An Evaluation of Residency Training in Interviewing Skills and the Psychosocial Domain of Medical Practice DEBRA L. ROTER, DrPH, KARAN A. COLE, DAVID E. KERN, MD, MPH, L. RANDOL BARKER, MD, ScM, MARSHA GRAYSON, MA Competent use o f i n t e r v i e w i n g skills is i m p o r t a n t f o r t h e care o f all p a t i e n t s b u t is especially critical, a n d f r e q u e n t l y deficien~ i n meeting the needs o f p a t i e n t s e x p e r i e n c i n g e m o t i o n a l distress. This study p r e s e n t s a n evaluation o f a curriculum in c o m m u n i c a t i o n a n d p s y c h o s o c i a l skills taught to f i r s t - y e a r medical residents. A r a n d o m i z e d exp e r i m e n t a l design c o m p a r e d t r a i n e d a n d u n t r a i n e d residents" ( n = 48) p e r f o r m a n c e s with a simulated p a t i e n t p r e s e n t i n g with at3~ical chest p a i n a n d p s y c h o s o c i a l distress. Evaluation w a s based o n analysis o f "vuleotapes, simulated p a t i e n t r e p o r t o f residents" behaviors, a n d c h a r t notation. T r a i n e d c o m p a r e d with u n t r a i n e d residents a s k e d m o r e o p e n - e n d e d q u e s t i o n s a n d f e w e r leading questions, s u m m a r i z e d m a i n p o i n t s m o r e f r e q u e n t l y , d i d m o r e p s y c h o s o c i a l c o u n s e l i n ~ a n d were r a t e d a s h a v i n g better c o m m u n i c a t i o n skills by the simulated patient. The u s e o f m o r e f o c u s e d a n d psychosocially directed questions, a n d f e w e r leading a n d grab-bag questions, w a s associated with m o r e accurate diagnoses a n d m a n a g e m e n t r e c o r d e d in t h e medical chart. However, n o significant difference w a s f o u n d i n the c h a r t i n g p r a c t i c e s o f t r a i n e d versus unt r a i n e d residents. Key words: interviews; interview, psychologleaJ; education, medical~ i n t e r n s h i p a n d residence; i n t e r n a l medicine; psychiatry; p r i m a r y health care. J GEN INTERN MED 1990; 5 : 3 4 7 - 3 5 4 .
EFFECTIVE INTERVIEWING SKILLS have b e e n associated w i t h a variety of positive effects, including accurate diagnosis, ~ effective patient education, 2 patient satisfaction, 3 patient c o m p l i a n c e , 4 and favorable health outcomes. 5 In v i e w of these findings, there has b e e n a growing consensus a m o n g professional medical societies that greater attention be directed to the teaching of interviewing skills to y o u n g d o c t o r s . 6,7 Medical schools have r e s p o n d e d to this call with increased efforts to teach interviewing skills; it is estimated that a b o u t 70% of medical schools provide such training.S A
Received from the Department of Health Policy and Management, The Johns Hopkins University, School of Hygiene and Public Health (DR), and the Department of Medicine, The Johns Hopkins University, School of Medicine, Francis Scott Key Medical Center (KC, DK, LRB, MG), Baltimore, Maryland. Presented in part at the Mental Disorders in General Health Care Settings Research Conference, Seattle, Washington, June 2 5 - 2 6 , 1987. Supported in part by a residency training grant from the Bureau of Health Professions, Health Resources and Services Administration; by an institutional grant from The Chesapeake Educational and Research Trust, Chesapeake Physician, Pa; and by the National Institute of Mental Health. Address correspondence and reprint requests to Dr. Roter: School of Hygiene and Public Health, Johns Hopkins University, 624 North Broadway, Baltimore, MD 21205.
recent r e v i e w of training efforts identified m o r e than 2 O0 p u b l i s h e d articles that describe or evaluate curricula in this domain, 9 b u t n o t e d that progress in teaching recognition, diagnosis, and m a n a g e m e n t of psychosocial p r o b l e m s has not paralleled the advances made in the teaching of m o r e general interviewing skills. The failure to m e e t training needs in the psychosocial arena is u n d e r s c o r e d by estimates that a third of patients seen in p r i m a r y care practice have s o m e significant psychosocial p r o b l e m deserving o f physician attention. 1° Further, these patients are high utilizers of nonpsychiatric medical care; s o m e estimates of utilization are as m u c h as t w i c e that of the non-disturbed patient population.X Deficiencies in physician recognition of patients' psychosocial p r o b l e m s have b e e n attributed to p o o r interviewing skills, 12 and this p o o r p e r f o r m a n c e appears widespread. In reporting on f r e q u e n t l y observed errors in the c o n d u c t of physical examinations b y interns and residents, Wiener and Nathanson c o n c l u d e d that the c o m m o n e s t errors involved interviewing techn i q u e ) 3 Rapidly fired questions often led to disjointed and discontinuous stories f r o m patients, or to minimally informative yes and no answers. Patients' complaints w e r e p o o r l y defined, and i n c o m p l e t e characterizations of major s y m p t o m s w e r e a c c e p t e d w i t h o u t further attempts at clarification. Housestaff and attendings s h o w similar interviewing errors. After observing m o r e than 300 interviews, Platt and McMath ~ c o n c l u d e d that there was a serious p r o b l e m of clinical h y p o c o m p e t e n c e in the use o f interviewing skills, particularly in the frequent use of direct questions to control and limit patient input. Moreover, the authors f o u n d that the t h e r a p e u t i c content of m a n y observed interviews was e x t r e m e l y low; it was a novel idea to the housestaff that a diagnostic interview should be a t h e r a p e u t i c process that is sensitive and helpful to the e m o t i o n a l distress of the patient. The current study was devised to evaluate a training c u r r i c u l u m that stresses interviewing and psychosocial diagnostic and m a n a g e m e n t skills for year I internal m e d i c i n e residents. Major study hypotheses included: 1) trained residents w o u l d have better c o m m u n i c a t i o n skills than untrained residents; 2) trained residents w o u l d b e rated as better c o m m u n i c a t o r s than untrained residents b y the simulated patient; and 3) diagnostic and m a n a g e m e n t decisions of trained residents w o u l d be m o r e appropriate than those of untrained residents. 347
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METHODS Since 1983, all year I internal medicine residents at Francis Scott Key Medical Center (formerly Baltim o r e City Hospital), a university-affiliated teaching hospital, have participated in a month-long m e d psych rotation that provides intensive training in interviewing skills. 9 Our evaluation is based on three years (July 1983 - J u n e 1986) of e x p e r i e n c e and includes 48 residents. Each year a total of 16 residents took the rotation; based on random assignment, stratified by training track (traditional vs. general internal medicine), half of the group received training b e t w e e n July and D e c e m b e r (the trained group), while the other half took the rotation from January to June (untrained group). Trainees were not randomized in the first year; however, since the trainees were u n k n o w n to the chief resident at the time they were assigned to the rotation, selection bias was unlikely.
The Training Intervention The m e d - p s y c h rotation 9 was taken each m o n t h by one or two year I residents as a p r o t e c t e d rotation with no competing medical inpatient or night call responsibilities. Faculty included a team of two general internists, a behavioral scientist, and a psychiatrist. The program was piloted on primary care residents during four previous years and had evolved to include three major training components: interviewing and psychosocial skills training, participation in the consult a t i o n - l i a i s o n psychiatry service, and observation of c o m m u n i t y and hospital programs important for managing psychosocial problems. These training experiences were s u p p l e m e n t e d by a syllabus of required readings on interviewing skills and the psychosocial problems c o m m o n l y seen in medical practice. During the interviewing and psychosocial skills c o m p o n e n t , the teaching strategies w e r e primarily experiential. Experiential methods included role-plays and individualized p r e c e p t o r feedback on residents' interviews with simulated and actual patients. Use of these strategies is briefly described to provide a feel for the methods of training, as well as its content. Approximately ten different c o m m o n l y encountered situations were role-played, practiced, and discussed during the course of training. For example, scenarios i n c l u d e d those focusing on communicating bad news to the patient, discussing " d o not resuscitate" (DNR) orders with the patient's family, communicating with angry family members, and treating a noncompliant patient. The role-plays were generally quite short, lasting only a few minutes, and specifically directed toward p r o b l e m areas. In this way, lack of skill in an area was readily identified and addressed through an immediate o p p o r t u n i t y for practice. Residents also practiced skills with simulated patients, interviewing an average of six different patients over the course o f the month. The encounters covered
the following situations: n o n c o m p l i a n c e related to p o o r understanding of hypertension; a post-myocardial infarction patient and his wife w h o were e x p e r i e n c i n g marital stress; previously u n d e t e c t e d alcoholism in a patient with h}qgertension and p e p t i c symptoms; anxiety due to real illness (undiagnosed severe anemia); hypochondriasis; and adjustment disorder with depressed mood. The simulated-patient exercises were interactive, with the p r e c e p t o r and simulators providing feedback and p r o m p t i n g on critical knowledge and skills. Following each session, the resident received a c o p y of a p r e c e p t o r - c o m p l e t e d Interaction Rating Form (IRF), w h i c h is a checklist of interviewing behaviors with comments on strengths and on skills needing further work. In addition to work with simulated patients, residents were videotaped with real patients during four of their regularly scheduled, w e e k l y outpatient sessions. The resident reviewed each o f these videotapes with one of the faculty internists, and also received a c o p y of the p r e c e p t o r - c o m p l e t e d IRF with comments on strengths and weaknesses. Another c o m p o n e n t of the r e e d - p s y c h rotation was e x p e r i e n c e with the c o n s u l t a t i o n - liaison service. Residents spent approximately half of their time working with the attending psychiatrist w h o directed the c o n s u l t a t i o n - liaison psychiatry service. Each resident interviewed an average of 30 new patients and gained supervised e x p e r i e n c e in the evaluation of depressive syndromes, delirium and dementia, personality disorders complicating medical care, and other psychiatric problems, including anxiety and somatoform disorders. This was s u p p l e m e n t e d with didactic discussions of depression, anxiety, delirium, and dementia. Finally, approximately 10% of the resident's time was spent b e c o m i n g familiar with hospital and community resources. A primary focus involved treatment programs for alcoholics and their families such as Alcoholics Anonymous, Al-Anon, and hospital- or community-based residential treatment facilities. Other hospital resources included the h o m e care program, outpatient psychiatry, the hospice program, and cardiac rehabilitation. Evaluation of resident performance was delayed until two months after training in order to assess retention of learned skills after trained residents had returned to their traditional housestaff routines. Each trained resident, and one control group resident of the same year, c o n d u c t e d a c o m p l e t e medical visit with the same simulated patient. The visit was videotaped and was the basis of evaluation along with a simulatedpatient report and chart review, as described below.
Data Sources for Evaluation The simulated-patient case for the evaluation was that of a 45-year-old married w o m a n w h o was coming
JOURNALOF GENERALINTERNALMEOIC]NE, Volume 5 (July/August). 1990
to see the physician because of atypical chest pain. The patient had a history of a previous myocardial infarction (three years ago) and ulcer (ten years ago). The correct diagnosis for this patient at the current visit was an adjustment disorder with somatization and mixed emotional features (anxiety and depression). Worsening alcoholism in the patient's spouse was the primary stressor. During the visit, the patient simulated one hyperventilation episode. Appropriate management of this patient included recognition of the stress-related c o m p o n e n t to her chest pain, supportive listening, counseling, referral to AI-Anon, and the decision not to admit her to the hospital. No attempt was made to mask the identity of the simulated patient, and she was clearly identified to the resident. However, the resident was instructed to treat the patient as an actual patient, to c o m p l e t e a write-up of the visit, and to fill out all prescription a n d / o r laboratory forms as necessary. The resident was given a limit of one hour to c o m p l e t e the visit. Prior to the interview the resident reviewed the patient's chart, w h i c h was provided in an abbreviated format. The simulated patient was a professional actress w h o was t h o r o u g h l y trained to 1) present a c o m p l e t e case history in w h i c h all facts of medical and psychosocial history and symptoms w e r e scripted; 2) simulate appropriate physical findings; and 3) reflect an appropriate affective state related to the patient's current situation. Rating of the resident's c o m m u n i c a t i o n skills, using the IRF, and c o m p l e t i o n of a post-visit questionnaire reporting impressions of the visit and recall of information c o m m u n i c a t e d w e r e additional responsibilities. The simulated patient remained blind to the experimental status of the residents at all times during the study. Variables Scored from the Simulated Patient Visit Videotape Process Analysis. Complete video: tapes of the simulated patient visits were content-analyzed using Roter's modification of Bales' process analysis scheme adapted for videotape, is The unit of analysis for this scheme is an utterance, defined as the smallest discriminable speech segment to w h i c h a c o d e r can assign a classification and w h i c h expresses or implies a c o m p l e t e thought. This may be a single word, a phrase, a clause, or a c o m p l e t e sentence. All utterances are assigned to mutually exclusive categories that imply a grammatical or functional structure, with content-specific subcategories for frequent classifications such as question-asking, information-giving, or counseling. There are 22 broad categories, with 49 possible classifications w h e n subcategories are considered. Questions w e r e categorized by type as open, focused, leading, or grab-bag, with the content of each question falling within medical or psychosocial categories. Open-ended questions provide patients the opportunity to choose content and "tell their story" in their
349
own words (e.g., "Tell me about h o w things are going at h o m e " - - psychosocial; "Tell me about y o u r chest p a i n " - - m e d i c a l ) . Focused questions are used to progressively narrow discussion so that specific aspects of a p r o b l e m may be e x p l o r e d or clarified (e.g., "Are you u n d e r any special pressure at w o r k ? " - - p s y c h o s o c i a l ; "Is there anything that seems to bring the chest pain o n ? " - - m e d i c a l ) . Grab-bag questions suggest to a patient a n u m b e r of response alternatives (e.g., " W o u l d you say the pain lasts for seconds, minutes, hours? medical). Leading questions influence the patient to respond in a certain way or provide the patient with an answer ( e . g . , " G e t t i n g out and keeping busy cheers you up, doesn't it?" - - psychosocial; "Does the pain go into your left arm?, - - medical). Information-giving and counseling statements were also g r o u p e d into subcategories. Examples of c o d e d utterances and content-specific subcategories, w h e n applicable, are: "Nice to see you again," categorized as a social remark; "You're doing well with your diet," as a compliment; "Your b l o o d pressure is normal," as information-giving (specifically, about a medical condition); "It is very important for you to get out of the house at least once a day and talk to p e o p l e , " as counseling (psychosocial). A random sample of 15% (n = 7 cases) of the videotapes was drawn to assess inter-coder reliability in the application of the process analysis schemes. Each of these videotapes was c o d e d by two different coders at different times to establish the reliable use of the coding categories. Intercoder reliability (Pearson productm o m e n t correlations) averaged 0.83. Simulated Patient's Ratings o f Residents" Communication Skills. The simulated patient used a slight modification of the IRF used b y preceptors after each observed interview during the training m o n t h for evaluation and feedback (see Appendix). Post-visit Patient Self-report. Two specific open-ended questions answered by the simulated patient at the end of the interaction were: 1) "What did the doctor say the p r o b l e m ( s ) was?" (diagnostic recall); and 2) "What were the next steps in y o u r care?" (management recall). Chart Notation. Each physician's written note on the visit was scored for the presence or absence of items related to diagnostic reasoning. These items formed five subscales: 1) notation of the characterization of the patient's complaint (nature, onset, duration, chronology, severity, location, radiation, precipitating, relieving, and associated factors); 2) notation of hyperventilation; 3) notation of depressive symptoms or inclusion of depression on the p r o b l e m list; 4) notation of symptoms of anxiety or indication of anxiety on the problem list; and, 5) notation of thinking n e e d e d in differential diagnosis (considers cardiac or medication problem, notes presence of social p r o b l e m or stress, specifically notes husband's alcoholism, notes current symptoms secondary to stress). Indicators of p r o b l e m
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Roter etaL, RESIDENCYTRAININGIN INTERVIEWINGSKILLS
TABLE 1 Numbers and Types of Questions Asked by Trained and Untrained Residents Open Questions
Focused Questions
Trained residents (n = 24) Mean SD
9.69 4.07
63.26 19.67
Untrained residents (n = 24) Mean SD
7.04 2.44
t-Value p-Value*
Grab-bag Questions
Leading Questions
Total
5.83 4.62
6.00 3.87
84,78 22.94
67.04 28.22
8.37 7.87
11.12 10.93
93.58 39.54
2.70
--0.53
-- 1.36
--0.216
--0,94
0.01
0.60
O. 18
--0.04
0.35
*All p-valuesare two-tailed.
TABLE Z Specific Question Types Expressedas Percentagesof Physician Talk Open
Focused
Grab-bag
Leading
Questions
Questions
Questions
Questions
Trained residents (n = 24) Mean SD
3% 1.5%
20% 6.4%
2% 1.4%
2% 1.2%
Untrained residents (n = 24) Mean SD
2% 1.2%
22% 7.0%
3% 2.00/0
3% 2.3%
t-value
1.77
--0.76
-- 1.66
--2.76
p-value*
0.09
0.45
O. 10
0.01
*All p-valuesare two-tailed.
management were also taken from the chart, including: the decision to admit to the hospital, medications prescribed, request for cardiology consult, counseling, and referral to AI-Anon.
RESULTS Videotape Process Analysis Content analysis revealed interviewing differences between the trained and untrained groups to be primarily within question-asking categories. Table 1 reflects statistically significant differences in the frequencies of o p e n questions and leading questions such that trained residents asked more o p e n questions and fewer leading questions than did non-trained residents. Table 2 shows the proportions of all physician talk that were c o m p o s e d of question types. This table presents an important perspective on question-asking relative to other aspects of physician talk. This is done by dividing the f r e q u e n c y of talk in each category b y the total n u m b e r of physician utterances in the interview. Overall, about one-fourth of what the doctor says during the medical visit is in the form o f questions. Focused questions, the most c o m m o n form of question-
asking, represent about 21% of physicians' talk; the remaining types each contribute an additional 2 - 3%. Significant differences are evident for leading questions b e t w e e n groups, with leading questions composing less of trained residents' total talk. Differences between groups in other question categories relative to total talk fail to reach statistical significance, although there is a trend for a lower p r o p o r t i o n of grab-bag questions and higher p r o p o r t i o n o f o p e n questions for trained residents. In terms of question content, there was no difference b e t w e e n the groups; about the same p r o p o r t i o n of all questions in either group reflected psychosocial (32%) and medical content (68%). However, trained residents t e n d e d to ask more o p e n psychosocial questions and fewer grab-bag and leading questions of this type. In addition to question type, differences b e t w e e n groups w e r e evident in several other aspects of interaction. Differences favored trained residents for more psychosocial counseling (t = 1.87 p < 0 . 0 7 ) and the provision of summary statements (t = 1.89 p < 0 . 0 7 ) . There were no evident differences b e t w e e n the groups in the lengths o f the medical visits or in any other verbal behaviors.
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JOURNALOFGENERALINTERNALMEDICINE,Volume 5 (July/August), 1990
TABLE 3 Types of QuestionsVersus Chart Indicators of Proficiency
Chart Notes
Open Questions
Establishment of complaint Diagnosis/problem list Anxiety Differential diagnosis Hyperventilation
Focused Questions
Grab-bag Questions
Leading Questions
All Questions with Psychosocial Content
--0.3997*
0.27471` 0.2312t"
--0.2320t
0.31051`
--0.2483t
0.4336* --0.2190* 0.33341`
Medical management *p
EFFECTIVE INTERVIEWING SKILLS have b e e n associated w i t h a variety of positive effects, including accurate diagnosis, ~ effective patient education, 2 patient satisfaction, 3 patient c o m p l i a n c e , 4 and favorable health outcomes. 5 In v i e w of these findings, there has b e e n a growing consensus a m o n g professional medical societies that greater attention be directed to the teaching of interviewing skills to y o u n g d o c t o r s . 6,7 Medical schools have r e s p o n d e d to this call with increased efforts to teach interviewing skills; it is estimated that a b o u t 70% of medical schools provide such training.S A
Received from the Department of Health Policy and Management, The Johns Hopkins University, School of Hygiene and Public Health (DR), and the Department of Medicine, The Johns Hopkins University, School of Medicine, Francis Scott Key Medical Center (KC, DK, LRB, MG), Baltimore, Maryland. Presented in part at the Mental Disorders in General Health Care Settings Research Conference, Seattle, Washington, June 2 5 - 2 6 , 1987. Supported in part by a residency training grant from the Bureau of Health Professions, Health Resources and Services Administration; by an institutional grant from The Chesapeake Educational and Research Trust, Chesapeake Physician, Pa; and by the National Institute of Mental Health. Address correspondence and reprint requests to Dr. Roter: School of Hygiene and Public Health, Johns Hopkins University, 624 North Broadway, Baltimore, MD 21205.
recent r e v i e w of training efforts identified m o r e than 2 O0 p u b l i s h e d articles that describe or evaluate curricula in this domain, 9 b u t n o t e d that progress in teaching recognition, diagnosis, and m a n a g e m e n t of psychosocial p r o b l e m s has not paralleled the advances made in the teaching of m o r e general interviewing skills. The failure to m e e t training needs in the psychosocial arena is u n d e r s c o r e d by estimates that a third of patients seen in p r i m a r y care practice have s o m e significant psychosocial p r o b l e m deserving o f physician attention. 1° Further, these patients are high utilizers of nonpsychiatric medical care; s o m e estimates of utilization are as m u c h as t w i c e that of the non-disturbed patient population.X Deficiencies in physician recognition of patients' psychosocial p r o b l e m s have b e e n attributed to p o o r interviewing skills, 12 and this p o o r p e r f o r m a n c e appears widespread. In reporting on f r e q u e n t l y observed errors in the c o n d u c t of physical examinations b y interns and residents, Wiener and Nathanson c o n c l u d e d that the c o m m o n e s t errors involved interviewing techn i q u e ) 3 Rapidly fired questions often led to disjointed and discontinuous stories f r o m patients, or to minimally informative yes and no answers. Patients' complaints w e r e p o o r l y defined, and i n c o m p l e t e characterizations of major s y m p t o m s w e r e a c c e p t e d w i t h o u t further attempts at clarification. Housestaff and attendings s h o w similar interviewing errors. After observing m o r e than 300 interviews, Platt and McMath ~ c o n c l u d e d that there was a serious p r o b l e m of clinical h y p o c o m p e t e n c e in the use o f interviewing skills, particularly in the frequent use of direct questions to control and limit patient input. Moreover, the authors f o u n d that the t h e r a p e u t i c content of m a n y observed interviews was e x t r e m e l y low; it was a novel idea to the housestaff that a diagnostic interview should be a t h e r a p e u t i c process that is sensitive and helpful to the e m o t i o n a l distress of the patient. The current study was devised to evaluate a training c u r r i c u l u m that stresses interviewing and psychosocial diagnostic and m a n a g e m e n t skills for year I internal m e d i c i n e residents. Major study hypotheses included: 1) trained residents w o u l d have better c o m m u n i c a t i o n skills than untrained residents; 2) trained residents w o u l d b e rated as better c o m m u n i c a t o r s than untrained residents b y the simulated patient; and 3) diagnostic and m a n a g e m e n t decisions of trained residents w o u l d be m o r e appropriate than those of untrained residents. 347
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METHODS Since 1983, all year I internal medicine residents at Francis Scott Key Medical Center (formerly Baltim o r e City Hospital), a university-affiliated teaching hospital, have participated in a month-long m e d psych rotation that provides intensive training in interviewing skills. 9 Our evaluation is based on three years (July 1983 - J u n e 1986) of e x p e r i e n c e and includes 48 residents. Each year a total of 16 residents took the rotation; based on random assignment, stratified by training track (traditional vs. general internal medicine), half of the group received training b e t w e e n July and D e c e m b e r (the trained group), while the other half took the rotation from January to June (untrained group). Trainees were not randomized in the first year; however, since the trainees were u n k n o w n to the chief resident at the time they were assigned to the rotation, selection bias was unlikely.
The Training Intervention The m e d - p s y c h rotation 9 was taken each m o n t h by one or two year I residents as a p r o t e c t e d rotation with no competing medical inpatient or night call responsibilities. Faculty included a team of two general internists, a behavioral scientist, and a psychiatrist. The program was piloted on primary care residents during four previous years and had evolved to include three major training components: interviewing and psychosocial skills training, participation in the consult a t i o n - l i a i s o n psychiatry service, and observation of c o m m u n i t y and hospital programs important for managing psychosocial problems. These training experiences were s u p p l e m e n t e d by a syllabus of required readings on interviewing skills and the psychosocial problems c o m m o n l y seen in medical practice. During the interviewing and psychosocial skills c o m p o n e n t , the teaching strategies w e r e primarily experiential. Experiential methods included role-plays and individualized p r e c e p t o r feedback on residents' interviews with simulated and actual patients. Use of these strategies is briefly described to provide a feel for the methods of training, as well as its content. Approximately ten different c o m m o n l y encountered situations were role-played, practiced, and discussed during the course of training. For example, scenarios i n c l u d e d those focusing on communicating bad news to the patient, discussing " d o not resuscitate" (DNR) orders with the patient's family, communicating with angry family members, and treating a noncompliant patient. The role-plays were generally quite short, lasting only a few minutes, and specifically directed toward p r o b l e m areas. In this way, lack of skill in an area was readily identified and addressed through an immediate o p p o r t u n i t y for practice. Residents also practiced skills with simulated patients, interviewing an average of six different patients over the course o f the month. The encounters covered
the following situations: n o n c o m p l i a n c e related to p o o r understanding of hypertension; a post-myocardial infarction patient and his wife w h o were e x p e r i e n c i n g marital stress; previously u n d e t e c t e d alcoholism in a patient with h}qgertension and p e p t i c symptoms; anxiety due to real illness (undiagnosed severe anemia); hypochondriasis; and adjustment disorder with depressed mood. The simulated-patient exercises were interactive, with the p r e c e p t o r and simulators providing feedback and p r o m p t i n g on critical knowledge and skills. Following each session, the resident received a c o p y of a p r e c e p t o r - c o m p l e t e d Interaction Rating Form (IRF), w h i c h is a checklist of interviewing behaviors with comments on strengths and on skills needing further work. In addition to work with simulated patients, residents were videotaped with real patients during four of their regularly scheduled, w e e k l y outpatient sessions. The resident reviewed each o f these videotapes with one of the faculty internists, and also received a c o p y of the p r e c e p t o r - c o m p l e t e d IRF with comments on strengths and weaknesses. Another c o m p o n e n t of the r e e d - p s y c h rotation was e x p e r i e n c e with the c o n s u l t a t i o n - liaison service. Residents spent approximately half of their time working with the attending psychiatrist w h o directed the c o n s u l t a t i o n - liaison psychiatry service. Each resident interviewed an average of 30 new patients and gained supervised e x p e r i e n c e in the evaluation of depressive syndromes, delirium and dementia, personality disorders complicating medical care, and other psychiatric problems, including anxiety and somatoform disorders. This was s u p p l e m e n t e d with didactic discussions of depression, anxiety, delirium, and dementia. Finally, approximately 10% of the resident's time was spent b e c o m i n g familiar with hospital and community resources. A primary focus involved treatment programs for alcoholics and their families such as Alcoholics Anonymous, Al-Anon, and hospital- or community-based residential treatment facilities. Other hospital resources included the h o m e care program, outpatient psychiatry, the hospice program, and cardiac rehabilitation. Evaluation of resident performance was delayed until two months after training in order to assess retention of learned skills after trained residents had returned to their traditional housestaff routines. Each trained resident, and one control group resident of the same year, c o n d u c t e d a c o m p l e t e medical visit with the same simulated patient. The visit was videotaped and was the basis of evaluation along with a simulatedpatient report and chart review, as described below.
Data Sources for Evaluation The simulated-patient case for the evaluation was that of a 45-year-old married w o m a n w h o was coming
JOURNALOF GENERALINTERNALMEOIC]NE, Volume 5 (July/August). 1990
to see the physician because of atypical chest pain. The patient had a history of a previous myocardial infarction (three years ago) and ulcer (ten years ago). The correct diagnosis for this patient at the current visit was an adjustment disorder with somatization and mixed emotional features (anxiety and depression). Worsening alcoholism in the patient's spouse was the primary stressor. During the visit, the patient simulated one hyperventilation episode. Appropriate management of this patient included recognition of the stress-related c o m p o n e n t to her chest pain, supportive listening, counseling, referral to AI-Anon, and the decision not to admit her to the hospital. No attempt was made to mask the identity of the simulated patient, and she was clearly identified to the resident. However, the resident was instructed to treat the patient as an actual patient, to c o m p l e t e a write-up of the visit, and to fill out all prescription a n d / o r laboratory forms as necessary. The resident was given a limit of one hour to c o m p l e t e the visit. Prior to the interview the resident reviewed the patient's chart, w h i c h was provided in an abbreviated format. The simulated patient was a professional actress w h o was t h o r o u g h l y trained to 1) present a c o m p l e t e case history in w h i c h all facts of medical and psychosocial history and symptoms w e r e scripted; 2) simulate appropriate physical findings; and 3) reflect an appropriate affective state related to the patient's current situation. Rating of the resident's c o m m u n i c a t i o n skills, using the IRF, and c o m p l e t i o n of a post-visit questionnaire reporting impressions of the visit and recall of information c o m m u n i c a t e d w e r e additional responsibilities. The simulated patient remained blind to the experimental status of the residents at all times during the study. Variables Scored from the Simulated Patient Visit Videotape Process Analysis. Complete video: tapes of the simulated patient visits were content-analyzed using Roter's modification of Bales' process analysis scheme adapted for videotape, is The unit of analysis for this scheme is an utterance, defined as the smallest discriminable speech segment to w h i c h a c o d e r can assign a classification and w h i c h expresses or implies a c o m p l e t e thought. This may be a single word, a phrase, a clause, or a c o m p l e t e sentence. All utterances are assigned to mutually exclusive categories that imply a grammatical or functional structure, with content-specific subcategories for frequent classifications such as question-asking, information-giving, or counseling. There are 22 broad categories, with 49 possible classifications w h e n subcategories are considered. Questions w e r e categorized by type as open, focused, leading, or grab-bag, with the content of each question falling within medical or psychosocial categories. Open-ended questions provide patients the opportunity to choose content and "tell their story" in their
349
own words (e.g., "Tell me about h o w things are going at h o m e " - - psychosocial; "Tell me about y o u r chest p a i n " - - m e d i c a l ) . Focused questions are used to progressively narrow discussion so that specific aspects of a p r o b l e m may be e x p l o r e d or clarified (e.g., "Are you u n d e r any special pressure at w o r k ? " - - p s y c h o s o c i a l ; "Is there anything that seems to bring the chest pain o n ? " - - m e d i c a l ) . Grab-bag questions suggest to a patient a n u m b e r of response alternatives (e.g., " W o u l d you say the pain lasts for seconds, minutes, hours? medical). Leading questions influence the patient to respond in a certain way or provide the patient with an answer ( e . g . , " G e t t i n g out and keeping busy cheers you up, doesn't it?" - - psychosocial; "Does the pain go into your left arm?, - - medical). Information-giving and counseling statements were also g r o u p e d into subcategories. Examples of c o d e d utterances and content-specific subcategories, w h e n applicable, are: "Nice to see you again," categorized as a social remark; "You're doing well with your diet," as a compliment; "Your b l o o d pressure is normal," as information-giving (specifically, about a medical condition); "It is very important for you to get out of the house at least once a day and talk to p e o p l e , " as counseling (psychosocial). A random sample of 15% (n = 7 cases) of the videotapes was drawn to assess inter-coder reliability in the application of the process analysis schemes. Each of these videotapes was c o d e d by two different coders at different times to establish the reliable use of the coding categories. Intercoder reliability (Pearson productm o m e n t correlations) averaged 0.83. Simulated Patient's Ratings o f Residents" Communication Skills. The simulated patient used a slight modification of the IRF used b y preceptors after each observed interview during the training m o n t h for evaluation and feedback (see Appendix). Post-visit Patient Self-report. Two specific open-ended questions answered by the simulated patient at the end of the interaction were: 1) "What did the doctor say the p r o b l e m ( s ) was?" (diagnostic recall); and 2) "What were the next steps in y o u r care?" (management recall). Chart Notation. Each physician's written note on the visit was scored for the presence or absence of items related to diagnostic reasoning. These items formed five subscales: 1) notation of the characterization of the patient's complaint (nature, onset, duration, chronology, severity, location, radiation, precipitating, relieving, and associated factors); 2) notation of hyperventilation; 3) notation of depressive symptoms or inclusion of depression on the p r o b l e m list; 4) notation of symptoms of anxiety or indication of anxiety on the problem list; and, 5) notation of thinking n e e d e d in differential diagnosis (considers cardiac or medication problem, notes presence of social p r o b l e m or stress, specifically notes husband's alcoholism, notes current symptoms secondary to stress). Indicators of p r o b l e m
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Roter etaL, RESIDENCYTRAININGIN INTERVIEWINGSKILLS
TABLE 1 Numbers and Types of Questions Asked by Trained and Untrained Residents Open Questions
Focused Questions
Trained residents (n = 24) Mean SD
9.69 4.07
63.26 19.67
Untrained residents (n = 24) Mean SD
7.04 2.44
t-Value p-Value*
Grab-bag Questions
Leading Questions
Total
5.83 4.62
6.00 3.87
84,78 22.94
67.04 28.22
8.37 7.87
11.12 10.93
93.58 39.54
2.70
--0.53
-- 1.36
--0.216
--0,94
0.01
0.60
O. 18
--0.04
0.35
*All p-valuesare two-tailed.
TABLE Z Specific Question Types Expressedas Percentagesof Physician Talk Open
Focused
Grab-bag
Leading
Questions
Questions
Questions
Questions
Trained residents (n = 24) Mean SD
3% 1.5%
20% 6.4%
2% 1.4%
2% 1.2%
Untrained residents (n = 24) Mean SD
2% 1.2%
22% 7.0%
3% 2.00/0
3% 2.3%
t-value
1.77
--0.76
-- 1.66
--2.76
p-value*
0.09
0.45
O. 10
0.01
*All p-valuesare two-tailed.
management were also taken from the chart, including: the decision to admit to the hospital, medications prescribed, request for cardiology consult, counseling, and referral to AI-Anon.
RESULTS Videotape Process Analysis Content analysis revealed interviewing differences between the trained and untrained groups to be primarily within question-asking categories. Table 1 reflects statistically significant differences in the frequencies of o p e n questions and leading questions such that trained residents asked more o p e n questions and fewer leading questions than did non-trained residents. Table 2 shows the proportions of all physician talk that were c o m p o s e d of question types. This table presents an important perspective on question-asking relative to other aspects of physician talk. This is done by dividing the f r e q u e n c y of talk in each category b y the total n u m b e r of physician utterances in the interview. Overall, about one-fourth of what the doctor says during the medical visit is in the form o f questions. Focused questions, the most c o m m o n form of question-
asking, represent about 21% of physicians' talk; the remaining types each contribute an additional 2 - 3%. Significant differences are evident for leading questions b e t w e e n groups, with leading questions composing less of trained residents' total talk. Differences between groups in other question categories relative to total talk fail to reach statistical significance, although there is a trend for a lower p r o p o r t i o n of grab-bag questions and higher p r o p o r t i o n o f o p e n questions for trained residents. In terms of question content, there was no difference b e t w e e n the groups; about the same p r o p o r t i o n of all questions in either group reflected psychosocial (32%) and medical content (68%). However, trained residents t e n d e d to ask more o p e n psychosocial questions and fewer grab-bag and leading questions of this type. In addition to question type, differences b e t w e e n groups w e r e evident in several other aspects of interaction. Differences favored trained residents for more psychosocial counseling (t = 1.87 p < 0 . 0 7 ) and the provision of summary statements (t = 1.89 p < 0 . 0 7 ) . There were no evident differences b e t w e e n the groups in the lengths o f the medical visits or in any other verbal behaviors.
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JOURNALOFGENERALINTERNALMEDICINE,Volume 5 (July/August), 1990
TABLE 3 Types of QuestionsVersus Chart Indicators of Proficiency
Chart Notes
Open Questions
Establishment of complaint Diagnosis/problem list Anxiety Differential diagnosis Hyperventilation
Focused Questions
Grab-bag Questions
Leading Questions
All Questions with Psychosocial Content
--0.3997*
0.27471` 0.2312t"
--0.2320t
0.31051`
--0.2483t
0.4336* --0.2190* 0.33341`
Medical management *p
