Limited English Proficiency Patients Research Articles

Training to Care for Limited English Proficient Patients and Provision of Interpreter Services at U.S. Dental School Clinics

Legal protections in the United States mandate that individuals with limited English proficiency (LEP) have equal access to health care. However, LEP populations are at higher risk of poor health. Dental school clinics offer lower cost care by supervised dental students and often provide care for LEP patients. The aims of this study were to survey dental students about their clinical experience with LEP patients, the interpreter resources available at their dental school clinics, and the extent of instruction on these topics. Academic deans at 19 dental schools (30.6% of 62 invited schools) distributed the survey to their students, and the survey was completed by 325 students (4.2% of students at the 19 participating schools). Among the responding students, 44% reported their dental school clinic lacked formal interpreter services, and most of the respondents reported receiving minimal instruction on caring for LEP patients. Only 54% of the responding students reported feeling adequately prepared to manage LEP patients following graduation. These results suggest there is limited access to interpreter services for students while in dental school. A large proportion of these dental students thus reported feeling unprepared to treat LEP patients after graduation.

The Effect of Limited English Proficiency on Pediatric Hospital Readmissions.

The relationship between limited English proficiency (LEP) and worse pediatric health outcomes is well documented. To determine the relationship between LEP status and pediatric hospital readmissions. We performed a retrospective cohort analysis of children ≤ 18 years old admitted to a tertiary children's hospital from 2008 to 2014. The main exposure was LEP status. Independent variables included sex, age, race/ethnicity, insurance, median household income, surgical/medical status, severity of illness (SOI), the presence of a complex chronic condition, and length of stay. Primary outcome measures were 7- and 30-day readmission. From 67 473 encounters, 7- and 30-day readmission rates were 3.9% and 8.2%, respectively. LEP patients were more likely to be younger, poorer, and Hispanic; have lower SOI; and government-subsidized insurance. Adjusted odds for 7- or 30-day readmission for LEP versus English-proficient (EP) patients were 1.00 (P = .99) and 0.97 (P = .60), respectively. Hispanic ethnicity (adjusted odds ratio [aOR]: 1.26 [P = .002] and 1.14 [P = .02]), greater SOI (aOR: 1.04 [P < .001] and 1.05 [P < .001]), and the presence of a complex chronic condition (aOR: 2.31 [P < .001] and 3.03 [P < .001]) were associated with increased odds of 7- and 30-day readmission, respectively. White LEP patients had increased odds of 7- and 30-day readmission compared with white EP patients (aOR: 1.46 [P = .006] and 1.32 [P = .007]) and the poorest LEP patients had increased odds of 7- and 30-day readmission compared with the poorest EP patients (aOR: 1.77 [P = .04] and 2.00 [P < .001]). This is the first large study evaluating the relationship between LEP and pediatric hospital readmission. There was no increased risk of readmission in LEP patients compared with EP patients.

Through the Veil of Language: Exploring the Hidden Curriculum for the Care of Patients With Limited English Proficiency.

Patients with limited English proficiency (LEP) experience lower-quality health care and are at higher risk of experiencing adverse events than fluent English speakers. Despite some formal training for health professions students on caring for patients with LEP, the hidden curriculum may have a greater influence on learning. The authors designed this study to characterize the hidden curriculum that medical and nursing students experience regarding the care of patients with LEP. In 2014, the authors invited students from one medical school and one nursing school, who had completed an interprofessional pilot curriculum on caring for patients with LEP 6 to 10 months earlier, to participate in semistructured interviews about their clinical training experiences with LEP patients. The authors independently coded the interview transcripts, compared them for agreement, and performed content analysis to identify major themes. Thirteen students (7 medical and 6 nursing students) participated. Four major themes emerged: role modeling, systems factors, learning environment, and organizational culture. All 13 students described negative role modeling experiences, and most described role modeling that the authors coded as "indifferent." Students felt that the current system and learning environment did not support or emphasize high-quality care for patients with LEP. The hidden curriculum that health professional students experience regarding the care of patients with LEP is influenced by systems limitations and a learning environment and organizational culture that value efficiency over effective communication. Role modeling seems strongly linked to these factors as supervisors struggle with these same challenges.

Caring for Children and Families With Limited English Proficiency: Current Challenges and an Agenda for the Future.

This month’s issue of Hospital Pediatrics features 2 articles addressing quality of care for children and families with limited English proficiency (LEP),1,2 highlighting an important area of growing concern for clinicians and researchers. Children from LEP families make up a large and expanding proportion of the US population,3 but as these 2 articles show, we continue to face substantial challenges both in providing these children with high-quality, equitable care and in studying them, which is an important prerequisite to developing effective interventions to improve care. A primary challenge in both caring for and studying LEP patients and families lies in correctly identifying them. Many institutions do not consistently collect language data, and those that do often record the primary language spoken at home, which does not adequately identify the presence of a language barrier or the need for interpretation.4,5 This situation leads to clinicians being unable to rely on the language information captured in the medical record to determine interpreter need, which then encourages many to assess the family’s English ability with each communication and “get by” without an interpreter if they can.6,7 The collection of less helpful or inconsistent language information also makes it very difficult to study language barriers within large databases such as the Pediatric Health Information System, given the variability in the institution-level data. In pediatrics, we face the additional challenge of trying to determine whose English proficiency or interpreter need to document, because different caregivers’ needs may differ and not all caregivers are always present. For the purposes of clinical care, it would be ideal to assess and document the English proficiency or interpreter need …

Spanish-Speaking Immigrants' Access to Safety Net Providers and Translation Services Across Traditional and Emerging US Destinations.

Policy Points: Latino immigrants have recently spread beyond traditional US enclaves to “emerging destinations.” The arrival of limited English proficiency (LEP) Spanish‐speakers to these areas can challenge the health care system, as translation services may not be readily available for LEP patients. Trained auditors posed as family members of LEP patients seeking primary care in a safety net setting. We found substantially lower appointment availability for LEP adults in emerging destinations compared to traditional destinations. Greater bilingual resources are needed within safety net clinics to accommodate LEP Spanish speakers as this population continues to grow and expand throughout the United States. ContextRecent demographic trends show Latino immigrants moving to “emerging destinations” outside traditional Latino enclaves. Immigrants in emerging destinations with limited English proficiency (LEP) may experience greater challenges finding health care services oriented to their linguistic needs than those in traditional enclaves, especially if the supply of language resources in these areas has not kept pace with new demand.MethodsThis study uses an experimental audit design to directly compare the ability of uninsured Spanish‐speaking LEP adults to access interpreter services and to obtain new patient primary care appointments at federally qualified health centers (FQHCs) across traditional and emerging destinations. We additionally compare the appointment rates of English‐proficient uninsured and English‐proficient Medicaid patients across these destinations that contacted the same FQHCs. English‐proficient patients serve as an access benchmark that is independent of differences in Spanish language services.FindingsResults indicate that LEP Spanish‐speaking patients within emerging destinations are 40 percentage points less likely to receive an appointment than those in traditional destinations. English‐proficient groups, by contrast, experience similar levels of access across destinations. Disparities in safety net provider access by destination status are consistent with differences in the availability of bilingual services. Ninety‐two percent of FQHCs in traditional destinations offered appointments with either Spanish‐speaking clinicians or translation services with non‐clinical bilingual staff, while only 54% did so in emerging destinations. LEP patients denied care in emerging destinations must also travel greater distances than in traditional destinations to reach the next available safety net provider.ConclusionsOur findings highlight that current language resources in emerging destinations may be inadequate for keeping up with the transforming needs of the patient population. As the Latino immigrant population continues to expand and diffuse, better accommodation within the health care safety net is likely to increase in importance.

Developing a Spanish for Health Professions Course: A Preliminary Mixed-Methods Study

The mixed-methods pilot study described in this article traces the development of a Spanish for Specific Purposes: Health Professions course that was designed to help future health care professionals develop their linguistic proficiency and intercultural abilities. The study included nursing, medical, and dental students and was conducted at a large public university in an area of the southeastern United States that has experienced an increase in the Spanish-speaking Limited English Proficiency (LEP) population. The purpose of the study was to explore students’ perceptions of the course and its curricular design, as well as to investigate students’ perceptions with respect to a series of motivation constructs. The findings indicated that Language for Specific Purposes courses focused on health professions can have a positive impact on students’ perceptions, while preparing language-concordant providers to more effectively and sensitively meet the needs of LEP patients. Benefits were related to the context-specific nature of the course and tasks, while challenges included curricular constraints and schedule conflicts.

Is There Inequity in Hospital Care Among Patients With Acute Coronary Syndrome Who Are Proficient and Not Proficient in English Language?: Analysis of the SNAPSHOT ACS Study.

The provision of equitable acute coronary syndrome (ACS) care in Australia and New Zealand requires an understanding of the sources of variation in the provision of this care. The aim of this study was to compare the variation in care and outcomes between ACS patients with limited English proficiency (LEP) and English proficiency (EP) admitted to Australian and NZ hospitals. Data were collected from 4387 suspected/confirmed ACS patients from 286 hospitals between May 14 and 27, 2012, who were followed for 18 months. We compared hospital care and outcomes according to the proficiency of English using logistic regressions. The 294 LEP patients were older (70.9 vs 66.3 years; P < .001) and had higher prevalence of hypertension (71.1% vs 62.8%; P = .004), diabetes (40.5% vs 24.3%; P < .001), and renal impairment (16.3% vs 11.1%; P = .007) compared with the 4093 EP patients. Once in hospital, there was no difference in receipt of percutaneous coronary intervention (57.0% vs 55.4%; P = .78) or coronary artery bypass graft surgery (10.5% vs 11.5%; P = .98). After adjustment for medical history, there were no significant differences (P > .05) between the 2 groups in the risk of major adverse cardiovascular events and/or all-cause death during the index admission and from index admission to 18 months. These results suggest that LEP patients admitted to Australian or New Zealand hospitals with suspected ACS may not experience inequity in hospital care and outcomes.

Lost in translation: impact of language barriers on children's healthcare.

As the cultural and linguistic diversity of the United States grows, a greater number of patients with limited English proficiency will enter the healthcare system. Best practices for the care of these individuals include identification of their language assistance needs and prompt provision of interpreter services. This review will summarize the legal basis for providing language access in the healthcare setting, discuss the impact of interpretation services on clinical care, and explore the effects of language barriers on health outcomes. There has been greater awareness of language as an important and independent determinant in the racial and ethnic disparities that exist in healthcare. Studies have shown that there is suboptimal identification of patients who require linguistic assistance and, as such, there are missed opportunities to bridge language gaps with many of our patients. The lack of interpretation, or use of informal, untrained interpreters, has significant effects on patient safety, quality of care, and patient satisfaction. Though federal and regulatory guidelines mandate meaningful access to language services, such processes are still a work in progress in many healthcare settings. Further research and quality improvement initiatives are needed to provide clinicians the knowledge and skills needed to effectively communicate with their limited English proficient patients.

The “Battle” of Managing Language Barriers in Health Care

Providing safe and high-quality health care for children whose parents have limited English proficiency (LEP) remains challenging. Reports of parent perspectives on navigating language discordance in health care are limited. We analyzed portions of 48 interviews focused on language barriers from 2 qualitative interview studies of the pediatric health care experiences of LEP Latina mothers in 2 urban US cities. We found mothers experienced frustration with health care and reported suboptimal accommodation for language barriers. Six themes emerged relevant to health care across settings: the "battle" of managing language barriers, preference for bilingual providers, negative bias toward interpreted encounters, "getting by" with limited language skills, fear of being a burden, and stigma and discrimination experienced by LEP families. Parents' insights highlight reasons why effective language accommodation in health care remains challenging. Partnering with families to address the management of language barriers is needed to improve health care quality and safety for LEP patients and families.

The relationship between language proficiency and surgical length of stay following cardiac bypass surgery.

Anglophone nurses face the challenge of communicating health information to patients who do not speak or understand English. Limited English-proficient patients are at higher risk of misinterpreting health information teaching. Successful recovery after coronary artery bypass graft surgery requires patients' engagement with healthcare professionals and active participation in therapies and related undertakings. Determination of whether limited English-proficient patients undergoing coronary artery bypass graft surgery recover at the same pace as the general population is of interest. This study examined whether limited English-proficient patients had prolonged post-operative length of stay following coronary artery bypass graft surgery. The patients' length of stay with regard to a clinical pathway target was also examined. A retrospective medical record review of all patients undergoing isolated coronary artery bypass graft surgery in a 2-year period was conducted. A screening tool was developed to identify limited English-proficient patients through examination of their medical records. A total of 691 of 712 (97.1%) patients met the inclusion criteria; 103 (14.9%) patients were identified as limited English-proficient. The post-operative median length of stay of limited English-proficient patients was 7 days compared with 6 days for the English-proficient patients (p = 0.007). Limited English-proficient patients had higher infection rates (29.1%) vs. English-proficient patients (16.7%) (odds ratio = 2.05 (95% confidence intervals 1.27-3.30)). Post-operative infection was the strongest predictor of length of stay and fully mediated the relationship between language proficiency and length of stay. When compared with English-proficient patients, limited English-proficient patients had greater infection rates, which were associated with longer length of stay. These findings warrant examination of the mechanisms through which post-operative infections are acquired by limited English-proficient patients.

Challenges in cancer self-management of patients with limited English proficiency

Objective:This paper summarizes the barriers and challenges in cancer care reported from a validation project of a self-management intervention handbook from Chinese-American cancer patients with limited English proficiency (LEP).Methods:Seven health-care providers (HCPs) and 16 Chinese-American cancer survivors with LEP were invited to validate a self-management intervention handbook through networking sampling method. Bilingual versions were developed and validated using the repeated translation process. Online and paper-based survey and interview were conducted to collect information on the perception of barriers and experiences on cancer care. Data were analyzed by the content analysis method.Results:The HCPs reported a bilingual self-management handbook which is useful and feasible for patient self-management. The challenges in giving cancer care to LEP patients included: patients do not engage in discussion, different cultural health beliefs, unable to speak to patients in their primary language, and patients are less likely to discuss emotional and social challenges during treatments. The common barriers and experiences during cancer care included: limited understanding about treatment/medication and side effects, language barriers such as unable to communicate to make the decision, unable to understand information related to resources and do not know what questions to ask, and do not know what to expect during their cancer treatment.Conclusions:The current findings highlight the need of cancer self-management support for culturally diverse LEP cancer patients. Further research can include applying the supportive intervention to all LEP cancer patients.

Computer use, language, and literacy in safety net clinic communication.

Objective: Patients with limited health literacy (LHL) and limited English proficiency (LEP) experience suboptimal communication and health outcomes. Electronic health record implementation in safety net clinics may affect communication with LHL and LEP patients.We investigated the associations between safety net clinician computer use and patient-provider communication for patients with LEP and LHL. Materials and Methods: We video-recorded encounters at 5 academically affiliated US public hospital clinics between English- and Spanish-speaking patients with chronic conditions and their primary and specialty care clinicians. We analyzed changes in communication behaviors (coded with the Roter Interaction Analysis System) with each additional point on a clinician computer use score, controlling for clinician type and visit length and stratified by English proficiency and health literacy status. Results: Greater clinician computer use was associated with more biomedical statements (+12.4, P = .03) and less positive affect (−0.6, P < .01) from LEP/LHL patients. In visits with patients with adequate English proficiency/health literacy, greater clinician computer use was associated with less positive patient affect (−0.9, P < .01), fewer clinician psychosocial statements (−3.5, P < .05), greater clinician verbal dominance (+0.09, P < .01), and lower ratings on quality of care and communication. Conclusion: Higher clinician computer use was associated with more biomedical focus with LEP/LHL patients, and clinician verbal dominance and lower ratings with patients with adequate English proficiency and health literacy. Discussion: Implementation research should explore interventions to enhance relationship-centered communication for diverse patient populations in the computer era.

Coping and resiliency enhancement program (CARE): a pilot study for interpreters in cancer care.

There is a growing demand for interpreters in the cancer setting. Interpreters, the link to quality care for limited English proficiency patients, face many psychosocial stressors in their work. This project assessed interpreters' experiences of stress and piloted a resiliency program to help interpreters cope with stressors. From 2013 to 2014, we pilot tested a targeted resiliency program with interpreters from three Boston-based hospitals. In Phase 1, we conducted five focus groups (n = 31) to identify interpreters' psychosocial needs. In Phase 2, we developed and tested a 4-h group program with 29 interpreters (response rate = 90%; 69% female, 54% Hispanic, 85% born outside of the U.S.). Phase 1. Stressors were patient-based (seeing young patients decline), interactions with medical team (unsure of role), and systems-based (appointment unpredictability). Phase 2. At baseline interpreters reported low abilities to cope with stress (measured by the Measure of Current Status (MOCS-A)). At 4-week follow-up we found improvements in job satisfaction (p = .02; Cohen's d = .41) and declines in sick days (p = .08; Cohen's d = .38). Stress reactivity (MOCS-A) improved; specifically participants reported feeling more assertive about their needs (p = .10; Cohen's d = .30) and more able to relax at will (p = .10; Cohen's d = .35)-important mechanisms to lower distress. We piloted a resiliency program for medical interpreters in cancer care. We found that interpreters experience distress and have low coping skills. This program resulted in improved work factors and stress reactivity. Future research should include further implementation and testing in a larger, randomized trial.Copyright © 2016 John Wiley & Sons, Ltd.

Spanish-Speaking Limited English Proficiency Patients and Call Light Use.

Despite a continuous increase of the limited English proficiency (LEP) population in the United States, disparities in the quality of care received in health care systems persist. This qualitative study explores the perceptions of hospitalized LEP patients on their call light use, as well as their perceptions of a prototype of a new multilingual call light system, Eloquence™. Individual interviews were conducted with 10 Spanish-speaking patient participants. Using a constant comparative method, the following themes emerged: (1) reasons for call light use, (2) challenges with communication, (3) patients' adaptation to language barriers, (4) perceived staff responses to call light, and (5) responses to the Eloquence™ demonstration. Data from this study shed light on the patient care experience of LEP patients and can help guide clinicians and administrators in providing culturally and linguistically competent care.

The Association Between Limited English Proficiency and Unplanned Emergency Department Revisit Within 72 Hours

Language barriers are known to negatively affect many health outcomes among limited English proficiency patient populations, but little is known about the quality of care such patients receive in the emergency department (ED). This study seeks to determine whether limited English proficiency patients experience different quality of care than English-speaking patients in the ED, using unplanned revisit within 72 hours as a surrogate quality indicator. We conducted a retrospective cohort study in an urban adult ED in 2012, with a total of 41,772 patients and 56,821 ED visits. We compared 2,943 limited English proficiency patients with 38,829 English-speaking patients presenting to the ED after excluding patients with psychiatric complaints, altered mental status, and nonverbal states, and those with more than 4 ED visits in 12 months. Two main outcomes-the risk of inpatient admission from the ED and risk of unplanned EDrevisit within 72 hours-were measured with odds ratios from generalized estimating equation multivariate models. Limited English proficiency patients were more likely than English speakers to be admitted (32.0% versus 27.2%; odds ratio [OR]=1.20; 95% confidence interval [CI] 1.11 to 1.30). This association became nonsignificant after adjustments (OR=1.04; 95% CI 0.95 to 1.15). Included in the analysis of ED revisit within 72 hours were 32,857 patients with 45,546 ED visits; 4.2% of all patients (n=1,380) had at least 1 unplanned revisit. Limited English proficiency patients were more likely than English speakers to have an unplanned revisit (5.0% versus 4.1%; OR=1.19; 95% CI 1.02 to 1.45). This association persisted (OR=1.24; 95% CI 1.02 to 1.53) after adjustment for potential confounders, including insurance status. We found no difference in hospital admission rates between limited English proficiency patients and English-speaking patients. Yet limited English proficiency patients were 24% more likely to have an unplanned ED revisit within 72 hours, with an absolute difference of 0.9%, suggesting challenges in ED quality of care.

Capsule Commentary on Genoff et al., Navigating Language Barriers: A Systematic Review of Patient Navigators' Impact on Cancer Screening for Limited English Proficient Patients.

Capsule Commentary on Genoff et al., Navigating Language Barriers: A Systematic Review of Patient Navigators' Impact on Cancer Screening for Limited English Proficient Patients.

Regional Variation in Diabetic Outcomes by Country-of-Origin and Language in an Urban Safety Net Hospital.

Adherence to diabetic care guidelines among US immigrants remains low. This study assesses adherence to diabetic care guidelines by country-of-origin and language among a limited English-proficient (LEP) population. Timely completion of diabetic measures and acceptable levels of hemoglobin A1c (A1c), low density lipoprotein (LDL) cholesterol, and blood pressure (BP) were compared between LEP and English-proficient (EP) patients in this 2013 retrospective cohort study of adult diabetics. More LEP patients met BP targets (83 vs. 68%, p<0.0001) and obtained LDL targets (89 vs. 85%, p=0.0007); however, they had worse LDL control (57 vs. 62%, p=0.0011). Ethiopians and Somalians [adjusted OR (95% CI)=0.44 (0.30, 0.63)] were less likely than Latin Americans to meet BP goals. LEP patients outperformed EP peers on several diabetic outcomes measures with important variation between groups. These data highlight the success of a safety net hospital in improving diabetes management among diverse populations.

Navigating Language Barriers: A Systematic Review of Patient Navigators' Impact on Cancer Screening for Limited English Proficient Patients.

To systematically review the literature on the impact of patient navigators on cancer screening for limited English proficient (LEP) patients. Electronic databases (PubMed, PsycINFO via OVID, Web of Science, Cochrane, EMBASE, and Scopus) through 8 May 2015. Articles in this review had: (1) a study population of LEP patients eligible for breast, cervical or colorectal cancer screenings, (2) a patient navigator intervention to provide services prior to or during cancer screening, (3) a comparison of the patient navigator intervention to either a control group or another intervention, and (4) language-specific outcomes related to the patient navigator intervention. We assessed the quality of the articles using the Downs and Black Scale. Fifteen studies met the inclusion criteria and evaluated the screening rates for breast, colorectal, and cervical cancer in 15 language populations. Fourteen studies resulted in improved screening rates for LEP patients between 7 and 60%. There was great variability in the patient navigation interventions evaluated. Training received by navigators was not reported in nine of the studies and no studies assessed the language skills of the patient navigators in English or the target language. This study is limited by the variability in study designs and limited reporting on patient navigator interventions, which reduces the ability to draw conclusions on the full effect of patient navigators. Overall, we found evidence that navigators improved screening rates for breast, cervical and colorectal cancer screening for LEP patients. Future studies should systematically collect data on the training curricula for navigators and assess their English and non-English language skills in order to identify ways to reduce disparities for LEP patients.

Access to Interpreter Services at U.S. Dental School Clinics

The number of Americans with limited English proficiency (LEP) is growing, and legal protections mandate that LEP individuals have equal access to health care services. The aim of this study was to determine the availability of interpretation services in U.S. dental school clinics and the kinds of instruction dental students are given regarding treatment of LEP patients. A survey was distributed to the academic deans of all U.S. dental schools; 35 completed the survey for a response rate of 58%. Respondents were asked to report on the number of LEP patients treated in their student clinics, the resources available to students working with LEP patients, and the extent of instruction offered. Descriptive statistics were calculated. The results indicated that the proportion of LEP patients treated at U.S. dental schools was perceived to be higher than that of the general population. The availability of interpreter services and the extent of student education about LEP individuals varied widely. Among the responding schools, the most common language spoken by LEP patients was Spanish, followed by Chinese (Mandarin and Cantonese) and Russian. Most of the responding dental schools reported offering fewer than two hours of instruction to their predoctoral students on treating LEP patients. Although almost 90% of the respondents indicated believing LEP patients received care equal in quality to that of non-LEP patients in their clinics, only 61.9% indicated that their students were adequately prepared to manage LEP patients following graduation. These findings suggest that dental schools should consider curricular innovations that will prepare students to work with LEP populations and improve the ability of LEP patients to receive care in the teaching clinic setting.

Establishing Medical Students' Cultural and Linguistic Competence for the Care of Spanish-Speaking Limited English Proficient Patients.

Limited English proficient (LEP) patients are at risk of disparities in health and health care quality. These disparities can be mitigated by providing care in a language they understand. Undergraduate medical education provides an opportunity to stress that language barriers negatively impact the quality and safety of health care for LEP patients and to teach students how to overcome them. Because the preponderance of LEP patients in the USA is Spanish speaking, the majority of US medical schools have established medical Spanish coursework for interested students. However, 70% of medical schools note significant obstacles to delivering this curriculum. The most commonly cited obstacles include a lack of time to deliver it, heterogeneous student skill levels, and insufficient faculty support. We also note that educators need to make sure not to propagate disparities and medical errors for LEP patients. We provide recommendations for establishing medical students' linguistic and cultural competence for the care Spanish-speaking limited English proficiency patients, with the caution that this instruction must be coupled with education as to when to call on an interpreter if participants are not fluent in Spanish at the end of the course.