Workshop Guide

Open Workshop Guide




Open Instructor Guide

Challenging Patient Curriculum Instructor Guide^

PGY-1: Refugee and Immigrant Patients

Cross-cultural Communication: Interacting Effectively with Patients from Diverse Backgrounds


There are two main goals and accompanying “parts” of the workshop. They can be presented together or separately.

  1.  A PGY1 resident will understand the meaning of culture and the components and skills defining cultural competency.

Specific Objectives:

  1. Define culture and cultural competence
  2. Learn how to effectively collaborate and care for patients whose cultural experiences and beliefs differ from those of “mainstream” US medical culture
  3. Identify laws and standards related to caring for LEP patients
  4. Learn different methods of effective communication
  1.  A PGY1 resident will be able to communicate effectively with patients from different cultural and linguistic backgrounds, including use of interpreters.

Specific Objectives:

  1.  Learn different methods of effective communication and interaction
  2. Learn how to effectively communicate through interpreters

ACGME Core Competencies:

 Patient Care

  • Demonstrate the ability to conduct culturally competent interviews and establish rapport across cultural differences

Medical Knowledge

  • Develop an understanding of how being a refugee impacts upon physical and emotional health and health care
  • Develop an understanding of the history, traditions, values, belief system, acculturation and/or migration patterns of an individual refugee

 Practice-Based Learning and Improvement

  •  Gain competence in working with an interpreter

 Interpersonal and Communication Skills

  •  Demonstrate the ability to perform a cultural beliefs/explanatory model interview based on Kleinman
  • Gain competence in working with an interpreter


  • Demonstrate awareness of his or her own personal attitudes, beliefs, biases and behaviors and how these may impact clinical care

Systems-Based Practice

  •  Identify laws and policies that apply to patients with limited-English proficiency as well as language services available to patients at UVA


Session Guide^

Time Needed:  

Part 1: 2 hours

Part 2: 1 hour

Equipment Needed:

  •  Computer with DVD-ROM drive and LCD projector (PowerPoint is on a DVD)

Personnel Needed: Refugee with limited English proficiency and professional interpreter. You also may consider asking a small number of patients to participate (one at each workshop).

Suggested Reading:

Kleinman A, Eisenberg L, Good B. Culture, illness and care: Clinical lessons from anthropologic and cross-cultural research. Annals Intern Med 1978;88:251-8.

Instructor Script and Notes

Part 1 – 2 hours

    1.  Introduction to Interpreter Skills
      1. Introduce the objectives of the session as outlined in the PowerPoint presentation.
      2. PowerPoint presentation – “Cross-Cultural Communication: Interacting Effectively with Patients from Diverse Backgrounds”
        1. Review the meaning of culture and components of culture slides.
        2. Slide #9: Ask the residents to reflect, and then discuss the following. There is time for 2-4 residents to share their stories (can include more and encourage others to participate).
          1. Think about your own culture, especially your beliefs and values.
          2. Describe your cultural “profile” keeping in mind the preceding components.
          3. How do your beliefs and values influence your attitudes and experiences with health and health care? (You may need to think about the time before you entered medical school)
        3. The next several slides provide an overview of the components of medical culture. For each one there is a “blank slide” where the residents are asked to identify aspects of medical culture that fit into that component. The components are:
          1. Environment
          2. Economy
          3. Technology
          4. Religion/world view
          5. Language
          6. Social structure
          7. Beliefs and values
            • Each blank slide is followed by a “filled in” slide providing some of the answers.
        4. Review the next set of slides with the residents:
          1. Definition and Importance of Cultural Competence
          2. The LEARN Model: One Model to Help Facilitate the Understanding of Culturally Competent Communication Techniques
          3. Slide #28: Ask the residents to provide some examples of questions they can ask to elicit the patient’s health beliefs and practices)
          4. Laws and Standards that Apply to the Use of Interpreters and Other Aspects of Culturally Competent Care at the Health System Level
        5. The next series of slides focuses on interpreting. The barriers to interpreting can be a more interactive piece – ask the residents their thoughts on the barriers from the patients’, doctors’ and interpreters’ perspectives. Ask the residents about what skills are used in with an interpreter before reviewing the slides that provide these hints.

Part 2 – 60 minutes

  1.  Interview of Patient with Interpreter
    1. Introduction
      1. Patient and interpreter will arrive to the classroom.
      2. Introduce the patient and interpreter.
      3. Explain the purpose of the “interview.”
    2. Interview
      1. 2-3 of the residents will have an opportunity to interview the patient directly (one at a time). They will introduce themselves to the patient and interpreter. The purpose is NOT to take a usual medical history but to get a feel for the patient, her/his experiences as a refugee, what it is like to get healthcare in the US/at UVA, compared with their birth country or second country, what are some of the cultural traditions of the patient’s cultural group; what have been the challenges of communicating in their native language, experience with interpreters, family and social history. Each resident will interview the patient for 5-10 minutes, and usually there is a break when the resident stops, or exhausts questions. If not, the instructor should stop them when appropriate, then ask for feedback from the resident and others. Then, repeat with the next 1-2 residents. After that, open up questions to the group to ask of the patient or the interpreter. The instructor needs to be thinking of feedback and suggestions during this time.
      2. At the end of the hour, thank the guests for coming and make sure they know how to find their way.



LEARN Model Handout^


  1. Define culture and cultural competence
  2. Learn how to effectively collaborate and care for patients whose cultural experiences and beliefs differ from those of “mainstream” US medical culture
  3. Identify laws and standards related to caring for limited-English proficient patients
  4. Learn different methods of effective communication and interaction
  5. Learn and demonstrate how to effectively communicate with patients through interpreters

Models of Effective Cross-Cultural Communication and Negotiation

There are many mnemonics that can be used for clinical interviewing and communication beyond the standard SOAP format you’ve learned.  These models each provide an easily remembered framework for a patient encounter and can help you to improve your skills in cross-cultural, patient-centered care. You may have heard of some of these models: LEARN, ETHNIC(S), BELIEF, BATHE, ESFT, etc.  For this assignment, you will practice using the modified LEARN model to help you elicit your patient’s history:


  • Identify and greet family or friends of the patient
  • Ideally, provide an interpreter when interacting with limited-English proficiency (Note: we recognize that not all sites have interpreters available)
  • Start with open-ended questions and avoid interruption for the first 30 seconds that a patient speaks, e.g.:
    • Could you please tell me your reason for the visit today?
    • How can I help you today?
  • Listen with sympathy & understanding to the patient’s perception of the problem

E = Elicit

  • Elicit the patient’s health beliefs as they relate to the reason for the visit as well as his/her health behaviors.  The following questions may help in the process:
    • What do you think has caused your problem/illness?
    • Why do you think it started when it did?
    • What do you think your sickness does to you?
    • How severe is your sickness?  Will it have a long or short course?
    • What kind of treatment do you think you should receive?
    • What are the most important results you hope to receive from this treatment?
    • What are the chief problems your sickness has caused for you?
    • What do you fear most about your sickness?
    • How can I be of most help to you?

(These questions are adapted from the work of Arthur Kleinman. See the attached paper, Culture, Illness, and Care. Clinical Lessons from Anthropologic and Cross-Cultural Research. It is a worthwhile read.)

 A = Assess

  • Assess potential attributes and problems in a person’s life that may have an impact on his/her health and health behaviors. Medicine in this country may be totally foreign to someone.  Also, in some cultures, families make decisions together as a unit, or individuals may turn to an elder for health advice. Lastly, people may be too shy to discuss their needs out of respect for the physician. Here are some examples of questions you can ask (we provide some of these in the assignment):
    • I’d like to get to know you more today. Could you tell me about yourself?  With whom you live? Where you work?
    • What brought you here to this country? How does medical care differ here?
    • Do you have family and friends who help you with decisions or who give you advice?
    • Do you have coverage for your medications?
    • Are there times that are bad for you for appointments? Is transportation a problem for you?
    • Do you have any trouble reading medicine bottles or appointment cards?

R = Recommend

  • Recommend a plan of action with an explanation of your rationale using language that the patient is able to understand. Physicians underestimate the amount of information that patients want and often provide the information using medical jargon that is unintelligible to the patient. Patients often are too embarrassed to admit this. You can check how well you taught the patient, by using the following questions:
    • To make sure that we understand one another, can you tell me what it is that I just told you?
    • Is there any part that you don’t understand?

N = Negotiate

  • Negotiate a plan of action with your patient after you have made your recommendations. You can use these questions:
    • Now that we understand each other, let’s come up with a plan that works for you.
    • What do you think should be the next steps?

(Adapted from: Cultural Competency in Medical Education: A Guidebook for Schools. Published by HRSA,September 2004.)


Open Interpreter

Quick Tips for Working with Interpreters Handout^


  • Clinician introduces self to patient and interpreter
  • Clinician defines the role of the interpreter
    • Tells the patient that the interpreter will repeat everything that they say and asks patient to speak in short phrases
  • Reassure the patient that information is confidential
  • Position the interpreter correctly (interpreter is next to patient, ideally a little behind)
  • Speak in short phrases, maximum one to two phrases or sentences at a time, to allow interpreter time to interpret
  • Avoid jargon or slang, use simple language
  •  Don’t get frustrated if it seems to take too long to interpret. In many languages, the words we use in English, especially for medical conditions, either don’t exist or are longer.
  •  Maintain eye contact with patient
  •  Speak to the patient in a normal tone of voice (no shouting!)
  •  Speak directly to the patient (not to the interpreter) for most of the interview
  •  If you are asking a question of the interpreter, e.g., for clarification, let the patient know that you are doing this
  •  Remember that everything you say will be interpreted