English proficiency level and satisfaction with studying medicine: a mediation analysis by age among domestic and international students in Argentina

Nivel de dominio del inglés y satisfacción con estudiar medicina: análisis de mediación por edad en estudiantes nacionales y extranjeros en Argentina

Introduction: Satisfaction with studying medicine may be influenced by English language proficiency level and student age. Research exploring the indirect relationships between these variables is limited.

Objective: To analyze whether age mediates the association between English proficiency level and satisfaction with studying medicine.

Materials and method: Analytical cross-sectional study using secondary data. The dataset was derived from a survey administered between October and November 2020 to 2 301 first- and fifth-year medical students in Argentina. The association between English proficiency level and satisfaction with studying medicine was evaluated, considering age as a mediator and adjusting for sociodemographic covariates. Hayes’ PROCESS model 4 with bootstrap resampling (5 000 samples) was used, and a directed acyclic graph was created to visually represent the proposed causal relationships.

Results: The mean age of the students was 23.67 years, 79.10% were women, 72.10% reported an intermediate/advanced English proficiency level, and 77.31% expressed satisfaction with studying medicine. English proficiency level was significantly associated with younger age (B=-1, p<0.001), whereas being a student of an advanced academic year (fifth year vs. first year) and having children were associated with older age (B=1, p<0.001 and B=10, p<0.001). Other variables associated with older age included marital status, sex, and studying at a private university. The model explained 45.7% of the variance in age (R2=0.457, p<0.001). In the logistic regression model, age was negatively associated with satisfaction with studying medicine (B=-0.041, p=0.002), and English proficiency level showed no direct effect (B=0.051, p=0.653). The mediation analysis showed a significant indirect effect of English proficiency level on satisfaction with studying medicine through age (B=0.052, BootSE=0.019, 95%CI: 0.018 to 0.094), confirming its mediating role.

Conclusions: English proficiency level was indirectly associated with satisfaction with studying medicine, and this association was mediated by age.

Introducción. La satisfacción con estudiar medicina podría estar influida por el dominio del inglés y la edad de los estudiantes. Sin embargo, la exploración de las relaciones indirectas entre estas variables es limitada.

Objetivo. Analizar si la edad de los estudiantes universitarios mediatiza la asociación entre el nivel de inglés y la satisfacción con estudiar medicina.

Materiales y método. Estudio transversal analítico basado en datos secundarios. Se usó la base de datos de una encuesta aplicada entre octubre y noviembre de 2020 a 2 301 estudiantes de primer y quinto año de medicina en Argentina. Se evaluó la asociación entre el nivel de inglés y la satisfacción con estudiar medicina, considerando la edad como mediadora y ajustando por covariables sociodemográficas. Se empleó el modelo 4 de PROCESS de Hayes con remuestreo bootstrap (5 000 muestras) y se creó un diagrama acíclico dirigido para representar visualmente las relaciones causales planteadas.

Resultados. La edad promedio de los estudiantes fue 23.67 años, 79.10% eran mujeres, 72.10% declararon tener un nivel de dominio intermedio/avanzado del inglés y 77.31% expresaron estar satisfechos con estudiar medicina. El nivel dominio del inglés se asoció significativamente con menor edad (B=-1; p<0.001), mientras que pertenecer a un año de estudio superior (quinto año vs. primero año) y tener hijos se asociaron con una mayor edad (B=1; p<0.001 y B=10; p<0.001). Otras variables asociadas con mayor edad incluyeron estado civil, sexo y estudiar en una universidad privada. El modelo explicó el 45.7% de la varianza en la edad (R2=0.457; p<0.001). En el modelo de regresión logística, la edad se asoció negativamente con la satisfacción con estudiar medicina (B=-0,041; p=0.002) y el nivel de dominio del inglés no mostró un efecto directo (B=0.051; p=0.653). El análisis de mediación evidenció un efecto indirecto significativo del nivel de dominio del inglés sobre la satisfacción con estudiar medicina a través de la edad (B=0.052; BootSE=0.019; IC95%: 0.018 a 0.094), confirmando su papel mediador.

Conclusiones. El nivel de dominio del inglés se asoció indirectamente con la satisfacción con estudiar medicina y esta asociación estuvo mediada por la edad.

Original research

Alberto Guevara-Tirado1

1 Universidad Científica del Sur - Faculty of Medicine - Lima - Peru.

Open access

Received: 03/07/2025

Accepted: 29/04/2026

Corresponding author: Alberto Guevara Tirado. Facultad de Medicina, Universidad Científica del Sur. Lima. Perú. E-mail: albertoguevara1986@gmail.com.

Keywords: Students, Medical; Personal Satisfaction; Communication Barriers; Motivation; Mediation Analysis (MeSH).

Palabras clave: Estudiantes de Medicina; Satisfacción Personal; Barreras de Comunicación; Motivación; Análisis de Mediación (DeCS).

How to cite: Guevara-Tirado A. English proficiency level and satisfaction with studying medicine: a mediation analysis by age among domestic and international students in Argentina. Rev. Fac. Med. 2026;74:e121355. English. doi: https://doi.org/10.15446/revfacmed.v74.121355.

Cómo citar: Guevara-Tirado A. [Nivel de dominio del inglés y satisfacción con estudiar medicina: análisis de mediación por edad en estudiantes nacionales y extranjeros en Argentina]. Rev. Fac. Med. 2026;74:e121355. English. doi: https://doi.org/10.15446/revfacmed.v74.121355.

Copyright: ©2026 The Author(s). This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International License, which permits unrestricted use, distribution, and reproduction in any medium, as long as the original author and source are credited.

Abstract

Resumen

Introduction

In today’s globalized world, English has become the lingua franca across all scientific fields, including medical science and medicine.1,2 It serves as the primary medium for academic communication (correspondence, conferences, international collaboration) and for accessing updated scientific and biomedical knowledge (journal article publication and opportunities for international medical training programs and medical specialties).1-3 Consequently, English language proficiency is no longer just an option in medical training.

However, the acquisition of this competence is not a uniform process and appears to be influenced by generational factors and exposure to technology, with younger students showing greater familiarity with the language due to their immersion in global digital environments where English is widely used.4-6 This extramural exposure, facilitated by digitalization, allows digital natives to develop English language skills as a second language informally and continuously, creating a significant gap with previous generations.4-8

University-level student satisfaction is typically understood as the happiness and well-being students experience when their needs and expectations are met.9 This influences both how much students enjoy their time at university and their academic performance.9 It is considered a multidimensional variable that encompasses the entire university experience10 and varies by field of study.11 High student satisfaction is associated with lower dropout rates, better academic performance, and greater long-term professional commitment,3 meaning that understanding the factors that influence it can provide valuable evidence to design interventions that promote more successful and sustained educational pathways.

Although its definition may vary depending on the perspective used, academic satisfaction can be defined as positive student attitudes toward their field of study. This has become an important subjective variable in educational outcomes for educational institutions because of its relationship with fundamental constructs such as tolerance to stress, student retention, class attendance, and academic performance. Indeed, it positively associates with self-efficacy, optimism, resilience, and study commitment.12 In turn, the medical profession is one of the most demanding, and it has been reported that student satisfaction with studying medicine decreases as medical training progresses. This highlights the need to reflect not only on the motivation to study medicine but also on students’ satisfaction with their career choice and the stress they experience during training13

Despite the importance of English proficiency in medical training within today’s globalized world,1-3 its relationship with satisfaction with studying medicine has not been explored in Latin America. Furthermore, since English communication skills could be influenced by generational factors in terms of natural exposure to the language, it is plausible to hypothesize that, in countries with a native language other than English, student age could play a mediating role in the relationship between English proficiency level and satisfaction with studying medicine.

Recent studies, both in international contexts14 and in Argentina,15 have analyzed educational satisfaction levels and quality of life among medical students, respectively. However, the analysis of indirect relationships between academic and sociodemographic variables using mediation models remains limited in this field.

In view of the foregoing, the objective of this study was to analyze whether university students’ age mediates the association between English proficiency level and satisfaction with studying medicine. It is expected to provide empirical evidence on a little-explored aspect of medical training, with implications for curriculum design, university language policies, and student academic support

Materials and methods

Study type

Analytical cross-sectional study based on secondary data.

Data analyzed and source

The database used was derived from a survey administered between October and November 2020 to first- and fifth- (and/or final-) year medical students in Argentina. This database (openly accessible since 2023 in the institutional repository of the Consejo Nacional de Investigaciones Científicas y Técnicas [National Scientific and Technical Research Council, CONICET by its Spanish acronym] at https://ri.conicet.gov.ar/handle/11336/217330) contains information from the 2 301 students who fully completed the questionnaire, constituting the analytical sample for this study.

The survey was administered online and consisted of 22 multiple-choice questions aimed at obtaining information on students’ sociodemographic and academic characteristics, as well as their motivations for studying medicine and their perceptions of the program. These questions were selected from the 81 questions of the Red Latinoamericana de Investigación en Recursos Humanos en Salud (Latin American Network for Research on Human Resources in Health, LIRHUS by its Spanish acronym) survey, previously administered to medical students in 11 Latin American countries.

Students were recruited through convenience sampling. Participation was voluntary and promoted via social media (Facebook, Instagram, WhatsApp) and through professors from different universities. Complete information about the instrument and its administration is available in the study by Rousseau-Portalis et al.16

This database was selected because the participants represent opposite ends of the educational process, allowing for a comparison of perceptions based on the level of academic progress in medical school. Furthermore, while a nationally representative sample cannot be guaranteed due to the sampling method, it is a large sample that includes students from most medical programs offered in Argentina.

Variables and measurements

The independent variable was English proficiency level, assessed in the survey with four response options (does not speak English, basic, intermediate, advanced) and dichotomized in this study as “low level” (does not speak/basic) and “intermediate/advanced level”. The dependent variable was satisfaction with studying medicine, evaluated using a 5-point Likert scale and dichotomized into satisfied (“very satisfied” and “satisfied”) and dissatisfied (“neutral,” “dissatisfied,” and “very dissatisfied”) based on conceptual and statistical criteria. This facilitated the use of logistic regression and mediation models and allowed identifying profiles at higher risk for academic dissatisfaction. In any case, it should be noted that this dichotomization was already present in the study by Rousseau et al.14 and in the database.

Age was treated as a continuous mediating variable. In addition, academic year (first/fifth year), having children (yes/no), marital status (single, married, cohabiting, other), university funding source (public/private), and sex were considered covariates and were adjusted for in the models due to their potential role as confounding factors.

Statistical analysis

Data are described using absolute frequencies and percentages for categorical variables and means and standard deviations for continuous variables (age) since a normal distribution was observed (Kolmogorov-Smirnov test).

The proposed mediation model was evaluated using the PROCESS macro v5.0 (developed by Andrew F. Hayes) implemented in IBM SPSS Statistics (version 27). Simple mediation Model 4 was used, which allows estimating whether the effect of a predictor variable (English proficiency level) on a binary outcome (satisfaction with studying medicine) is fully or partially explained by a continuous mediating variable (age).17

Direct and indirect effects were calculated using the bootstrapping resampling technique, a non-parametric method consisting of generating multiple random samples with replacement (5 000 in this case) from the original sample (n=2 301). This technique allows for robust estimation of 95% confidence intervals (95% CI) for the effects18 without assuming normality in the distribution of the indirect effect estimator, which is particularly useful in mediation models where this parameter is rarely normally distributed.

Multiple linear regression was applied to model the relationship between English proficiency and age, followed by a binary logistic regression to analyze the effect of age and English proficiency level on satisfaction with studying medicine, both adjusted for sociodemographic covariates (academic year, having children, marital status, university funding source, and sex). Finally, a directed acyclic graph was developed using the website www.dagitty.net to visually represent the proposed causal relationships, illustrating the role of mediation and control variables in the model.

Ethical considerations

As a secondary analysis of anonymized, open-access data (Creative Commons CC BY 2.5 license), this study did not require an institutional ethics committee approval. Additionally, the original study from which the analyzed database originated was conducted in accordance with the ethical principles for medical research involving human subjects established in the Declaration of Helsinki19 and was approved by the Institutional Ethics Committee of the Instituto Alberto C. Taquini (V1.0, 28/06/2021).16 All students participated voluntarily, and their informed consent was obtained implicitly upon completing the survey. For further information, the repository can be accessed at the following link: https://ri.conicet.gov.ar/handle/11336/217330#anchorFiles.

Results

The mean age of the students was 23.67 years, and the majority were women (79.10%), born in Argentina (82.14%), and single (90.09%). The distribution by academic year was similar (first year: 49.59%), 86.92% studied at a public university, 72.10% reported having an intermediate/advanced level of English proficiency, and 77.31% expressed being satisfied with studying medicine. The characteristics of the 2 301 students are described in Table 1.

Table 1. Sociodemographic and academic characteristics of first- and fifth-year medical students in Argentina (n=2 301).

Variable	Category	n	%
Sex	Female	1820	79.10%
	Male	481	20.90%
Country/region of origin	Argentina	1890	82.14%
	Latin-American (except Argentina)	200	8.69%
	Europa	118	5.13%
	Asia	45	1.96%
	Africa	27	1.17%
	United States	10	0.43%
	Oceania	10	0.43%
	Antarctica	1	0.04%
Academic year	First year	1141	49.59%
	Fifth year	1160	50.41%
Marital status	Single	2073	90.09%
	Married	45	1.96%
	Cohabiting	145	6.30%
	Other	38	1.65%
Children	No	2223	96.61%
	Yes	78	3.39%
University funding source	Public	2000	86.92%
	Private	301	13.08%
Satisfaction with studying medicine	Satisfied	1779	77.31%
	Dissatisfied	522	22.70%
English level	Low level	642	27.90%
	Intermediate/advanced level	1659	72.10%
Continuous variable	n	Mean	Standard deviation
Age	2 301	23.67	4.699

Source: Own elaboration.

According to the results of the linear regression model analyzing the influence of English proficiency level on students’ age, including relevant covariates, English proficiency level was significantly associated with a younger age (B=-1; p<0.001), suggesting that younger students tend to report a higher proficiency level in the language. In addition, being in an advanced academic year (fifth year vs. first year) (B=1; p<0.001) and having children (B=10; p<0.001) were associated with an older age. Other variables such as marital status (B=1; p<0.001), university funding source—studying at a private university—(B=-0.54; p=0.013), and sex (B=0.35; p=0.050) also showed significant associations with age. The model explained 45.7% of the variance in age (R²=0.457; p<0.001), indicating a robust and relevant fit for understanding the mediating role of age in the association between English proficiency level and satisfaction with studying medicine (Table 2).

Table 2. Linear regression model of the mediator (age) as a function of English level and covariates.

Variable	Coefficient (B)	Standard error (SE)	t	p-value	95%CI (LL-UL)
(Constant)	21	0.174	120.26	<0.001	20.546 a 21.227
English proficiency level	-1	0.163	-7.85	<0.001	-1.594 a -0.957
Academic year	1	0.037	28.44	<0.001	0.973 a 1.117
Having children	10	0.415	23.85	<0.001	9.087 a 10.715
Marital status	1	0.122	8.83	<0.001	0.836 a 1.314
Funding source	-0.536	0.216	-2.48	0.013	-0.960 a -0.113
Sex	0.352	0.179	1.96	0.05	0.000 a 0.703

Note: Direct and indirect effects are adjusted for academic year, having children, marital status, university funding source, and sex.

Source: Own elaboration.

The logistic regression model showed that age was inversely associated with satisfaction with studying medicine (B=-0.041; SE=0.013; p=0.002), indicating that older age is associated with a lower probability of reporting satisfaction with the decision to study medicine. This association remained statistically significant even after adjusting for English proficiency level and sociodemographic variables. Conversely, English proficiency level did not show a direct effect on satisfaction (B=0.051; p=0.653), suggesting that its influence might depend on indirect paths or be mediated by other variables, as explored later. The included covariates (academic year, children, marital status, university funding source, and sex) were not significantly associated with satisfaction, reinforcing the specific weight of age as a relevant factor in this context (Table 3).

Table 3. Logistic regression of satisfaction with studying medicine by age, English level, and covariates.

Variable	Coef. (B)	SE	Z	p-value	95%CI (LL-UL)
(Constant)	2.000	0.308	7.43	<0.001	1.684 a 2.890
English	0.051	0.113	0.45	0.653	-0.171 a 0.272
Age	-0.041	0.013	-3.07	0.002	-0.067 a -0.015
Academic year	-0.049	0.029	-1.69	0.090	-0.106 a 0.008
Children	0.252	0.307	0.82	0.412	-0.350 a 0.854
Marital status	0.017	0.084	0.20	0.839	-0.148 a 0.182
Funding source	0.095	0.154	0.62	0.537	-0.207 a 0.397
Sex	0.064	0.125	0.51	0.610	-0.181 a 0.308

Note: Direct and indirect effects are adjusted for academic year, having children, marital status, university funding source, and sex.

Source: Own elaboration.

The mediation analysis revealed that the direct effect of English proficiency level on satisfaction with studying medicine was not statistically significant (B=0.051; BootSE=0.113; 95%CI: -0.171 to 0.272), indicating that, in the absence of the mediator, English proficiency level does not directly predict student satisfaction. However, a significant indirect effect was identified through age (B=0.052; BootSE=0.019; 95%CI: 0.018 to 0.094), suggesting that English proficiency level influences satisfaction with studying medicine but in a way that is mediated by age. This finding supports the presence of an indirect mechanism whereby students with lower English proficiency tend to be older, and these older students, in turn, report lower satisfaction with studying medicine. The confidence interval not including zero confirms the robustness of the observed indirect effect (Table 4).

Table 4. Direct and indirect effects of English level on satisfaction with studying medicine.

Effect type	Effect	BootSE	95%CI
Direct effect (X→Y)	0.051	0.113	-0.171 a 0.272
Indirect effect via age	0.052	0.019	0.018 a 0.094

Note: Direct and indirect effects are adjusted for academic year, having children, marital status, university funding source, and sex.

Source: Own elaboration.

A directed acyclic graph was constructed to graphically represent the mediation model evaluated in the study. In this graph, English proficiency was established as the exposure variable, satisfaction with studying medicine as the outcome, and age as the mediating variable. The diagram showed an indirect path from English proficiency to satisfaction, mediated by age, which aligns with the findings from the PROCESS Model 4. Additionally, five covariates were incorporated (academic year, having children, marital status, university funding source, and biological sex), which showed significant associations with age in the linear regression model and were therefore represented with arrows pointing toward the mediator. This graphical representation clearly illustrates the hypothesized causal path, as well as the adjustment variables considered to control for confounding in the main relationship (Figure 1).

Figure 1. Directed acyclic graph of the mediation model of English proficiency on satisfaction with studying medicine, mediated by age and adjusted for covariates.

Source: Own elaboration.

Discussion

The findings of the present study reveal a significant mediating effect of age on the relationship between English proficiency level and satisfaction with studying medicine, providing novel evidence regarding the subjective determinants of academic well-being among university students. First, it was identified that a higher level of English proficiency is associated with a younger age, even after adjusting for sociodemographic variables such as academic year, marital status, children, sex, and university funding source. This inverse relationship can be interpreted as a reflection of a generational phenomenon in which younger students learn English easier, likely due to the increasing incorporation of this language into secondary education and greater digital exposure to it.4,5,20

Furthermore, the logistic regression model showed that age is negatively and significantly related to satisfaction with studying medicine, suggesting that older students tend to report a lower level of satisfaction. This pattern could be explained, at least partially, by daily life factors such as more family responsibilities and age-related changes in learning styles.21

Contrary to expectations, English proficiency level did not show a significant direct effect on satisfaction, reinforcing the relevance of the indirect path through age as the main mechanism of influence. The mediation analysis confirmed this mechanism, demonstrating a significant indirect effect of English level on satisfaction with studying medicine through age, even though the direct effect was not significant. This finding suggests that English, beyond its instrumental value in medical training,1 could be acting as a marker of generational integration and, consequently, of differentiated educational experiences that affect the subjective perception of the professional career.

Finally, the statistical robustness of the model (demonstrated by 45.7% of the variance explained in age [R2=0.457, p<0.001] and a significant indirect effect with confidence intervals that do not include zero [95%CI: 0.018 to 0.094]) and the consistency of the results after controlling for multiple covariates support the validity of the conclusions obtained. Additionally, although the study was conducted at Argentine universities, nearly 18% of the students were foreign, which provides a certain degree of international heterogeneity. This diversity suggests that the relationship between age, English proficiency level, and academic satisfaction could be replicated in contexts with migrant or international student populations. However, it should be noted that stratified analyses based on origin and/or international student status were not performed, so this aspect should be interpreted with caution. This reinforces the relevance of exploring these associations in multicultural educational settings or with student mobility.

The findings of this study provide evidence regarding the mediating role of age in the relationship between English proficiency level and satisfaction with studying medicine, representing a relevant contribution to the understanding of academic and motivational factors in Spanish-speaking university contexts. Based on these results, medical schools in the country, and even in the region, could implement language support programs focused on older students, as they report lower levels of satisfaction; for example, English workshops with emphasis on medical terminology. Likewise, our findings suggest that knowing the medical students’ English proficiency level at the beginning of their training would allow for the design of personalized teaching strategies that promote academic adaptation, such as peer mentoring.

However, this mediation model also raises new questions that should be explored, namely, what other factors, such as prior work experience or vocational motivation, could simultaneously influence English proficiency level and academic satisfaction, and how does the relationship between English proficiency level and academic satisfaction vary across different stages of medical training or between studying at public and private universities. These questions highlight the need for longitudinal and multinational studies to expand the scope and applicability of the results obtained here.

The present study has some limitations that must be considered when interpreting the results. First, its cross-sectional design prevents the establishment of definitive causal relationships, meaning that the findings must be interpreted as associations. Second, all variables were self-reported, which may introduce social desirability bias or recall errors; moreover, the assessment of English level was based on self-perception rather than a standardized test, which may affect the precision of the construct. Third, information on relevant factors in English acquisition—such as prior bilingual education, extracurricular education, or daily exposure to the language—was not available; these factors could act as confounders, so residual confounding cannot be ruled out. Fourth, academic or psychological variables such as prior performance, vocational motivation, or institutional support were not considered, which could influence the level of satisfaction with studying medicine. Fifth, students were recruited through convenience sampling (voluntary participation in a survey distributed via social networks and by professors), which introduces self-selection bias and limits national representativeness, meaning that generalization of the results should be done with caution.

Conclusion

Among medical students in Argentina, English proficiency level was indirectly associated with satisfaction with studying medicine, and this association was mediated by age. Younger students, characterized by a higher level of English proficiency, reported higher levels of satisfaction. These results demonstrate the relevance of considering the influence of linguistic and age variables on the academic well-being of medical students and suggest the incorporation of differentiated institutional support strategies for older students or those with lower English proficiency, given their profile of higher risk for dissatisfaction with their decision to study medicine.

Conflicts of interest

None stated by the authors.

Funding

None stated by the authors.

Acknowledgments

None stated by the authors.

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