriculum at CUSM-SOM. Participation in the program was voluntary, and students self-selected into the curriculum, which spanned the entire pre-clerkship phase (three semesters, including the first year and the first semester of the second year). The study aimed to evaluate the effectiveness of the Vida Medical Spanish curriculum in enhancing the communication skills of medical students in the pre-clerkship curriculum with Spanish-speaking patients. The curriculum focused on integrating language training with clinical practice through standardized instructional and assessment methodologies.

The Spanish-speaking SP pool was carefully selected through a comprehensive interview process, including a role-play scenario conducted entirely in Spanish to evaluate proficiency and suitability. The SP pool consists of individuals who are fully proficient in Spanish, including some who are monolingual. To ensure consistency and accuracy in simulated patient interactions, a dedicated SP Educator conducted weekly training sessions before each large group session. These sessions emphasized standardized vocabulary, grammar structures, and interaction protocols aligned with the educational objectives of the curriculum. This rigorous preparation process ensured that SPs could reliably replicate patient cases, providing students with realistic and linguistically accurate practice opportunities.

During each session of the Vida Medical Spanish curriculum, the instructor systematically introduced grammar and vocabulary directly tied to 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. Following the instructional segments, interactive role-playing exercises with trained SPs were conducted to accurately replicate actual patient cases. The SP scripts, crafted by the course director and aligned with educational objectives, were meticulously taught to the SPs by the SP Educator. This training process ensured both accuracy and consistency in the simulated clinical encounters, providing students with realistic and reliable practice opportunities. Three SP script samples are included in the supplements.

Research community and sample size

The study population comprised medical students from the Class of 2026 at CUSM-SOM who were enrolled in the elective pre-clerkship Vida Medical Spanish curriculum. Each cohort at CUSM-SOM typically consists of approximately 130 students. Of the Class of 2026, 112 students initially enrolled in the Vida program when it was offered as an optional elective.

During the 18-month study period, 84 students completed the final assessment, as some participants encountered challenges balancing the Vida curriculum with other academic and personal responsibilities. From these 84 students, a purposive sample of 56 students participated in the post-course assessments conducted in November 2023, representing a 66.7% participation rate among those who completed the final assessment. This sample included students with varying levels of initial Spanish proficiency, ensuring a comprehensive evaluation of the curriculum's effectiveness. Demographic information, including gender and baseline Spanish proficiency, was collected to provide context for the analysis as shown in Table 1.

Table 1.

Demographic characteristics of study participants

Characteristic	N (%)
Gender
- Male	25 (44.6%)
- Female	30 (53.6%)
- Other	1 (1.8%)
Baseline Spanish Proficiency (Self- reported)
- Beginner	20 (35.7%)
- Intermediate	36 (64.2%)
Previous Spanish Coursework
- None	10 (17.9%)
- 1–2 Courses	25 (44.6%)
- 3 or More Courses	21 (37.5%)

Intervention

Students enrolled in the Vida Medical Spanish curriculum were expected to participate in weekly small group sessions focused on hands-on practice and feedback, facilitated by Spanish-speaking instructors. While attendance at large group sessions—which typically comprised a lecture presentation followed by interactive practice with SPs—was not mandatory, it was highly recommended to enrich the learning experience. Consequently, the level of engagement with SPs varied among students, with some attending most of these sessions to practice their skills, while others participated less frequently. To systematically monitor student participation, attendance at large group sessions, where interactions with SPs occurred, was meticulously tracked throughout the 18-month study period by the course director using digital attendance logs.

Post-course assessments

All students enrolled in the Vida curriculum were required to complete the post-course assessment, the Medical Spanish OSCE. The OSCE was designed to evaluate the integration of Spanish language skills into clinical interactions, closely mirroring the structure of the Clinical Skills courses at CUSM-SOM [14]. Each student completed three different scenarios or stations during the assessment, each lasting 15 min:

• Neurological Examination Station: Selected for its demand for diverse Spanish language structures applicable to various physical examinations, necessitating the use of formal commands and enabling effective communication during procedural tasks.

• Comprehensive History-Taking Station: Evaluated students’ proficiency in conducting thorough patient exams with an emphasis on respectful, sensitive, and inclusive Spanish communication.

• Diabetes Counseling Station: Focused on culturally competent communication in managing diabetes, a condition with high prevalence and impact among Hispanic populations in the United States.

To accommodate all participants, these three scenarios were replicated across nine stations, with three instances of each scenario running concurrently during the assessment period.

Data collection instruments

Data were collected using the Medical Spanish OSCE, which consisted of nine simultaneous stations (three stations per scenario type) to ensure efficient testing of all participants. A total of 56 students participated in the OSCE, each completing all three scenario types: Neurological Examination, Comprehensive History-Taking, and Diabetes Counseling. This structure resulted in a total of 168 individual encounters (56 students × 3 scenarios per student).

Each encounter lasted approximately 15 min and was conducted over a single day, from 8:30 AM to 3:30 PM, including scheduled breaks for SPs to rest and manage personal needs. This format ensured that students were evaluated across a range of clinical scenarios while maintaining the consistency and quality of the SP-led interactions.

The three assessment stations were graded by faculty members using standardized checklists derived from Bates' Guide to Physical Examination and History-Taking [15]. The checklists utilized a scoring system that awarded 0 points for actions not performed, 1 point for actions executed with errors, and 2 points for actions completed with minimal errors. To ensure consistency and reliability in grading, nine raters underwent comprehensive training, which included standardized workshops and calibration exercises. Inter-rater reliability was assessed using Cohen’s Kappa, yielding a coefficient of 0.82, indicative of strong agreement among raters. Detailed checklists are provided in Additional File 2, and three SP script samples are included in Supplemental File 1.

Data analysis

Data analysis was conducted using IBM SPSS Statistics version 28.0. The following analytical methods were employed:

• Descriptive Statistics: Demographic characteristics of the sample, attendance rates, and overall OSCE scores were summarized using means, standard deviations, frequencies, and percentages.

• Regression Analysis: The relationship between students’ attendance in Medical Spanish classes and their performance in the OSCE was examined. Multiple linear regression was conducted with OSCE scores as the dependent variable and attendance rates, baseline Spanish proficiency, and demographic variables as independent variables. Assumptions of linearity, independence, homoscedasticity, normality, and absence of multicollinearity were assessed and met.

• Inter-rater Reliability Assessment: Consistency and reliability in the grading of OSCE performances were ensured by calculating Cohen’s Kappa for inter-rater agreement between SPs and faculty on a subset of OSCE performances. The analysis demonstrated a strong level of inter-rater reliability (κ > 0.75).

• Correlation Analysis: Pearson correlation coefficients were used to explore the relationship between specific dimensions of language proficiency (e.g., grammar, vocabulary) and overall OSCE performance.

Ethical considerations

The study was reviewed and approved by the Institutional Review Board (IRB) of the California University of Science and Medicine under Protocol #HS-2024–16. All procedures were conducted in accordance with ethical standards. Informed consent was obtained from all participants, ensuring voluntary participation and confidentiality of data. Data were anonymized prior to analysis to protect participant privacy.

Results

The analysis evaluated the impact of attending medical Spanish lessons with SPs on OSCE performance, highlighting the significance of these educational methods in improving linguistic skills in clinical settings.

The regression analysis, as presented in Table 2, revealed a coefficient of determination (R²) of 0.5478, indicating that approximately 54.78% of the variation in OSCE grades can be explained by participation in Spanish medical courses. This substantial percentage underscores a strong association between course attendance and OSCE performance among medical students. The R² value highlights the predictive effectiveness of attendance in influencing clinical evaluation outcomes. While causation cannot be inferred from correlation alone, the significant correlation coefficient suggests that consistent attendance in Spanish medical classes plays a vital role in enhancing students’ clinical assessment capabilities. These findings emphasize the importance of active participation in such courses to improve clinical skills proficiency.

Table 2.

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 presented in Table 3 highlights that attendance is a statistically significant predictor of OSCE grades for medical students. The model's F-statistic of 65.41 and an associated p-value of less than 0.001 (7.12 × 10⁻¹¹) indicate that the model accounts for a substantial portion of the variability in medical Spanish OSCE scores. Specifically, the regression model explains a significant amount of the total variability (Sum of Squares = 2646.54 for the regression term, out of 4831.42 total).

Table 3.

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 F-statistic evaluates whether the regression model provides a better fit than a model with no predictors. In this case, the exceptionally low p-value (< 0.001) confirms that the relationship between attendance and OSCE grades is unlikely to be due to random chance. This highlights the important role of attendance as a key predictor, demonstrating that consistent class participation is strongly associated with better clinical assessment outcomes.

The residual variance (Sum of Squares = 2184.88) reflects the variability in OSCE scores not explained by attendance alone, indicating that other factors might also contribute to performance. However, the large regression sum of squares relative to the total sum of squares highlights the significant explanatory power of attendance within the model.

The analysis, as illustrated in Fig. 1 and detailed in Table 4, demonstrates a significant positive relationship 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 highlights the critical role that consistent class participation plays in developing clinical skills. The observed positive relationship suggests that regular attendance in Spanish medical courses improves outcomes in practical clinical evaluations. Students with higher attendance have more opportunities to enhance both their language skills and clinical abilities, as reflected in their OSCE performance.

Fig. 1.

Relationship between attendance and OSCE grades

Table 4.

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 intercept term in the model (Grade: Coefficient = 72.90, Standard Error = 1.55, t-statistic = 47.00, P-value < 0.001) represents the theoretical baseline OSCE grade for a scenario of zero attendance. While this scenario is hypothetical and lacks practical relevance, it establishes a baseline for medical Spanish OSCE performance independent of attendance. This baseline, as reflected by the intercept, aids in understanding the variability in OSCE grades that is not explained by attendance. Although the intercept has limited direct practical interpretation, it contributes to the regression model's overall accuracy by accounting for systematic variability beyond what is attributed to attendance.

The analysis also provides 95% confidence intervals for both the intercept and the attendance coefficient. The confidence interval for the intercept (69.79–76.01) suggests that, in the theoretical scenario of zero attendance, the true average OSCE grade would likely fall within this range. Similarly, the confidence interval for the attendance coefficient (0.66–1.09) indicates the range within which the actual effect of attendance on OSCE grades can be confidently estimated. These intervals offer valuable insights into the precision of the estimates and reinforce the statistical significance of the findings.

Addressing multicollinearity

The Pearson correlation analysis presented in Table 5 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.

Table 5.

Pearson correlation data between class participation and OSCE scores

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

Discussion

The findings indicate a significant positive correlation between SP session attendance and higher OSCE scores, reinforcing the potential benefits of experiential learning in developing clinical Spanish proficiency. These results align with prior research demonstrating that SP interactions play a role in fostering clinical competence among healthcare students [1]. Additionally, students with greater exposure to Spanish and structured language training exhibited higher proficiency in clinical encounters [16]. This study further suggests that active engagement with SP may contribute to improved performance in OSCEs.

The correlation observed in this study highlights the potential role of interactive learning approaches in medical Spanish education. Prior studies have suggested that experiential learning models, including structured patient interactions, can help students refine their communication skills in a controlled yet practical environment. Engaging with SPs provides students with opportunities to apply medical Spanish terminology, navigate patient-centered conversations, and build confidence in using the language in clinical scenarios. Further research is needed to determine the extent to which these findings generalize to other settings and medical training programs, particularly those with different curricular structures and student populations.

These results also raise important considerations for curriculum design in medical Spanish education. While this study focused on an elective program, future investigations could explore whether integrating SP sessions into required coursework might further support medical Spanish proficiency among a broader student population.

However, this study acknowledges several limitations. First, the study was conducted at a single medical school (CUSM-SOM) with a relatively small sample of medical students, which may limit the generalizability of the findings to other institutions or student populations. Additionally, the elective nature of SP session participation may introduce selection bias, potentially confounding the relationship between attendance and OSCE performance. The lack of a control group further limits the ability to attribute improvements in medical Spanish proficiency solely to participation in the Vida curriculum. Additionally, initial Spanish proficiency levels were self-reported by participants rather than objectively assessed, which may have influenced the results and introduced variability based on inaccurate or inconsistent reporting. To address these limitations, future studies should consider implementing mandatory Standardized Patient participation, incorporating objective pre-assessments of language skills, and including a comparison group to ensure a more accurate and comprehensive evaluation.

Another limitation involves the presence of multicollinearity, as indicated by a strong correlation between attendance and OSCE scores (r = 0.740). This issue may hinder the ability to isolate the individual effects of predictors within the regression model, potentially compromising the stability and interpretability of the results. To mitigate this, future research should explore advanced statistical techniques, such as ridge regression or principal component analysis, to enhance model robustness and ensure reliable interpretation of findings.

An additional limitation of this study is the grading approach used for assessing language proficiency, which differed from standardized tools such as the Physician Oral Language Observation Matrix (POLOM) [17]. While the assessment method employed was tailored to align with the Clinical Skills curriculum at our institution, it may not have captured the full complexity of clinical language proficiency. As the Vida Medical Spanish Program has evolved, we have integrated an assessment tool informed by Physician Oral Language Observation Matrix principles for subsequent cohorts to provide a more standardized and nuanced evaluation of clinical communication skills. Future research should aim to validate the use of such tools within medical Spanish education to ensure comprehensive and comparable assessments of language proficiency in clinical contexts.

While prior research has examined the role of SPs in clinical training, there is a lack of studies assessing their specific impact on language acquisition and patient communication skills in medical Spanish education. Most existing studies rely on self-reported language proficiency or qualitative feedback rather than objective assessments such as OSCE performance. This study addresses that gap by quantitatively evaluating the relationship between SP participation and clinical communication outcomes, providing empirical data that supports the integration of structured language training into pre-clerkship medical education. Future research should explore the long-term impact of such training, including retention of language skills and patient outcomes in clinical settings.

Conclusions

This study demonstrates that participation in structured medical Spanish instruction within the pre-clerkship curriculum is associated with higher performance in the OSCEs. While these findings suggest potential benefits of experiential learning through Standardized Patient interactions, this study only establishes a correlation and does not imply causation. Other factors, such as students' prior Spanish proficiency, individual motivation, or additional educational experiences, may have contributed to their performance.

Given these considerations, future research should explore the long-term impact of structured medical Spanish training and investigate causal relationships through controlled study designs. Additionally, refining assessment tools and conducting multi-institutional studies will be essential in assessing the broader applicability and effectiveness of language-specific clinical training in medical education.

Abbreviations

SPs

Standardized Patients

CUSM-SOM

California University of Science and Medicine School of Medicine

OSCE

Objective Structured Clinical Examinations

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. CR participated in manuscript draft preparation, review, and editing. All authors read and approved the final manuscript.

Funding

None.

Data availability

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

Declarations

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 involved in the study.

Ethics approval and consent to participate

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

Consent for publication

Not applicable.

Competing interest

The authors declare no competing interests.