The AAVMC has prioritized diversity as one of its core values. Its DiVersity Matters initiative is helping veterinary medicine prepare for the changing demographics of the United States. One example of the changing demographics is the growing Hispanic population. In 2013, the Texas A&M University College of Veterinary Medicine & Biomedical Sciences responded to the needs of this growing sector by introducing medical Spanish into the core curriculum for Doctor of Veterinary Medicine (DVM) students. The medical Spanish course takes place over 5 weeks during the second year of the curriculum, and is composed of lectures and group learning. While this may seem like a very compressed time frame for language learning, our goal is to provide students with basic medical vocabulary and a limited number of useful phrases. In this paper, we outline the implementation of a medical Spanish course in our curriculum, including our pedagogical approaches to the curricular design of the course, and an explanation of how we executed these approaches. We also discuss the successes and challenges that we have encountered, as well as our future plans for the course. We hope that the successes and challenges that we have encountered can serve as a model for others who plan to introduce a foreign language into their curriculum as a component of cultural competency.
Introduction
In 2005, the AAVMC launched the DiVersity Matters initiative to prioritize diversity as a core value of veterinary medicine. The Colleges of Veterinary Medicine (CVMs) have been “encouraged to expand efforts to increase racial and ethnic diversity in academic veterinary medicine.”1(p.43) In addition to increasing diversity at the level of the CVMs through active recruiting and retention, we must train and prepare our current students to be culturally competent. While progress has been made in many aspects of diversity, there is still room for improvement,2 as veterinary medicine has been named the whitest profession in America.3 A recent study found that fewer than 20% of veterinary students nationally described themselves as able to provide medical information to a client in Spanish.4
The Hispanic population is growing in the United States. The number of Hispanic students in the nation's public schools nearly doubled from 1990 to 2006, accounting for 60% of the total growth in public school enrollments over that period. Strong growth in Hispanic enrollment is expected to continue for decades, and it is projected that there will be more school-age Hispanic children than school-age non-Hispanic white children by 2050.5 Texas is currently the nation's second most populous state, both in terms of overall population and Hispanic population, and it is expected to remain so by 2025. Estimates project that 17% of the national Hispanic population will reside in Texas.6 Eighty percent of Texas A&M DVM graduates stay in Texas to start their professional veterinary careers and the ability to converse in Spanish will be a significant skill as Texas becomes a majority-minority state.
Medical Spanish has been taught in the human health care curriculum for decades, particularly in areas with Latino-heavy populations. This includes programs in medicine, physical therapy, pharmacy, and others.7–9 Spanish educational programs range considerably from single courses to week-long immersions to fully integrated curricula.7
Most commonly, however, Spanish curricula employ both didactic and immersive experiences. Didactic experiences are combined with cultural immersion in a clinical setting.8 Programs typically follow the natural approach to language learning developed by Krashen and Terrell, which emphasizes the acquisition of a language through communication rather than learning the rules of grammar.10
In 2013 at Texas A&M University CVM, we added medical Spanish as a core component to our curriculum in place of content that was moved to orientation or into other courses. Our goal is to teach some basic Spanish language skills and to emphasize the importance of establishing a business environment welcoming to Hispanic clients. Initially, we designed the medical Spanish course around the pedagogical approach of peer-assisted learning (PAL). The students were instructed through traditional lectures and then given the opportunity to apply what they learned in small-group settings. There was no formal assessment, and we collected qualitative data. For the second iteration of the course, we created a blended learning experience and introduced simulated clients. The students were instructed through lectures that were hosted online, and they applied their knowledge in small-group settings and in exercises with a simulated client. We introduced a pre- and post-test to measure the students' knowledge and we collected qualitative data. This study was granted expedited approval by the Institutional Review Board at Texas A&M University.
Year 1
Year 1: Pedagogical Approach
Because of the relatively large size of the veterinary class and the limited number of fluent instructors available to teach, we elected to use a PAL approach to facilitate part of the class sessions.
Peer-Assisted Learning
PAL is defined as “people from similar social groupings who are not professional teachers helping each other learn and learning themselves by teaching.”11(p.322) PAL is not new to veterinary medical education. It has, for example, been used in communications skills training,12 bovine rectal palpation training using the Haptic Cow simulator,13 and anatomy courses.14
PAL has many benefits, such as enhanced learning in the context of social interactions and increased student comfort via interactions with tutors who have firsthand understanding of what the students are going through.12 Another significant benefit is the reduced workload for faculty and staff, the resulting small group sizes, a more intimate learning environment, and greater cost efficiencies.
Year 1: Implementation
We introduced medical Spanish into the curriculum in fall 2013 as a component of Clinical Correlates III, a multifaceted two-credit-hour course that addresses non-scientific veterinary knowledge and skills for second-year veterinary students (2VMs). In addition to medical Spanish, the course covers animal handling, animal welfare, cultural competency, and communications training. The medical Spanish section was offered over the first five Fridays of the fall semester and was divided into 1-hour traditional lectures in the morning and 2-hour group sessions in the afternoon. The first four lessons were designed to represent a typical veterinary visit, and the fifth to provide specialized vocabulary for large-animal practices:
•
Greetings and Basic Phrases (Bienvenidos, Saludos y Estructura de Frases)
•
History and Physical Examination (Historia y Examen Físico)
•
Diagnostics and Treatment (Diagnóstico, Tratamiento, Medicina Preventiva)
•
Discharge and Follow-Up (Seguimiento, Salida)
•
Large-Animal Medicine (Medicina de Animales Grandes)
Before the course started, students self-assessed their Spanish-speaking ability. This was done on a scale of 1 (fluent/native speakers) to 5 (no Spanish knowledge at all). We then divided the entire class (132 students) into four large groups. Each large group was assigned a Spanish-speaking faculty facilitator. The large groups (33 students) were subdivided into four small groups composed of students of similar skill levels based on their self-assessment. We assigned at least one advanced student speaker (level 2 or 3) to each of the smaller groups with the understanding that these students would serve as peer tutors. In addition, each small group was supported by a volunteer Spanish-speaking first-year veterinary student (1VM) or graduate student.
Grades during the medical Spanish section of Clinical Correlates were based exclusively on attendance.
Year 1: Student Outcomes
No formal assessment of the students took place. We collected qualitative student and instructor feedback but we did not assess student mastery of the material. In addition, we did not assess student retention of the material.
The most common student suggestion (n=13) was that the content/amount of material was overwhelming: “the pace was way too fast,” “it was significantly overwhelming if you had no Spanish experience,” and “as a non-Spanish speaker, I felt overwhelmed by the Spanish course.” This demonstrated the disadvantage of a one-size-fits-all lecture. The second most common suggestion (n=7) was to improve the overall organization of the course: “a little more structure to the Spanish lab time would be helpful” and “the lab section seems very disorganized.”
Year 1: Successes and Challenges
Content Delivery
Our goal for the course was not to make our students fluent in Spanish but to provide an introductory level of practical medical Spanish that prepares the students for basic Spanish encounters. We quickly learned, however, that the educational benefits to the students varied greatly depending on their pre-existing Spanish knowledge. Because the lectures were designed at a low-to-intermediate level, fluent speakers already knew much of the material and therefore had little advancement in knowledge through lecture. On the other hand, novice students (those that self-assessed as having little Spanish knowledge) gained very little because the material was too complex for them, and they were unable to keep up with the pace of the lectures.
Peer-Assisted Learning
To facilitate the PAL sessions, each small group in the afternoons had one Spanish-speaking 2VM and one Spanish-speaking 1VM or graduate student to serve as peer tutors. This helped to reduce our group sizes to approximately eight students per group. Though still larger than ideal, this created a better learning environment and more manageable group sizes than would have been otherwise possible. Feedback from the students serving as the peer tutors was generally positive: “I had a lot of fun teaching my colleagues” and “[being a peer tutor] was a great experience for me, as well as helping out my colleagues.”
The primary challenge that we faced with the small-group sessions was student engagement. Some student groups were clearly more motivated to learn than others, which appeared to depend on a variety of factors including the particular students in the group, the leadership of the PAL, the chemistry of the group, and other extraneous influences. Select student evaluations highlighted the following: “I feel that some groups were not structured … and spent a lot of time off topic”; “often times, we would talk for half the time and only practice for a few minutes”; and “people were getting tired of the [Spanish] program and wanted to get to work with the animals.”
Conclusions from Year 1
To accommodate our novice speakers who were unable to keep up with the pace of the course, we chose to digitize our lectures and implement a blended learning approach in the second year, meaning a combination of face-to-face teaching and online teaching, following the definition of Sharma.15 We decided to alter the structure of the PAL sessions and add simulated clients to help qualify student retention of the material and improve individual motivation. Finally, we recognized the need to assess the students on their progress throughout the course.
Year 2
Year 2: Pedagogical Approach
The PAL approach was helpful to facilitate our large class size with a limited number of instructors, so it was retained. To address the pacing and difficulty issues raised in the first year, we chose to make the class a hybrid of online and face-to-face teaching (blended learning). To address the problem of variable student engagement, we chose to introduce simulated clients as a formative assessment at the end of the course.
Blended Learning
The blended approach permitted students to review the material as much as necessary, and to do so at their own time and pace. This method shares commonalities with the flipped classroom model where the students might be assigned video lectures as pre-course work, freeing up the instructor's time in class to facilitate discussion rather than lecture.16 In our case, the online lectures replaced the morning lectures, rather than being in addition to them.
Simulated Clients
Simulated clients have been used in medical education, and more recently in veterinary medical education, as an aspect of communication skills training. Simulated clients offer students the opportunity to learn in a safe environment with controlled scenarios, and permit each student to see a similar case. For our purposes, the greatest benefit of simulated client interactions is the opportunity for students to apply the didactic Spanish lessons in a real-world setting.17,18
Year 2: Implementation
As in the first year, the medical Spanish section was offered over the first five Fridays of the fall semester and was divided into 1-hour lectures followed by 2-hour group sessions in the afternoon. However, the traditional lectures were digitized and placed onto a Learning Management System (LMS) for the students to access at their own pace. The lessons remained the same as in the previous year.
All students were required to self-assess their Spanish-speaking ability. As before, this was done on a scale of 1 (fluent/native speakers) to 5 (no Spanish knowledge at all). In addition to this, we also administered a course pre-test to students on the LMS. The course pre-test included 20 questions of varying difficulty. Self-assessment and pre-test scores were significantly correlated (Spearman's rho, p<.01), suggesting that student self-assessments were relatively accurate (data not shown). We used both the self-assessment scores and the scores on the course pre-test to divide the students into groups for the afternoon sessions. We divided the groups in the same way as in the previous year.
All students were required to take a pre-lesson assessment for each of the five lessons. The lesson assessment questions were presented in a random order and were written at a basic-to-intermediate level. Students who scored 100% on the pre-lesson assessment were excused from watching the digital lecture. This was implemented to respect the time of the advanced students and reward them for serving as peer tutors. Students who did not obtain a perfect score were required to watch the digital lecture and then complete a post-lesson assessment with a passing score of 70% to receive credit for attendance. After the 5 weeks, students completed the course post-test to measure their progress.
The last change we made from Year 1 was to divide students into groups of four to work together in interactions with Spanish-speaking simulated clients. During these scenarios, the students introduced themselves to their clients in Spanish, took a history, performed a physical exam, and communicated diagnostic and treatment information to their clients. These interactions took place after the conclusion of the 5 weeks of medical Spanish, and each group had two simulated client interactions on a single day. As in the previous year, a student's grade for the medical Spanish section of Clinical Correlates was based on attendance.
Year 2: Student Outcomes
The course pre-test was designed to separate students into five distinct skill levels. The pre-test consisted of 20 questions: four very basic questions, six low-intermediate questions, six high-intermediate questions, and four advanced questions. All questions were single-answer multiple choice, had an option for “I don't know,” and were presented in order of difficulty. Students were encouraged to select this option instead of guessing at an answer to help place them in the correct PAL group based on their true skill level. Approximately half of the questions required the students to listen to an audio file, one quarter of the questions required the students to read and interpret text, and the advanced questions required the students to watch a video encounter of two native Spanish speakers holding a rapid conversation. Students were not provided with an answer key after completing the test. After the completion of the medical Spanish portion of Clinical Correlates, students took a course post-test that was identical to the pre-test.
Out of 20.0 possible points, mean scores improved from 9.5 on the course pre-test to 15.0. Median scores improved from 9.0 to 15.0, and the lowest test score improved from 1.0 to 7.0. The difference in mean and median scores from pre-test to post-test is statistically significant with p<.001, using a paired t-test (Figure 1). Student performance on each group of questions (based on difficulty) also improved from pre-test to post-test (Table 1). The “I don't know” answer choice was selected 1,111 times in total on the course pre-test, but only 360 times on the course post-test. The number of times that “I don't know” was selected was significantly different for all of the questions from pre-test to post-test, with the exception of questions 2 and 4, using a sign test (Figure 2).
Total scores were significantly different from pre- to post-test (paired t-test, n=128, p<.001).
Figure 1: Student scores on the course pre-test (n=132) and post-test (n=128)
Table 1: Number of students who correctly answered all of the questions of each difficulty level on the pre-test and post-test
Difficulty of questions
Pre-test n
Post-test n
Basic
71
91
Low-intermediate
25
59
High-intermediate
10
31
Advanced
13
22
The number of “I don't know” responses for each question was significantly different from pre- to post-test with the exception of questions 2, 3, and 4 (sign test, p<.05 for each question).
Figure 2: Percentage of students who selected a correct answer, an incorrect answer, or the “I don't know” option for each question on the course pre-test (top) and post-test (bottom)
We were not surprised by the improvement in test scores of students who started as very basic Spanish speakers, as the course assessment seems to be an accurate reflection of the information taught throughout the class. Students who had pre-existing Spanish experience improved approximately one level based on the course pre-test to post-test (e.g., from low-intermediate to high-intermediate), which we consider a success. At this time, however, we are unable to determine the students' true skill level in the real world. Regardless, the authors believe that the development of a tiered structure of difficulty for the course content would be beneficial to all students.
The number of times the “I don't know” answer was selected decreased dramatically and significantly from the course pre-test to the course post-test. Although the correct answer was not always selected, this suggests that students felt more confident in their abilities after the course. Anecdotally, we witnessed this confidence during the encounters with the simulated clients, where the students were willing to give their best attempt at communicating in Spanish.
One limitation of the post-test was that the same questions were used as in the pre-test, but this influence was reduced by the “I don't know” answer option, the inability of students to view the answer key after taking the pre-test, and the amount of time (and other coursework in the curriculum) that elapsed between the two tests. Four students completed the course pre-test but not the post-test. This emphasizes the need to attach a grade to performance in the course, rather than relying simply on attendance.
Year 2: Successes and Challenges
Content Delivery
The introduction of the material on a LMS was relatively painless and worry-free due to the skills of the technology support staff. Barring a few intermittent technical errors, students were able to access all course material and to take the assigned tests. Any parties interested in taking a similar approach would be well advised to first ascertain the technology and support staff at their disposal.
The students who benefitted most from this approach were the novice speakers, who could watch the lectures as many times as needed to learn the material. An unintended benefit of digitizing the lessons was that we have been able to utilize them for other purposes. For example, we distributed the digital lectures before a continuing education workshop on medical Spanish to give those participants the opportunity to prepare in advance.
Simulated Client Interactions
The authors of this paper are of the opinion that the introduction of simulated clients to the medical Spanish course had the greatest learning impact on the students. It seemed to us, witnessing the interactions firsthand, that many students had a “wake-up call” to the practicality of the course material. In addition to the opportunity to practice the Spanish language, the simulated client interactions introduced students to different cultural norms. Student feedback on the encounters was also quite positive: “The client simulations were a bit nerve-wracking, but they ended up being very enjoyable and helpful in practicing communication with all types of clients”; “The client communications exercise in Spanish was a great way to top off the course! It felt very real to me and the actors did a great job”; and “I also really enjoyed role playing where we communicated with Spanish speakers.”
Peer-Assisted Learning
No changes were made in the second year to the PAL portion of the class. We continued to recruit fluent Spanish-speaking first-year DVM students to serve as peer tutors, each group was still composed of approximately eight students, and student engagement continued to be variable. We hope, however, that students who struggled during the simulated client scenarios will see the real-world applicability of the material and will consider learning it on their own time. Furthermore, we anticipate that the engagement of future classes will improve as they hear about the simulated client scenarios through word of mouth.
Plans for Year 3
For the third year of the course, we will make modest changes, given time and budget constraints, and will collect additional data. We plan to introduce a medical Spanish encounter with a simulated client to the 3VM communications curriculum. We hope that this will provide us early data on long-term knowledge retention. More importantly, we will make the students' scores on the post-lesson assessments count as a portion of their overall grades in the Clinical Correlates course. We presume this will have a large impact on increasing student engagement in the course.
Continuing Challenges for Future Years
As the veterinary curriculum is updated and refined, the medical Spanish course should be adapted to complement those changes. The simulated client interactions should be tailored so that they help bridge material from other courses. Not only will this allow students to practice their Spanish, it will also help them develop basic veterinary communications techniques and demonstrate their knowledge from scientific-based courses in the curriculum. For example, a case could be created so that the students must select the correct parasiticide for a patient, incorporating the information they are currently being taught in parasitology.
The most critical alteration that is necessary to improve student outcomes is the development of different learning tracks. An improved pedagogical approach would assess an individual student's current level of understanding, teach to that level, and then assess his or her new level of understanding. By assigning students to the different tracks based on their skill level, we could optimize their learning experience. Students who test to the most basic levels, for example, would take lessons that primarily teach vocabulary terms. The fluent speakers, in contrast, might have short didactic lessons that focus on specific medical terminology. These learning tracks would follow a blended learning approach, and ultimately we plan to design the course so that they can be integrated into the curricula of other CVMs, although additional funding would be needed to achieve this goal.
We faced pedagogical challenges related to second-language teaching. Non-proficient use of a second language in a clinical setting has been shown to increase the risk of misunderstandings and medical errors. In human medicine, federal law requires that hospitals ensure the competence of individuals who provide interpretation.19 The use of professional medical interpreters is the gold standard, as this has been shown to reduce or eliminate these risks.20 There are currently no such mandates in veterinary medicine regarding interpretation, and using an in-house professional may not be economically feasible for many veterinary practices. An ad hoc interpreter is an untrained individual such as a family member or a bilingual staff member who can provide interpretation.21 Although ad hoc interpreters are commonly used, they have the potential to inaccurately interpret the conversation or cause bias.20 An infrequently (and possibly underutilized) alternative is telephone interpretation. Pay-as-you-go telephone interpreters could provide a cost-effective means of professional interpretation to the veterinary clinic.22 Technological advances in translation software and apps can also serve as supplemental interpretation aids. Students and practitioners should be made aware of the interpretation options available to them.
The challenge of balancing an expanding body of knowledge against a limited amount of time in the curriculum is one that cannot be ignored. Perhaps, then, a reasonable approach would be to spend the majority of the novice students' time focused on cultural awareness and how to use the interpretation resources at their disposal, with only a small amount of time devoted to everyday vocabulary. The more advanced students, on the other hand, could spend the majority of their time focusing on advanced medical vocabulary.
Blueprints for Implementation
The authors hope that organizations interested in implementing a similar program can avoid some of the pitfalls that we experienced and immediately benefit from some of our successes.
1.
Identify your resources: peer-assisted learning offers tremendous logistical advantages that permit us to create smaller learning groups. This is certainly possible with a course such as Spanish, where a certain percentage of the student population will have some pre-existing level of knowledge, but it might be more difficult to implement in other courses.
2.
Recognize your technological limitations: we are fortunate to have the infrastructure and technological resources at our disposal to deploy a blended learning course and to track student progress throughout. Before implementing something similar, we highly recommend discussions with your support staff to identify what possibilities exist.
3.
Set reasonable expectations: while the introduction of any new course to a curriculum can be demanding, motivating students to study and learn soft skills such as cultural competence can often be particularly challenging. We hope, in the future, to develop individualized learning tracks for students of different skill levels, but we recognize the associated expense and the commitment this would entail. We would highly recommend that others “start small” and reassess thereafter.
4.
Use appropriate assessments: as can be expected, many students are motivated by their performance in a course. We found that formative assessments, such as simulated client interactions, engage the students and demonstrate the practicality of the course material. However, summative (and graded) assessments might be necessary to get further engagement in the course.
Conclusion
Teaching a foreign language is only one aspect of increasing cultural competence in our students, and one in which we as teachers can demonstrate competence. At Texas A&M University, we added 5 weeks of basic medical Spanish training to our curriculum. The program has evolved each year as we strive to improve and refine our pedagogical approaches.
The first year focused on PAL and was an opportunity for us to see what worked well and what needed improvement. The second year employed a blended learning approach and introduced simulated clients to the course. The quantitative data that we gathered show that the course has been modestly successful, especially for the novice Spanish-speaking students. More research is needed to see what impact this course has on diversity and cultural competence of the students, and to measure long-term retention of Spanish-speaking ability.
ACKNOWLEDGMENTS
The authors would like to thank the following for their hard work and dedication:
•
Texas A&M Health Science Center, Clinical Learning Resource Center
•
Supporting faculty: Tony Caraballo, Maria Esteve-Gassent, Jill Heatley, Mauricio Lepiz, and Franklin Lopez
•
Production team: Scott Birch and Tonya Miles
•
First-year veterinary students and graduate students who helped with the peer-assisted learning
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Landau RE, Beck A, Glickman LT, et al. Survey of US veterinary students on communicating with limited English proficient Spanish-speaking pet owners. J Vet Med Educ. 2015;42(4):324–31. https://doi.org/10.3138/jvme.0215-025R. Medline:26291506
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Biography: Jordan D. Tayce, DVM, MA, is Instructional Assistant Professor, The Center for Educational Technologies, Texas A&M University, College Station, TX 77843–4458 USA. Email: [email protected].
Biography: Suzanne Burnham, DVM, is Senior Veterinary Public Health Specialist, Center for Infectious Disease Research and Policy (CIDRAP), University of Minnesota, Minneapolis, MN 55455 USA. Email: [email protected].
Biography: Glennon Mays, DVM, is Clinical Associate Professor, Large Animal Clinical Sciences, Texas A&M University, College Station, TX 77843–4475 USA.
Biography: Juan Carlos Robles (deceased), DVM, was Clinical Assistant Professor, Department of Veterinary Physiology & Pharmacology, Texas A&M University, College Station, TX 77843–4466 USA.
Biography: Donald J. Brightsmith, PhD, MS, is Assistant Professor, Department of Veterinary Pathobiology, Texas A&M University, College Station, TX 77843–4467 USA.
Biography: Virginia R. Fajt, DVM, PhD, DACVCP, is Clinical Associate Professor, Department of Veterinary Physiology & Pharmacology, Texas A&M University, College Station, TX 77843–4466 USA. Her research interests include clinical pharmacology and pharmacology education.
Biography: Dan Posey, DVM, DABVP (beef cattle), is Director of Student Affairs, Office of the Dean, Texas A&M University, College Station, Texas 77843–4461 USA. Email: [email protected].
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