Increasing Health Care Workers' Proficiency With Using Professional Medical Interpretation: A Workshop

Educational Objectives

By the end of this activity, learners will be able to:

Introduction

The challenges of providing excellent medical care to patients and families with limited English proficiency (LEP) are multifaceted and well documented. Language barriers threaten effective communication between patient and provider, and numerous studies have highlighted medical errors and poor outcomes that disproportionately affect individuals with LEP.^1–4 In turn, research consistently demonstrates the benefits of using professional medical interpretation, which include improved access to care, improved satisfaction with care, better outcomes, and fewer errors.^3,4 Professional medical interpretation can occur through multiple modalities, including in-person interpretation, interpretation over the phone, and video interpretation using a tablet. Nonetheless, obstacles at the individual and institutional levels continue to limit the use of professional medical interpretation by health care workers,^1,5–7 thereby impeding access to high-quality care for patients and families with LEP. This workshop is designed to facilitate discussion of the challenges faced by health care workers when caring for LEP families and to teach best practices for the use of professional medical interpretation.

Numerous studies have identified barriers that prevent health care workers from consistently utilizing professional medical interpretation.^1,5–7 Access to professional medical interpretation at an institutional level is crucial to providing adequate care for individuals with LEP, and the US Department of Health and Human Services has indicated that the failure to provide interpreter services to patients with LEP constitutes a form of discrimination.⁸ However, professional medical interpretation remains largely underutilized, even at institutions where interpreter services are readily available.^5,7,9 Obstacles responsible for the underutilization of medical interpretation include lack of time, lack of training, and normalization of the underuse of interpreters.^1,5–7,10 These obstacles can operate in isolation or in concert. For example, health care workers who are not trained to use professional medical interpretation may be less efficient at using these resources when available, and lack of training on this subject may diminish its perceived importance at an institutional level. For these reasons, development and implementation of training focused on increasing the proper use of professional medical interpretation represent a critical step in providing high-quality care for LEP families. However, the literature lacks clear guidelines for developing or implementing such training.

Prior studies centering on improving the use of medical interpreters have often focused on web-based curricula^11,12 (e.g., use of an e-learning module¹¹) or discussion of best-practice guidelines.¹³ While these approaches have the advantage of being easily accessed, the use of a web-based format lacks the additional educational benefit provided by simulation and role-play. Engaging in a skill through role-play or simulation has been shown to increase confidence with the skill as well as the likelihood that the skill will be implemented when compared to didactic methods.^14,15 These approaches have been shown to be successful with regard to the use of professional medical interpretation.^16,17 However, the use of simulation often requires a significant amount of resources and time expenditure (e.g., with standardized patients¹⁶ or lengthy simulations¹⁷).

In contrast to the above methods, this workshop focuses on practical skills that can be taught by anyone in the health care field, and the content is appropriate for anyone who works with LEP patients and families. In addition, a workshop format provides other advantages over web-based curricula and standardized simulation. For example, a workshop can be easily customized according to the resources available at a given institution, making the content more relevant to the audience. Finally, the workshop format carries the unique capacity to break the culture of underutilization, as it encourages multidisciplinary recognition of the importance of medical interpretation among colleagues, facilitates discussion of common challenges facing health care workers when caring for LEP patients, and promotes the identification of viable solutions within the unique clinical context of a particular institution. This workshop has been designed to be an adaptable method for teaching health care workers the skills needed to access and appropriately use professional medical interpretation.

Methods

Institutional Review Board Approval

This study was submitted for review by the Stanford Institutional Review Board and was determined not to meet the definition of human subject research (Protocol Number: 45076, approval date: January 30, 2018).

Facilitators

The workshop was facilitated by eight presenters (two residents, two fellows, two faculty members, and two fellowship coordinators). Facilitators had prior experience with medical interpretation and reviewed the workshop activities. The number of facilitators per workshop was chosen to target a ratio of four to seven participants to one facilitator. Because each facilitator was familiar with different segments of the workshop, any member of the facilitator group was able to lead a particular activity if others were unavailable. This shared responsibility among the team effectively encouraged consistency, flexibility, and accountability.

Target Audience

This workshop was intended to be held within groups of health care workers, including but not limited to physicians, nurse practitioners, physician assistants, nurses, nursing assistants, pharmacists, physical/occupational/speech therapists, respiratory therapists, medical residents, and medical students.

Workshop

The workshop lasted approximately 90 minutes. At the start, participants were divided into small groups, and the lead facilitator briefly discussed the workshop's learning objectives (see Appendix A). The lead facilitator then introduced the warm-up activity (see Appendix B), an activity designed to highlight how hard it was to complete a task in a foreign language. At the conclusion of the activity, the group was asked to discuss reactions to the activity.

In the following segment of the workshop, participants were asked to silently read the case scenario and associated questions (included in Appendix C) and then to discuss their answers to the questions within their small groups. After discussion in small groups, the floor was opened for individuals to share salient points that had arisen in their respective group discussions. The experienced facilitators were adept at highlighting themes and major points that emerged from group discussion.

Following discussion of the case scenario, participants attended three different stations (each focused on a different type of interpretation) with their small groups (ideally four to seven people with each facilitator). An equal amount of time was allotted for each group to practice role-play activities involving in-person interpretation, video interpretation, and phone interpretation (Appendix C). One facilitator was assigned to each interpretation modality, and facilitators rotated between the three stations from workshop to workshop to make each discussion more dynamic. As in previous segments, facilitators allowed the discussion to flow naturally based on the role-play and highlighted key points as they arose.

After the three small-group interpretation scenarios, participants came together to discuss their reactions to the activities. This discussion provided an excellent transition to discussing key take-home points that had emerged throughout the session. During this discussion, participants were asked to think about and/or share steps they planned to take to change their own practice (e.g., distributing resources, modeling behaviors, creating training sessions). Participants were also provided with index cards to document their individual goals. The cards were collected and mailed back to the participants 2–4 weeks later as a reminder.

Evaluation

As the workshop concluded, participants were asked to complete the anonymous postworkshop evaluation (Appendix D), which was used to evaluate the effectiveness of the workshop.

Time Line and Materials

The workshop time line (with materials) is as follows:

Results

This workshop was presented at six academic conferences, including three local conferences (2018 Stanford Diversity and Inclusion Forum, 2018 Stanford Innovations in Medical Education Conference, and 2018 Interpreter and Translator International Week at Stanford University), one regional conference (2018 Academic Pediatric Association Western Regional Conference), and two national conferences (2018 Annual Spring Meeting of the Association of Pediatric Program Directors and 2018 Annual Medical Education Conference of the Student National Medical Association). Conferences were selected to maximize practice with the workshop as well as exposure to different types of learners. Participants in the workshop included a diverse mix of health care workers (staff, students, residents, faculty), and we collected 53 postworkshop evaluations (results summarized in Table 1).

Table 1. Summary of Learner Responses to Postworkshop Evaluation (N = 53)^a

As shown in Table 1, the large majority of participants reported that the workshop met the learning objectives, represented a valuable use of time, and included useful handouts. In addition, 90% of participants reported that the information shared in the workshop would be applied to their medical practice.

We asked participants to provide written responses to indicate changes they planned to implement as a result of the workshop, and a number of compelling themes emerged from these comments (summarized in Table 2). After attending the workshop, many participants shared ways in which it would change their own practice (e.g., assessing the language needs of their patients, paying attention to their position and eye contact when using an interpreter, using teach-back strategies when appropriate). In addition, a number of participants expressed their intention to use content and resources gleaned from the workshop as the starting point for improving education on interpreter use for trainees and colleagues at their home institution. Taking this intention one step further, a number of participants expressed the desire to change the infrastructure surrounding use of professional medical interpretation. For example, one participant endorsed the intent to have “continued discussion with division about using interpreters on FCR [family-centered rounds],” and another participant shared the commitment to “fight for the quality of care for limited English speakers.”

Table 2. Summary of Learner Responses to “What Two Things Will You Do as a Result of This Workshop?”

When asked to indicate what barriers might prevent them from applying what they had learned at the workshop, participants frequently mentioned time (25% of responses), cost/availability of resources (32% of responses), or both (16% of responses). In addition, a minority of participants mentioned institutional factors such as “institutional pushback/inertia” or “push-back from providers.”

Discussion

Contribution to Existing Literature

We developed and implemented a workshop to teach best practices of using professional medical interpretation to health care workers. This workshop was presented at local, regional, and national academic conferences and was well received by participants from diverse clinical backgrounds. Feedback from participants indicated that the workshop fills an important gap in medical education and provides a comprehensive orientation to interpretation resources and best practices. While prior studies have focused on teaching medical interpretation within departmental silos (e.g., medicine,^11–13,16 dentistry¹⁷), this workshop is appropriate for anyone in the health care field and encourages multidisciplinary cooperation. Furthermore, while many prior studies have relied on web-based interfaces,^11,12 this workshop capitalizes on simulation and role-play while remaining adaptable based on the context of a particular institution.

Workshop Iterations

In the course of giving this workshop to various audiences, we learned several lessons to maximize its benefit. Introductory material was added to the participant packet to maximize benefit for participants with less experience working with medical interpreters. For more experienced audiences, we learned to draw from the cumulative experiences of the group for a richer discussion of real-life clinical scenarios and challenges. We also edited the case scenario and role-play to decrease the amount of text and increase participant interaction.

Limitations

The modalities explored within this workshop (in-person, video, and phone interpretation) may not be available at every institution or practice setting, which may limit generalizability between settings. However, at least one type of interpretation modality is usually available in a given setting (phone interpretation being most common), and this workshop provides a foundation for accessing and using available resources, which is often a significant rate-limiting step for health care workers. In addition, because this workshop was developed by pediatric providers, the cases and scenarios are weighted towards pediatrics. However, the basic principles within each scenario are consistent between pediatric and adult medicine. Finally, the tool used to evaluate the workshop is limited in scope and does not assess participant responses based on their clinical background or prior exposures to medical interpretation.

Future Directions

Because of the dynamic nature of the workshop, the content is best explored in small groups with a low learner-to-facilitator ratio to allow active engagement in all activities. One of the barriers we encountered when running the workshop was finding enough facilitators to achieve a low learner-to-facilitator ratio. To overcome this challenge in the future, we plan to expand potential facilitators to include anyone in the health care field who has experience with medical interpretation. Training a multidisciplinary group of facilitators has the dual advantage of augmenting the sustainability of the workshop and enabling widespread institutional change. In addition, future investigation will assess the impact of this workshop on provider practice.

Conclusions

We successfully developed an effective workshop to help health care workers from diverse clinical backgrounds improve the use of professional medical interpretation. This workshop empowers health care workers to provide excellent communication and care to patients and families with LEP. Implementation of this workshop and others like it on a national scale is an essential step in addressing and potentially ameliorating disparities in the care received by patients and families with LEP.