Lessons Learned from the Process of Developing a Resident-Interpreter Workshop

A multidisciplinary team consisting of a process improvement specialist, certified health interpreters, hospitalist, pediatric resident, and medical students took on the development of a workshop to improve care for patients who required an interpreter. The workshop focused on improving the interactions between residents and interpreters to overcome language barriers. We would like to share the lessons learned from developing our project.


Introduction
Often when we evaluate a project, we focus on the outcomes. However, sometimes important lessons can be learned from reflecting on the development of a project.

What problem was addressed?
It has been well studied that language barriers make patients more vulnerable to receiving poorer quality of healthcare (Quigly et al., 2019;Emeriz-Wiener et al., 2014;Jacobs, Diamond and Stevak, 2010;Gadon, Balch and Jacobs, 2007;Karliner et al., 2007). At our institution, an online survey of pediatric residents showed that "language barrier" was a frequently mentioned cause of frustration when providing care for Limited English Proficiency (LEP) patients. These findings are in line with the literature (Diamond, Schenker, Curry, Bradley et al., 2009), resident satisfaction is associated with the volume of LEP patients they have to take care of, and also if they are trained in using an interpreter (Hernandez et al., 2014). The lack of (physician) training on utilizing language services optimally limits the efficacious use of interpreters, which is a disservice to patients ( Hernandez et al., 2014;Jacobs, Diamond and Stevak, 2010;McEvoy et al., 2009;Abu and Elamin, 2009;Karliner et al., 2007). We aimed to improve the resident-dynamic in order to improve LEP patient care by training our residents to work effectively with interpreters (Fune et al., 2020).

What was tried?
A multidisciplinary team consisting of a physician (n=1), pediatric resident (n=1), medical students (n=8), certified health interpreters (n=4), and a process improvement (PI) specialist (n=1) developed a workshop to address these issues. The three-hour workshop consisted of a presentation by the interpreters, hands on learning through simulated patient encounters, two Observed Standardized Clinical Examinations (OSCE), followed by an interactive question and answer session facilitated by the interpreters. The workshop was implemented during residents' didactic time. We evaluated the learning outcomes of the workshop by analyzing the OSCE results. For the process evaluation, we interviewed participating residents (n=10), and reviewed feedback from the residency program and the reflections from the team on the development of the workshop. We would like to focus on the lessons learned outside of the educational outcomes of the study as those results are shared in another contribution (Fune et al., 2020).

Three Lessons Learned
The effect of the workshop went beyond resident's improvement of their collaboration skills with interpreters, such as learning how a patient's culture can affect their care. The project also showed the value of uncovering hidden assumptions from interpreters about residents and vice versa, and advantages of working with a multidisciplinary team.
Residents can learn beyond the objectives of a workshop. In addition to focusing on achieving the objectives 1.
(i.e., perform certain actions), residents also sought feedback from the interpreters on how they could have better partnered with them to provide care for the patient. Residents valued the workshop; it gave them more insight in culturally sensitive aspects such as superstitions, types of interpreting (simultaneous versus consecutive), and building rapport with patients. The majority of residents agreed or strongly agreed that they would change their current practice in regard to LEP patients on a post-workshop survey.

Uncovering hidden assumptions regarding diverse team members is important in the earlier stages of developing 2.
a project. It took away initial resistance and led to mutual understanding between the multidisciplinary team members. In the development process, it appeared interpreters had misunderstandings about physicians' roles. For example, they were unaware of the lack of training physicians receive for working with LEP patients and some did not realize that residents were already physicians. The physicians and students on the team were unaware of the restrictions placed on interpreters due to medical-legal boundaries. During the designing of OSCEs, both parties discussed their assumptions and talked them through. This discussion helped to keep the interpreters invested and restructure their presentation to better suit the residents. After the workshop, they felt that residents had changed their attitude towards them and interpreters felt like part of the patient care team.
Creation of a multidisciplinary team generated an opportunity for everyone's learning and helped stimulate 3.
everyone. The medical students were very good in pointing out unclear aspects and sparked out-of-the box thinking for others. In turn, they were made aware of the inequities LEP patients face in healthcare and were taught techniques to better communicate with them at an earlier stage of their training. The PI-specialist taught everyone how to perform a robust process improvement project thereby promoting a systematic approach which was further supported by weekly meetings and feedback sessions.

Conclusion
In conclusion, our study was successful in improving residents' knowledge on how to partner with interpreters to take care of LEP patients. The creation of a multidisciplinary team ensured buy-in from all stakeholders and promoted learning of other members of the team thereby adding a strong process improvement component to our study. We could not have accomplished the design, development, and implementation within six months without this team.

Take Home Messages
Process evaluation helps uncover dynamics between physicians and interpreters Working with a multidisciplinary teams adds value to a project Learning skills to communicate with patients who require an interpreter is an important skill and should be learned early This is an area that seems to be neglected, and more training is needed