Date: Friday, 10/30/09 Time

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Clinical Skills: Working with Interpreters1


Friday, 10/30/09


1:15-3:05 pm (Groups E-H)

3:15-5:05 pm (Groups A-D)


Fleischmann Labs

Responsible Faculty:

Schillinger, Basaviah, Stanford Interpreter Services, E4C Faculty

Session Goal

Develop skill in effectively working with interpreters.

Learning Objectives

At the end of the session the students will be able to:

  1. Identify when to use an interpreter;

  2. Demonstrate effective work with interpreters;

  3. Gain awareness of linguistic challenges to the medical interview and developing relationships with patients;

  4. Define relationships and roles with interpreters and patients, and;

  5. Reinforce effective communication strategies, including cross-cultural patient perspectives of illness.

Special Instructions

Professional dress required for the interviewing practice.


5 minutes

Overview of session

5 minutes

Review reading

3 minutes

Review “guidelines for working with interpreters”

10 minutes

Role play/demo and debrief

10 minutes

Practice patient interview and working effectively with interpreters and standardized patients: students should work in groups of 4 and split the medical interview (2 students interview 1 patient)

20 minutes each patient x 2 = 40 minutes

Debrief patient interview

10 minutes each x 2 = 20 minutes

Group debrief: What did you learn?

10 minutes

Learner reflection, and establishment and recording of personal learning goals.

5 minutes


108 minutes


  • Coulehan and Block. Chapter 12 “Cultural Competence in the Medical Interview” pp 234-236
    • NYU Online “Working with Interpreters” Module: (Username = demo; Password = demo) Please do NOT complete post-test; it will complete the module for this demo account, and other students will not be able to access it.




In today’s session, we will emphasize the following parts of the “Stanford Interview Elements”:

Opening the Interview, including greeting, introductions, explanation of role and purpose of the interview, gaining consent, inquiry into the patient’s reason(s) for the visit, and setting an agenda;

Building the Relationship / Establishing Personal Rapport, including establishing patient comfort, using verbal and non verbal communication that show care and concern, avoiding technical jargon;

Professionalism, including seeming to know what s/he is doing, appearing to have the patient’s interest at heart, and inspiring confidence;

Active Listening, including using facial expressions/body language to expression encouragement, paying attention to nonverbal cues, and asking clarifying questions;

Information Gathering, including the use of open- and closed-ended inquiry, collecting information in an organized way, clarifying details as necessary, summarizing, and transitioning smoothly from one part of the interview to another;

Patient Perspective, including eliciting the patient’s chief concern;

Information Sharing, including communicating to patient pertinent information;

Closing, including summarizing, checking for mutual understanding, thanking the patient for his/her time;

Ground rules for today:

  1. The focus of today’s interviews will be on gaining skills in working effectively with interpreters. This will impact all parts of the medical interview learned up to this point: opening, rapport building, open-ended questioning, HPI, PPI, PMH, FH, and SH.

  2. Make sure you practice summarizing and transitioning.

Suggested behaviors, skills to work on, and common pitfalls

Opening the Interview

Behaviors of the interviewer:

Common Errors:

  • Greets the patient

  • Introduces self (first name, last name, and title) and others

  • Explains purpose of interview/ give road map

  • Gains consent to proceed

  • Allows patient to complete opening statement without interruption

  • Elicits full set of concerns

  • Negotiates agenda for the visit

  • Does not use patient’s name

  • Does not knock

  • Introduces self by first name only

  • Does not introduce the team/ others in the room

  • Does not explain purpose of interview/ give road map
  • Does not gain consent to proceed

  • Interrupts patient’s opening statement

Building the Relationship / Establishing Personal Rapport

Behaviors of the interviewer:

Common Errors:

  • Establishes patient comfort

  • Use words and nonverbal gestures to show care and concern

  • Avoid technical jargon

  • Elicits and addresses patient’s emotional reaction to illness (PEARLS)

  • Does not attend to patient comfort

  • Uses technical jargon “I need to elicit your history,” “I am going to palpate your spleen now.”

  • Misses opportunities for connection with the patient


Behaviors of the interviewer:

Common Errors:

  • Demonstrates confidence / appears competent

  • Appears to have patient’s interest(s) at heart

  • No white coat or name tag

  • Jeans, exposed knees

  • Frazzled appearance

  • Not putting patient’s interests first

Active Listening

Behaviors of the interviewer:

Common Errors:

  • Uses facial expressions / body language to express encouragement

  • Pays attention to both verbal and non-verbal cues

  • Asks questions to make sure s/he understands what is said

  • Stuck in notes, not looking at patient

  • Does not name and address important verbal and non verbal cues

Information Gathering

Behaviors of the interviewer:

Common Errors:

  • Begins with open-ended questions

  • Collects information in a way that seems organized

  • Clarifies details as necessary using closed, or yes/no, questions

  • Summarizes and check accuracy with patient (“ask back”)

  • Starting to structure the interview too soon

  • Uses closed-ended questions too quickly

  • Asks complex, compound, or multiple questions

  • Asks questions in random order rather than trying to structure the patient’s story

Patient Perspective

Behaviors of the interviewer:

Common Errors:

  • Elicits patient’s chief concern / Explored patient’s explanatory model of illness

  • Asks re: events, circumstances, other people that might affect health

  • Responds explicitly to patient statements re: ideas, feelings, values

  • Asks if patient has any questions

  • Focuses only on the biomedical view of illness, rather than incorporating the patient’s experience and interpretations

Closing the Interview

Behaviors of the interviewer:

Common Errors:

  • Checks for mutual understanding of plan

  • Asks if patient has questions or concerns for next time

  • Summarizes (or asks pt to summarize) plans until next visit

  • Clarifies follow-up or contact arrangements

  • Leaves no time for patient questions about the assessment or plan

  • Closes the interview ambiguously, e.g. continuing to talk, or without a closing comment



  • The Standardized Patients and interpreters should also participate in the debrief, along with the observing students and preceptor/TA. SPs should give feedback if student missed portions of the history or comment on the students’ use of interpreters.
  • For the interview demonstration, please move swiftly through the elements of the interview already learned (CC, HPI, PPI, FH, PMH, SH).

Overview of session learning goals and objectives (5 minutes)

Please give students a road map for today’s session. By the end of the session, students should be able to:

  1. Identify when to use an interpreter;

  2. Demonstrate effective work with interpreters;

  3. Gain awareness of linguistic challenges to the medical interview and developing relationships with patients;

  4. Define relationships and roles with interpreters and patients, and;

  5. Reinforce effective communication strategies, including cross-cultural patient perspectives of illness.

Review reading (3 minutes)

Students will have completed the readings either online or via their paper course reader. The group facilitator’s role is to:

  1. Make sure students have done the reading;

  2. Help students synthesize major issues, and;

  3. Address concerns and questions about the reading.

Students will have completed the anonymous NYU online interpreter module. In brief, the module covers legal and social aspects of limited English proficient patients in the medical setting, the role and expectations of interpreters and physicians during the encounter, and short clips highlighting common challenges and effective strategies. The module should prepare students for this session as well as provide a good foundation for future medical encounters. You may also wish to discuss perspectives relevant to California.

Review “Guidelines for Working with Interpreters” (10 minutes)

The following are recommendations on working with trained interpreters from Stanford Hospital Interpreter Services:

  • Look at the patient.

  • Speak directly to the patient.

  • Speak in short sentences and pause, giving the interpreter time to repeat accurately what was said.

  • Speak the same way you would to an English-speaking patient.

  • Be aware of your choice of words and body language.

  • The trained interpreter may act as a “cultural broker.”

The following are recommendations on working with untrained interpreters from Stanford Hospital Interpreter Services:

  • Introduce yourself to the patient and to the person acting as the interpreter.

  • Assess the interpreter’s English skills and confirm with them that you expect everything you say, or the patient says, to be interpreted accurately and completely, with no additions, omissions, or changes to the original message. Also confirm the importance of patient confidentiality with the interpreter.

  • If the interpreter and patient get into a side conversation, politely ask what is being said.

Role Play Demo and Debrief (10 minutes)

In this first demonstration of working with interpreters we would like for you, the preceptor, to interview a non-English speaking patient with an interpreter present. You should do a BAD JOB interviewing. Some suggestions:

  • Don’t introduce yourself and/or the interpreter

  • Don’t explain your and the interpreter’s role

  • Don’t mention confidentiality (your and the interpreter’s obligations)

  • Intentionally cut the patient out of the loop

  • Don’t make eye contact with him/her

  • Make no effort at establishing rapport or checking for understanding

  • Sit in a way that you are not facing the patient

  • Use the third person pronoun (he/she) in talking about the patient

  • Speak quickly, with medical jargon if possible

  • Don’t pause for understanding—speak in long paragraphs

  • Try to engage the interpreter in a long discussion that excludes the patient

  • If the patient and interpreter engage in discussion, try to “zone out” and allow yourself to become disengaged

  • Don’t ask for the patient’s questions

  • Don’t provide closure or formal goodbye

Ask students to comment on effective use of interpreters, drawing on specific, concrete examples from your demonstration.

Practice patient interview and working with interpreters in triads, followed by triad debrief (20 minute interview + 10 minute debrief)
For this session, students should work in groups of 4.
Each quartet should team up with a Standardized Patient and interpreter. The standardized patients for today’s session have been given a short scenario to act out. This scenario maps to the topic of the session. There will be 2 or 3 SPs per small group.
Students should work in pairs to interview the SP, splitting up the interview and debriefing with the group between each student. One student should open the encounter and elicit the CC, HPI, PMH; the other student should elicit the FH, SH, and close the encounter. The other students should be observing using the Stanford Interview Elements (SIE – copies will be provided at the beginning of the session).

The facilitator may choose to debrief after each student’s interview; that is, at the halfway point of the interview. Alternatively, you may wish to wait until the conclusion of the interview to debrief with the entire quartet, SP, and interpreter.

After the debrief, the triad then rotates to the next Standardized Patient.

Since we are using interpreters who will be playing both trained and untrained roles for this session, there will be some deviation from the “ideal” use of interpreters during the medical interview. Students should feel comfortable correcting the interpreter if needed (e.g., positioning, limiting side conversations, etc.).

For the new patient, with a different presentation, the observing students should now take the role of interviewing the SP. There will only be 2 patient encounters per quartet for this session.

Notes for reflection and feedback on the interview:

  • The “doctor” should first give his/her perceptions of the interview, starting with what went well and not so well, observations of the patient, and emotional reactions to the patient and the interview.

  • Using the principles of feedback, emphasizing an appreciative approach, the observers should give constructive feedback to the “doctor.” Students should remember to give specific feedback on observed behaviors. (“Great job!” is not helpful.)

SP Scenarios for Today’s Session (for preceptors only; students should not be given ahead of time)

  1. Pain in lower right abdomen, nausea, and mild fever; appendicitis.

  2. Productive cough, shortness of breath, and fatigue; bronchitis.

  3. Numbness in right hand; carpel tunnel syndrome.

  4. Sore, swollen throat, with secondary symptoms of headache and body ache; strep throat.

Group Debrief: What did you learn? (10 minutes)

Ask students to discuss challenging aspects of assessing a patient’s nutritional status, and the core skills needed to elicit a history, as delineated in the reading. Ask students to describe their understanding of these skills.

Wrap-up (5 minutes)

Allow 5 minutes to wrap up, review relevant lessons from the day, and plan for next time. This time for learner reflection should include establishment and recording of personal learning goals for each student.

While students reflect and record their own learning goals, this is an appropriate time for you to make notes on your students’ performance in this session. There are facesheets located in your preceptor binder; use these to record formative evaluation comments on your students. When student evaluations are due at the end of the quarter, you can refer to these notes in order to track your students’ progress.


For the next session, the students will practice eliciting a Review of Systems with their classmates. Encourage students to read the assignments and be prepared for class.

Students need to come to class with notes that will enable them to elicit a ROS. Each “student doctor” will be interviewing a fellow student in his/her triad to elicit the ROS. Each student must therefore come prepared to act the role of a patient with a straightforward health problem and positive (and negative) findings on Review of Systems. Please encourage students to thoroughly research a common problem, and be prepared to provide a brief CC/ HPI, and then add significant richness to the story through the ROS responses.

1 [Based in part on “Cultural Competence” module of the SFDC Professionalism in Contemporary Practice course]

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