1. Using Interpreters in Medical Encounters: Assessing Medical Students STFM Predoctoral Conference, Feb. 2-5 2006 Charleston, SC Désirée Lie, MD, MSED, Charles Vega, MD, John Boker, PhD, Ellen Lewis, RN, MSN, Sue Ahearn, RN and Manuela Vasquez, BA University of California, Irvine School of Medicine

2. Using Interpreters in Medical Encounters Session Objectives: Identify skills and knowledge for effectively using medical interpreters. Address challenges of teaching these skills. Describe methods for assessing skills. View and critique an SP assessment case. Discuss obstacles/solutions for assessing students. Discuss strategies for remediating students demonstrating low performance.

3. Using Interpreters in Medical Encounters Audience Survey: 1. How many currently teach use of medical interpreters in the formal curriculum? 2. What teaching methods are used? 3. What assessment methods are used? 4. If not currently assessing students, how many plan to assess students in this skill?

4. Using Interpreters in Medical Settings Rationale for Teaching: 10 million Americans with LEP (Limited English Proficiency). LEP contributes to poor access to care, poor health outcomes and affects quality of clinician-patient relationship. Using interpreters is a core cultural competency. Improving clinician cultural competency shown to improve health outcomes. Ferguson W. Culture, Language, and the Doctor-Patient Relationship. Fam Med. 2002;34:353-61. Drouin J. Training Medical Students to Communicate with a Linguistic Minority Group. Acad Med. 2003;78(6):599-604. Karliner, LS, Eliseo J. Pérez-Stable, Ginny Gildengorin, The Language Divide. The Importance of Training in the Use of Interpreters for Outpatient Practice, JGIM, 19;175, Feb 2004

5. Using Interpreters in Medical Encounters What skills and knowledge are involved regardless of the language used (Audience)? 1. Knowledge 2. Skills Ref: U.S. Department of Health and Human Resources, Office of Minority Health. National Standards for Culturally and Linguistically Appropriate Services. Rockville, MD: DHHS. http://www.omhrc.gov/clas/http://www.omhrc.gov/clas/

6. Using Interpreters in Medical Encounters Potential methods of assessment: Direct observation with feedback Patient surveys and feedback SP cases Self-assessment/reflection Written cases Computer simulations Others?

7. Using Interpreters in Medical Encounters Challenges of designing SP Case 1. Include/exclude culture-specific issues? 2. Level of English proficiency of patient? 3. Level of interpreting skill of interpreter?

8. Using Interpreters in Medical Encounters Challenges of Designing SP Case (contd.): 4. Who assesses the student? (faculty, patient, interpreter?) 5. What standards to use (e.g. when student has some vs. no language proficiency)? 6. Do skills generalize to encounters with other languages? 7. Other challenges?

9. Using Interpreters in Medical Encounters Pilot Project Background: Chose MS3 9-station CPX to pilot interpreter station at end of year 3. Sought expert opinion (panel) and performed lit. review on smoking cessation and cultural issues. Adapted existing case. IRB approved.

10. Using Interpreters in Medical Encounters Pilot project participants SP: Miguel Martinez Monolingual Latino male businessman age 40s, seeking help with smoking cessation. Interpreters: 11 students at end of training. MS3: Randomly selected 39/92 MS3 from required CPX.

11. Using Interpreters in Medical Encounters Measure (empiric) 1. SP assessment of MS3 (14-item yes/no). 2. Interpreter assessment of MS3 (8-item yes/no). 3. MS3 self-assessment (11 item). 4. (Interpreter faculty assessment of interpreter students) Skills assessed: History-taking, negotiation, communication (with SP and interpreter), explanatory facility, language proficiency (student)

12. Use of Interpreters in Medical Encounters Measures that were not used: 1. Faculty assessment of MS3. 2. MS3 assessment of interpreter skills.

13. Using Interpreters in Medical Encounters Audience task: 1. Select a checklist (SP or interpreter). 2. Assess student #1 in video. 3. Assess student #2 in video. Discussion: 1. What are we measuring with checklists? 2. How do we set performance standards? 3. What remediation might follow?

14. Using Interpreters in Medical Encounters Results of Pilot Study 1. MS3 perception of encounter higher if self- identified as high Spanish fluency (α=0.80). 2. MS rated interpreter participation good to excellent 80% of the time. 3. SPs scored MS3 highly (80% items done, α=0.54)).

15. Use if Interpreters in medical Encounters Results of pilot study (contd.): 4. SPs gave higher scores to MS3 with lower Spanish proficiency. 5. Interpreters gave lower score to students with lower Spanish proficiency but reliability was low (α=0.25).

16. Using Interpreters in Medical Encounters What next? 1. Compare PRIME-LC with ‘regular’ students. 2. Generalizability across languages (Spanish vs. Vietnamese). 3. Multiple assessors and assessments across time?

17. Use of Interpreters in Medical Encounters What next (contd.)? 4. SP assessments in ‘real’ encounters (unannounced SPs) 5. Compare with different teaching strategy (Come to STFM Spring meeting, SF, CA, April 2006!). 6. Identifying students in difficulty.

18. Using Interpreters in Medical Encounters Getting started (audience suggestions): 1. Which MS year? 2. What setting? 3. What performance measures? 4. What outcomes? Consider: ? Unannounced SPs ?Assess students ability to evaluate interpreter performance

19. Using Interpreters in Medical Encounters Acknowledgements: 1. Manuela M. Vazquez, B.A., was a summer research intern from the University of Illinois College of Medicine at the time of the study. 2. Grants: NIH (NHLBI) grant K07 HL079256-01 and Molina Health Care. 3. Staff of UCI Student Training Center and the UCI medical students.

20. Using Interpreters in Medical Encounters Additional Resources: http://www.aamc.org/meded/tacct/start.htm Contact: Désirée Lie, MD, MSEd dalie@uci.edu (714) 456-5171 Questions? Thank You.