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Patient Experience Journal
Volume 9, Issue 3 – 2022, pp. 180-190
Patient Experience Journal, Volume 9, Issue 3
© The Author(s), 2022. Published in association with The Beryl Institute.
Downloaded from www.pxjournal.org 180
Case Study
Enhancing patient-centered care for limited English proficiency patients
through Tell Me More®: A student-driven initiative to explore the patient
as a person and develop students’ communication skills
Angela Liu, Contra Costa Regional Medical Center Family Medicine Residency Program, aliu3@cchealth.org
Alicia W. Leong, Icahn School of Medicine at Mount Sinai, alicia.leong@icahn.mssm.edu
Alice Fornari, Zucker School of Medicine at Hofstra/Northwell, afornari@northwell.edu
Taranjeet Kalra Ahuja, Zucker School of Medicine at Hofstra/Northwell, taranjeet.ahuja@hofstra.edu
Abstract
Tell Me More® (TMM) is a medical student-driven initiative to build rapport between patients, students, and the
healthcare team through patient interviews and collaboratively created posters. Patients with limited English proficiency
(LEP) often experience impaired communication with providers. TMM has the potential to address the loss of patient-
centered dialogue in interpreter-mediated communications. In this exploratory pilot study, we aimed to include LEP
patients in TMM by using medical interpreter phones (MIPs) at Long Island Jewish Medical Center, Northwell Health.
Our objectives were to: (1) evaluate the feasibility of this approach, (2) compare TMM engagement between LEP and
English-speaking (ES) patients, and (3) document the impact of this initiative on the medical student. Following the
standardized TMM interview structure, the student used the MIP to interview LEP patients about who they are as
people beyond their illnesses. This expanded social history was transcribed to bedside posters to enhance patient
connection with the healthcare team. At the end of interviews, patients rated TMM’s impact on their hospital stay.
Additionally, medical student reflections were recorded weekly. Our quantitative results from 12 LEP and 49 ES patients
support significantly higher TMM participation for LEP compared to ES patients. Qualitative examination of student
reflections suggests that TMM enriches medical education by promoting understanding of the LEP patient experience.
Our results demonstrate that MIP-supported TMM is a feasible approach to enhance patient-centered care for LEP
populations. Further research is needed to explore inclusion of LEP patients in patient-centered care initiatives such as
TMM.
Keywords
Limited English proficiency, interpreter devices, medical education, student reflection, patient experience, patient-centered
care, health disparities, communication skills, Tell Me More®
Background
Disparities in care of patients with limited English
proficiency (LEP)
More than 67 million (22%) of United States residents
over the age of five years speak a language other than
English at home.1 Of these individuals, more than 25
million reported having limited English proficiency (LEP),
or speaking English less than “very well” according to US
Census Bureau categories.1 LEP is one of the primary
contributors to racial and ethnic health disparities in the
United States.2,3 Individuals with LEP, a population
growing in number every year,4 often face difficulties
obtaining health insurance,5–8 accessing medical services,9–
13 receiving high-quality care with high patient
satisfaction,14–16 and communicating with their healthcare
providers.7,17–20 Furthermore, patients with LEP are more
likely to have worse health outcomes than patients who are
proficient in English.21–26
To eliminate healthcare disparities experienced by
individuals with LEP, policymakers have mandated the
provision of language assistance services, such as
professional medical interpreter services, in government-
funded hospitals and clinics.3,27,28 Utilization of
professional medical interpreter services has led to
improved quality of care and health outcomes among
patients with LEP.29–32 However, disparities in patient-
provider communication for LEP versus English-
proficient individuals persist even after decades of efforts
by clinicians, researchers, and policymakers.17 In particular,
interpreters tend to convey less patient-centered dialogue
than what patients and providers directly express.33,34
Interpreter-mediated exchanges seem to include fewer
emotional, psychosocial, and lifestyle content relative to
biomedical content.34,35 This loss of emotional connection
and patient-centeredness in interpreted encounters may
compromise mutual trust,36 collaborative decision-
Enhancing patient-centered care for limited English proficiency patients through Tell Me More®:, Liu et al.
Patient Experience Journal, Volume 9, Issue 3 – 2022 181
making,37–39 patients’ overall experience of care,40,41 and
thus patients’ engagement with and adherence to
treatment.42–44
In addition, formal training on how to care for patients
with LEP is not uniformly available across medical
education programs.45,46 Due to underutilization of
interpreters and limited self-efficacy in delivering care to
LEP patients, trainees and providers have highlighted a
need for more formal training on working with
interpreters.47–50 While a number of programs have trained
medical students to work with medical interpreters,51–54
medical education has afforded little attention to the loss
of patient-centered and empathic dialogue in interpreter-
mediated communication. One exception is a program
implemented by Penn State College of Medicine that
provided medical interpreter and cultural competency
training to bilingual medical students that effectively
increased students’ self-reported measures of empathy and
humanism.55
However, to our knowledge, no studies with LEP patients
have explored student-driven initiatives to collect patients’
expanded social histories with interpreter support. This is
especially important considering that patients with LEP
not only report distrust in the medical system and
challenges in communicating their medical needs and
understanding their treatment plans,56,57 but also have
limited non-clinical social interactions with hospital staff
and are more likely to experience social isolation in the
hospital.58
The Tell Me More® (TMM) model
Tell Me More® (TMM) is a medical student-driven
initiative licensed by the Arnold P. Gold Foundation to
build rapport between patients, students, and the
healthcare team through patient interviews involving
expanded social histories and collaboratively created
posters. The TMM program was created in 2014 by
members of the Gold Humanism Honor Society (GHHS)
chapter at the Icahn School of Medicine at Mount Sinai to
celebrate National Solidarity Day for Compassionate
Patient Care, and it has since been offered to over 85
GHHS chapters and health care systems in the United
States and Canada. In the TMM model, a member of the
patient’s care team uses a list of open-ended questions
from a poster template developed by the Gold Foundation
to learn more about the patient as an individual beyond
their diagnosis by exploring the patient’s strengths, values,
aspirations, hobbies, and personality (Figure 1). These
prompts are designed to help facilitate meaningful dialogue
and active listening between the patient and interviewer
and often lead to deeper conversations. The interviewer
and patient are encouraged to work together to personalize
the TMM poster template, adding other details the patient
would like their care team to know. The completed poster
is then displayed in a highly visible spot in the patient’s
hospital room, allowing for them to be known beyond
their illness. It also allows for clinicians and staff to
understand and connect with the patient at a personal
level. The initial TMM project at Zucker School of
Medicine at Hofstra Northwell was conducted in the
summer of 2016, and data from this project were
published in 2018.59
Past studies of TMM have shown that TMM projects have
the potential to increase patient-provider connection,
decrease healthcare team burnout, as well as enhance the
medical student educational experience.59,60 We believe
TMM is well designed to address not only the reduction in
patient-centered dialogue, connectedness, and trust during
language-discordant encounters, but also support medical
education on communicating with LEP populations.
Figure 1. Tell Me More® poster template. Provided by the Arnold P. Gold Foundation, the TMM poster template features
three blocks for patients and the interviewer to complete together. Each block focuses on each of the following questions:
“How would your friends describe you?”; “What are your strengths?”; and “What has been most meaningful to you?”
Enhancing patient-centered care for limited English proficiency patients through Tell Me More®:, Liu et al.
182 Patient Experience Journal, Volume 9, Issue 3 – 2022
However, previous TMM initiatives were offered only to
English-speaking (ES) patients.59
Study objectives
In this exploratory pilot study, we aim to include
hospitalized LEP patients in TMM by using medical
interpreter phones (MIPs). The objectives of our study are
to: (1) evaluate the feasibility of this approach, (2) compare
TMM engagement between LEP and ES patients, and (3)
document the impact of this initiative on the medical
student.
Methods
Study setting
This study was implemented over 6 weeks by a second-
year medical student on a medicine teaching floor at Long
Island Jewish Medical Center (LIJMC), Northwell Health.
LIJMC is located in Queens, New York, the most
ethnically diverse urban region in the world.61
Participants
Over the course of the program, clinical staff would
recommend patients who were admitted to the floor and
met the following inclusion criteria for program
participation: awake, cooperative, and verbally fluent in
English or another language. Patients were not
recommended for participation if they were going to be
discharged on the day of the TMM interview or if they
were determined by clinical staff as uncooperative (e.g.,
agitated or endangering student safety). The student was
not a member of the healthcare team yet was encouraged
to attend daily rounds to gather updates on patient status
and medical condition.
LEP status was determined by the medical student. LEP
patients were defined as patients who requested use of
MIPs to complete the majority of their interview. ES
patients were patients who completed the interview in
English without use of MIPs.
Instrumentation
The MIP utilized in the study was a pre-existing telephonic
language interpretation service at LIJMC provided by
Pacific Interpreters, Inc. The service was accessed on the
medical student’s mobile device.
Data collection
Patient interviews
The TMM interviews were conducted in each patient’s
hospital room. With supervision from a nurse manager
lead, patient experience culture leader, and/or clinician, the
medical student initiated each conversation by asking
whether the patient would like to use the MIP before
providing a short self-introduction. The MIP was used for
the interview process upon patient request. The interview
would then be conducted following an interview script
modified from previous TMM projects59 (supplemental
material provided upon request).
The student explicitly obtained verbal consent three times
along the interview process: (1) to proceed with the
interview after the introduction, (2) to create the TMM
poster after the initial conversation, and (3) to display the
poster in the patient’s room to encourage their clinical
team to get to know the patient as a person and not just an
illness with symptoms. If the patient refused to participate
at any point, the encounter was brought to a natural close.
The student documented the patient’s reason for refusing
an interview.
Depending on the patient’s preference, the TMM poster
was completed either by the student with the patient’s
input, collaboratively by both the patient and the student,
Figure 2. Tell Me More® posters. Figures 2a and 2b present posters created by two patients with limited English
proficiency in collaboration with the medical student. Figures 2c and 2d present posters created by two English-speaking
patients in collaboration with the student.
a
b
c
d
Enhancing patient-centered care for limited English proficiency patients through Tell Me More®:, Liu et al.
Patient Experience Journal, Volume 9, Issue 3 – 2022 183
or solely by the patient. Posters for LEP patients included
phrases in both English and the patient’s native language.
Each poster was documented through photography
(Figure 2).
To close the interview, the medical student asked each ES
and LEP patient to rate the conversation’s impact on their
hospital stay on a five-point Likert scale (1=no or negative
impact, 5=strong, positive impact).
Student experience
Each week, the student reflected on their experience
through personal journaling, providing commentary on the
patient experience, developments in the student-patient
relationship, and interactions between the student and the
healthcare team.
Data analysis
Patient data
A total of 61 patients who met inclusion criteria were
approached for an interview. Of those patients, 49 were
ES and 12 were LEP. The Mann-Whitney U test was used
to compare LEP and ES patients’ self-reported ratings of
the impact of the TMM interview on their hospital stay.62
Chi-squared tests were used to compare participation rates
between LEP and ES patients at each stage of the TMM
program.63
Qualitative analysis of student experience
Six weekly journal reflections were submitted by the
medical student over the course of the six-week
experience. Another member of the research team
analyzed these reflections for case examples highlighting
the TMM experience for LEP patients and TMM’s impact
on the student.
Ethics
The Institutional Review Board (IRB) of Northwell Health
approved this study (#HS16-0408) and granted it an
exempt status as per 45 CFR 46.101.
Results
Incorporating hospitalized LEP patients in TMM
Utilization of MIPs
Of the 12 LEP patients invited to participate in TMM, 12
verbally consented to participate and were successfully
interviewed using the MIP. Figure 3 provides an overview
of the languages spoken by LEP patients who participated
in TMM with MIP support. Facilitated by the MIP, eleven
of these LEP patients also agreed to prepare a TMM
poster following their interview.
Comparison of participation rates between LEP and ES patients
A total of 33 out of 49 ES patients invited to participate in
TMM agreed to participate. Of those 33 ES patients, 30
provided a rating for the impact of the interview on their
hospital stay. Their self-reported ratings ranged from 4 to
5 (M=4.93, SD=0.22).
All 12 LEP patients invited to participate in TMM agreed
to participate. Of the 12 LEP patients who participated in
a TMM interview, nine provided a rating for the impact of
the TMM interview on their hospital stay. All nine LEP
patients rated the impact of the interview on their hospital
stay as 5. There was no significant difference between LEP
Figure 3. Diversity of language spoken by LEP patients in Tell Me More®. Six languages were represented in this
exploratory pilot study, highlighting the utility of the medical interpreter phone.
Enhancing patient-centered care for limited English proficiency patients through Tell Me More®:, Liu et al.
184 Patient Experience Journal, Volume 9, Issue 3 – 2022
and ES patients in the self-rated impact of TMM on
hospital stay (U=121.5, p=0.66).
Compared to ES patients, LEP patients were more likely
to participate in TMM (χ2(1)=5.312, p<0.05; Figure 4).
Among LEP and ES patients who agreed to participate in
TMM, there was no significant difference between the
number of LEP and ES patients who consented to the
creation of a TMM poster (χ2(1)=0.006, p=0.937), or
between the number of LEP and ES patients who
consented to displaying their TMM poster in their hospital
room (χ2(1)=0.503, p=0.478). Figure 5 summarizes
patients’ reasons for declining to participate in the TMM
interview.
Student journal reflections
Student reflections of LEP patients’ experiences in TMM
Provided below are two case examples identified from the
medical student’s journal reflections which illustrate the
experiences of LEP patients who participated in TMM,
particularly the uncertainty while facing barriers to
healthcare access, such as immigration status, language and
cultural differences, and the need for advocacy to address
Figure 4. Percent of total English-speaking and limited English proficiency patients involved in Tell Me More®. 67%
and 100% of ES and LEP patients, respectively, agreed to participate in the TMM interview. 61% and 92% of ES and LEP
patients, respectively, agreed to make a poster for TMM. 55% and 75% of ES and LEP patients, respectively, agreed to have
their TMM poster displayed in their hospital room. Significant differences are marked with an asterisk (*).
Figure 5. Eligible English-speaking and limited English proficiency patients’ reasons for declining to participate in
a Tell Me More® interview. Of note, no LEP patients declined to participate in a TMM interview.
Enhancing patient-centered care for limited English proficiency patients through Tell Me More®:, Liu et al.
Patient Experience Journal, Volume 9, Issue 3 – 2022 185
the healthcare disparities and challenges experienced by
LEP patients.
(1) Uncertainty characterized the hospital experience of
C.G., a patient from Guatemala who spoke primarily
Spanish. His healthcare team was “worried about
where they could discharge him” since “he was
undocumented, so not qualified for the continuation
of care [and social services] that he needed.” After
learning from the patient’s TMM interview that “he
has a sister and a daughter who live[d] in New York,”
the student “spoke up for the first time at rounds” to
inform the team “that there were people they could
perhaps call for him.” This information expedited the
patient’s discharge from the hospital.
(2) For J.B., a young woman from Bangladesh who
“moved to the US a month ago so she knew almost
no spoken English,” language discordance between
her and the healthcare team resulted in considerable
uncertainty in her interactions with the team,
highlighting the need to bridge linguistic gaps in order
to provide safe, effective care to LEP patients.
Because “her husband was the one who had
translated [all] of her symptoms to her doctors
[without the use of the MIP] it seemed [like] she was
speaking solely through her husband’s voice.”
Impact of TMM experience on student
Below are two case examples from the medical student’s
reflections portraying the impact of the TMM experience
on the student interviewer, particularly the student’s
change in understanding of themself and others, and the
student’s growth as a patient advocate. Provided below are
supporting quotes drawn from the student’s reflections of
the encounters with C.G. and J.B. which demonstrate
shifts in the student’s perspective:
(1) The student’s reflections of working with C.G. reveal
that their consideration of his health and well-being
broadened to include that of his family members.
After volunteering information about this patient’s
relatives during rounds, the student reflected on the
consequences of their words: “I wonder…I worry.
[Was] his family also undocumented? Did I get them
in trouble? Did I say too much?”
(2) While working with J.B., the student reflected on their
own positionality and biases related to gender roles.
When J.B. mentioned that she relocated to become “a
good housewife” for her husband, the student initially
noted, “[P]art of me who had grown up in Western
culture rebelled against taking pride in being [a] stay-
at-home wife who was dependent on her husband.”
The student "found out that not all [their]
preconceptions of [the patient] were true” after
learning during the TMM interview that the patient
“valued education” and "was a student" in
Bangladesh. Further contributing to this perspective
change was the student’s subsequent encounter,
where the patient was eating a homemade meal from
her mother-in-law. This allowed the student to realize
that the meal may indicate “the husband’s, and the
husband’s family’s, respect towards this young girl.”
Discussion
The quantitative and qualitative results from our
exploratory pilot study demonstrate that MIP-supported
TMM is an implementable approach to help eliminate the
gaps in providing humanistic care to patients with LEP.
The diversity of languages encountered (six different
languages, see Figure 3) emphasizes the necessity of MIP
use. MIP use enables LEP patients, who experience worse
clinical outcomes and receive lower quality care than ES
patients,64 to participate for the first time in a humanistic,
patient-centered program. TMM has been previously
shown to personalize and enhance the ES patient
experience,59 thus MIP-supported TMM has the potential
to address the loss of patient-centered communication in
language-discordant encounters.
Implications of MIP-supported TMM for LEP
patients
In this pilot, MIP-supported TMM enabled patients to
actively participate in their care and encouraged the
healthcare team to provide person-centered care beyond
diagnosis to the individual patient. For some LEP patients,
MIP-supported TMM presented an opportunity to
exercise their autonomy. LEP patient autonomy is often
compromised when patients do not feel comfortable
asking for clarification on a diagnosis or laboratory
findings,65 or when patients rely on a family member to
serve as an interpreter.66 For instance, J.B. had initially
relied on her husband to serve as an ad hoc interpreter,
although it was unclear whether she had done this due to
cultural norms or to a lack of understanding of her patient
rights to an interpreter.67 However, J.B. used the MIP to
first communicate her symptoms and concerns before
beginning the TMM interview. Patient J.B. also found her
own voice through TMM, sharing with the student
interviewer not only her symptoms, but also her
experiences growing up in Bangladesh and adjusting to life
in the United States.
Even with the support of medical interpreters in patient-
provider encounters, interpreter-mediated communication
tends to feature more biomedical than personal/emotional
content.33–35,68 By presenting opportunities for patients
with LEP to share their life experiences, interests, and
hobbies, the incorporation of MIPs in TMM may help
reduce this social isolation as well as counteract the loss of
personal and emotional information during translation.
The TMM posters also provide a readily available visual
summary of the patient’s unique qualities and strengths as
a person, thus serving as a nonverbal form of
Enhancing patient-centered care for limited English proficiency patients through Tell Me More®:, Liu et al.
186 Patient Experience Journal, Volume 9, Issue 3 – 2022
communication to bridge the language discordance
between LEP patients and their providers.
Notably, we observed significantly higher TMM
participation rates for LEP versus ES patients. This
finding may suggest that there is a greater need for clinical
teams to connect with LEP patients, who often feel
overlooked, silenced, and alone in the hospital.58,69 Further
investigation of the reasons for increased LEP
participation is warranted. Although not evaluated in this
pilot, it is possible that LEP patients may feel compelled to
participate in TMM when approached by the medical
student. This reluctance to say no to the opportunity may
be due to a desire to use the MIP, fears of disapproval
from healthcare professionals,70 concerns about seeming
like a “problem patient”,71,72 or worries about being a
burden to staff or on the healthcare system.69,73
There is also a need to distinguish between language
versus cultural influences on LEP patient participation in
TMM. In this study, LEP patients were defined as those
who requested for and used MIPs for the majority of the
TMM interview; ES patients completed the interview in
English without MIPs. Given these criteria, patients who
did not speak English as their primary language but were
fluent enough in English to complete the interview
without MIP were also considered ES patients in this
study. Separate consideration of these patients as a third
group compared to LEP and ES patients may help
elucidate whether cultural or language differences have
greater influence on LEP patients’ decisions to participate
in TMM.
Implications of MIP-supported TMM for medical
education
Findings from our pilot study indicate that a medical
student-driven, medical interpreter-supported program
that emphasizes the personal stories of LEP patients is
feasible. Over the course of implementing the MIP-
supported TMM program, the student experienced roles
of patient liaison and advocate, mediating interactions
between the patient, medical interpreter, and the
healthcare team. For example, the student was able to
communicate to the healthcare team the needs expressed
by C.G. in their TMM conversation. Additionally, the
student exhibited self-reflection in their journal entries, as
they examined how their beliefs, words, and actions
shaped these encounters with LEP patients and their
families. Further exploration of the MIP-supported TMM
program may help fill gaps in medical training and care for
linguistically and culturally diverse patients.
Practice implications and future directions
We developed a medical student-driven initiative to build
rapport and trust between LEP patients, medical students,
and the healthcare team through interpreter-mediated
patient interviews and collaboratively created posters.
Participation rates were significantly higher for LEP than
ES patients, suggesting the need for more in-depth
evaluation of TMM’s role in LEP patient care. Student
reflections also indicated that the initiative has potential to
not only promote patient autonomy and patient-centered
care for LEP patients but also enhance cross-cultural
medical training.
Limitations to our study are characteristic of most pilot
studies, including the need for reproducible results with
larger sample sizes and more nuanced analyses of TMM’s
impact on the LEP patient experience. In this exploratory
pilot study, one medical student conducted all of the TMM
interviews with LEP and ES patients; future studies
including additional students are needed to evaluate the
generalizability of educational benefits gained from
implementing interpreter-supported TMM. In this pilot,
the overall self-rated impact of TMM on hospital stay
among both LEP and ES patients was positive. This single
rating scale, however, could not sufficiently nor
comprehensively capture the ways and extent to which
TMM positively impacted LEP versus ES patients.
Sociodemographic data, with the exception of participants’
primary language, were not collected in this pilot but
should be included in future efforts with LEP and non-
LEP patients to more comprehensively define patients’
multifaceted identities, monitor sociodemographic
differences in the impact of TMM on patient experience,
and delineate the complex interactions between language
proficiency, race/ethnicity, gender, and other
sociodemographic characteristics in disparate barriers to
equitable care and disparate health outcomes. Future
applications of interpreter supported TMM should also
consider the time investment required of participating
students. MIP-supported conversations between the
student and LEP patients in this pilot could sometimes
take as long as four hours, compared to ES interviews that
typically lasted two hours. However, we believe the
potential benefits of TMM for LEP patients, a persistently
marginalized population, outweigh this time cost.
Additional considerations include the incorporation of
different professions and interpreting modalities. The
format of this initiative makes it especially well-suited for
medical students at the beginning of their clinical training,
who have more time available to build relationships with
patients.59 In fact, the structure of interpreter-supported
TMM could be easily adapted to include high school,
college, volunteer, and/or pre-health and other health
professions students to foster an earlier appreciation for
the challenges LEP patients face to access and receive
quality care. In addition, compared to telephonic
interpreting, in-person and video interpretation services
could help increase intimacy and have been rated more
favorably among providers and interpreters,74 though
expansion to other interpreting modalities must be
balanced with resource allocation.
Enhancing patient-centered care for limited English proficiency patients through Tell Me More®:, Liu et al.
Patient Experience Journal, Volume 9, Issue 3 – 2022 187
By simultaneously engaging medical students, LEP
patients, providers, and medical interpreters, this team-
based initiative serves as a promising practical strategy to
address healthcare disparities confronted by LEP patients.
The reproducibility of TMM with ES patients has been
previously demonstrated.59 The present pilot study
demonstrates that the inclusion of LEP, in addition to ES
patients, in the TMM program is feasible with the support
of medical interpreter services, and therefore future
iterations of the program should include both ES and LEP
patients. LEP should not be an exclusion criteria for future
TMM projects.
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