*Review* **The Use of Interpreters in Medical Education: A Narrative Literature Review**

**Costas S. Constantinou \*, Andrew Timothy Ng, Chase Beverley Becker, Parmida Enayati Zadeh and Alexia Papageorgiou**

> Department of Basic and Clinical Sciences, Medical School, University of Nicosia, Nicosia 2408, Cyprus; ng.a@live.sgul.ac.cy (A.T.N.); becker.c@live.sgul.ac.cy (C.B.B.); enayatizadeh.p@live.sgul.ac.cy (P.E.Z.); papageorgiou.a@unic.ac.cy (A.P.)

**\*** Correspondence: constantinou.c@unic.ac.cy

**Abstract:** This paper presents the results of a narrative literature review on the use of interpreters in medical education. A careful search strategy was based on keywords and inclusion and exclusion criteria, and used the databases PubMed, Medline Ovid, Google Scholar, Scopus, CINAHL, and EBSCO. The search strategy resulted in 20 articles, which reflected the research aim and were reviewed on the basis of an interpretive approach. They were then critically appraised in accordance with the "critical assessment skills programme" guidelines. Results showed that the use of interpreters in medical education as part of the curriculum is scarce, but students have been trained in how to work with interpreters when interviewing patients to fully develop their skills. The study highlights the importance of integrating the use of interpreters in medical curricula, proposes a framework for achieving this, and suggests pertinent research questions for enriching cultural competence.

**Keywords:** interpreters; medical education; educational and health outcomes; cultural competence

#### **1. Introduction**

Medical doctors practice medicine in multicultural societies and are expected to exercise cultural competence, such as working with interpreters in order to provide the best quality of care to their patients [1–4]. There are many definitions of cultural competence, although it generally refers to knowledge regarding social and cultural factors that affect health and illness and to actions necessary for the provision of quality and accessible care [1,2]. The need for cultural competence has been recognized in literature as it may reduce health disparities [2], and doctors can improve their skills and knowledge in this area of practice [5]. Research has shown that cultural competence is associated with increased patient satisfaction and adherence to therapy [1,6] and has helped physicians enhance their cultural sensitivity [7].

Despite these findings, the integration of cultural competence in medical curricula has been underdeveloped [4,8]. Alizadeh and Chavan [1] found 18 models of cultural competence, with many training paradigms for medical practitioners revealing a link between cultural competence and enhanced patient satisfaction and adherence to therapy. However, none of these models were specifically tailored for education purposes. In support of these findings, Sorensen et al. [9] also highlighted the importance of cultural issues and the need to integrate cultural competence in medical curricula.

Cultural competence encompasses several skills: from understanding the social and cultural determinants of health, exploring patients' beliefs and showing understanding, to working in partnership with patients based on their tailored and individual social and cultural needs. One aspect of cultural competence is to work effectively with people with limited command of the language spoken by health care professionals and to recruit interpreters to assist with this task. This is vital to ensure patients from non-native cultures have equal access to essential information, diagnostic procedures, and treatment regimens [10].

**Citation:** Constantinou, C.S.; Ng, A.T.; Becker, C.B.; Zadeh, P.E.; Papageorgiou, A. The Use of Interpreters in Medical Education: A Narrative Literature Review. *Societies* **2021**, *11*, 70. https://doi.org/ 10.3390/soc11030070

Academic Editor: Gregor Wolbring

Received: 27 April 2021 Accepted: 23 June 2021 Published: 1 July 2021

**Publisher's Note:** MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

**Copyright:** © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

The evidence on the use of interpreters in medical consultations is rich and generally demonstrates that when communication between doctors and patients is augmented, there is a reduction in errors [11] and the cost of medical care in terms of decreased visits in emergency rooms and lower readmission rates [12]. However, Himmelstein, Wright, and Wiederman [13] explained that there is negligible evidence about medical students working with interpreters within the medical curricula. On this note, we think that the following questions are important to consider. First, are medical/health care undergraduate students provided with professional and/or ad hoc interpreter resources when they are at their clinical placements and they encounter patients that do not speak the language of instruction? Second, have the students and interpreters been through a training before they come to work together at the clinical placements? Third, are undergraduate medical/health care students provided with training on how to use interpreters in health care consultations when they graduate? The third question is easier to answer and there is more literature available as it will be shown in this review. However, one might say that if students are taught how to use professional interpreters when interviewing patients, they might be able to use the knowledge and skills when they are provided with interpreters at their clinical placements. This is where the difficulty lies. How many medical schools provide professional and/or ad hoc interpreters when students are sent to their clinical placements in order for the students to fulfill course requirements such as Direct Observations and MiniCex (Mini Consultation Evaluation Exercise)? Are these interpreters trained on how to help students maximize their knowledge and experience and collect evidence for their portfolios? Are the clinical tutors and other clinical staff who supervise the students trained on how to use interpreters to achieve the learning outcomes of the curriculum? What about the patients who are vulnerable when attending these health care settings, especially when they do not speak the health care professionals' and students' language? How do they feel to be interviewed by students accompanied by interpreters?

Based on a gap identified by Wright and Wiederman [13] and on the questions above, the research aim of this study focuses on understanding the extent of interpreter utilization in medical education as part of the curriculum and its effects on educational and health outcomes. To address the research aim, this study has conducted a narrative literature review as presented below.

#### **2. Methodology**

The methodology used for this narrative review was based on guidelines by Ferrari [14] and the SANRA (Scale for the Assessment of Narrative Review Articles) [15]. These guidelines clarified that narrative reviews should include a clear research aim, ample justification, and a search strategy. The aim of this narrative review is to explore the use of interpreters (ad hoc and professional) in international medical education. Due to the lack of a fixed research hypothesis, as per the guidelines for narrative reviews [14], as per Table 1 our inclusion and exclusion criteria were the following: peer-reviewed articles, theses, dissertations, literature reviews, conference papers, editorials, and books or textbooks that include medical students, published between 2000 and 2020 in the English language.


**Table 1.** Inclusion and exclusion criteria.

Based on the criteria above, the following databases were searched: PubMed, Medline Ovid, Google Scholar, Scopus, CINAHL, and EBSCO. We relied on databases which could help us extract papers in social sciences, medical education, and health care, and to which our Institution had access. In order to achieve a focused search and address the aim of the project, we used specific keywords, and these were: interpreters, translators, medical education, medical school, curriculum, medical training, education, medicine, medical students, clinical education, clinical settings, language barriers, facilitators, barriers, confidence, satisfaction, patient perspective, patient outcomes. For facilitating our search and review of the identified articles we organized several questions into four main areas, namely utilization, perspective, impact, and barriers/enablers, as per Table 2 below. We did not treat the questions in Table 1 as research questions but only as guides for our search and for reviewing the articles in order to ensure that the articles selected were the most relevant. These questions were also used as the context for generating codes and constructing overarching themes.

**Table 2.** Organization of search questions.


As per Figure 1, the initial search generated 257 articles. The process of excluding duplicates and irrelevant papers resulted in 96 articles. Based on reading the abstracts of these sources in accordance with our inclusion and exclusion criteria, 34 sources were selected for in-depth review. After careful review, 14 articles were excluded because they did not relate to the research aim of this review. These articles largely pertained to clinicians or early career doctors, and challenges faced with language barriers, but they did not discuss interpreting services. The detailed review resulted in the selection of 20 articles as they reflected, directly or indirectly, the research aim of this study.

**Figure 1.** Flowchart on the literature selection process based on guidelines by Ferrari (2015).

For the analysis of the articles, we relied on an interpretive approach to effectively understand the use of interpreters in medical education and on Thomas and Harden's [16] thematic synthesis technique. Thematic synthesis consists of three stages. Firstly, the articles were thoroughly read multiple times to become familiar with the methods and the findings. Secondly, the findings in each article were coded based on the research aim of this study. Thirdly, the codes were grouped together in order to construct overarching themes, ultimately forming a codebook which helped organize and interpret the results. After the construction of the codes and themes, the analysis was drafted and refined by revisiting the articles, initial codes and themes. To ensure the validity of the results, a two-level quality assurance process was instituted, whereby the researchers split into two groups and followed the review procedure (i.e., check codes and themes, revisit the articles, refine the codes and themes) independently.

For the critical appraisal of the articles included, the Critical Assessment Skills Programme (CASP) was used as a guide [17] due to the absence of specific appraisal guidelines for narrative literature reviews [14]. Consequently, the critical appraisal of the articles is presented under results in the form of a narrative and in a table in Appendix A.

#### **3. Results**

From the coding of the articles, two overarching themes emerged, largely reflecting the types of articles identified. That is, "use of interpreters during undergraduate medical/health care curricula", and "developing students' skills through training in how to use interpreters in health care interviews or consultations".

#### *3.1. Use of Interpreters during Undergraduate Medical/Health Care Curricula*

This section is centrally relevant to the research aim of this study because it focuses on the use of interpreters during undergraduate medical/health care curricula. Interestingly, only five papers discussed the actual use of interpreters in medical or health care education as part of the curriculum [13,18–21]. More specifically, Itaya et al. 2009 [18] conducted a survey with students and faculty members to understand how the limited English patients (LEP) were managed in dental education and what was the perceived impact on the quality of education. One hundred and twenty-two (122) students and fifty-six (56) faculty members from five out of six dental schools in California—United States of America (USA) completed the survey and the results revealed that only ad hoc interpreters were used when dental students interacted with LEP patients at their clinical placements. Further, it revealed that the use of interpreters did not meet the required standards by the U.S. Department of Health and Human Services and the Commission on Dental Accreditation (CODA) and that the lack of professional interpreters in dental schools had a negative impact on the quality of dental education. For example, it increased the length of appointments and decreased the students' ability to provide high-quality care for these patients (e.g., getting patients to accept treatment plans, gaining compliance with home oral health preventive behaviors, completing treatment plans, etc.).

Another study by Simon et al. [19] with a larger sample of participants exploring what dental schools in the USA did to prepare their students to work effectively with interpreters when interacting with LEP patients during their clinical placements—and therefore improve the care of LEP patients—found the same trends. That is, students from 19 out of the 62 dental schools who completed the survey reported that there was insufficient integration of interpreters in their clinical teaching and poor-quality training for this. To elaborate, only 56.3% of the 325 respondents reported that there was some integration of interpreting services in their education. Additionally, 43.7% said that interpreting services were not used and approximately 30% of the students explained that such lack of services compromised the quality of care provided to LEP patients and the achievement of their dental education outcomes. Only 54% of the respondents agreed that they were well prepared to manage LEP patients after graduation.

In addition to dental schools, a more recent study was conducted using medical schools in the USA [13]. Out of the 147 schools that received a survey link, 38 responded with 29 schools reporting their curriculum addressed the use of interpreters. However, only 10 of these 29 schools had used simulated environments for students' learning or used didactic teaching sessions. The rest of the schools did not have any relevant curriculum. The majority of the schools (22) offered such training during the first two years of education, while seven schools offered the training later: during years three and four. Eighteen (18) of these schools started training their students how to work with interpreters in the last 10 years. However, this study did not explore whether the medical schools provided trained interpreters or ad hoc interpreters to their students when meeting LEP patients at their clinical placements.

The fourth relevant study by Omoruyi et al. [20] developed and evaluated a curriculum to teach medical students how to use telephone interpreter services during their 8-week outpatient pediatric clinical rotation. This is the only study we found to evaluate medical students' ability to use interpreter skills in actual patient encounters. The researchers used a case-cohort comparison to investigate "behavioral outcomes of the exposed learners to evaluate if the training had an impact on actual patient encounters." The results of the study suggested that this type of interventions increased medical students' perceived self-efficacy

in using interpreters in actual patient encounters. More specifically, the students who went through the curriculum were more likely to use effectively the skills below than the students who did not receive the curriculum:


The fifth relevant study by Mazori et al. [21] evaluated a program of working with interpreters at a free clinic. Of the 76 medical students, 40 were allocated to the intervention group and 36 were allocated to the control group. The results of the study were very similar to those of Omoruyi et al. (2018) in that when medical students in the intervention group interviewed a LEP patient in their clinical placements (family medicine clerkship), they were able to improve their communication skills such as:


The findings from these five papers show that the use of interpreters in clinical settings in medical education is scarce—or has not yet been documented—and when interpreting services were used, they were underdeveloped in the sense that a few schools used these services or used them on an ad hoc basis. These papers provided some insights into the use of interpreters in medical education in the USA, but we still do not know the extent of the use of interpreters in medical education globally; what patients think about the services; and how students and interpreters feel about it. Although Omoruyi et al.'s [20] and Mazori et al.'s [21] studies discussed the impact of using interpreters on students' skills, there is no study included in this review which presents information about long-term educational outcomes, student satisfaction, and the impact of interpreting services in medical education on patients and their health outcomes. Such lack of evidence highlights a huge gap in improving medical education in multicultural environments and the need to empirically explore the impact of interpreting services on educational and health outcomes. Finally, we did not find any studies focusing on students', patients', interpreters', or doctors' perspectives on interpreting services, and on the facilitators and barriers for utilizing interpreters in medical and health care education. However, despite these gaps, students at some schools have been trained in how to work with interpreters, as discussed below.

#### *3.2. Developing Students' Skills through Training in How to Use Interpreters in Health Care Interviews or Consultations*

Fifteen (15) articles were not centrally located in our research aim because they did not discuss the direct use of interpreters in clinical settings as part of the curriculum. However, they indirectly addressed the training of students in using interpreters. That is, these trainings have largely involved interpreters through scenarios or in simulated environments rather than in actual clinical placements or as part of the existing curriculum like the studies discussed in the previous section. Such trainings indirectly relate to our research aim because it is important to know whether they have helped students, thereby informing decisions about the integration of interpreters in medical education.

The findings of these articles indicated that there has been a variety of training paradigms utilized, especially during the pre-clinical years, such as web-based modules [22–24], workshops [25], and evaluation of a longitudinal program [26]. The majority of these paradigms were effective because they helped students develop their skills of

using interpreters in their health care interviews/consultations. Specifically, the results demonstrated students had improved their skills in working and collaborating with interpreters [22–27], had improved attitudes [23], were more careful while working with people from other cultures, and appreciated patients' immigration status [23]. In addition, their self-confidence [28,29] and self-efficacy [30,31] were enhanced. Students also became more familiar with the relevant procedures used when working with interpreters and LEP patients [29], enhanced their cultural competence skills [32–35], and managed to match what they practiced with their curriculum [28].

Moreover, Kalet, Gany, and Senter's [22] and Kalet et al.'s [23] studies indicated that students greatly appreciated the training paradigms they used and expressed a strong interest in learning to collaborate with interpreters. In addition to the use of professional interpreters, two studies focused on the use of medical students as interpreters [21,34]. The results revealed that these students improved their skills and enhanced their cultural competency, but were challenged when attempting to separate the two roles in educational settings.

All these findings highlight that various training programs have helped students become more fluent in working with interpreters for the benefit of health care praxis and subsequently for patients. Interestingly, these training programs also suggested that occasionally student skills did not improve and that new paradigms should be explored to further develop the curricula. For instance, Lie, Bereknyei, and Vega's [26] study found that the skills "ask one question at a time", "listen without interruption", and "invited questions" deteriorated over time. The authors postulated several reasons for this. They suggested that relying on ad hoc or temporal training paradigms should be avoided because students' skills may deteriorate if they do not immerse themselves in life-long reflective development [20,26]. In other words, students should engage in repeated utilization of interpreters during their medical studies as part of the curriculum to enhance their fluency. Lie, Bereknyei, and Vega's study further suggested that without linking this to the formal curriculum, which combined didactic teaching and reflective practices, skills may not be sustainable. Finally, the skill of using interpreters should be taught separately initially for students to master the relevant skills before integrating them with other competencies [26].

#### **4. Critical Appraisal of the Articles Reviewed**

The 20 articles reviewed were evaluated based on their relevance to the research aim and scientific vigor. Based on CASP (Critical Assessment Skills Programme) guidelines, all articles had either a clear aim, research question(s), or hypotheses, and their importance ranged from moderate to high (see Appendix A for more detail). This was gauged on how valuable each research paper was in accordance with the following criteria: appropriateness of research design, sampling and data collection, use of validated instruments, discussion of contribution to scholarship, identification of new areas in research, and generalizability or transferability of the findings. The sample sizes in the studies ranged from a few cases (i.e., schools) and a few participants [18] to a few hundred [2,5,25,26,31,35] with varying research methods. Some of the articles employed cross-sectional designs and surveys and used questionnaires to measure perceived effectiveness of training paradigms [5,19,35]. Many articles used pre-post scoring scales or tests [22–24,27,30,31], while only very few articles relied on control trials with control or intervention/control groups [20,21,29]. In general, all articles answered their research aim and presented useful results which could inform decisions and open new directions in research.

The review of these articles also revealed some important limitations. In some cases, sample sizes were small [17,33,36], the instruments used were not validated [21,32], or there was no randomization of the population studied [25,30,33]. Additionally, the employment of qualitative methods as a primary research methodology was not seen. The use of qualitative methods could help give an in-depth understanding of the challenges and need for using interpreters. For example, qualitative interviews, focus groups, and observations guided by phenomenological frameworks could provide useful insights and address many

research questions regarding students', patients', and doctors' experience with using interpreters in medical education. In a few studies, a focus group was used either for exploratory or expansion purposes [29,35]. Moreover, there is a need to design more randomized control trials in order to better understand the impact of the use of interpreters on educational and health outcomes for students and patients, respectively. The studies were largely from the United States or were about university- or school-specific training paradigms. No comparison between schools and even counties was identified in the literature. In some studies, the testing of students' skills did not occur in real clinical settings [22–24,31]. This raises the issue of the transferability of the results. Although most studies showed improved skills by students, there was no evidence for the sustainability of these skills. Lastly, in general, studies focused on patients from Western countries and were based on the assumption that patients eagerly utilized health care services. This limitation suggests that working with interpreters should be part of the broader canopy of cultural competence whereby both medical students and medical doctors develop skills for working with diverse populations, such as understanding cultural beliefs, daily practices, their perception of evidence-based medicine, and so forth, and involving patients in shared decision making.

#### **5. Discussion**

This literature review focused on exploring the use of interpreters with physical presence in medical education and the effects on the quality of medical education and patient care. The findings indicated that the use of interpreters in medical education is scarce or has not yet been documented. Interestingly, medical students have been trained either through their curriculum or on an ad hoc basis on how to work with interpreters effectively based on scenarios or simulated environments; yet the clinical use of interpreters either in pre-clinical or clinical years has been very limited.

The findings regarding the use of interpreters in health care education reflect the existing literature about the usefulness of cultural competence in medical education and health care in general [1,6,7] and also their use in medical consultations [11,12]. Additionally, this study has revealed that training students in how to work with interpreters helps students develop their clinical communication skills and enhance their familiarity in this area which can potentially help them when entering health care settings for their clinical years. This finding is in accordance with what other studies show about the improved skills of doctors when trained in working with interpreters [11,12]. The study's main contribution to scholarship is that it has shown the significant gaps in the development of medical interpreter use curriculum and the impact of using interpreters in medical education on educational and health outcomes for students and patients respectively. Therefore, the questions which were utilized as a guide for this study's search strategy, and the review of the selected papers, could be used for research. For example, the following research questions derived from this study can be explored through robust research designs, provided that the use of interpreters in medical education is well integrated:


Based on the findings of this study and the identified need to integrate interpreting services in medical education and scientifically explore its impact, we propose a framework for achieving such integration. As per Figure 2, working with interpreters should be under the cultural competence curriculum whereby students acquire knowledge in social and cultural determinants of health and skills in how to work with diverse patients and interpreters. During this stage, training in cultural competence and working with interpreters could be achieved by integration with social sciences and through lectures, interactive cases, and interactive videos. As students move into their medical program and develop their skills, learning how to work with interpreters should be integrated with already-acquired clinical and communication skills. Mastering these skills to work with interpreters could be achieved in simulated environments whereby students learn and practice in small groups utilizing clinical scenarios aided by real simulated patients. Later in their studies, during medical practice or clerkships in hospitals, students could activate the knowledge and skills they gathered from previous years and work effectively with interpreters in health care settings. On this note, this proposed framework suggests that integration of working with interpreters in medical education should be longitudinal and learning should be developed through constructivist and spiral learning approaches.

**Figure 2.** Longitudinal integration of the use of interpreters in medical education.

#### **6. Conclusions**

This narrative literature review focused on understanding the scale of utilization of interpreters in medical education and its potential effects on educational and health outcomes. Interestingly, only five papers were identified in that area, two of which were about dental schools and three about medical schools. These five papers showed that the use of interpreters in medical education is scarce and needs to be improved. However, fifteen more articles were reviewed for this study because they indirectly explored the effectiveness of training medical students in how to use interpreters in health care consultations, which showed that students improved their knowledge and skills, although there was no evidence for the sustainability of these skills. This study is an important contribution to the existing scholarship as it highlighted a need to integrate interpreters in medical education within the context of cultural competence curriculum in order to help students to acquire sustainable skills. The study suggested important questions to address research gaps for the future and proposed a framework for achieving successful integration of utilizing interpreters in medical education curricula.

**Author Contributions:** All authors have contributed substantially to the study and the preparation of the manuscript. C.S.C. has coordinated the study, reviewed and coded the articles, drafted and finalized the manuscript. A.T.N., C.B.B., and P.E.Z. have worked on the design of the study, the search and review of articles, and provided feedback on drafts of the manuscript. A.P. has coordinated the study, provided guidance, reviewed the articles, and provided feedback on drafts of the manuscript. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Institutional Review Board Statement:** Not applicable.

**Informed Consent Statement:** Not applicable.

**Conflicts of Interest:** The authors declare no conflict of interest.

#### **Appendix A**

Review table of selected papers based on CASP criteria. We used the criteria for qualitative studies as they applied to all types of studies included in this review, such as surveys, qualitative, and randomized control trials.



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