UC Berkeley

The United States is experiencing a linguistically diverse population growth. Although linguistically based healthcare disparities are well documented, there is a paucity of strategies to mitigate the effects on the quality of care and communication with limited English proficient. Educating healthcare providers is one solution that may influence linguistically competent communication; however, there is limited evidence that provider training enhances communication with LEP patients.

The dissertation was conducted to connect what is known about linguistic competency with best practices in medical education. The presented research expands on this gap by identifying successful strategies of outcomes based educational practices, determining the communication needs of LEP patients and their providers in one pediatric clinic, and incorporating and evaluating these lessons into a novel data-driven linguistic competency training for clinicians.

A comprehensive literature review was conducted on linguistic competency training programs with patient, provider and systems outcomes. Thirteen studies were identified as either providing language acquisition or communication skills training to work effectively with interpreters to improve access to care for LEP patients and evaluated using the Medical Education Research Study Quality Instrument (MERSQI). All studies evaluated the impact of the training on provider outcomes, such as knowledge and skill, patient outcomes, such as satisfaction, and system outcomes, such as increased interpreter use. A detectable but small effect on provider competency was demonstrated for most studies, but the primary impact on patients was limited to improved patient satisfaction. In addition, the studies tended to be heterogeneous in the curricular type and model used as well as how outcomes were measured. The results provided examples of curricular elements for engaging health care providers through training in order to improve their ability to care for their LEP patients.

Prior to developing a curriculum on communicating with LEP patients and working effectively with interpreters, a needs assessment was performed at one pediatrics outpatient clinic. One hundred monolingual Spanish-speaking LEP patients participated in the needs assessment and responded to survey questions about their knowledge of language laws and policies, familiarity and utilization (and type) of interpreter services, and assessment of their clinician's language skills. Thirty-one pediatric clinicians in the same clinic also responded to additional questions about: prior training programs on language skills, if they speak any languages other than English, the extent to which they interact with LEP patients, the percentage of their LEP patients and the frequency with which they experience language barriers, and their level of frustration during language discordant communication.

Patients were satisfied with the language services and communication strategies provided to them in the clinic. Just under half of all patients reported communicating directly with a Spanish-speaking clinician and that they were satisfied with their clinician's level of Spanish. LEP patients expressed high satisfaction when able to speak in their language, either with a trained medical interpreter or a Spanish-speaking clinician. Although prior studies have shown limited awareness of language laws and policies amongst LEP patients, patients at this clinic had higher rates of familiarity than the historical figures and nearly three-quarters of monolingual Spanish-speaking patients surveyed were familiar with local policy regarding their rights to request an interpreter for their visit. There was no association between patients' familiarity with laws providing them the right to have an interpreter during a clinic visit; however, there was a significant association between awareness of local policies on interpreter usage and having a Spanish-speaking clinicians.

Clinicians rated themselves highly on their ability to speak another language, often frustrated in their ability to communicate with LEP patients during language discordant visits, experienced prior language skills training and some exposure to working effectively with interpreters. Clinicians felt confident in their ability to schedule interpreters and establishing rapport with LEP patients; however, most clinicians did not feel confident in their ability to answer LEP patient questions. In addition, clinicians felt confident that they were able to identify the need for interpreters but not their abilities to work effectively with interpreters. Some clinicians stated that they often regret not using an interpreter when needed. Clinicians were mostly aware of both language laws and local policies on providing interpreters. Knowledge of language laws was not associated with the frequency with which clinicians offered trained medical interpreters during language discordant visits. Conversely, knowledge of local policy on interpreter use was highly associated with offering interpreters.

The combined data from the systematic review and the needs assessment ultimately informed the development of a focused educational intervention based on the gaps in knowledge, skills and confidence previously measured. Eighteen pediatric residents and attendings participated in the highly interactive workshops with specific training elements to enhance their abilities to communicate effectively during language discordant visits by working with interpreters (in-person or telephone), competence in working with hospital interpreter services, and their knowledge of language laws and policies as they relate to patient care and services. Participants evaluated the workshops by self-assessing their knowledge, skill and confidence for specific training elements with a retrospective and post assessment. All training element items were significantly higher after the workshop, including confidence, suggesting that a focused training on working effectively with interpreters is a valuable tool in developing a linguistically competent healthcare practitioner. Developing a data-driven linguistic competency educational intervention suggests an effective approach to training healthcare providers to enhance their communication with LEP patients.