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The importance of teaching clinicians when and how to work with interpreters
Elizabeth A. Jacobsa,b,*, Lisa C. Diamondc, Lisa Stevakd
aJohn H. Stroger, Jr Hospital of Cook County, USA
bRush University Medical Center, USA
cPalo Alto Medical Foundation Research Institute, USA
dSt. Mary and Elizabeth Medical Center, USA
especially in North America, Europe, and Australia where growing
economies and democracy attract individuals looking for better
across cultural and linguistic barriers. This challenge is felt most
acutely by clinicians for whom communication is essential to
diagnosis and treatment; however, as highlighted by the papers by
Fatahi  and Hseih  in this issue, clinicians in these systems are
rarely prepared to recognize and address these challenges. As a
result they do not work effectively with interpreters  or use
inappropriate interpreters .
Language barriers in health care pose multiple problems to
health care processes and outcomes among patients who do not
increase the risk of medical errors that can lead to serious
consequences [4–6]. This risk can be reduced and/or eliminated
when physicians use professional interpreters or communicate
proficiently with patients in their preferred language [7–9]. Yet
studies have shown that clinicians under-use appropriate inter-
preters [7–13] and use their own limited language skills during
clinical encounters, despite awareness of their own language
limitations and the fact that it might negatively impact communi-
cation and care .
An important factor in encouraging the use of appropriate
interpreters in the health care setting is education. Studies have
shown that clinicians who have received any training about how
language barriers contribute to problems in health care or the use
of interpreters are more likely to call on appropriate interpreters
when needed [15,16]. In addition, it provides an opportunity to
teach clinicians about cultural issues that frequently arise in the
setting of language barriers and how to work in effective
collaboration with interpreters, needs which have been highlight-
ed by both Hseih and Fatahi, and others, in this issue [1,2].
In this paper, we describe a curriculum about how best to over
come language barriers in health care for medical students in the
Patient Education and Counseling 78 (2010) 149–153
A B S T R A C T
Objective: To describe the importance of teaching clinicians when and how to overcome language
barriers inclinical practice, provide an example of acurriculum for teaching on this topic, and outlinethe
critical issues that must be addressed in this type of teaching.
Methods: We describe a 1.5 h educational program for students in a large urban medical school as an
example curriculum and how it impacted student responses on a 28-item questionnaire measuring their
knowledge, attitudes and likelihood of future behaviour before and after the course. The course
components are described and highlight the essential components that should be included in teaching
about overcoming language barriers in clinical practice.
Results: There were significant improvments in knowledge, attitudes, and reported likelihood of future
behaviors after the educational program. Recommendations for essetential curricular components are
Conclusion: Teaching clinicians about language barriers in health care and how to overcome them
should be essential toall clinical curricula.Brief educational interventions can meet thisneed and should
include a core set of essential teaching points as outlined.
Practice implications: Teaching clinicians when and how to overcome language barriers in health care
will help to reduce the impact of this barrier, make clinicians and interpreters’ jobs easier and more
transparent, and improve patient care and satisfaction.
? 2009 Elsevier Ireland Ltd. All rights reserved.
* Corresponding author at: 1900 W Polk St, 16thFloor, Chicago, IL 60612-9985,
USA. Tel.: +1 312 864 7311; fax: +1 312 864 9694.
E-mail address: firstname.lastname@example.org (E.A. Jacobs).
Contents lists available at ScienceDirect
Patient Education and Counseling
journal homepage: www.elsevier.com/locate/pateducou
0738-3991/$ – see front matter ? 2009 Elsevier Ireland Ltd. All rights reserved.
Author's personal copy
United States as an example of the kind of curriculum that is
needed for clinicians and use it, along with other described
curriculum, to formrecommendationsfor what should be included
when teachingclinicians aboutlanguage barriers in the health care
Medical students encounter patients with limited ability to
speak English during the course of their training. However, they
have little exposure to the challenges of providing care when faced
to address language barriers prior to beginning their clinical
rotations. This is a critical point in their transition to becoming
practicing physicians when professional lifelong habits are
established and not providing medical students with guidance
on how to best practice in the face of language barriers is a missed
The clerkship directors at Rush University Medical College
recognized this missed opportunity and established the Clinical
Resources and Skills for the Hospital (CRASH) curriculum that takes
students an intensive period of training on the practical skills they
will need as they start their ward rotations and throughout their
clinical years. It includes courses on EKG reading, Professionalism,
clerkships. We were invited to teach a course on how to overcome
language barriers in health care. Below we describe the curriculum
and data we collected measuring its impact on medical students’
knowledge of and attitudes about overcoming these barriers and
their intent to modify their future behavior.
We developed and implemented this curriculum based on our
experience working and collaborating with interpreters and
community groups, previous research, and by following the
guidance of professional organizations such as the National
Council for Interpreting in Health Care a US-based health care
interpreter policy and advocacy organization . The course is a
one and a half hour teaching session in which all 2nd year medical
students participate. In order to allow for discussion and role-
playing the 75–80 medical students are divided into three groups.
The course has four curricular components: (1) a trigger tape
followed by discussion of the consequences of using untrained
interpreters, (2) a didactic portion in which students are provided
with best principles for choosing and working with interpreters,
(3) a modeling session in which faculty members model how to
effectively work with interpreters, and (4) a role-playing session in
which students have the opportunity to practice working with an
interpreter. Because language and culture are difficult to separate,
we also provide teaching on how to address cultural issues in an
interpreted encounter. Before and immediately after the session
students filled out an evaluation and a 28-item questionnaire to
measure change in knowledge, attitudes and intended behavior.
The faculty of the course include a general internist with
experience in the field (EAJ), a master’s level educator (LS), and the
director of interpreter services of Rush University Medical Center.
In addition several interpreters (Spanish, Polish and Korean-
speaking) role-played patients and interpreters with the students.
2.1.1. Curricular components
22.214.171.124. Trigger-tape (10 min). In order to engage students to think
about and discuss what can go wrong when an encounter is badly
interpreted or an inappropriate interpreter is used (e.g. family
member or untrained interpreter) a 5-min teaching tape was
shown in which a Muslimwoman’s sister-in-law is interpreting for
her when she comes to the doctor to discuss the fact that she has
been bleeding after sex . Clearly the patient and sister-in-law
are uncomfortableinthe situation and the sister-in-law violatesall
principles of interpreting (editorializing, not interpreting what is
being said, embarrassing and chiding her husband’s sister, and
cutting the encounter short). Students are usually able to identify
all these issues and name other reasons family member should not
interpret (they may not be fluent in both languages, they may bias
the conversation, they may take control, etc.). They are also asked
a situation by using a trained interpreter and rescheduling the
patient when a trained interpreter is available. We also highlight
how language barriers contribute to disparities in health care.
designed to be brief yet provide students with guidelines on
common problems that arise when working with untrained
interpreters, how best to work with professional interpreters,
and how to access interpreter services within the two hospitals
that they typically rotate. Students learn that untrained inter-
preters frequently are not fluent in both English and the target
language, that they may not know how to ‘‘get around’’ words or
concepts that occur in one language but not the other, that they
may ‘‘polish’’their language,distortorexaggerate meaningoromit
information because of their lack of language ability or their
relationship to the patient. They learn how to access professional
face-to-face interpreters and how best to work with them
including where to place the interpreter and themselves in the
encounter, to always look at the patient, how to brief and debrief
the interpreter, to speak slowly, in simple language and in
manageable ‘‘chunks’’ of information. They are also informed of he
laws and regulations in the United States and the fact they are
required by law to provide these services. Finally the fact that
children should never be used as interpreters and the ethical
reasons why are emphasized.
session(10 min). Thedidacticsession was
126.96.36.199. Modeling session (10 min). Before role playing three of the
instructors model what a good interpreted encounter should look
director of interpreter services is the interpreter, and one of
the other faculty members plays the patient. In this scenario the
patient isSpanish-speakingand believes that her brokenfoot isnot
healing because she was subject to mal de ojo, or evil eye, by one of
her husband’s girlfriends. The physician models briefing and
debriefing with the interpreter, speaking slowly in simple
language, asking the interpreter for cultural information and
being open to and addressing the patient’s beliefs about mal de ojo.
In the end she and the patient develop a plan together as to how to
address her pain and the mal de ojo. The interpreter models proper
positioning of the interpreter (beside and slightly behind the
patient), explaining to the physician and patient how he must
interpret all that is said, and providing cultural information to the
188.8.131.52. Role-playing session (60 min). The majority of the session is
devoted to role-playing in which the students have a first-hand
experience of working with an interpreter and what to do when
encountering patients whose beliefs and cultural models differ
from the biomedical model. Students are split into 3 groups and
each group rotates through three different role playing scenarios:
(1) A young Korean immigrant who declines a cast for her broken
arm because it will interfere with her involvement in her sister’s
wedding and therefore embarrass her family, (2) a young polish
E.A. Jacobs et al./Patient Education and Counseling 78 (2010) 149–153
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mother whose baby has a potentially life-threatening congenital
heart defect that she believes should improve with prayer and
fasting, and (3) a Spanish-speaking diabetic woman who declines
oral medication because she wants to use ‘‘natural’’ medicines.
Each role-play was observed and feedback and teaching provided
by one on the instructors, the interpreter, the simulated patient
and their fellow students.
To evaluate the impact of the teaching session, students
completed a 28-item questionnaire before and after the session in
addition to providing feedback about what they thought of the
course. The 28-item questionnaire was adapted from one
developed by the Asian Health Coalition of Illinois to measure
how their cultural competence curriculum impacted the knowl-
edge of and attitudes towards cultural competency. The instru-
ment was modified to make all questions specific to working in the
context of language barriers and we added several questions about
their intended behavior when facing language barriers when
encountering patients who did not speak English well. Sample
items from each of these components are included in Table 1. In
response to each item students circled one of five Likert scale
responses: strongly disagree, disagree, unsure, agree, and strongly
agree. Pre- and post-test difference scores were calculated for each
student and t-tests were used to assess whether or not there was a
significant change in responses to each of the 28 items.
Seventy-two of the 79 students who took the course completed
both the pre- and post-questionnaires. The majority of students
were female (57%), their age ranged from 21 to 32 years. The
majority was self-identified as Caucasian (49%) and Asian (37%).
Seventy-four percent stated that they had had previous cultural
competency training and 49% stated they spoke a language other
There were significant improvements in knowledge, attitudes
and intended future behavior after the course. There was
significant improvement in 6 of 8 knowledge items. Students
improved in their understanding of the best place to situate an
interpreter inan encounter, that family and friends arenot the best
choice for an interpreter, that patients are not responsible for
providing their own interpretation, and how to best work with an
interpreter (Table 1). There was significant improvement in 5 of 11
attitude items. After the course, students were significantly more
likely to endorse that it is easy to work with interpreters, that
cultural competency is necessary to provide high quality health
care, that the information obtained through interpreters is
accurate, and that they will not find it frustrating and more
rewarding to care for limited English proficient (LEP) patients.
Finally students were significantly more likely to agree with 3 of 6
items asking them about their future behavior. They were more
likely to say that they would seek out a professional interpreter,
ask patients to repeat back instructions, and take culture into
account when taking care of LEP patients. For items where there
were no significant differences pre- and post-testing, students’
pre-tests indicated that they already had appropriate knowledge,
acceptable attitudes and were planning on working appropriately
with interpreters; there was no room for improvement.
In general the course evaluations were positive and students
felt the material would be helpful to them as they entered their
clerkships. The role-playing highlighted as the best component.
4. Recommended curricular components
4.1. Learning from existing curriculum
Our curriculum is similar to the few other published curricula
on this topic [19–24] in that it includes information about the
pitfalls of working with untrained interpreters, how to access and
best work with interpreters, and provides students with the
experience of working with interpreters and feedback on how
well they did seeing a patient in this context. Our and other
curricula highlight the fact that cultural and linguistic barriers
frequently co-occur and provide students with an introduction to
how they can address these cultural issues [19,23]. We also
include teaching about the impact of language barriers on health
and health outcomes, which is important to helping students
recognize the importance of overcoming these barriers through
methods have been described, in person and web-based [19–24],
and standardization but the disadvantage of not being able to
provide the experience of working with an interpreter to deliver
Our and other curricula have also been evaluated to measure its
impact on students [19–26]. Methods of evaluation include
measuring changes in survey answers before and after educational
interventions and ratings of students by standardized patients.
Like in our study these evaluations have demonstrated that these
curricula have met their goals and improved knowledge and
Questionnaire items with significant improvement from pre-test to post-test.
Direction of Change
The best place to have an interpreter sit is between you and your patient
Family members and friends are usually the best people to use as interpreters
It is inappropriate to use family members as interpreters
When speaking through an interpreter it is important to look at the doctor and patient
When speaking through an interpreter it is important to slow down and use short sentences
It is easy to work with interpreters
Cultural competency is necessary to provide high quality health care services
The information I obtain using a trained medical interpreter is accurate
I think I will feel frustrated when caring for LEP patients
I think I will find it rewarding to work with LEP patients
Future behavior items
You will arrange for a professional interpreter to help you communicate with LEP pts
You will ask patients to repeat back instructions
You will take culture into account in pt care plans
E.A. Jacobs et al./Patient Education and Counseling 78 (2010) 149–153
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increased desired behavior. However, only one has measure the
impact later than immediately after the educational intervention
, although the results were not well-described, so the long
term impact of these educational interventions is unknown.
4.2. Learning from other literature
It is useful to ask if existing curricula would teach to the issues
raised by both Hsieh  and Fatahi , and others, in their
research. They would address some but not all of the issues they
raise. Our and many of the other educational curricula would help
providers understand how to access appropriate interpreters, the
good reasons behind interpreter speech patterns, encourage
providers to be open to and ask for feedback from the interpreters
about cultural issues that might impact the encounter, and provide
them with the tools for recognizing when interpreters are
inappropriately claiming medical expertise.
Fatahi, Hseih, and others [1,2,27] of how interpreters and
physicians see the role of the interpreter differently and how this
can lead to miscommunication and missed opportunities. Provi-
ders also need to be educated as to what can be expected from
interpreters and how they can communicate and collaborate with
interpreters in a mutually satisfying manner. In addition, clinicians
need to learn to respect and be open to hearing interpreters’
insights into patient cultural norms and political experiences
which, when missed by physicians, have important consequences
on the development of the therapeutic relationship.
This literature provides a guide to what should be taught to
clinicians when teaching them about language barriers and how to
overcome them and how to measure their impact on clinicians’
knowledge, attitude, and behavior (Table 2). These recommenda-
tions include covering the basics of how language barriers
negatively impact care and why they need to be appropriately
addressed in clinical care; why ad hoc interpreters such as family
and friends should not be used; what interpreters should be used
and how to access them; and how best to work with interpreters.
This latter curricular component should include a discussion of
how to work collaboratively with interpreters in a way that the
clinician invites feedback from the interpreter, provides feedback
to the interpreter, and seeks and encourages the interpreter to
provide cultural insight that the clinician may be missing. In
addition the impact of this type of curricula should be measured,
ideally by examining its impact on how the student interacts with
a patient in the context of a language barrier-either in a simulated
or real encounter, and it should be measured in the short term and
long term. This latter measure will provide educators with
information about whether or not they need to conduct refresher
Language barriers in the health care setting are an increasing
global problem that threatens the quality and safety of health care.
As highlightedinthe papers byFatahi andHseihinthisissue
of Patient Education and Counseling, clinicians often do not have
the appropriate tools and skills to be able to recognize when
language barriers pose a problem and how to overcome them by
and what skills and tools can be used to address them can help to
mitigate the problems posed by language barriers and increase the
likelihood of using appropriate professional interpreters. As we
demonstrated in our curriculum, the educational intervention
need not be long or complicated and can have a significant impact
on students’ attitudes,knowledge,and behavior aslong as it covers
the important recommended topics.
Curriculum should also evolve with educators’ experience and
feedback from students and other sources. Fatahi  and Hseih 
raise important issues about the complexity of working with
cultural context that increases the complexity of the interaction.
Their findings highlight the importance of teaching clinicians
about this complexity and how they can collaborate with the
interpreter to better understand and address the cultural issues
that go hand-in-hand with language barriers. From the literature it
taught, but it clearly should be.
Evaluation of the short- and long-term impact of teaching on
much of an impact this type of teaching has, where there are gaps
in teaching/learning, and if there is a need to have expanded or
refresher courses. While examining changes in attitudes, knowl-
edge, and likelihood of future behavior before and after educa-
tional programs are quick and relatively easy, positive changes on
this type of evaluation could be the result of teaching students
what you want them to say rather than truly reflecting a change in
the way they think or intendto behave. It also gives no information
about the long-term impact of the intervention unless a post-
survey months or years after the intervention is conducted. Using
simulated patients gives the students the opportunity to have an
experience working with an interpreter and to get feedback on
their actual behavior, but this method may also just measure what
the student will do in a test situation and not what they will do in a
real encounter in which language barriers are present. Also it is
expensive and time-consuming to do a pre- and post-simulated
patient evaluation. The best way to evaluate educational programs
teaching residents how to overcome language barriers may be a
combination of a written survey that is taken before, right after,
and then months or a year later, in addition to evaluating a
simulated or real patient encounter some time after the
6. Practice recommendations
Clinicians who are likely to encounter patients in the context of
language barriers need to be educated about the impact of those
barriers on care and how best to overcome them. This curriculum
should include a core set of teaching points including how
language barriers negatively impact care and why they need to be
appropriately addressed in clinical care; why ad hoc interpreters
such as family and friends should not be used; what interpreters
interpreters, including inviting feedback from the interpreter and
seeking and encouraging the interpreter to provide cultural insight
that the clinician may be missing. Finally the impact of this type of
Recommendations for curricular content for teaching clinicians to overcome
language barriers and curricular evaluation methods.
Recommended curricular components
Impact of language barriers on health and health outcomes
What interpreters should not be used
Which interpreters should be used and how to access them
How best to work with interpreters
How to collaborate with interpreters to understand cultural
issues impacting communication and care
Pre- and post-survey testing, with post-testing repeated months
Rating of simulated or actual patient encounter working with an interpreter
E.A. Jacobs et al./Patient Education and Counseling 78 (2010) 149–153
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curriculum should be measured, examined, and used to modify the
teaching module to make it the most impactful and engaging for
We would like to thank those who supported the development
Kim, MPH who were instrumental in its development and teaching,
Robert Rosen, MD of Rush University Medical College and the Asian
in the course. Finally we would like to thank Carlos Olvera for his
excellent interpreting and teaching. This teaching innovation was
Meeting, April 26–29, Los Angeles, CA.
 Fatahi N. Experiences of Kurdish war-wounded refugees in communication
with Swedish authorities through interpreter. Patient Educ Couns 2009;1–24.
 Hseih E. Provider-interpreter collaboration in bilingual health care: competi-
tions of control over interpreter-mediated interactions. Patient Educ Couns
 Jacobs E, Agger-Gupta N, Chen A, Piotrowski A, Hardt E. Language barriers in
health care settings: an annotated bibliography of the research literature. The
California Endowment 2003;August.
 Flores G, Laws MB, Mayo SJ, Zuckerman B, Abreu M, Medina L, Hardt EJ. Errors
in medicalinterpretation and their potential clinical consequences in pediatric
encounters. Pediatrics 2003;111:6–14.
 DiviC,KossRG,SchmaltzSP,LoebJM.Languageproficiencyandadverse events
in US hospitals: a pilot study. Int J Qual Health Care 2007;19:60–7.
 Van Kempen A. Legal risks of ineffective communication. Virtual Mentor
 Karliner LS, Jacobs EA, Chen AH, Mutha S. Do professional interpreters improve
clinical care for patients with limited English proficiency? Asystematic review
of the literature. Health Serv Res 2007;42:727–54.
 Fernandez A, Schillinger D, Grumbach K, Rosenthal A, Stewart AL, Wang F,
Pe ´rez-Stable EJ. Physician language ability and cultural competence: An
exploratory study of communication with Spanish-speaking patients. J Gen
Intern Med 2004;19:167–74.
 Jacobs E, Sadowski L, Rathouz P. The impact of an enhanced interpreter service
intervention on hospital costs and patient satisfaction. J Gen Intern Med
 BakerDW,Parker RM,WilliamsMV,CoatesWC,PitkinK.Useand effectiveness
of interpreters in an emergency department. JAMA 1996;275:783–8.
 Burbano O’Leary SC, Federico S, Hampers LC. The truth about language
barriers: one residency program’s experience. Pediatrics 2003;111:e569–73.
 YawmanD,McIntoshS,FernandezD,AuingerP,Allan M,WeitzmanM.Theuse
of Spanish by medical students and residents at one university hospital. Acad
 Schenker Y, Wang F, Selig SJ, Ng R, Fernandez A. The impact of language
barriers on documentation of informed consent at a hospital with on-site
interpreter services. J Gen Intern Med 2007;22(S2):294–9.
 Diamond L, Schenker Y, Bradley E, Curry L, Fernandez A. Getting by: underuse
of interpreters by resident physicians. J Gen Intern Med 2009;24:256–62.
 Karliner LS, Perez-Stable EJ, Gildengoren G. The language divide, the impor-
tance of training in the use of interpreters for outpatient practice. J Gen Intern
 Lee KC, Winickoff JP, Kim MK, Campbell EG, Betancourt JR, Park ER, Maina AW,
Weissman JS. Resident physicians’ use of professional and nonprofessional
interpreters: a national study. JAMA 2006;296:1050–3.
 www.ncihc.org [Accessed 28.07.09].
 Valuing Diversity. ‘‘Red faces all around.’’ 1999. London: Royal College of
Practitioners. [Video Recording].
Can a web-based curriculum improve students’ knowledge of, and attitudes
about, the interpreted medical interview? J Gen Intern Med 2005;20:929–34.
 WieseHJC, Torbeck L,Matheny SC.Learning howtouse interpreters. MedEduc
 Kennedy CC, Rho JP. Using interpreters to teach. Med Educ 2004;38:557.
 Marion GS, Hildebrandt CA, Davis SW, Marin AJ, Crandall SJ. Working effec-
tively with interpreters: a model curriculum for physician assistant students.
Med Teach 2008;30:612–7.
 Haack S. Engaging pharmacy students with diverse patient populations to
improve cultural competence. Am J Pharm Educ 2008;72:1–6.
 Freeman J, Dobbie A. Teaching and assessing family medicine clerks’ use of
medical interpreters. Fam Med 2008;40:313–5.
 Lie D, Boker J, Bereknyei S, Ahearn S, Fesko C, Lenahan P. Validating measures
of third year medical students’ use of interpreters by standardized patients
and faculty observers. J Gen Intern Med 2007;22(Suppl. 2):336–40.
 Farnill D, Todisco J, Hayes SC, Bartlett D. Videotaped interviewing of non-
English speakers: training for medical students with volunteer clients. Med
 Hudelson P. Improving patient-provider communication: insights from inter-
preters. Fam Pract 2005;22:311–6.
E.A. Jacobs et al./Patient Education and Counseling 78 (2010) 149–153