Communicating Effectively with Limited English Proficiency Patients: Incorporating Training on Working with Medical Interpreters in the Undergraduate Medical Curriculum

doi:10.21203/rs.3.rs-2011122/v1

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Communicating Effectively with Limited English Proficiency Patients: Incorporating Training on Working with Medical Interpreters in the Undergraduate Medical Curriculum

https://doi.org/10.21203/rs.3.rs-2011122/v1

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Background: As the number of patients with limited English proficiency (LEP) grows in the United States, medical trainees must be competent to provide care to LEP patients with the use of professional medical interpreters (MIs). Since little time in undergraduate medical education (UME) is devoted to this competency, we developed an educational workshop on effective communication with professional MIs and Spanish-speaking LEP patients.

Methods:In the winter semester of 2022, a two-hour required workshop was implemented with first-year medical students at Nova Southeastern University Dr. Kiran C. Patel College of Allopathic Medicine. This featured four educational strategies: 1) Facilitator-led instructional simulation activity, 2) Interactive didactic via PowerPoint, 3) Small group clinical case discussion, and 4) Large group MI simulation activity. Participant volunteers completed an anonymous, pre - and post-workshop evaluation and a self-assessment to determine post-intervention readiness to interact with MIs.

Results:Of the 51 participants, 43 (84%) completed the pre- and post-workshop evaluations. Approximately 83% reported “little to no” or “limited” Spanish language fluency. Participants reported a statistically significant (p<0.05) increase in their confidence to explain the importance of using MIs to improve LEP patient care, and to demonstrate both respect for the individual and cultural humility when using MIs. The self-assessment showed an increase in the average score for all questions tested. Ninety-eight percent of the participants strongly agreed or agreed that the workshop met its objectives. Thematic analysis of qualitative feedback centered around three major themes: MI need, MI practice, and medical Spanish knowledge.

Conclusions:Our curricular intervention was successful in increasing self-reported measures of skills and best practices on how to communicate effectively with Spanish-speaking LEP patients with the use of MIs. Implementation of MI training programs in UME can be a successful strategy to prepare trainees to provide care for the growing LEP population.

medical interpretation

limited English proficiency

medical student

undergraduate medical education

cultural competency

professional medical interpreter

medical Spanish

cross-cultural communication

health disparities.

Effective communication between health care providers and patients is essential to the provision of safe and high-quality patient-centered healthcare ¹. Patients with language barriers experience health disparities including higher risk for non-adherence to treatment recommendations and receiving inadequate information for health prevention, disease state, and medical consent ^{2, 3}. They also have a greater dissatisfaction with care and higher risk for medical errors resulting in physical harm ^{4, 5}. In 2020, people with limited English proficiency (LEP), defined by the US census as those who speak English less than “very well,” represented 8.2% (25.3 million) of the US population that are five years old and older ⁶. About 21.5% (66.1 million) of the United States population speaks a language other than English, with Spanish being the most common language spoken at home ⁶. In Florida, 21.8% (4.4 million) of the population speaks Spanish at home ⁶. The above factors highlight the importance of improving communication in healthcare settings to bring better health outcomes.

A professional medical interpreter (MI) can minimize the health disparities experienced by LEP patients. Studies have consistently shown that the use of a MI is associated with enhanced communication between LEP patients and providers as well as improved health processes and outcomes. Some benefits include improved comprehension, fewer communication errors, lower risk of adverse effects, and increased patient satisfaction ⁷. Despite federal mandates for provision of health care services in a patient’s language by means of qualified professionals, as part of Title VI of the 1964 Civil Rights Act, the use of family members or untrained staff as ad hoc interpreters remains widespread and presents serious patient safety risks ^{8, 9}.

Despite the growing awareness of adverse health outcomes for the LEP patients and increasing numbers of non-English-speaking patients seen by providers, there is generally little curricular time in medical training devoted to the effective use of MIs. In 2017, only 29 of 147 LCME accredited medical schools offered a formal curriculum that taught medical students how to work with MIs and/or patients with LEP ¹⁰. Many of these curricular activities concentrating on improved use of MIs have focused on web-based or discussion-based practices ^{11, 12}. While these approaches are useful, they lack the educational benefits provided by the use of role play, simulation, reflection, and feedback. Engaging in a skill through role play has been shown to increase confidence with the skills practiced in various fields including the use of professional medical interpretation ^13–15.

As the LEP population continues to grow, it is imperative that medical students become aware of the importance of medical interpretive services and become more skilled in the use of MIs to improve patient care with the LEP population. To address the need for incorporating the effective use of professional MIs in undergraduate medical education (UME), we developed an educational workshop designed to provide medical students with skills and best practices on how to communicate effectively with MIs and Spanish-speaking LEP patients.

Institutional Review Board Approval and Curriculum Implementation

This study was reviewed and approved with exempt status by the Nova Southeastern University Institutional Review Board (IRB #: 2022 − 109). The two-hour interactive workshop was embedded into the reflection, integration, and assessment (RIA) week at the end of the Gastrointestinal/Human Nutrition/Endocrine/Reproductive (GIHNER) organ system course, which takes place in the winter semester of year one of the curriculum at Nova Southeastern University Dr. Kiran C. Patel College of Allopathic Medicine (NSU MD). The session was strategically placed in the curriculum after the students learned about sexually transmitted infections, practiced taking a patient’s medical sexual history, and were introduced to the use of MIs through problem-based learning cases. The skills and knowledge in these areas were beneficial for student preparedness for this workshop.

Participants

Fifty-one first-year medical students at the NSU MD participated in this workshop. Of them, 43 participated in the study by completing evaluations that included self-assessments.

Workshop Design And Facilitation

At the start of the workshop, facilitators discussed the learning objectives and participants were asked to complete a voluntary, anonymous pre-workshop evaluation (See Additional File 1) which included a self-assessment to determine their readiness to interact with MIs in a clinical setting. The workshop featured four primary educational strategies: 1) Facilitator-led instructional simulation activity, 2) Interactive didactic component via PowerPoint presentation, 3) Small group activity, and 4) Large group interpretation simulation activity. The facilitator-led simulated activity exemplified best practices and limitations when eliciting a medical history with a Spanish-speaking LEP patient using a MI. At the conclusion of the encounter, facilitators guided the students to reflect on this activity. The interactive presentation started with introducing information on how language barriers can adversely affect quality of care and patient safety, and with the description of the Title VI of the Civil Rights Act of 1964, which affects persons with LEP ⁸. The participants were then introduced to topics including when to use a professional MI, types of MIs, and best practices to work effectively with a MI. Furthermore, exercises were present during this component: Participants were asked to read a scripted dialogue between a physician and a nurse, exemplifying the use of a nurse as ad hoc interpreters.

Additionally, a case scenario depicting the limitations and repercussions of using a family member as an interpreter was presented. Finally, participants engaged in a medical Spanish exercise where they practiced how to introduce themselves and the professional MI to the patient in Spanish during a patient encounter, followed by early stages of the medical interview.

These activities were immediately followed by participants being divided into small groups. Participants were asked to read the case scenarios and associated questions, and then discuss their answers to the questions within their small groups. The case scenarios represented circumstances where the use the on-site professional MI services were warranted to elicit the patient history and to provide the appropriate care to the patient. Participants were provided with a medical English-to-Spanish translation Handout (See Additional File 2) to aid them during this exercise.

In the segment of the workshop that followed, individual groups had the opportunity to simulate the case scenarios they previously discussed during the small group activity. In short, participants simulated a physician, a Spanish-speaking LEP patient and a professional MI. After each simulation, all participants came together as a large group to discuss their reflection and reaction to the activity. The facilitator-guided discussion provided a transition to discuss key take-home points that emerged throughout the session. This activity highlighted how difficult it was to complete a task in a foreign language, the importance of utilizing a professional MI, and introduced best practices for utilizing a professional MI.

Evaluation

As the workshop concluded, participants were asked to complete the anonymous post-workshop evaluation (See Additional File 3), which was used to evaluate the effectiveness of the workshop. The evaluation also included the pre-workshop self-assessment to determine post-intervention readiness to interact with MIs in a clinical setting.

Data Analysis

An unpaired student’s t-test was used to assess the statistical significance of the data obtained using GraphPad Prism version 9.3.1 for Windows (GraphPad Software, San Diego, California USA). A p-value less than 0.05 was considered as significant.

There were 51 participants attending the workshop, of which 43 completed the pre- and post-workshop evaluations. The respondents self-identified their race/ethnicity as 20 (47%) white, 12 (28%) Asian, 4 (9%) Black or African American, 3 (7%) Hispanic or Latinx, 1 (2%) multiracial and other 3 (7%). In terms of gender, 23 (53%) identified as male and 20 (47%) identified as female. Participants reported their self-assessment on Spanish language fluency with 13 (30%) reporting little to no fluency, 23 (53%) limited fluency, 2 (5%) proficient fluency, and 5 (12%) being fluent in Spanish (Table 1).

Table 1

Demographic characteristics of participants (n = 43) who completed the pre- and post-session evaluation.
Participant Demographics
		n (%)
Gender	Male	23 (53)
Gender	Female	20 (47)
Age	≤ 24	30 (70)
	25–29	12 (28)
	30–34	1 (2)
Ethnicity	White	20 (47)
	Asian	12 (28)
	Black or African American	4 (9)
	Hispanic or Latinx	3 (7)
	Multiracial	1 (2)
	Other	3 (7)
Spanish Language Fluency	Little to none	13 (30)
	Limited	23 (53)
	Proficient	2 (5)
	Fluent	5 (12)

Self-assessment of participants regarding their confidence in their ability to meet the workshop’s learning objectives ranged from no confidence to complete confidence. Results from the unpaired student’s t-test comparing the pre- and post-workshop results demonstrated that, for each objective, confidence improved, and the difference was statistically significant for 3 out of 4 learning objectives (Table 2).

Table 2

Mean responses to Pre- and Post-workshop confidence self-assessment questions (n = 43).
Objective	Mean Pre-workshop Evaluation^a	Mean Post-workshop Evaluation^a	p-value
Explain the importance of using interpreters to improve limited English proficiency patient care.	1.6	2.1	< 0.05
Recognize when a professional interpreter is needed for effective communication in clinical care.	2.0	2.2	> 0.10
Employ medical Spanish vocabulary during a medical interview to elicit sexual history.	0.6	1.5	< 0.0001
Demonstrate respect for the individual and cultural humility when using interpreters.	2.0	2.4	< 0.05
^aRated on a 4-point Likert scale with 0 indicating “No confidence” and 3 indicating “Complete Confidence”.

In terms of the effect of the workshop on participants’ knowledge base, a comparison of pre- and post-workshop questionnaire responses on best practices when working with a MI showed an increase in the average score for the self-assessment (Fig. 1) and for each individual question (See Additional File 4). A statistically significant increase was seen in the question asking for the ideal position for the medical interpreter during a provider-patient interview (p < 0.0001).

As shown in Table 3, the large majority of participants reported the workshop met objectives, the presentation was informative, and included useful resources. In addition, they also agreed that the case discussions fostered their learning, the simulated cases were realistic, and the facilitators were helpful in fostering discussions.

Table 3

Summary of Participant Responses to Post-workshop Evaluation (n = 43).
Statement	Number of Responses (%)
Statement	Disagree or Strongly Disagree	Neutral	Agree or Strongly Agree
Workshop met objectives.	0 (0)	1 (2)	42 (98)
Presentation was informative and included useful resources.	0 (0)	2 (5)	41 (95)
Case discussions fostered my learning.	1 (2)	3 (7)	39 (91)
The simulated cases were realistic.	0 (0)	2 (5)	41 (95)
The facilitators were helpful in fostering discussions.	0 (0)	4 (9)	39 (91)

The participants were asked to provide written responses to indicate changes they plan to implement because of the workshop, and a number of compelling themes emerged from these comments (Table 4). After attending the workshop, many participants shared their awareness on their language limitations and when a MI is needed. They also shared ways they will implement what they learned to better utilize MIs in the clinical setting with LEP patients. In addition, several participants expressed their intent to use content and resources from the workshop as the starting point for improving their medical Spanish vocabulary.

Table 4

Summary of Learner Responses to “Please name two things that you will do/change as a result of this workshop”
Theme	Representative Quotes
Medical Interpreter Need	“I now understand the role of a medical interpreter and when they should be used.”
	“More readily call upon the assistance of interpreters.”
	“Be more aware of when an interpreter might be needed.”
	“Offer a patient a medical interpreter even if they have a family member available.”
	“Using a medical interpreter when I encounter language barriers between myself and patients.”
Medical Interpreter Practice	“Use short sentences when using an interpreter.”
	“Understand how to position an interpreter in a conversation with a patient.”
	“Make sure to talk directly to the patient and make eye contact.”
	“Address the patient directly when an interpreter is used.”
Medical Spanish Knowledge	“Study common phrases (in Spanish) to explain certain basic situations to a patient during those moments we are waiting for an interpreter”
	“Practice my medical Spanish vocabulary more.”
	“Understand the medical terminology in Spanish more thoroughly.”

Participants also provided valuable insight into how to improve the workshop. Participants suggested future workshops should also include videos portraying a clinical encounter of a physician using a professional MI to provide care for a LEP patient. Several participants would have liked more resources to learn medical Spanish:

“Perhaps have more videos on professional interpreters and discuss their techniques.”
“Having more resources that people can use to learn more about medical Spanish.”

The most common remark regarding what was most appreciated about the workshop was its interactivity (between the students and with the facilitators), simulation activities, the case studies, and the opportunity to learn medical Spanish phrases:

“The examples of the students in the class acting out and then discussing their performance.”
“I liked how engaging it was and how I was able to practice my Spanish.”
“I enjoyed the cases and the role playing that was involved.”

As the population of individuals and families with LEP continues to expand in the United States, physicians will need to be better prepared to care for growing numbers of patients with LEP and to understand the issues pertaining to communication with this population. Existing literature has documented the deficiencies in physician’s effectiveness in medical encounters with LEP patients, indicating the importance of improving medical training in this domain ¹⁶. Additionally, a study that surveyed medical students found that only 20% of them reported being very well or well prepared to provide care to LEP patients ¹⁷. Therefore, we developed and implemented a workshop as an early intervention to teach first-year medical students the skills and best practices on how to communicate effectively with MIs and Spanish-speaking LEP patients. This workshop fills an important gap in UME and provides a comprehensive orientation to interpretation resources. It is important to begin the training of medical students on this topic early in their training with the potential to reinforce this information at a later time in the curriculum. Many of the institutions that offer a formal curriculum to train students to work with MI and/or patients with LEP do so during the first two years of medical school, with a few schools spanning their training across 2 to 4 years ¹⁰.

The workshop was well received by the participants who reported that: the workshop met its objectives; the presentation was informative and included useful resources; the case discussion fostered their learning; and the simulated cases were realistic. Comparison of pre- and post-evaluation data showed that the workshop facilitated statistically significant improvements in the confidence of participants to explain the importance of using interpreters to improve limited English proficiency patient care, to employ medical Spanish vocabulary during a medical interview to elicit sexual history, and to demonstrate respect for the individual and cultural humility when using interpreters. Although the self-assessment test on best practices when working with an MI showed an increase in the average score, the increased score for some questions were not statistically significant. This implication may indicate that the participants already had prior knowledge to this information, such as from personal experiences and/or from other parts of the curriculum such as case-based learning curriculum that address this content. The post-workshop item responses also provide important continuous quality improvement data for areas that can be addressed further in future iterations of the workshop and/or later in the curriculum as part of the longitudinal delivery of these topics.

As demonstrated by the qualitative feedback received, participants have increased awareness of their language limitations and of when a professional MI is needed to care for LEP patients. The feedback also highlighted best practices on communication skills participants can apply when interacting with a LEP patient using a professional MI. Moreover, participants emphasized the importance of understanding and learning more medical Spanish. As the predominant and fastest growing non-English language in the United Sates, many medical schools have reported having a medical Spanish curriculum. However, the curricula are not consistently linked to learner assessment ¹⁸. Assessment should be necessary to demonstrate Spanish language competency and should include safety measures to prevent communication errors.

There were several challenges and limitations in our study. First, our sample size was small due to class size. However, the demographics and Spanish proficiency of the participants are comparable to other programs in the United States. Second, due to time constraints, six out of ten small groups had the opportunity to simulate the case scenarios provided. We ensure there was substantial reflection, feedback and discussion for the groups that participated. Finally, we utilized Spanish speaking faculty and staff with experience in this area, including a practicing clinician but we did not make use of professional MI during the simulation activities. We will aim to incorporate professional MIs in future iterations of the workshop as they can also provide their direct experiences and insights during teaching and discussion.

The results from our study suggest that implementation of MI training in the undergraduate medical curriculum can aid in the development of medical students equipped with the skills and best practices on how to communicate effectively with professional MIs and Spanish-speaking LEP patients. This workshop focused on Spanish speaking LEP patients, but this design can be adapted for any LEP patient population. Though not directly measured, we expect this intervention to have improved quality of care for LEP patients through professional interpreter services.

LEP

limited English proficiency

Medical interpreter

UME

Undergraduate Medical Education

RIA

Reflection, Integration, and Assessment

GIHNER

Gastrointestinal, Human Nutrition, Endocrine, Reproductive.

Acknowledgments: The authors would like to acknowledge Maria Ortega for her participation in the simulation activities as a Spanish-speaking limited English proficiency patient.

Ethics approval and consent to participate: Students were informed about the study and signed the informed consent form. Students participated voluntarily. Ethical Approval has been granted for this study by the Institutional Review Board of Nova Southeastern University (IRB #: 2022-109). This project was designated exempted research by the Nova Southeastern University Institutional Review Board. We confirm that all methods were carried out in accordance with guidelines and regulations of the Ethics Committee at Nova Southeastern University.

Consent for publication: Not applicable.

Availability of data and materials: The datasets generated and analyzed during the study are not publicly available due to the participants’ data and anonymity but are available from the corresponding author upon written request.

Competing interests: The authors declared that they have no competing interests

Funding: Not applicable.

Authors' contributions: AW contributed to the study concept, study design, data analysis, data

interpretation and writing the manuscript. LF contributed to the study design, data interpretation and revising the manuscript. DG contributed to the study concept, study design, data analysis, data interpretation and revising the manuscript. All authors read and approved the final manuscript.

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No competing interests reported.

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Communicating Effectively with Limited English Proficiency Patients: Incorporating Training on Working with Medical Interpreters in the Undergraduate Medical Curriculum

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Abstract

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Background

Methods

Institutional Review Board Approval and Curriculum Implementation

Participants

Workshop Design And Facilitation

Evaluation

Data Analysis

Results

Discussion

Conclusions

Abbreviations

Declarations

References

Additional Declarations

Supplementary Files

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