Setting and Problem
The Lawrence Family Medicine Residency aims to train full-spectrum family medicine residents with a focus on care for underserved populations. While many US residency programs provide training in settings serving a majority of non–English-speaking patients, and some provide support for language training during residency, we believe ours is distinct in providing integrated, multidimensional Spanish language instruction including 1-on-1 training. Lawrence, Massachusetts, has a long history as a destination for immigrants. In the 2010 census, the population of Lawrence was 73.8% Hispanic/Latino. This setting is ideal to provide excellent Spanish language instruction to resident physicians, especially those who intend to continue working in underserved settings.
Our Spanish Language Acquisition program balances 2 major competing demands—the need for more Spanish-speaking physicians and the already grueling demands of residency training. Starting with an objective assessment of fluency at the start of residency, we are able to design personalized programs within residents' zone of proximal development and eliminate less-effective group classes. Additionally, residents work in a functional immersion environment in their continuity clinic, supported by medical assistants and translators who encourage their independence as their abilities grow.
Intervention
We utilized the Clinician Cultural and Linguistic Assessment from ALTA Language Services (http://www.altalang.com/language-testing) to assess Spanish proficiency of residents. This telephone language assessment was developed by Kaiser Permanente to assess proficiency in clinical settings. Residents' Spanish-speaking skills are evaluated on entry, then annually until residents score “proficient” on the assessment (score ≥ 80%). A Spanish curriculum is integrated into residency training as part of the work day. There are 4 curricular components:
Intensive Spanish language instruction and immersion course during orientation;
Individual Spanish lessons integrated into all first-year rotations or until proficiency is achieved;
Daily use of Spanish with interpreter support during clinical work; and
Second intensive Spanish language instruction and immersion elective during the first year.
The initial intensive Spanish language instruction and immersion takes place at the Rassias Center for World Languages and Cultures at Dartmouth College—a 10-day, live-in course providing 100 hours of instruction. Multiple levels of instruction are offered, from beginner to advanced, so the entire incoming intern class can attend. After July, residents are scheduled for individual 1-hour language lessons with a private teacher who is contracted with the program. These occur once to twice per week for beginners, every other week to monthly for those with intermediate Spanish, and monthly to quarterly for more advanced residents. Residents who matriculate with beginner or intermediate Spanish use their 2-week elective for a second intensive language experience at an international language school, for at least 50 additional hours of formal language instruction.
Outcomes to Date
Our residency program has used this model for the last 4 years (having selected components from 23 years of Spanish instruction). Spanish fluency is not a prerequisite for acceptance in our program. In fact, upon entry, 11% of entering residents scored < 10% (no Spanish), while 22% tested at or above proficiency. Significantly, 98% scored at or above proficiency prior to graduation. Average training cost is $7,975 for a resident who enters the program with no Spanish and $6,750 for a resident who enters with intermediate Spanish. A cost analysis on the value of the Spanish program found that if just 25% of residents' patients speak Spanish, the cost of teaching Spanish to residents is less than interpreting costs for the second and third years of residency (Table). Thus this “new idea” of 1-on-1 language instruction helps residents achieve fluency and save money.
Table.
Potential Cost Savings From Teaching Residents Spanish
