Including interpreters in resident physician assessments of complex psychosocial patient care issues

Background: More than ever primary care doctors need to address the complex psychosocial issues of their patients. Cultural competency, including interpreter use, is critical to assessing patients' perspective, attitudes and behavior. This project aims to evaluate resident physician performance in psychosocial assessments with and without an interpreter present.

Methods: In July 2009, 27 family medicine residents (11 interns, 5 PGY2s, and 11 PGY3s) participated in a psychosocial-themed objective structured clinical examination (OSCE). The OSCE consisted of 4 cases: a mother with postpartum depression, a man with terminal prostate cancer, a monolingual Vietnamese victim of domestic violence, and a monolingual Spanish diabetes patient. Each resident participated in two cases – one with an interpreter and one without. Six faculty observers evaluated the residents on case-specific measures based on the Accreditation Council for Graduate Medical Education Core Competencies. Standardized patients and interpreters also evaluated resident encounters. Summary statistics were analyzed.

Findings: Close to 80% of residents found the OSCE a helpful tool in discovering areas where they would like additional experience. Overall resident performance on the interpreter cases had a similar mean and range to performance on the non-interpreter cases. On a 5-point scale (1=not done; 2=done, but poorly; 3=done fairly; 4=good; 5=outstanding) faculty evaluation of residents' competence with and without an interpreter was: professionalism, 3.4 and 3.6; patient care, 2.8 and 3.5; medical knowledge, 3.5 and 3.2; interpersonal and communication skills, 2.9 and 3.7; systems-based practice, 2.7 and 2.5; and case-specific objectives, 2.5 and 2.6. The lowest performance was in the monolingual Vietnamese domestic violence case (anecdotally the most difficult).

Measures “not done” by 30% or more of residents happened most often in the domestic violence case (11), terminal prostate case (5), and diabetes case (3). These include: determines the frequency of abuse (50%), tells patient that she does not need to be a victim (71.4%), and appropriately explored patient's perspective on domestic violence (78.6%). No measure on the postpartum depression case was missed by 30% or more of residents. Conclusions: A monolingual Vietnamese domestic violence case was the most challenging for residents. Residents were most comfortable dealing with postpartum depression. Overall, residents, particularly interns, found the OSCE a positive learning experience. Many identified open-ended questions, end-of-life conversations, interpreter introduction and domestic violence resources as areas for improvement. This is the first OSCE in the history of this residency; subsequent psychosocial-themed OSCEs are planned for Julys 2010 and 2011.