Assessing Medical Student Readiness to Navigate Language Barriers in Telehealth: Cross-sectional Survey Study

Abstract

Background: The COVID-19 pandemic has greatly increased telehealth usage in the United States. Patients with limited English proficiency (LEP) face barriers to health care, which may be mitigated when providers work with professional interpreters. However, telehealth may exacerbate disparities if clinicians are not trained to work with interpreters in that setting. Although medical students are now involved in telehealth on an unprecedented scale, no educational innovations have been published that focus on digital care across language barriers.

Objective: The aim of this study is to investigate advanced medical students' confidence in caring for patients with LEP during telehealth encounters.

Methods: We administered a written survey to medical students on clinical clerkships at one US institution in August and September 2020. We assessed students' overall confidence in working with interpreters; confidence in performing 8 clinical tasks during in-person versus telehealth encounters; and frequency of performing 5 different clinical tasks with patients with LEP compared to English-speaking patients during in-person versus telehealth encounters. Wilcoxon signed-rank tests and chi-square tests were used to compare confidence and task performance frequency, respectively, for patients with LEP versus English-speaking patients during telehealth encounters. Students were also asked to identify barriers to care for patients with LEP. The free-response questions were qualitatively analyzed using open coding to identify key themes.

Results: Of 300 medical students surveyed, 121 responded. Furthermore, 72 students answered >50% of questions and were included in the analyses. Compared to caring for patients with LEP during in-person encounters, respondents were less confident in working with interpreters (P<.001), developing trust (P<.001), identifying agenda (P=.005), eliciting preferences for diabetes management (P=.01), and empowering patients in lifestyle modifications (P=.04) during telehealth encounters. During both in-person and telehealth encounters, approximately half of students (40%-78%) reported engaging less frequently in every clinical task with patients with LEP and this was as low as 22% (13/59) for some tasks. Students identified these key barriers to care for patients with LEP: time pressure, interpretation quality and access, technical difficulties, cultural differences, and difficulty with rapport building.

Conclusions: Advanced medical students were significantly less confident caring for patients with LEP via telehealth than in person. Broader implementation of training around navigating language barriers is necessary for telehealth care, which has rapidly expanded in the United States. Our study identified potential key areas for curricular focus, including creating patient-centered agendas and management plans within the constraints of virtual settings. These developments must take place simultaneously with systems-level improvements in interpreter infrastructure to ensure high-quality care for linguistically diverse patients.

Keywords: clinician; health care professional; interpreters; language barriers; limited English proficiency; medical education; medical students; online education; telehealth; telemedicine.

Figure 1

Confidence performing clinical tasks during telehealth encounters. Comparing medical students' self-reported confidence in performing 8 patient-centered tasks in the telehealth setting when working with patients with LEP versus English-speaking patients. Graphs show the percentage of respondents who were "confident" in performing each of the 8 tasks with either patient in the telehealth setting. Percentages reflect only those who rated their confidence in performing clinical tasks with both patients in the telehealth setting (N=61-64). *P<.001 (Wilcoxon signed-rank test, see Table S1 in Multimedia Appendix 2). DM: diabetes; LEP: limited English proficiency.

Figure 2

Confidence performing clinical tasks when caring for patients with LEP by clinical setting. Comparing medical students' self-reported confidence in performing 8 patient-centered tasks during in-person versus telehealth encounters with patients with LEP. Percentages reflect only those who rated their confidence in performing clinical tasks in both settings with patients who have LEP (N=61-64). *P<.05 (Wilcoxon signed-rank test, see Table S2 in Multimedia Appendix 2). DM: diabetes; LEP: limited English proficiency.