The Medical Interview: curriculum development, teaching, assessment

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The Medical Interview curriculum development,
teaching,assessment

• Ted Parran, M.D.
• Mack Lipkin, M.D.
• Macy Initiative in Health Communications

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Thesis

• Communication in the medical encounter is
  fundamentally important to care
• Medical practitioners do not currently optimally
  perform health communications
• Robust data
• Detail what to do
• Demonstrate how to teach and improve

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Some Implications of Thesis

• Individual practitioners, departments, and
  institutions can now commit to a higher standard
• To promulgate standards (adopt, teach assess)
  requires

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To promulgate standards requires

• Agreement on what they are
• Common language to describe them
• Behaviorally specific competencies
• Effective methods to teach them
• Reliable, valid efficient, assessments

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To promulgate standards requires

• A paradigm shift
• A unified theory and practic
• Political will and access
• Agreement by boards, academies, etc.
• Top down local support
• Curriculum control or access
• The CWRU-Macy Dissemination Process

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Criteria for a Unified Theory

• Coherent and comprehensive
• Empirically derived
• Respectful of diversity and free of ideology
• Understandable
• Teachable
• Concrete, behaviorally specific, monitorable
• Demonstrated impact on health outcomes

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Approach this morning

• This hour
• Review the importance of the medical interview
  and its current state of performance
• Introduce research methods and sample findings
• Next hour
• Introduce competency based teaching approaches
  and data supporting them
• Present current core competencies and precepts

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The Importance of the Medical Interview In
medicine in general

• the core clinical skill
• most time spent between practitioner and patient
• most important contribution to clinical
  reasoning, diagnosis, and outcomes of care
• most prevalent behavior in clinical medicine and
  the most prevalent behavior in a clinicians
  lifetime

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The Importance of the Medical Interview

• determines data accuracy and completeness
• determines problems dealt with
• determines the nature of the provider patient
  relationship and its effectiveness

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The Medical Interview is a Major Determinant of

• compliance (therapeutic alliance).
• practitioner and patient satisfaction.
• with the encounter
• with overall care.
• health outcomes--biological, psychological,
  social.
• quality of life.
• placebo effect, and much more.

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Where Do We Stand?

• Public satisfaction with the doctor patient
  relationship has declined steadily
• Physician recognition of psychosocial problems is
  no more than 20-50 and standing still
• Dealing with common difficult situations is
  beyond average practitioners, including
• assisting with death and dying
• somatization
• even simple informed consent is the exception

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Where Do We StandStudent Performance

• Helfer et.al., student interpersonal skills and
  interest with patients across medical school,
  cross-sectional assessment
• Result students enter with very good
  interpersonal skills and interest Year 2
  these are flagging Year 3 significantly
  worse Year 4 terrible PGY 1-3 gradual
  improvement, not to baseline however (other
  authors)

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What Should We Teach/Learn?

• What has been documented to be true
• What is effective in practice
• What the learner is developmentally ready to
  hear, absorb, integrate
• What we know can be effectively taught

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Research Concerning the Medical Interview Types
of Research

• descriptive
• interactional analysis (RIAS)
• discourse analysis
• psychodynamic, etc.
• quasi-experimental
• e.g., send standardized patients into a practice
  and analyze information obtained by practitioner
  as a function of process variables

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Types of Research

• Experimental, e.g.,
• Randomly activate patients with a given
  condition, compare to controls with respect to
  biological outcomes
• Randomize practitioners to receive experimental
  educational intervention or a control
  intervention, assess and compare skills, patient
  and biological outcomes

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Quantity of Research

• About 8000 articles, chapters and monographs
• Hepatitis literature for 5 years also about 8,000
• Quality is typical of the medical literature
• i.e., only about 10 is demonstrably valid
• a few dozen are veterinary
• Some is heuristically interesting
• Much is garbage

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Growth in Interview Assessment Instruments

• 26 in 85 (Roter and Hall)
• 14 in 95 (Kraan et. al.--quality filtered)
• 44 in 98 (Boon and Stewart)

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Some Descriptive FindingsThe AAPP Collaborative
Study

• 550 primary care return visits
• convenience sample
• Visits audio taped
• Patient and Physician Exit questionnaires elicit
• problems dealt with
• priorities
• satisfaction
• intention to comply, etc.

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Allow Patients to Express their Major Concerns

• Satisfaction and compliance of patients with
  children in ER were greater when parents could
  express concerns
• Adults with headaches who were able to fully
  discuss problem were more likely to improve

• Korsch et al, 1968 Freemon et al, 1971
• Headache Study Group, 1989

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Allow Patients to Express their Major Concerns

• Blood pressure control correlated with patients
  ability to talk about concerns in their own
  words.
• Satisfaction of adults in medical walk-in clinic
  correlated with ability to talk about illness in
  own words.

• Orth et al., 1987
• Stiles et al., 1979a,b
• Putnam et al, 1988

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Elicit Patients Explanations of Their Illnesses

• Congruence between patients in pediatric clinic
  and physicians about patients problems
  correlated with improvement
• Congruence between patients in general medicine
  clinic and physicians about patients problems
  correlated with improvement.

• Starfield et al., 1981
• Freidin et al., 1980

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Involve Patients in Developing a Treatment Plan

• Greenfield et al., 1985
• Kaplan et al., 1989

• Adults with hypertension, diabetes, peptic ulcer
  disease who were trained to ask questions and
  given explanations of their diagnoses and
  treatments were more likely to improve than were
  control patients

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Health outcomes related to interview factors in
meta-analyses

• Physiological responses (e.g., BP, sugar)
• Symptom resolution
• Pain control
• Functional status
• Emotional health (decreased distress, anxiety)

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Quality measures related to interview factors

• Malpractice suits and wins
• Information completeness and accuracy
• Efficiency
• Elimination of door knob questions
• Patient satisfaction

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Two Surveys of Teaching In 1977, Kahn, Jason et.
al. found

• Most teachers were psychiatrists or
  psychologists
• Only 42 of programs used feedback or skills
  practice
• None used simulated patients effectively
• Role play was not mentioned
• Attention given to development or personal
  adjustment and growth of students

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Two Surveys of Teaching In 1993, Novack, et. al.

• a broad mix of teachers
• use of behaviorally sound skills practice and
  feedback
• role play
• attention to personal issues

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Barriers We Teachers Created

• This is so threatening you need our support
• This is so complex and subtle average students
  wont be interested in or master it
• A cacophony of jargons
• Morally haughty manner
• you ought to want to learn this if youre a
  good person if you dont youre not

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How Can the Situation Be Changed?

• Increasingly convincing data support that
• Trainers can be trained
• Learners can make major and enduring improvements
  in their knowledge, skills and attitudes
• Effective models have common features

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Integrated Model of Teaching and Learning

• Knowledge, skills, and attitudes are taught
  simultaneously (vs. sequentially or in isolation)
• Interactions and Arrangements model the method
  (the medium is the message)
• Developmentally appropriate learning
• Learner centered, esp. wrt attitudes,
  relationship building, emotion handling

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The future the science

• Regular, technical research meetings would be
  valuable--to ensure new investigators have
  rigorous methods and important goals
• Comparisons of assessment methods would speed
  progress and eliminate cacophony
• Strong outcomes research needed
• focus on high yield outcomes in practice
• focus on changing behavior in learners in
  education

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The future

• Practitioners and learners will be evaluated on
  their communications skills
• Self assessment and continued maintenance of
  skills will become the norm
• What action plans might you consider?

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Thesis

• Communication in the medical encounter is
  fundamentally important to care
• Medical practitioners do not currently optimally
  perform health communications
• Robust data
• Detail what to doa unified model
• Demonstrate how to teach and improve
• Individual practitioners, departments, and
  institutions can now commit to a higher standard