Title VI of the Civil Rights Act requires that language services be available to persons with limited English proficiency in order to ensure safe access to needed health care services. To address the need for more Spanish speaking healthcare providers at Loyola University Medical Center (LUMC), students at the Stritch School of Medicine (SSOM) developed a Student-Led Medical Spanish Program in the fall of 2008.
LUMC traditionally utilized a standardized Spanish medical interpreter exam to assure the competence of professional interpreters. However, it did not evaluate the skills medical students used to directly communicate with Spanish-speaking patients and serve as ad hoc interpreters. Consequently, students might not have had insight into their abilities to safely care for Spanish-speaking patients.
To address this potential barrier to patient safety and quality patient care we developed and implemented the Spanish Bilingual Medical Student Certification (Certification). The goals of this program are to increase patient safety at LUMC and meet the federal mandate to assure the competence of language assistance provided at all levels of care by evaluating students before they begin caring for patients during third year clerkships. A secondary benefit of the Certification is that it fulfills the Liaison Committee on Medical Education’s Educational Directives 19-22 which require medical schools to provide students with communication skills, teach them to address medical consequences of social issues, and provide students with the skills to provide culturally competent care.
Students are first invited to participate in the Certification during the summer between their second and third years of medical school. They remain eligible for Certification participation until graduation. All students who intend to speak Spanish while caring for patients during their clerkships are encouraged to complete the Certification exams regardless of whether they are native Spanish-speakers, learned medical Spanish through Loyola’s Peer Led Medical Spanish Program, or learned Spanish through outside programs. Although there is not a formal prerequisite or screening process required before participation in the Certification, students are provided with a description of the Certification exams and are advised that they should participate in the Certification only if they feel comfortable completing a history and physical exam in Spanish.
Bilingual medical students are expected to fulfill several duties including direct patient interactions, clinical decision-making, and ad-hoc interpreting. After exploring various existing standardized exams such as medical interpreter certification exams we were unable to identify a single exam that evaluated all of these skills. As a result, we selected a combination of three standardized, validated exams that collectively evaluate fluency in Spanish speech and listening, a broad medical Spanish vocabulary, medical Spanish-English interpreting skills, clinical skills, and cultural competency. To earn the Spanish Bilingual Medical Student Certification students must earn a passing score on all three component exams. Additionally, as all three component exams provide formative feedback, all students who complete the exams receive instruction on methods to improve their medical Spanish and clinical skills regardless of whether or not they earn the Certification.
Clinician Cultural and Linguistic Assessment – Spanish (CCLA): a validated, standardized phone exam developed by Kaiser Permanente and ALTA Language Services (www.altalang.com), a widely recognized leader in the field of language testing. This exam simulates primary care encounters through guided interviews pertaining to medical and sociocultural situations. The objective pass/fail score is determined by the candidate’s ability to elicit and reproduce history details, explain differential diagnoses, respond to patients’ questions, give treatment instructions, and provide follow up directions. Students must correctly communicate 80% of key words and concepts to pass this exam. The exam also subjectively assesses communicative competency, fluency, pronunciation, customer service, and cultural proficiency. This exam requires approximately one hour to complete.
Qualified Bilingual Staff Assessment – Spanish (QBS): a validated, standardized phone exam developed by Kaiser Permanente and ALTA Language Services. This exam requires candidates to participate in social conversation, customer service interpretation, diagnosis and medical instructions interpretation, sight translation, and direct measures of bilingual medical vocabulary. Students must correctly communicate 70% of key medical terms and concepts and achieve a preset level of Spanish fluency to pass this exam. The exam also subjectively measures pronunciation, grammar, conduit role function, ability to convey messages, and fluidity in language transition. This exam requires approximately one hour to complete.
Spanish Objective Structured Clinical Exam (OSCE): a clinical skills exam developed and administered by SSOM faculty which is based on patient cases and evaluation criteria currently used to evaluate medical students upon completion of their second year. This exam measures skills that are not observed in the phone exams including face-to-face interpersonal skills, cultural sensitivity in both history and physical exams, and ability to complete an unprompted clinical encounter. Furthermore, it evaluates candidates’ ability to elicit medical information in Spanish, use that information to make clinical decisions, and ultimately communicate the information obtained in Spanish to English-speaking team members. To pass this exam students must each 70% on each of the following tasks: completion of key history and physical exam components; standardized patients’ evaluation of interpersonal skills; and production of a list of pertinent positive and negative findings from the history and physical exam, a problem list, a diagnostic hypothesis, a diagnostic workup plan, a management plan, and clinical knowledge. In addition, students receive formative feedback from the standardized patients regarding their medical Spanish communication skills and from SSOM faculty regarding their clinical skills. This exam requires approximately two hours to complete.
As all students have unique Spanish backgrounds, they will all choose different methods to prepare for the Certification exams. Examples of some of the preparatory methods that they may choose to use include:
- Review history and physical exam components taught in Patient Centered Medicine.
- Review Loyola’s Peer Led Medical Spanish lessons at http://moodle.luhs.org/login/index.php.
- Listen to common health-care conversations at www.medicalspanishpodcast.com.
- Review Loyola Medical Spanish Online Resources at http://ssom.luc.edu/medspanish/resources/
- Observe professional interpreters as they participate in patient care.
- Practice using medical Spanish with an interpreter’s assistance.
- Practice using medical Spanish with bilingual patients.
The Certification is administered three times per year: July, August, and January. After registering for the Certification students will be given access codes for the CCLA and the QBS. These exams are available for students to complete 24 hours per day via a toll-free number. Additionally, students must have internet access to complete the sight translation component of the QBS. In order to continue on to the next step of the Certification, the OSCE, students must complete the CCLA and QBS by a deadline approximately two weeks prior to the OSCE administration date. Students will then receive an appointment time for the OSCE.
On the day of the OSCE students will complete a focused history and physical exam on a patient with a chief complaint of abdominal pain and then receive feedback regarding their Spanish communication skills from the standardized patients. They will then complete the computer documentation of the history and exam findings, diagnostic hypothesis, workup plan, management plan, and answer questions regarding clinical knowledge. Finally, students will review their clinical performance with the clinical skills faculty.
Upon completion of all three component exams, students will receive a detailed report of their performance on the exams as well as an overall pass/fail designation. All students will then have an opportunity to meet with a Spanish-speaking faculty member to receive additional guidance regarding methods to improve their medical Spanish and clinical skills.
Students who pass all three component exams will earn the Spanish Bilingual Medical Student Certification. This entitles them to:
“HABLO ESPAÑOL” Spanish Bilingual Medical Student Identification Tag: This tag displays “HABLO ESPAÑOL” while hanging behind students’ LUMC photo identifications. Students can then lift their photo identifications to reveal a description of the Certification which reads:
“I have successfully completed the SSOM Spanish Bilingual Medical Student Certification. As a certified student, I am:
- culturally and linguistically competent to complete the duties of a medical student in Spanish without the assistance of an interpreter.
- able to facilitate communication between the health-care team and Spanish-speaking patients.”
This same description is printed in Spanish on the back of the card. These identification tags allow patients and medical center staff to easily identify certified students and therefore optimize the valuable resources these students can provide. Additionally, the names of certified students will be provided to Interpreter Services for their reference.
Certification Integration in the Clinical Curriculum: The names of certified students will be provided to the clerkship directors and coordinators. Certified students will then receive priority placement at clerkship sites that have been designated as sites with a large proportion of Spanish-speaking patients. This policy is intended to maximize the resources that certified students can provide. It saves the expense of using Interpreter Services to care for the patients for who certified students care while simultaneously freeing the interpreters to join other health-care teams who require their services. Additionally, it maximizes the level of care that patients can receive as studies have shown that health-care outcomes are maximized and physical harm from adverse events is minimized when patients and health-care providers speak the same language. Finally, this policy optimizes educational opportunities for all students. Certified students will benefit from having ample opportunities to maintain their medical Spanish skills. Non-Spanish-speaking students will benefit by being placed at alternate sites where their clinical experiences will not be limited by the inefficiencies associated the inability to directly communicate with patients.
When instructions for the clerkship site lotteries are distributed, it will include information regarding sites that qualify for priority Spanish placement. As of now, those sites include:
- Family Medicine
- Cicero Health Center of Cook County
- Department of Family Medicine Cook County Bureau of Health Services – Prieto Clinic
- West Suburban Hospital Family Medicine Residency Program – Salud Clinic
- Loyola Access to Care Clinic
- St. Joseph Hospital/Resurrection Healthcare
- VNA of Fox Valley Health Center – Elgin
- John J. Madden Mental Health Center – Spanish-Speaking Pavilion
- Certified students will rank their clerkship site placement choices as usual, however they will note their Certification status next to designated Spanish sites on the lottery forms. Certified students will then receive priority placement over non-certified students at these sites regardless of their assigned lottery number. If more than one certified student desires placement at a single Spanish site, assignment at that site will be given to the certified student with the best lottery number. While certified students always have the option of receiving priority placement at Spanish-speaking sites, they are never required to participate in this priority placement program.
Certified students have permission to fulfill the usual role of a medical student while caring for Spanish-speaking patients without the assistance of an interpreter and to provide ad-hoc interpreting for English-speaking members of their own health-care teams. Students and staff must always note that the primary responsibility of all students is to fulfill the role of a medical student. Providing Spanish language services must never interfere with medical students’ learning opportunities. Certified students should not be assigned to Spanish-speaking patients on the team if doing so will limit the diversity of clinical experience that the students receive. Additionally,all health-care providers should continue to utilize Interpreter Services and should not rely on students to interpret for the students’ patients in situations other than formal rounds or other times when students would normally be expected to participate in patient care or for patients on other health-care teams. If at any time a certified students desire the assistance of an interpreter, they are encouraged to request such services.
Transcript Notation: Recognizing that certified students are likely to seek residencies and employment opportunities outside of LUMC, certified students will receive notation of the Certification on their transcripts so that residency programs and employers can easily recognize this distinction. The transcript notation will read as follows:
Bilingual Medical Spanish: This student has successfully completed the Spanish Bilingual Medical Student Certification. This Certification recognizes that the student is culturally and linguistically competent to complete the duties of a medical student and upon graduation the duties of a physician in Spanish without the assistance of an interpreter. Furthermore, the student is capable of facilitating communication between the health-care team and Spanish-speaking patients. In order to earn this Certification, the student passed the following components exams: ALTA Language Service’s Clinician Cultural and Linguistic Assessment – Spanish, a standardized, validated phone exam developed in collaboration with Kaiser Permanente to certify bilingual physicians to provide patient care; ALTA Language Service’s Qualified Bilingual Staff Assessment – Spanish, a validated phone exam developed in collaboration with Kaiser Permanente to certify bilingual medical staff members to provide customer service, medical assistance, and ad-hoc Spanish-English interpretation and sight translation; and Stritch School of Medicine’s Spanish Objective Structured Clinical Exam which is based on an exam that is administered to all students in English and evaluates students’ ability to complete a history and physical exam in Spanish and document in English the pertinent findings, diagnostic hypothesis, and treatment and management plans.
Students who do not pass all three component exams will not earn the Certification. They will meet with clinical skills and Spanish-speaking faculty to identify the deficiencies in their skills. Some reason why a student might not earn the Certification include: 1. the student did not have a broad enough medical Spanish vocabulary or sufficient Spanish fluency to interview and respond to the patient; 2. the student did not have sufficient medical or general Spanish vocabulary to understand the patient; 3. the student did not have strong enough clinical skills to complete the required tasks; 4. the student was unable to remember the information obtained from the patient; 5. the student did not have sufficient interpreting or translating skills; 6. the student was unable to document in English the information that he obtained in Spanish; and 7. focusing on speaking Spanish prevented the student from being able to maintain a usual level of clinical skills. Once the student and faculty members identify each student’s areas for improvement, the faculty will advise the students on how to improve their skills. Most often this remediation will include: strengthening clinical skills through experience during clerkships; broadening medical Spanish vocabulary through self study; and improving medical Spanish communication skills by observing medical interpreters, practicing medical Spanish with the assistance of a medical interpreter, and practicing medical Spanish with fully bilingual patients.
In order to earn the Certification students must retake the exams that they did not pass. If students feel that they have made sufficient improvements in their skills to be able to meet the requirements of the Certification, they will be allowed to retake the relevant component exams during the following semester’s Certification administration. Students who do not pass the exams on a second attempt will be allowed subsequent attempts during the following semesters. However, they must meet with the Certification faculty to demonstrate completion of significant remediation resulting in improvement in skills prior to exam attempts beyond the second.
The Certification is administered by SSOM’s Department of Education.
Director: Dr. Gregory Gruener, Senior Associate Dean, Medical Education. Dr. Gruener oversees all aspects of the Certification administration and approves the certification of each student.
Coordinator: Claudia Kubnick, Executive Secretary to Dr. Gregory Gruener. Mrs. Kubnick informs students of opportunities to participate in the Certification program, registers students for the Certification, administers access codes for the CCLA and QBS, maintains all Certification records, distributes ID tags, and shares the list of certified students with clerkship directors, clerkship coordinators, the Student Affairs Deans, the Registrar, and Interpreter Services.
OSCE Director: Donna Quinones, Manager, Clinical Skills. Mrs. Quinones trains the standardized patients, coordinates OSCE administration, and provides students with formative feedback regarding their clinical skills exhibited during the OSCE.
Bilingual Faculty: We are in the process of recruiting a native Spanish-speaking faculty member to serve as a resource for standardized patients to answer questions regarding medical vocabulary, portrayal of clinical signs and symptoms, and Spanish and communication skills feedback. This faculty member will also review OSCE videos and computer documentation and meet with students to advise them on methods to improve their Spanish clinical skills and to review their remediation efforts before they retake exams.
Standardized Patients: The standardized patients are native Spanish-speakers who are trained to portray the signs and symptoms of a given illness and to provide students with feedback regarding their Spanish communication skills and cultural competency.
Q: How do you know that certified students really have the skills necessary to safely provide care to Spanish-speaking patients without the assistance of an interpreter?
A: The Spanish Bilingual Medical Student Certification is composed of three component exams that are accepted as standards for determining the competency of bilingual physicians, bilingual medical staff members, and clinical-level medical students. By requiring students to meet all three predetermined standards we can have confidence that they are able to safely care for Spanish-speaking patients without the assistance of an interpreter.
Q: Is the Spanish Bilingual Medical Student Certification the same as the Spanish Medical Interpreter Certification?
A: No. The Spanish Bilingual Medical Student Certification evaluates interpreting skills but it does not use the Interpreter Certification exam. Also, the Spanish Bilingual Medical Student Certification evaluates many skills that are not evaluated by the Interpreter Certification exam including direct patient care, clinical decision-making, and sight translation.
Q: Can certified students interpret for me?
A: Yes and no. Because they passed the Spanish Bilingual Medical Student Certification exams we know that certified students have the skills to interpret. Students are encouraged to interpret for their own patients and team members in situations such as during rounds or when they are seeing Spanish-speaking patients in clinic with their supervising physicians. Students may also volunteer to interpret for other patients if they have time to do so. However, students’ primary responsibility is to be students and rather than pulling certified students away from their assigned learning responsibilities to interpret you should call interpreter services or use a phone interpreter.
Q: We are caring for a Spanish-speaking patient but do not have a certified student on our team. Can’t we just have a family member interpret for us rather than waste time waiting for an interpreter or tracking down a phone in order to use a phone interpreter?
A: No. Interpreters are specifically trained to accurately and fully interpret the conversation between patient and provider. Often family members directly answer the providers’ questions without verifying that the answer is indeed the one the patient would have provided. Also, family members may not have the English or Spanish medical vocabulary necessary to properly interpret. Additionally, patients may not be entirely forthcoming with sensitive information if they are communicating through one of their own family members.
Q: Does using Spanish in clinical settings interfere with students’ learning opportunities?
A: No. Certified students use Spanish to complete the tasks they usually complete during the clerkships. Being certified allows patients to be more efficient in patient care, but should never prevent them from participating in learning opportunities.
Q: I grew up speaking Spanish. Do I really need to take these exams in order to be certified?
A: Yes. Spanish fluency is just one requirement for being able to safely care for Spanish-speaking patients without an interpreter’s assistance. Many people who grow up speaking Spanish are not familiar with medical Spanish terminology. Also, interpreting requires a distinct skill set from direct communication. In fact, studies have shown that native Spanish-speakers do not perform better on the Certification exams than non-native Spanish-speakers.
Q: I participated in a medical Spanish immersion program and/or took extensive medical Spanish courses and/or am certified as a medical Spanish interpreter. Do I really need to take these exams in order to be a certified bilingual medical student?
A: Yes. Even if you are comfortable with the medical terminology, we still need to know that you have enough Spanish fluency to be able to communicate with patients. Also, because Spanish is your second language we need to make sure that speaking and thinking in Spanish does not interfere with your ability to maintain the analytical thought process necessary to complete the responsibilities of a medical student. Additionally, students need assistance in evaluating their level of Spanish skills as studies have shown that students who describe their on medical Spanish skills as fluent do not perform better on the Certification exams than students who describe their own skills as less than fluent.
Q: When a student or interpreter is interpreting for me and my patient, what exactly do they interpret?
A: Everything! The interpreter’s role is to interpret absolutely everything that is said in the patients’ room and to serve as a cultural broker by explaining cultural terms or beliefs that the patient/provider may not understand. In addition to communication directed towards the patient/provider, this includes communication between family members, between health-care team members, and between provider/patient and interpreter. Furthermore, the interpreter will interpret all that is said, not just provide a summary. So if you do not want the patients to hear what you are saying, do not say it in the patients’ rooms!
Q: Do all medical schools have a Spanish Bilingual Medical Student Certification?
A: No. As far as we can tell, we are the first medical school to implement this type of an objective, standardized certification to evaluate students’ bilingual skills before they use them during their clerkships. According to a report publish in 2009 by The George Washington University and The California Endowment, 18% of hospitals offered an evaluation of bilingual health-care providers’ fluency and only 9% of hospitals required an evaluation. Hospitals reported that they did not evaluate bilingual fluency because assessment was not priority, they did not have a good assessment tool, and assessments were too expensive. However, here at LUMC we felt it was important to implement this Certification as part of our commitment to providing high quality and safe patient care while also treating the human spirit.
Q: What are the outcomes of the Spanish Bilingual Medical Student Certification?
A: The outcomes of the Certification have been extremely positive. In addition to certifying many students, we have helped several students who previously thought they were capable of providing patient care in Spanish to recognize the limits of their skills. All students who participated in the program found it to be a valuable learning experience. Students who earned the certification and went on to care for Spanish-speaking patients found that both patients and staff members appreciated the valuable resource they were able to contribute to patient care. Also, patients have expressed sincere appreciation for the patient centered approach that certified students provide as they make difficult situations less challenging by communicating with patients in their own language.