Physician–Patient Relationship Assessing Medical Students’ Skills in Working With Interpreters During Patient Encounters: A Validation Study of the Interpreter Scale De ´ sire ´ e Lie, MD, MSEd, Sylvia Bereknyei, MS, Clarence H. Braddock III, MD, MPH, Jennifer Encinas, Susan Ahearn, and John R. Boker, PhD Abstract Purpose Interpreted patient encounters require distinct communication skills. The absence of available reliable, valid, and practical measures hinders the assessment of these skills; therefore, the authors aimed to construct and validate the Interpreter Scale (IS). Method The authors constructed the IS based on expert consensus and prior studies. They administered the IS to two classes (n = 182) in an interpreted standardized patient (SP) case setting. Standardized interpreters in the examination room assessed, using the IS, students’ communication skills. Concurrently, SPs, using the validated Patient-Physician Interaction scale (PPI) and the Interpreter Impact Rating Scale (IIRS), also assessed students’ skills. Trained observers watched DVDs and used the Faculty Observer Rating Scale (FORS) to assess student performance. A prior study documented the qualities of the IIRS and FORS. The authors determined the internal consistency reliability and examined construct validity of IS scores through factor analysis and concordance with other measures’ scores. Results IS reliability analysis yielded Cronbach  = 0.77. Factor analysis demonstrated two IS dimensions. Nine items, “managing the encounter,” and four items, “setting the stage,” explained 76% and 15% of score variance, respectively. IS and FORS scores significantly correlated (r = 0.385; P  .0001). IS factor 1 scores significantly correlated (all P  .0001) with FORS ( r = 0.402), IIRS ( r = 0.277), and PPI ( r = 0.332) scores. Conclusions The IS has reasonable internal consistency reliability and construct validity to warrant use for formatively measuring student communication skills in interpreted SP encounters, and it needs testing in actual patient encounters. Acad Med. 2009; 84:643–650. The United States is increasingly linguistically and culturally diverse. 1–3 Training future physicians to work with interpreters according to accepted standards 4–6 is essential for both the development of good clinical practice and the reduction of health disparities. 7,8 An increasing number of policy actions in the United States mandate minimum standards for language access for patients 9 and the allocation of resources directed at meeting these requirements. 10 Cultural competence curricula in medical schools 11–13 highlight the need for medical students and residents to be trained in working effectively with interpreters. The Association of American Medical Colleges’ Tool for Assessing Cultural Competency Training describes a skill set that comprises the knowledge and application of working effectively with interpreters as a distinct learning entity (Domain V). 13,14 A recent review of language interpreter use in the emergency department setting 15 found that patient satisfaction was lower among patients with limited English proficiency (LEP) compared with patients who spoke English well. 16 In two studies, patients with LEP experienced lower satisfaction with the visit (less courtesy, decreased respect, and lower quality of discharge instructions) and were less likely to return for care compared with patients who spoke English proficiently. 17,18 In addition, researchers have found that health outcomes and health care use are poorer for patients with LEP; doctors prescribe fewer medications, start fewer or inappropriate intravenous treatments, and order fewer or inappropriate tests and procedures, leading to subsequent increased expenses and longer stays for adult 19 –21 and pediatric 22,23 patients. For preventive care, one study 24 found that Latino patients proficient in English were twice as likely to receive a recommendation for a Pap smear from physicians compared with Latino patients with LEP. Studies with patient satisfaction as an outcome have indicated that some patients with LEP prefer language- concordant physicians, whereas others are equally satisfied with a language- concordant provider as with a professional interpreter. 25,26 For providers to be proficient in all their patients’ primary languages is unrealistic, so when communicating with patients with LEP, working effectively with an interpreter is important to optimize patient satisfaction and health care outcomes. Dr. Lie is director, Research/Faculty Development, Department of Family Medicine, University of California, Irvine, School of Medicine, Irvine, California. Ms. Bereknyei is research assistant, Stanford University School of Medicine and program manager, National Institutes of Health/National Heart, Blood, and Lung Institute-supported National Consortium for Multicultural Education for Health Professionals, Stanford, California. Dr. Braddock is associate dean, Medical Education, Stanford University School of Medicine, Stanford, California. Ms. Encinas is research coordinator, Department of Family Medicine, University of California, Irvine, School of Medicine, Irvine, California. Ms. Ahearn is director, Clinical Skills Training Center, University of California, Irvine, School of Medicine, Irvine, California. Dr. Boker is vice president, Academic Affairs, Geisinger Health System, Danville, Pennsylvania. Correspondence should be addressed to Dr. Lie, Department of Family Medicine, 101 The City Drive South, Bldg 200, Rm 512, Orange, CA 92868; telephone: (714) 456-5171; fax: (714) 456-7984; e-mail: (dalie@uci.edu). Academic Medicine, Vol. 84, No. 5 / May 2009 643