doctors: First insights into the benefits of collaborative practice in interpreter ... healthcare professionals experiencing difficulties in their communication with ...
Author accepted manuscript Please, cite as: Krystallidou, D., et al. (2018). Training doctor-minded interpreters and interpreter-minded doctors: First insights into the benefits of collaborative practice in interpreter training. Interpreting. An International Journal of Research and Practice in Interpreting, 20(1), 126144. https://doi.org/10.1075/intp.00005.kry
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REPORT Training “doctor-minded” interpreters and “interpreter-minded” doctors: The benefits of collaborative practice in interpreter training.
Demi Krystallidou, Céline Van De Walle, Myriam Deveugele, Evangelia Dougali, Fien Mertens, Amélie Truwant, Ellen Van Praet and Peter Pype Ghent University
Abstract In response to calls in the literature for more collaborative practice in interpreter training, this paper describes the design, implementation and part of the evaluation of an innovative joint training intervention for interpreting students (Master’s level) and 3rd- and 4th-year medical students at Ghent University. In order to assess the development of the students’ knowledge and skills, we employed self-efficacy questionnaires, while for the evaluation of the training intervention, we held a debriefing session with trainers from both fields. A development in skills that involve direct interaction with the primary participants and address specific communicative goals was noted. Our first evaluation suggests that interprofessional education and collaborative practice in interpreter training can create the conditions for interpreting students to develop a more insightful and reflective approach to their interpreting practice. Keywords: healthcare interpreting, joint training, interprofessional education, interpreter training, communicative goals
1.
Introduction
There is evidence in the literature to suggest that professional interpreters – despite their training – are not always familiar with specific intricacies inherent in medical consultations, such as the structure of the medical interview, the different stages of the medical consultation and the communicative goals attached to them and which doctors strive for (Krystallidou 2014; Hsieh 2016). Consequently, although interpreters do enable communication between patients and healthcare providers, they might act in ways that can adversely affect the flow of
the consultation which, by extension, might place undue strain on the doctor-patient relationship and might even have clinical implications (Hsieh 2007; Rosenberg et al. 2007). In a similar vein, research in the field of clinical communication has provided evidence of healthcare professionals experiencing difficulties in their communication with patients who speak a different language (Karliner 2004; Weissman et al. 2005, Park et al. 2006). In order to overcome the language barrier, they rely on informal and professional interpreters. However, since healthcare providers are not always familiar with the interpreter’s prescribed role in the consultation, they might expect interpreters to exceed their brief (Pöchhacker 2000; Davidson 2001; Fatahi et al. 2008). Such lack of synergy between doctors and interpreters in the workplace may well be due to deficits in the training of these professionals. More specifically, the training of interpreters has not paid due attention to the intricacies of clinical communication (Krystallidou 2014). On the other hand, when it comes to the training of doctors, the design of curricula on clinical communication skills has traditionally relied on full language concordance (i.e., the clinician and patient are proficient in each other’s language) (Fung et al. 2010; Bansal et al. 2014). At the same time, in the Interpreting Studies literature, there are a rising number of calls for interpreter training to rely more closely on real-life professional practice in order to account for authentic institutional discourse (Crezee & Grant 2013; Crezee 2015). By extension, trainers and researchers have argued in favour of joint training for (healthcare) providers and interpreters (Malek 2004; Raval 2007; Cambridge et al. 2012; Krystallidou 2014) and have made a plea for involving professionals from other disciplines in the training of interpreters (Perez and Wilson 2007; Balogh & Salaets 2015). They have also emphasized the need to familiarize interpreting students with the communicative strategies used by other professionals who might call on the help of interpreters (Tebble 2014). In response to the above need to have the training of both interpreters and doctors revisited and updated and in order for the two professionals to work closely and effectively with each other, a joint training initiative between interpreting students and medical students was launched at Ghent University in 2014. The initiative was conceived and led by Demi Krystallidou (DK) and Myriam Deveugele (MD), co-authors of this paper, and was situated within the regular undergraduate curriculum in clinical communication at the Faculty of Medicine. At the time of writing, this training intervention did not form part of the interpreting students’ regular curriculum and was designed as an extramural activity.
In this paper we describe the design and implementation of the joint training intervention and present results of its evaluation, focusing on the findings pertaining to the student interpreters’ evaluation of the intervention.
2.
The joint training intervention
For the development of the joint training intervention, the two coordinators (MD and DK) and Peter Pype (PP) relied on the six steps to curriculum development outlined by Kern et al. (2009) as “a practical, theoretically sound approach to developing, implementing, evaluating and continually improving educational experiences in medicine” (Kern et al. 2009). The six steps are (i) problem identification and general needs assessment, (ii) targeted needs assessment, (iii) goals and objectives, (iv) educational strategies, (v) implementation and (vi) feedback and evaluation.
2.1
Problem identification and general needs assessment
The need to introduce this joint training intervention emerged from deficits in both professional practice and in the education of both student groups, as documented in the literature, as well as from DK and MD’s observations and concerns as trainers in interpreting and clinical communication. As stated above, there is evidence that the unfamiliarity of doctors’ and interpreters’ with each other’s communicative practices and role in the consultation (Krystallidou 2013) might adversely affect the flow of the consultation, placing undue strain on the doctor-patient relationship (Hsieh 2007) and having even clinical implications. At the level of education, two main problems were identified: On the one hand, interpreter training has traditionally been interpreter-centred (Krystallidou 2014) and relied on a deontological ethical framework, in which interpreters learn what they “shall…will…[or] never do” (Dean & Pollard 2011). On the other hand, consultation models used in medical education are conceived with monolingual doctor-patient communication in mind and hardly address language barriers (Li et al. 2010; Bansal et al. 2014) leaving medical students unprepared for interpreter-mediated communication with patients.
2.2
Targeted needs assessment
At a micro level, neither student group had previously been brought together and no insights into each other’s professional communicative practices had previously been included in their training. The interpreting students had acquired some knowledge of the deontological framework within which community interpreters should operate across various institutional settings and had developed skills in consecutive interpretation and dialogue interpreting in general without, however, focusing on discourse and interaction in healthcare settings. The medical students had previously acquired knowledge on the structure of the medical consultation and the communicative goals attached to the different stages of it and had not received any training on interpreter-mediated communication. It should be clarified here that the term “communicative goal(s)” might generate different associations among doctors and trainers in clinical communication, as it might be understood to refer to the purposes of the consultation, namely creating a good interpersonal relationship, exchanging information and making treatment-related decisions (Ong et al. 1995). Although we acknowledge the three overarching purposes inherent in a medical consultation, as described by Ong et al. (1995), we do distinguish them from the context-dependent goals (where context here is each stage of the medical consultation as shown in Krystallidou 2016: 176). Therefore, in this paper, the term “communicative goal(s)” refers to the goal(s) doctors aim to accomplish at each stage of the medical consultation. For instance, in the “initiating the session” stage, the doctor’s communicative goals are to prepare the patient for the consultation, establish initial rapport with him/her and identify the reason(s) for the consultation. In order to accomplish these communicative goals, doctors employ communication strategies and techniques, such as the combined use of open- and closed-ended questions, paraphrasing, engaging in mutual eye contact with the patient, etc.
2.3
Goals and objectives
Based on the learning needs of the two student groups, we identified a set of learning goals and objectives. Goals are of a general nature and define the ideas that should be achieved, whereas objectives are defined specifically for measuring outcomes and can be described as knowledge and skills. Our overarching goal was to familiarize the two student groups with the communicative and interactional practices of each other they are expected to employ in their professional practice. With regard to the learning objectives, we focused on areas of
knowledge and skills that had been insufficiently addressed or developed in the training of the two student groups prior to the joint training intervention, if at all. Our selection of knowledge and skills as measurable objectives was informed by the relevant literature in the fields of Interpreting Studies and Clinical Communication, as well as by the professional practice. In terms of knowledge we wanted to investigate whether the interpreting students were aware of the different stages of the consultation, of the doctors’ communicative goals, the impact of structured information, emphasis and empathy, etc. With regard to skills, we wanted to find out if the interpreting students thought they were able to interpret accurately without adding or omitting anything, even when the doctor used medical terminology, and whether they were able to maintain the transparency of the communication, their own impartiality, and so on. (See Appendix).
2.4
Educational strategies
2.4.1 Plenary lecture For each student group, a plenary lecture on the acquisition of knowledge of each other’s communicative, interactional and normative practices was organised. More specifically, the lecture offered to the medical students focused on: i) the necessity of effective decisionmaking on the various options for language support in language discordant consultations, ii) the characteristics, advantages and disadvantages of the various options of language support in Flanders (e.g. informal and professional interpreting, remote interpreting, cultural mediation). Special attention was paid to professional interpreters’ normative interactional practices and to their role in the consultation and the doctor-patient communication. On the other hand, the interpreting students were introduced to the structure of the medical consultation by relying on the Calgary-Cambridge model of the medical interview (Silverman et al. 2013) as shown in Krystallidou (2016: 176) which the medical students at Ghent University are taught. Emphasis was placed on i) the communicative goals doctors aim to reach at the different stages of the medical consultation and the communicative strategies and resources they employ to that end, and ii) on the clinical relevance of maintaining the style in which information was shared by primary participants (e.g. order of information, emphasis, open ended questions).
In order to allow the students to develop the skills we defined in step 3 above (see Appendix), a few days after the plenary lectures MD, DK, PP and Fien Mertens (FM) organised a series
of joint practice sessions in which medical students and interpreting students were requested to perform in simulated interpreter-mediated consultations.
2.4.2 Joint practice sessions Over a period of four days, 35 student interpreters from the Master’s Programme at the Department of Translation, Interpreting and Communication at Ghent University received joint training with 256 third- and 238 fourth-year medical students at the Faculty of Medicine. Approximately 20 parallel practice sessions (each lasting 90min) were held every day for students from both disciplines. Small groups of approximately 8 medical students and 2 student interpreters participated in joint practice sessions. Each practice session allowed for two consultations (based on role-play scenarios) of approximately 20 minutes each, after which feedback was provided to the medical students enacting the role of the doctor (henceforth “doctors”) and the interpreting students acting as interpreters (henceforth “interpreters”). The practice sessions were jointly facilitated by 12 interpreter trainers and 8 trainers in clinical communication skills. The simulated consultations were held into and from Dutch (the students’ native language) and 7 other languages (EN, FR, ES, DE, IT, RUS, TUR). Each consultation was divided into three main components: i) gathering information on the patient’s problem, views, expectations and concerns, ii) history taking (medically oriented questions) and iii) explanation of diagnosis and negotiation of treatment plan. Each component involved a different “doctor” who was requested to hold part of the consultation by relying on previously acquired knowledge and by interacting with the “patient” through an “interpreter”. As opposed to the “doctors” who took turns, the “interpreter” remained the same throughout the entire consultation. By breaking down the consultation into smaller parts, a greater number of medical students were given the opportunity to practise. Due to the significantly low number of interpreting students, it was not deemed necessary to introduce a new “interpreter” in each part of the consultation. The interpreting students participated in the practice sessions in two distinct ways: either by enacting the role of the “patient” speaking a language other than Dutch – the “doctor’s” language, or by being the “interpreter”. The “patient” received information on the patient’s sociocultural background, symptoms and overall experience (feelings, expectations, concerns) a couple of days before the practice sessions. The “patient” was instructed to use specific vocabulary and act in ways that could potentially challenge the “interpreter’s” position in the interaction. In a similar vein, a few days before the consultation, the
“interpreters” received information on the place where the consultation would be held (e.g. GP’s practice, outpatient clinic), the gender and age of the patient and his/her main symptom (e.g. chest pain). Depending on the difficulty of the consultation, the “interpreters” received a couple of key terms that were likely to be used in the course of the consultation by the primary participants. As opposed to the “interpreters” and the “patients”, the “doctors” did not receive any information in advance and were briefed on the “patient’s” clinical condition just before the consultation. This is because, unlike the interpreting students who require preparation on the content of the joint training exercises, the group of medical students had already acquired knowledge and skills pertaining to the structure of the medical consultation and had had the opportunity to engage in communication exercises with simulated patients and do home visits (for a detailed account of the medical students’ communication curriculum, see Deveugele et al. 2005). The content of the consultation was provided by the tutors of clinical communication skills and enhanced further by the interpreter trainers. An example of the scenarios which were used for the joint practice sessions is found in Figure 1. Ms Smith and her sore knee Context Patient
is a 54-year old female lab assistant
has been suffering from diabetes and high blood pressure for 4 years
has been taking Metmorfine 850 1co/d, Bisoprolol 5mg 1co/d, Asaflow 80 1co/d and Simvastatine 40 ½ co/d
Cause Patient:
slipped on her way to work and fell on her left knee
managed to stand up and go to work (needed to be there on time)
applied Voltaren gel
noticed knee turned black and blue (day after)
feels pain while walking
Experience & additional information for the patient
leaving on a ski holiday to Zermatt in 2 weeks
past: ski champion; always uses red runs
now: worried, does not want to cancel holiday
maybe have an X-ray taken?
would physiotherapy help?
no previous knee-related problems
Deontological challenges for the interpreter
Patient cannot recall the name of the medication and wants to call her husband
Patient keeps telling she is in pain
Patient invites the interpreter to share her views on the doctor’s competence
Figure 1. Example of a scenario used in the joint practice sessions
2.5
Implementation
The plenary lectures and joint training sessions were conceived and organised by DK and MD, who coordinated the training intervention in their departments between 2014 and 2016, respectively during the preparation, implementation and evaluation stages of the intervention. The two coordinators could rely on the support of fellow trainers in their departments who contributed to the different stages of the intervention. The first author together with PP developed the post-and retro self-efficacy scales for both student groups, while MD, PP, FM and DK organized a trainer-debriefing session which was held a few days after the joint practice sessions.
2.6
Feedback and evaluation
With regard to the students’ individual assessment both in terms of knowledge acquisition and skills development, we opted for formative assessments (i.e. feedback provided during the practice sessions) and for summative assessments (i.e. self-efficacy questionnaires). In order to assess the training intervention, a debriefing session with trainers in both fields was held.
2.6.1 Formative assessment The feedback sessions occurred in a dynamic way, as the “doctors” and “interpreters” provided each other with feedback, while at the same time receiving feedback from tutors, as
well as from a small group of fellow students who sat in the audience and who observed the consultation. The feedback the “interpreters” received focused on their performance and, in particular, on their verbal and non-verbal interaction (where the former includes use of language and intonation and the latter refers to gaze, body orientation, gestures and facial expressions) toward the accomplishment of the primary participants’ communicative goals. During the provision of feedback, the trainers’ point of departure was whether the primary participants’ goals were reached. The accuracy and completeness in the interpreters’ delivery as traditional criteria for the assessment of the interpreters’ performance were replaced by the criterion whether the primary participants’ communicative goals were accomplished. Instead of focusing only on an accurate or less accurate rendition, the trainers approached the interpreters’ performance in a holistic way by checking whether the interpreters enabled and facilitated (Krystallidou 2013), or, indeed, hampered, the accomplishment of participants’ communicative goals both by means of verbal and non-verbal resources (i.e. gaze, body orientation, gestures, facial expressions). Excerpt 1 provides an example of a case which was discussed during a feedback session. Student participants were asked whether the primary participants’ communicative goals were reached at that stage of the consultation. It was observed that the “interpreter’s” share in the negotiation of meaning was essential as it seems to have shaped the way in which the discourse unfolded in the simulated situated professional activity. More specifically, a shift was noticed in the way in which the “doctor’s” communicative goals were introduced by him/herself, were rendered by the interpreter, responded to by the patient and negotiated further with the “doctor” in order for him/her to proceed with the consultation.
Excerpt 1 P: patient; INT: interpreter; D: doctor
26 P
no not really it’s mostly my knee
27 INT
nee niet echt enkel de knie no not really only the knee
28 D
euh ja oke dus dan komt u vandaag langs omdat u last heeft van uw knie en u zit daar eigenlijk mee in omdat u over twee weken wil skiën en dus wat u belangrijk vindt is dat u dat er een oplossing komt zodat u toch nog zou kunnen gaan skiën
euh yes okay so then you have come to see me today because you have a bad knee and you’re worried about that, because in two weeks’ time you would like to go on a skiing trip and so what you think is important is finding a solution so that you could go skiing 29 INT
so the most important thing for you is to find a solution before you go on your holiday↑
30 P
yeah sure I really want to go on holiday but I also want to know that my knee is fine
31 INT
ik wil zeker op reis gaan maar het belangrijkste voor mij is dat ik weet dat mijn knie in orde is I definitely want to go on holiday but what’s most important for me is that I know that my knee is fine
32 D
oké dan stel ik voor dat we nu eerst een aantal klinische praktische vragen stellen over uw knie en dat we dan verdergaan met het klinisch onderzoek okay, I suggest that we first ask you some medical practical questions about your knee and then we proceed with the clinical examination
It can be noted that while the “doctor” aims to explore the “patient’s” problem to discover i) the biomedical perspective (a bad knee), ii) the “patient’s” perspective, i.e. feelings and experience (Bickley 2013) (worried) and iii) the background information/context (upcoming skiing trip), the “interpreter” attends only to the patient’s perspective and the background information, leaving the biomedical perspective unattended. What is more, the shift in focus does not only concern the content of the information being exchanged among participants in order for communicative goals to be reached, but also the intensity attached to the communicative goals by each participant. This brings to mind the variation in graduation in terms of force (based on intensity) (Martin & White 2005), which has been identified in (trainee) interpreters’ performances (Tang & Li 2016). More specifically, in Excerpt 1, the “doctor” attaches importance to the patient’s perspective within the framework of the background information (what you think is important is finding a solution so that you could skiing) (turn 28). The “interpreter” accentuates this intensity further (so the most important thing for you is to find a solution before you go on your holiday↑) (turn 29). The “interpreter’s” turn prompts the “patient” to restore the intensity and re-introduce the biomedical perspective which was previously left unattended by the “interpreter” (yeah sure i really want to go on holiday but I also want to know that my
knee is fine) (turn 30). The “interpreter” maintains the intensity attached by the “patient” to the patient’s perspective and background information (I definitely want to go on holiday) and foregrounds the intensity attached to the biomedical perspective (but what’s most important for me is that I know that my knee is fine) (turn 31). The enhanced intensity attached to the biomedical perspective by the “interpreter” prompts the “doctor” to address the “patient’s” concern related to the biomedical perspective and announce the planned course of action (…we first ask you some medical practical questions about your knee and then we proceed with the clinical examination) (turn 32). Apart from discussions on the process of goal attainment, the “interpreters” also received feedback on their response to deontological challenges posed to them by the primary participants, as well as on their position in the triad. Due to time constraints issues of accuracy pertaining to the use of language (e.g. lexical choices) were addressed by the interpreter trainers immediately after the joint training sessions or during their regular classes.
2.6.2 Summative assessment For the summative assessment, the students of both groups were requested to complete selfefficacy questionnaires before (in retrospect), and after, the joint practice sessions. Below, we present the results of the analysis of the questionnaires that were filled out by the interpreting students. For the summative assessment, we used scales specially developed for this study. They focused on the intended learning outcomes and were pre-tested by Amélie Truwant (AT) by relying on cognitive interviewing as a validation procedure (Beatty & Willis 2007). For practical and pragmatic reasons (e.g. end of academic year and exams period), the scales were made available online one month after the practice sessions. We are aware of the implications (e.g. recall bias) this might have had on the overall assessment and therefore our findings should be interpreted with caution. Both the pre- and the post- scales were identical. However, respondents were instructed to assess their knowledge and skills BEFORE and AFTER the course; an example of the formulation of the post-scale is to be found in the Appendix. The Wilcoxon signed-rank test was used for the numeric scale (6-point Likert Scale) questions. The analysis of the self-efficacy questionnaires indicated a trend towards knowledge acquisition as a result of the course. The large number of non-respondents (16/35) did not allow us however to calculate statistical significance. Regarding skills acquisition statistically significant improvement was noted on the following items: i) the interpreter’s active
participation; ii) the interpreter’s direct address and iii) seeking clarification. No statistically significant improvement was reached for i) translating everything without adding/omitting anything; ii) medical terminology and iii) use of the I-form. The statistical analysis was conducted by Evangelia Dougali (ED). From the analysis of the questionnaires, it seemed that the interpreting students noticed the most significant shift in their knowledge on the communicative goals doctors strive for at the different stages of the medical consultation. At the level of skills, the student interpreters reported greater development in skills that involved direct interaction with the primary participants (e.g. the ability to remain impartial and restore the interactional flow after a primary participant’s attempt to involve the interpreter in the interaction), as opposed to skills that were related to self-initiated actions (e.g. the ability to provide complete and accurate renditions of the primary participants’ utterances).
Interpreting students
Interpreting students
BEFORE
AFTER
p-value
(in retrospect)
n yes (%)
n yes (%)
Mean (SD)
Mean (SD)
p-value
3.55 (0.596)
3.65 (0.745)
1
Medical terminology
3.09 (0.610)
3.25 (0.786)
.417
Interpreter’s active
3.86 (0.990)
4.45 (0.605)
.012*
3.86 (0.990)
4.45 (0.686)
.012*
Use of the I-form
4.14 (0.941)
4.50 (0.607)
.057
Seeking clarification
3.50 (1.058)
3.85 (0.587)
.048*
Skills Questions (N=20)
Translating everything without adding /omitting anything
participation Interpreter’s direct address
Table 1: statistical results of the self-efficacy questionnaires for interpreting students on skills (p
