Title: Assessing and Enhancing Students' Interviewing Skills with Interpreters in the Mini-CPX

Karen Hauer, MD; Jason Satterfield, PhD; Margo Vener, MD; Helen Loeser, MD
Fall 2003

BACKGROUND
A fundamental goal for physicians in training is to develop competence in performing a history and physical examination and in communicating with patients in a culturally sensitive, effective manner. The introduction by the ACGME of core competencies, including patient care and interpersonal and communication skills, has prompted much discussion about enhancing methods of evaluating trainees in these skill areas. At UCSF, the clerkships have endorsed several objectives related to interviewing and communication skills, including that students will:

o Treat patients with respect, demonstrating compassion and sensitivity to a patient'sindividuality.
o Use an understanding of the doctor patient relationship in a therapeutic, supportive, and culturally sensitive way for patients and families.

Despite the fact that all clerkships support these objectives, there are currently limited and incomplete assessments of students' skills in these areas. Clerkships often rely on evaluation data that are potentially incomplete but easily gathered, such as evaluations by students' supervising residents and attendings. A concern with resident/attending evaluations is that they may be based on limited or no bedside observation of students with patients. In clerkship evaluations, students consistently report that their supervisors have not observed them at the bedside with patients. This common report suggests that resident and attending evaluations may be based on proxy information, such as students' verbal presentation skills, rather than on their actual bedside abilities. Thus a more reliable, consistent method of evaluating students' interviewing skills and their cultural sensitivity is needed.

Working with medical interpreters is a particularly challenging clinical situation that forces students to confront cultural and language barriers in performing a history and communicating findings to a patient. Proper use of trained interpreters can increase patient satisfaction and quality of care. In recognition of the need for students to develop culturally sensitive interviewing skills, the School of Medicine and the culture and behavior (CAB) curricular theme have prioritized the teaching and assessment of students' interviewing skills with medical interpreters. Although the need for this skill spans all clerkships and most clerkship sites, the Family and Community Medicine (FCM) clerkship has taken primary responsibility for this objective. A medical interpreter curriculum is under development in the FCM clerkship and scheduled for piloting with housestaff in 2003-2004, with implementation for students anticipated in core clerkship year 2004-2005. Currently there is no objective skill-based assessment in development for this learning objective.

The Clinical Performance Examination (CPX) is a high-stakes, comprehensive clinical skills assessment jointly developed and administered by seven California medical schools to all students at the end of the core clerkship year. The mini-CPX is a formative, mid-third year assessment created at UCSF to give students the opportunity for mid-year feedback and to allow for direct feedback discussions between standardized patients and students. At this time, the standardized patient cases in the mini-CPX and CPX include only English-speaking patients. Although several of the cases address cultural differences, there is not a case that involves a non- English speaking patient. Thus, the mini-CPX is an ideal forum for assessing students' skills following presentation of the FCM didactic module.

GOALS
1. Assess students' skills working with an interpreter to take a patient history, perform a physical examination, and counsel a patient. (Mini-CPX, winter 2005) Data describing student performance will serve as an objective assessment of the efficacy of the FCM and CAB curriculum. In addition, it will allow for a comparison of the efficacy of the FCM clerkship curriculum by student site.
2. Create an educational video for the Mini-CPX, winter 2005, to be used in debriefing groups to facilitate discussion of proper techniques to use with interpreters, and cultural issues and biases that can affect a patient interview.

PROCEDURES - project design
We are proposing a two phase project that builds on CAB and FCM clerkship curriculum concepts related to culturally sensitive interviewing and working with medical interpreters.

Phase 1 is the development of an interpreter case for the mini-CPX exam, Winter 2005. We will develop a script for a standardized patient that is non English speaking and presents with chest pain. This case will require students to use a medical interpreter and demonstrate knowledge of cultural beliefs and barriers to health care. We are planning to include a Russian-speaking patient and interpreter because this is a common language spoken in San Francisco, and we would be able to recruit actors who speak the language. In addition, because few UCSF students speak Russian, few would bypass the interpreter in the mini-CPX encounter. To develop the case, we will work with a medical interpreter at UCSF, and we will consult faculty at UCSF with expertise in the use of interpreters. The actors portraying patients and those portraying interpreters will be trained to give verbal feedback to students from the perspective of their characters.

Phase II involves the development of a teaching videotape demonstrating a sample encounter to use in debriefing groups immediately after the mini-CPX. The videotape will serve as a focus of reflection and discussion for the students after the exam. The videotape will show the same encounter with a sample student (a trained medical provider or actor) conducting the interview and examination with the interpreter and patient. The video will include both correct and incorrect examples of culturally sensitive interactions through an interpreter. It will be constructed with pre-defined stop points that trigger discussion about strengths and weakness of the student actor's performance and reflection among the students about how they handled similar aspects of the encounter.

PLAN FOR MEASUREMENT AND DOCUMENTATION OF PROJECT EFFICACY AND OUTCOME
1. We will collect data from the mini-CPX exam to assess students' history taking, physical examination, and communication skills in the encounter with interpreter. This data will be gathered from the web-SP database, an online checklist program used by all of the standardized patients. We will then compare the data based on FCM clerkship site. Because only students doing their FCM clerkship in San Francisco will receive the new interpreter curriculum in 2004-5, we will compare the assessment data by FCM clerkship site (i.e. San Francisco students vs. Santa Rosa, Fresno, and Salinas students). These results would then serve as a useful feedback tool for the FCM clerkship and to the CAB group.
2. We will develop a survey to ask students about the perceived efficacy of the feedback from the patient, from the interpreter, and from the debriefing session. This data will be helpful in planning future innovations within the mini-CPX format. We will plan to describe our results in abstract or poster form for a regional or national meeting, or for possible publication in a medical education journal. We feel there will be some national interest in our results as many schools are beginning to integrate the use of medical interpreters into their curricula.

PLAN FOR CONTINUATION OF PROJECT AT THE END OF FUNDING CYCLE:
1. Case: The interpreter case will be added to the existing bank of cases used in the CPX and mini-CPX. Thus, it will be an enduring resource for future CPX administrations, both here and at our collaborating schools. Actors with language skills who are recruited and specially trained to portray characters in patient/interpreter encounters will be available in our CPX actor pool for future roles.
2. The medical interpreter curriculum in the FCM clerkship is envisioned as a permanent addition to the clerkship. The feedback to the clerkship about students' demonstrated and retained skills with interpreters will be a valuable tool for modifying and improving the curriculum as needed. The continued development and administration of this curriculum will be supported by the ongoing HRSA grant recently awarded to the Department of Family and Community Medicine.
3. The debriefing video will be an enduring teaching material that can be used in future mini-CPX administrations to enhance discussion in debriefing sessions. In addition, the process of creating the video, including the lessons learned about content and technical aspects, will facilitate the creation of future videos related to different cases.

For more information, please contact:
Karen Hauer, MD
Jason Satterfield, PhD
Margo Vener, MD
Helen Loeser, MD