Apr 28, 2004 - and the Accreditation Council for Graduate Medical Education. 3 ... school courses provided formal training in communication and clinical ...
An Innovative Curriculum Teaching the Integration of Communication and Clinical Reasoning Skills to Medical Students
Donna M. Windish, M.D. MPH Capstone Project April 28, 2004
Co-curriculum Developers: Eboni G. Price, M.D., Sarah L. Clever, M.D., M.S. MPH Capstone Advisor: Eric B. Bass, M.D., M.P.H.
ABSTRACT Context: Medical students rarely are taught how to integrate communication and clinical reasoning skills during patient-physician interactions. Objectives: For medical students to be able to demonstrate: (1) the connection between communication and clinical reasoning by integrating biomedical and psychosocial aspects of patient care, (2) strategies to engage in patient-centered communication, and (3) strategies for clinical reasoning during patient encounters. Design: Randomized trial of a curricular intervention in communication and clinical reasoning implemented in 2003. Setting: Johns Hopkins University School of Medicine. Participants: Sixty of 121 second-year medical students participated in the curriculum with the remaining 61 students serving as controls. Intervention: A 6-week, 18-hour course taught the integration of specific communication and clinical reasoning techniques in a small group setting using role-play, reflection and feedback in a structured iterative reflective process. Main Outcome Measures: Students interviewed standardized patients who assessed their communication skills in: establishing rapport, data gathering and patient education and counseling. For clinical reasoning, students generated problem lists and differential diagnoses for each case. Mean scores were calculated for each communication skill area, problems listed and differential diagnoses generated. Integration of communication and clinical reasoning was measured by students’ listing psychosocial history items on their problem lists. Results: Students in the curriculum were rated more favorably in their ability to establish rapport by the standardized patients (p=0.08). Participants listed on average one more patient problem on their
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problem lists compared to controls (mean 8.4 versus 7.5; p=0.05). Sixty-four percent of students in the curriculum versus 44% of controls listed one or more psychosocial history items in their problem lists (p=0.03). Groups did not differ significantly in other communication skill ratings or in the mean number of differential diagnoses generated. Ninety-five percent of curricular participants found importance in integrating communication and clinical reasoning skills. Conclusions: Teaching medical students communication and clinical reasoning skills concomitantly improved their ability to integrate the biomedical and psychosocial aspects of patient care. Similar educational initiatives in all stages of training could lead to improved patient-physician interactions and medical care.
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To provide good medical care, physicians must understand each patient as a whole including his or her biological, psychological, social and cultural background. This requires adequate knowledge of epidemiology and pathophysiology, effective communication, and good clinical judgment to generate and modify diagnostic hypotheses as information is gathered during a clinical encounter (i.e., clinical reasoning skills). Communication and clinical reasoning skills must be mastered during medical training, as required by the Association of American Medical Colleges,1 the Liaison Committee on Medical Education,2 and the Accreditation Council for Graduate Medical Education3. Successful use of these skills has been linked to important outcomes, including improved diagnostic and clinical proficiency,4,5 increased patient and physician satisfaction,6-8 reduced emotional distress,2 decreased frequency of medical errors,9 and improved efficiency in medical care10. Since clinicians use communication and clinical reasoning skills together, instruction in these areas should occur in an integrated fashion to help the learner understand how each element informs the other. Although communication skills training may improve a student’s diagnostic efficiency,4 we found no published examples of curricula that help medical students learn to integrate these skills. To overcome potential educational deficiencies, we developed a curriculum entitled AIME (An Integrated Medical Encounter) to teach the integration of communication and clinical reasoning skills to second-year medical students. The specific objectives of the curriculum were for students to be able to demonstrate: (1) the connection between communication and clinical reasoning skills by integrating biomedical and psychosocial aspects of patient care, (2) strategies to engage in patient-centered communication, and (3) strategies for clinical reasoning during patient encounters. This paper describes the development of the curriculum and the results of a randomized trial to determine the effectiveness of teaching these skills together.
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METHODS Background We used a six-step approach to curriculum development as described by Kern and colleagues.11 Briefly, from our literature review, we found five models that serve as the basis for teaching patientphysician communication.12-16 Of these, the Three Function Model of the Medical Interview12 (that emphasizes establishing rapport, gathering data, and educating and counseling patients) provides the best framework to discuss elements of communication and clinical reasoning. To teach clinical reasoning, we found teaching methods that focus on a case-based approach to learning with an emphasis on generating differential diagnoses.17-19
Institutional Needs Assessment To determine how communication and clinical reasoning skills were taught at the Johns Hopkins University School of Medicine, we conducted a needs assessment in 2002-3. We administered questionnaires and conducted in-person interviews with the instructors of the first year Introduction to Clinical Medicine course (emphasizing components of the medical interview through observation of a practicing physician), the second year Clinical Skills course (teaching history-taking and physical examination), and the Physician and Society course (emphasizing medical ethics in the patient-physician relationship). We also surveyed and interviewed clerkship directors in six required clerkships (Ambulatory Medicine, Inpatient Medicine, Neurology, Pediatrics, Psychiatry, and Surgery). We asked faculty to rate student preparedness for the clerkship years in seven communication skills and four areas of clinical reasoning using ratings of “less prepared”, “at the level they should be”, or “more prepared”. During the in-person interviews, we reviewed individual course syllabi and discussed the types of formal teaching provided in these areas.
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We also surveyed 96 third- and fourth-year students. We asked them to indicate which medical school courses provided formal training in communication and clinical reasoning and to self-rate their proficiency in each skill using responses of “no exposure”, “familiar with concept”, “can perform skill somewhat”, “can perform skill well”, or “can teach skill to other students”. In the preclinical years, we found that the Introduction to Clinical Medicine course introduces the Bayer Institute of Health Care Communication model: engagement, enlistment, empathy and education.20 Since the course is designed to be an observational experience of a community physician’s interaction with patients, opportunities to perform interviews and practice these skills vary based on preceptor assignment. The second-year Clinical Skills course assigns four students to a facilitator and allows student pairs to practice interviewing hospitalized patients one afternoon each week. This course emphasizes obtaining the biomedical components of the medical history (i.e., history of present illness, past medical history, social history, and family history) with no specific training or feedback in communication skills. In the Physician and Society course, no formal instruction is provided in communication skills; however, student groups have opportunities to practice interviewing standardized patients in sensitive areas including domestic violence and delivering bad news. For clinical reasoning, students may be introduced to differential diagnoses in their Clinical Skills group through informal discussions of the medical history gathered during patient interviews; however, they do not receive formal training in clinical reasoning in any preclinical course. Thus, in the preclinical years, specific instruction and reinforcement of communication and clinical reasoning skills was limited. Many of the clerkship directors indicated that they provide some formal training in communication and clinical reasoning during their clerkship (Table 1). Nevertheless, most used non-
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experiential learning techniques (e.g., handouts and small group discussion). The majority of faculty felt that students were less prepared than necessary in most communication and clinical reasoning skills, which is consistent with the results of a national survey of clerkship directors.21 Clerkship students also perceived their preparation in these areas as less than optimal, although most students acknowledged receiving some formal training (Table 1). Given the results of our needs assessment, it was clear that additional communication and clinical reasoning skills instruction was needed.
Curriculum Overview of Teaching and Learning Strategies Our intervention targeted second-year medical students and was taught concurrently with the courses on Pathophysiology and Clinical Skills. We used self-reflection, small group discussion, videotaped encounters, role-play, standardized patients, and feedback to teach different aspects of the doctor-patient encounter. The role-play cases were linked to medical information being taught concurrently in the Pathophysiology course. Most cases contained a communication barrier (e.g., patient reluctance to discuss illicit drug use) to allow students to work through specific communication challenges. To help students learn communication skills, we developed a Communication Skills Observation Guide that was modeled after the Calgary Cambridge Observation Guide (Figure 1).22 The guide contains questions corresponding to the Three Function Model of interviewing.12 We asked students to use the guide during role-plays to observe for and comment on the use of open and closeended inquiry, detection of verbal and nonverbal cues, elicitation of patients’ concerns about their health and elicitation of a patient’s psychosocial history. Our clinical reasoning instruction focused on developing a patient-specific problem list and differential diagnosis. We emphasized understanding the patient as a whole: including all elements of Windish 2004
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the patient’s medical history; understanding a patient’s preferences for medical care; and understanding how a patient’s psychosocial history and medical concerns can influence the plan of care. Using this information, students applied knowledge of epidemiology and pathophysiology to generate clinical hypotheses. To help students through the diagnostic thinking process, we presented a structured approach to developing a differential diagnosis. This included thinking broadly about disease processes using the mnemonic VINDICATE (vascular, infectious, neoplastic, drug related, inflammatory, collagen vascular, traumatic, endocrine/metabolic) and by reviewing potential diagnoses in each organ system to avoid premature closure in hypothesis generation.
Curriculum Structure The curriculum was taught over the course of six weeks in small groups of six students with one or two faculty facilitators. It consisted of weekly three-hour sessions designed to introduce techniques in communication and clinical reasoning in a step-wise fashion. The learning objectives and educational methods for each session are listed in Table 2. In brief, the first session introduced communication skills based on the Three Function Model of medical interviewing. The second session introduced clinical reasoning through the creation of problem lists and formulation of differential diagnoses. The third session addressed components of a psychosocial history, cultural competence, and patient education and counseling. Session four integrated communication skills and clinical reasoning through a small group exercise with a standardized patient. Session five introduced the role of epidemiology, pathophysiology and pre-test probability in diagnostic decision-making. Finally, session six presented the principles of and the rationale behind shared decision making. Each session began with a reflection on the communication and clinical reasoning skills students used during their interviews with hospitalized patients over the previous week. The facilitator
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then offered a brief didactic on the topic of the day. After discussion of the skill area, a brief video clip presented highlights of certain communication and clinical reasoning components of a medical encounter. The remainder of the session (between 60-90 minutes) was devoted to a patient-physician role-play. The role-play was a structured experience using time-outs to highlight the cognitive processes at work during a medical interview. One student played the patient and another student played the clinician. The remaining students were assigned to observe different communication skills using the Communication Skills Observation Guide. Time-outs occurred during the interview to allow reflection on communication skills and to brainstorm clinical hypotheses. The time-outs could be called by anyone in the group and focused on the communication or clinical reasoning challenge that the interviewing student was facing. During a time-out, the discussion used a six-step iterative reflective process with feedback by self-reflection, peers, faculty and patients to examine communication skills (Figure 2). The discussion also highlighted how the communication challenges affected the quality of the medical information obtained. The information gathered in that segment of the interview was listed in a problem list and differential diagnoses were generated using VINDICATE and an organ system approach. Finally, students discussed the medical information they obtained, the hypotheses they wished to test, and how best to approach the patient to gather more information. The role-play resumed with a different student continuing the interview. This six-step approach emphasized how communication affects clinical reasoning and how diagnostic hypotheses direct further interviewing.
Implementation In the 2003-4 academic year, there were 121 students in the second-year class. Sixty were randomly assigned to the AIME curriculum, and the remaining 61 students participated in AIME later Windish 2004
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in the year to ensure that all students received equal instruction. The Johns Hopkins Institutional Review Board approved the study protocol. We recruited faculty to teach who were not currently facilitating in other areas of the curriculum. To ensure uniform instruction, we held a two-hour faculty development session one week before starting AIME that allowed faculty to participate in an experiential session of role-playing using the iterative reflective process. We also met with faculty on a weekly basis to review the goals for each session.
Curriculum Evaluation Methods Baseline Assessment of Students’ Knowledge and Skills We introduced the curriculum to the second-year class in a lecture one week before the start of AIME. At this point in their training, students had only had one opportunity to practice interviewing a patient. Students completed background questions regarding their age, gender, college major, previous interviewing experience, and prior medical training. Students also rated their proficiency in specific communication and clinical reasoning skills on a 5-point scale, where 0 = no exposure, 1 = familiar with concept, 2 = can perform skill somewhat, 3 = can perform skill well, 4 = can teach to other students. To assess baseline knowledge and skills, students observed a video clip of a medical encounter involving a patient with alcoholic pancreatitis. The roles of the patient and the physician were scripted to display positive and negative communication behaviors. After viewing the tape, students answered questions about communication behaviors displayed by the physician, created a problem list and generated possible diagnoses with supporting and refuting reasons for their top three choices. Finally, students completed the Diagnostic Thinking Inventory which is a self-reported questionnaire designed
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to assess an individual’s clinical reasoning in two areas: the degree of flexibility in thinking and the degree of knowledge structure in memory.23 The inventory contains 41 questions rated on a six-point scale, with higher scores indicating a greater degree of diagnostic thinking ability, and has a reliability of 0.83 (Cronbach α).
Assessment of Student Performance One week after completing the curriculum, all students underwent a two-station standardized patient interaction to measure their communication and clinical reasoning skills. The cases represented disease processes previously covered in Pathophysiology (hyperthyroidism and rheumatoid arthritis). For each patient, students had fifteen minutes to complete a medical history and to perform a focused physical exam. To measure communication skills, the standardized patient completed a 30-item interpersonal checklist that rated behaviors on a 5-point Likert scale, where 1 = poor, 2 = adequate, 3 = good, 4 = very good, 5 = excellent. We combined select questions into three subscales relating to the elements of the Three Function Model, including five questions on data gathering (subscale reliability by Cronbach α was 0.85), eleven questions on establishing rapport (Cronbach α 0.95), and five questions concerning patient education and counseling (Cronbach α 0.86) (see Table 3). The standardized patients also completed a case-specific history item checklist to determine what areas of the medical history were elicited. To measure clinical reasoning skills, students generated a problem list and differential diagnosis giving supporting and refuting features for their top three choices. At the end of the session, students completed the Diagnostic Thinking Inventory. To check the accuracy of each clinical presentation, fifteen internal medicine physicians independently reviewed a written version of the
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history and physical exam for both scenarios and all supported hyperthyroidism and rheumatoid arthritis as the leading hypotheses.
Assessment of the Curriculum Students and faculty evaluated each of the six sessions and provided a final assessment at the end of AIME through questionnaires and informal discussions. Questions asked respondents to rate the effectiveness of the teaching methods to achieve the curricular objectives (4-point scale: 1 = very effective, 2 = somewhat effective, 3 = somewhat ineffective, 4 = very ineffective) and to assess the importance of teaching the targeted skills together (4-point scale: 1 = strongly agree, 2 = agree, 3 = disagree, 4 = strongly disagree). Open-ended questions asked for feedback regarding the most and least useful parts of the curriculum and suggestions for change.
Statistical Analyses We compared baseline characteristics of students using Student’s t-tests for continuous variables and chi-square analyses for categorical variables. We assessed differences in baseline selfrated proficiency in communication and clinical reasoning skills using the Wilcoxon rank-sum test. We used chi-square analyses to compare students’ baseline ability to document communication observations from the videotaped encounter. In the standardized patient encounters, we used four measures to assess communication skills, including a mean total interpersonal score for both cases, and three mean subscores reflecting elements of data gathering, establishing rapport, and patient education and counseling. We compared each of these scores using Student’s t-tests. We examined different aspects of clinical reasoning ability at baseline with the video assessment and after the course with the standardized patient exercise. These included the mean
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number of patient problems listed for both cases, the mean number of differential diagnoses generated for both cases, the mean number of supporting and refuting factors for each case’s correct diagnosis, and the Diagnostic Thinking Inventory scores. We evaluated differences in the mean number of patient problems listed, the mean number of differential diagnoses listed, and Diagnostic Thinking Inventory scores using Student’s t-tests. We used the Wilcoxon rank-sum test to assess differences in the mean number of supporting and refuting factors. We were particularly interested in the students’ ability to list psychosocial history items (including a patient’s concerns about their illness) as a measure of their ability to link the psychosocial aspects of communication skills with the biomedical aspects of clinical reasoning. We assessed the difference in the number of students listing one or more psychosocial history items on their problem lists using a chi-square analysis. For our analyses, we had 80% power to detect a difference of 0.22 in each of the four communication scale ratings (setting alpha at 0.05). We also had 80% power to detect a 1.2 difference in the mean total number of patient problems listed. All analyses were performed using Stata Statistical Software: Release 8.0 (Stata Corporation, College Station, Texas, 2002).
RESULTS Baseline Student Characteristics, Knowledge and Skills All 121 students randomized remained in their assigned group and 120 successfully completed the standardized patient exercise. At baseline, we found no differences in age, gender, college major or previous interviewing experience, but found a significant difference in previous medical training (see Table 3). With respect to self-rated proficiency in communication and clinical reasoning skills, AIME students were more likely to report familiarity with methods to develop a differential diagnosis
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before the curriculum (p=0.01). They did not differ from the non-AIME students in any other area of self-evaluation. For the baseline video assessment, we found no difference in the students’ ability to report on specific communication skills in data gathering and rapport building (Table 4). For clinical reasoning, 58% of students in each group listed pancreatitis as their top diagnosis. The groups had the same mean number of patient problems, differential diagnoses, and supporting and refuting factors for the diagnosis of pancreatitis (Table 4). The groups did not differ in their clinical reasoning ability as assessed by the Diagnostic Thinking Inventory.
Student Performance at the End of the Curricular Intervention For the standardized patient exercise, interpersonal score ratings were similar for AIME and non-AIME students (Table 5). In addition, each group obtained similar numbers of history items from the patients during the interviews (mean of 64.2% vs. 63.1%). Although communication skills did not differ significantly between groups, we observed a trend in the AIME students having an increased ability to establish and maintain rapport during a medical interview (p=0.08). For clinical reasoning, both groups listed a mean of 4 differential diagnoses. In the hyperthyroid case, 79% of AIME students listed the correct diagnosis as their top choice compared to 69% of non-AIME students (p=0.21). For the rheumatoid arthritis case, 92% of AIME students and 95% of non-AIME students listed rheumatoid arthritis as their top diagnosis (p=0.44). On average, each group generated two supporting factors and less than one refuting factor for the correct diagnosis (p=0.40). Differences were seen in the students’ ability to generate a problem list. AIME students had on average one more problem listed for each patient (mean 8.4 versus 7.5; p=0.05). In addition, their
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problem lists were more likely to contain elements of the history of present illness (mean 5.7 versus 4.8; p=0.01) and the psychosocial history (64% of AIME students listing one or more items vs. 44% of non-AIME students; p=0.03). We saw no difference between the groups in their Diagnostic Thinking Inventory scores.
Participant and Faculty Evaluation of the Curriculum At the end of AIME, 56 of 60 students provided feedback on the curriculum. Eighty-four percent reported that the curriculum was somewhat to very effective in teaching techniques to establish rapport, to elicit patient preferences and to develop problem lists and differential diagnoses. Ninetyfive percent of students found it beneficial to learn communication and clinical reasoning skills in an integrative fashion. Students rated self-reflection and observation as a highly effective learning strategy (98% of respondents). Seventy-five percent of students used approaches to the medical encounter taught in AIME during other patient interactions. Of those who had not used the approaches, 72% stated they did not have an opportunity to practice but hoped to use these skills in the future. Role-playing was felt to be the most useful part of the curriculum by 68% of students. Faculty felt strongly that role-play with time-outs allowed for meaningful discussion of communication and clinical reasoning [median of 1 (interquartile range (IQR) 1-2) with 1=strongly agree and 4=strongly disagree] and indicated that it was valuable to teach these skills together [median of 1 (IQR 1-2)]. Since teaching during role-play was a new technique for most facilitators, many felt that having additional instruction in this area would be beneficial. Half of the facilitators noted being more engaged in shared decision-making styles of communication with their own patients as a result of teaching in the curriculum.
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CONCLUSIONS We designed AIME to teach the integration of communication and clinical reasoning skills. We found that students who participated in the curriculum were better at integrating these skills during a medical encounter than those students who did not have the intervention. In particular, students were more likely to list elements of a patient’s psychosocial history on their problem lists, including a patient’s concerns about their illness. This suggests that AIME helped students understand the connection between biomedical and psychosocial aspects of patient care. We saw statistically significant differences in AIME students’ ability to integrate biomedical and psychosocial aspects of patient information during the standardized patient exercise. In communication skills, we saw a trend toward significance in AIME students’ ability to establish rapport with patients, which was an emphasis of our communication skills training. In clinical reasoning, AIME students listed more patient problems on their problem lists including more elements of the biomedical and psychosocial history. We did not see a difference between groups with respect to the number of diagnoses generated or in the Diagnostic Thinking Inventory scores. This most likely reflected the limited opportunities students had to practice generating hypotheses and to subsequently reflect on their thinking during patient encounters outside of AIME. In medical practice, good communication and clinical reasoning skills are important clinical competencies. However, research shows many physician inadequacies in these skills including incomplete solicitation of patient concerns24 and inconsistent exploration of psychosocial issues25. These practices can lead to inappropriate prioritization of problems, impaired clinical reasoning and poor therapeutic alliances with the potential for medical error and harm to patients. Providing medical students with the framework to integrate biomedical and psychosocial aspects of patient care early in their training may prevent these errors from occurring later in practice.
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A report summarizing the efforts to integrate basic sciences, clinical sciences and biopsychosocial medicine in the Robert Wood Johnson Foundation’s Program in Medical Education found that despite attempts at curriculum reform, “Basic science dominates; at best, biopsychosocial issues are treated as separate but equal—and often as separate and not equal.”26 This may lead students to perceive the psychosocial aspects of medicine as less important. We feel that by teaching the connection between communication skills and clinical reasoning through reflective learning in a patient-centered manner, students will understand the important relation between the biomedical and psychosocial aspects of patient care and value this approach to problem solving. This was supported by our formative curricular assessment that showed that both students and faculty appreciated the connection between the two skills and found importance in learning them together. Our work has several limitations. First, only two standardized patient interactions were used to evaluate differences between groups. Literature suggests that multiple stations of an objective structured clinical exam are needed to truly assess differences.27 Due to a limited number of cases, we may not have been able to detect all of the differences that may have existed between the two groups. In the future, we plan to use a more structured assessment to measure students’ acquisition of skills. Second, the structure of the standard Clinical Skills curriculum limits opportunities to interview patients on an individual basis until late in the second year. This restricted the students’ ability to practice techniques learned in AIME and may have limited our ability to show a difference in certain skills. We hope to incorporate AIME longitudinally into the Clinical Skills curriculum this upcoming year. With more practice, both communication and clinical reasoning scores might improve. Third, despite randomization, students assigned to the AIME curriculum reported more prior medical training and familiarity with techniques to generate differential diagnoses. We doubt that this played a role in the higher clinical reasoning scores we saw in the final assessment, because the baseline assessment of
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these skills did not differ between groups. Finally, since we intended to explore various domains of communication and clinical reasoning, we used multiple measures to determine differences in performance. Although we did not adjust our tests of statistical significance for multiple comparisons, the significant differences and the non-significant trends were consistently in the direction of improvement in skill acquisition with the curricular intervention. We believe that teaching students communication and clinical reasoning skills in a patientcentered manner using reflection and feedback promotes understanding the patient as a whole, allows individual thinking, and encourages collaborative learning among peers, skills that are important to future success in medical practice. With this innovative curriculum, we have shown that these closely related, yet often separately taught, skills can be integrated and are valued when learned together. The results of this study should help other educators develop curricula aimed at teaching the integration of these important clinical competencies. Future educational initiatives in all stages of training could lead to improved patient-physician interactions and positively impact satisfaction and health outcomes.
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REFERENCES 1. Association of American Medical Colleges (AAMC). Learning objectives for medical student education—guidelines for medical schools: report I of the medical school objectives project. January 1998; Available from: http://www.aamc.org/meded/msop/. Accessed March 28, 2003. 2. Liaison Committee on Medical Education (LCME). Functions and structures of a medical school: standards for accreditation of medical education programs leading to the M.D. degree. July 2003; Available from: http://www.lcme.org/. Accessed July 16, 2003. 3. Accreditation Council for Graduate Medical Education (ACGME). Outcome project: enhancing residency education through outcomes assessment. Available from: http//www.acgme.org/Outcome/. Accessed March 28, 2003. 4. Evans RJ, Stanley RO, Mestrovic R, Rose L. Effects of communication skills training on students’ diagnostic efficiency. Med Educ. 1991;25(6):517-26. 5. Roter D, Hall JA, Kern DE, Barker LR, Cole KA, Roca RP. Improving physicians’ interviewing skills and reducing patients’ emotional distress: A randomized clinical trial. Arch Intern Med. 1995 Sept 25;155(17):1877-84. 6. Little P, Everitt H, Williamson I, Warner G, Moore M, Gould C, Ferrier K, Payne S. Observational study of effect of patient centredness and positive approach on outcomes of general practice consultations. BMJ. 2001 Oct 20;323(7318):908-11. 7. Roter DL, Hall JA, Katz NR. Relations between physicians' behaviors and analogue patients' satisfaction, recall, and impressions. Med Care. 1987 May;25(5):437-51. 8. Mead N, Bower P. Patient-centred consultations and outcomes in primary care: a review of the literature. Patient Educ Couns. 2002 Sep;48(1):51-61.
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9. Kempainen RR, Migeon MB, Wolf FM. Understanding our mistakes: a primer on errors in clinical reasoning. Med Teach. 2003;25(2):177-81. 10. Weise J, Saint S, Tierney, Jr. LM. Using clinical reasoning to improve skills in oral case presentation. Seminars in Medical Practice. 2002 Sep;5(3):29-36. 11. Kern DE, Thomas PA, Howard DM, Bass EB. Curriculum development for medical education: a six-step approach. Baltimore: The Johns Hopkins University Press, 1998. 12. Bird J, Cohen-Cole SA. The three function model of the medical interview. Adv Psychosom Med. 1990;20:65-88. 13. Keller V, Carroll J. A new model for physician-patient communication. Patient Educ Couns. 1994;23:131-40. 14. Kurtz S, Silverman J. The Calgary-Cambridge Referenced Observation Guides: an aid to defining the curriculum and organizing the teaching in communication training programs. Med Educ. 1996;30:83-9. 15. Makoul G. “The SEGUE Framework for teaching and assessing communication skills.” Patient Educ Couns. 2001;(45):23-34. 16. Stewart M, Brown JB, Weston WW, McWhinney IR, McWilliam CL, Freeman TR. Patientcentered medicine: transforming the clinical method (patient-centered case series). Thousand Oaks: Sage, 1995. 17. Thomas RE. Teaching medicine with cases: student and teacher opinion. Med Educ. 1992;26:200-7. 18. Rogers JC, Swee DE, Ullian JA. Teaching medical decision making and students’ clinical problem solving skills. Med Teach. 1991;13(2):157-63.
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19. Menahem S, Paget N. Role play for the clinical tutor: towards problem-based learning. Med Teach. 1990;12(1):57-61. 20. Bayer Institute for Healthcare Communication. Available from: http://www.bayerinstitute.com. Accessed March 22, 2004. 21. Windish DM, Paulman PM, Goroll AH, Bass EB. Do clerkship directors think medical students are prepared for the clerkship years? Acad Med. 2004;79:56-61. 22. Kurtz SM, Silverman JD, Draper J. Teaching and learning communication skills in medicine. Oxford: Radcliffe Medical Press, 1998. 23. Bordage G, Grant J, Marsden P. Quantitative assessment of diagnostic ability. Med Educ. 1990; 24(5):413-25. 24. Marvel MK, Epstein RM, Flowers K, Beckman HB. Soliciting patient’s agenda: have we improved? JAMA. 1999 Jan 20;281(3):283-7. 25. Levinson W, Roter D. Physicians’ psychosocial beliefs correlate with their patient communication skills. J General Intern Med. 1995 Jul;10(7):375-9. 26. Schmidt H. Integrating the teaching of basic sciences, clinical sciences, and biopsychosocial issues. Acad Med. 1998 Sep;73(9 Suppl):S24-31. 27. Norcini J, Boulet J. Methodological issues in the use of standardized patients for assessment. Teach Learn Med. 2003 Fall;15(4):293-7.
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Figure 1. Communication Skills Observation Guide Used During Role-play Encounters Student instructions: As you observe the clinical encounter, think about how the “physician” moves through the various stages of the medical interview. The following questions serve as guide as to what you should try to observe. List examples of questions, comments or behaviors that you notice. If you have any helpful suggestions for the “physician”, write down your suggestions for feedback.
Stage of Medical Interview Initiating the session
Examples or Suggestions
1. Does the physician greet the patient? 2. Does the physician’s opening question encourage the patient express all of their concerns?
Gathering information 1. Does the physician encourage the patient to tell his/her story in own words? 2. Does the physician use leading questions? Do they occur as a “string of questions”? 3. Does the physician use medical jargon? (orthopnea vs. shortness of breath with lying down) 4. Does the physician use summary statements to check understanding of patient’s story? 5. Does the physician explore the patient’s social history?
Building the relationship 1. How does the physician show empathy? 2. What behaviors does the physician display that suggest he/she is listening to the patient? 3. How does the physician explore verbal and non-verbal cues? 4. How does the physician handle sensitive and potentially embarrassing information?
*Adapted from The Calgary Cambridge Guide to the Medical Interview. Kurtz SM, Silverman JD, Draper J (1998). Teaching and Learning Communication Skills in Medicine. Radcliffe Medical Press (Oxford).
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Figure 2. Sample Time-Out Using a Six-Step Iterative Reflective Process to Integrate Communication and Clinical Reasoning Skills The Interview Patient:..and that’s when I decided it was time to see a doctor. Student Interviewer (Paul S.): Can I call a time-out? Facilitator: Sure. Why did you want to stop? Student Interviewer: I didn’t know what to ask next. Step 1: Self-reflection on interviewing skills Facilitator to Student Interviewer: Paul, what do you think you did well during the interview? Student Interviewer: I think I did a good job establishing rapport with the patient. Facilitator: What didn’t go so well? Student Interviewer: Well, although I started the interview by asking some open-ended questions, I used a lot of close-ended questions. I didn’t get a lot of information that way.
Review of communication skill observations
Step 2: Giving and receiving feedback on communication style Facilitator to Observer 1: How do you think Paul did in establishing rapport? Observer 1: I liked how he started off the interview with some small talk about the weather. This seemed to put the patient at ease. He also let the patient talk without interruptions. Facilitator to Observer 1: Do you have any suggestions for change? Observer 1: No. I think he opened the interview well. Facilitator to Observer 2: How did Paul do in gathering information? Observer 2: He started off with open-ended questions but did go to close-ended questions rather quickly. The patient seemed a bit annoyed with that type of questioning. Facilitator to Observer 2: Any suggestions for change? Observer 2: Just consider adding one more open-ended question in the beginning of the interview. Facilitator: Thanks. Paul I think you did a really nice job. Your body language showed you were engaged and the patient responded to your calm voice. One thing to think about is summarizing what you heard to the patient. This will tell the patient you were listening, and will allow you time to regroup your thoughts. Step 3: Brainstorming techniques to overcome communication challenges Facilitator: Were there any communication challenges that came up during the interview? Observer 2: The patient seemed to shy away from questions around her social history. So I’m not sure we know everything about her from that perspective. Facilitator: Are there ways you could you find out this information that might allow the patient to feel more comfortable answering these types of questions? Observer 2: Well, you could start by saying, “I need to ask some potentially sensitive questions. I ask these questions to everyone because they may play a role in the problems you are having.” Facilitator: Good.
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Figure 2. Sample Time-Out Using a Six-Step Iterative Reflective Process to Integrate Communication and Clinical Reasoning Skills (Continued)
Using communication to inform clinical reasoning
Generating hypotheses based on pathophysiology and epidemiology
Using clinical reasoning to inform communication skills
Step 4: Generation of a problem list and differential diagnosis Facilitator: What types of problems should we add to our problem list? Student Interviewer: Fever, chills, cough. Observer 1: Smoking. Observer 2: Family history of lung cancer. Observer 1: Concern about pneumonia. Facilitator: Anything else? (pause) Ok, I think that was it. Paul, were you entertaining any diagnoses when you were interviewing? Student Interviewer: Well, when she said her father died of lung cancer, I wondered if she might have lung cancer as well. Also, she mentioned a concern about pneumonia, and given her fever and cough, pneumonia is a possibility. Facilitator: Ok, let’s put those up on the board. Using our mnemonic VINDICATE and our organ systems approach, is there anything else people were considering? Observer 2: I think she has cancer. Facilitator: Why do you think that? Observer 2: Well, she’s a smoker and her father died of cancer. Step 5: Identifying diagnoses that require more data to support or refute hypotheses Facilitator: Do you think you have enough information about the diagnoses you are entertaining? Observer 2: No. I think we need to ask more review of systems questions. I want to know if she’s lost weight, if she has night sweats, etcetera. Observer 1: I’m wondering if we need to know more about her social history first. We know she smokes, but we don’t know about drug use or alcohol use. Observer 3: I wonder if she’s traveled out of the country recently. That would helpful to know. Step 6: Organizing thoughts and identifying a new direction for the interview Facilitator: Does anyone have any suggestions of where to go next in the interview? Observer 2: I want to find out more about her family history. She said her father died recently, so I know this might be a sensitive area, but I think we need to know more about that. Observer 1: I want to know more about her work. She mentioned things were not good lately. Maybe there is something going on there that might help us with our diagnosis. Student Interviewer: Also ask about drug history and sexual history. Facilitator: Ok. Sandy, you’re up. You’ve heard some suggestions from the others about where to go next in the interview. Go ahead when you’re ready. End of Time Out
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Table able 1. Reports of Formal Training in Communication and Clinical Reasoning Skills and the Level of Student Preparedness for the Clerkships as Assessed by 96 Clerkship Students and Six Clerkship Directors Before the Curriculum Intervention. Clerkship Students Reporting They Had Formal Training*
Clerkship Faculty Reporting They Provide Formal Training*
Clerkship Students Reporting They Are Less Prepared In Skills†
Clerkship Faculty Reporting Students Are Less Prepared ‡ In Skills
92
33
11
80
88
40
41
80
89
50
32
100
70
66
53
60
Clinical Reasoning Skills, % Creating a problem list
96
100
55
0
Developing differential diagnoses
81
66
68
17
Using methods to develop a differential diagnosis (e.g., mnemonics)
81
NR§
73
NR§
Communication Skills, % Using verbal and nonverbal cues during an encounter to demonstrate listening Eliciting patients’ concerns, beliefs and expectations of their health/illness Encourage questions from patients regarding their health and illness Eliciting patient preferences for their role in decision-making
*Formal training is defined as using handouts, lectures, small group discussion, standardized patients, or real patients in instruction. Students reported whether they received formal training in any part of medical school and clerkship directors indicated whether they provided formal training in their clerkship. †“Less Prepared” was any student self-rating of “no exposure”, “familiar with concept”, or “can perform skill somewhat”. ‡Faculty rated students as “less prepared”, “at the level they should be” or “more prepared” in skills. §Not rated by the clerkship directors.
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Table 2. AIME: An Integrated Medical Encounter Curriculum Overview Session Learning Objectives Introduction to Communication skills
• Identify strategies that facilitate history-taking. • Identify barriers to history-taking. • Identify three functions of the medical interview: establishing rapport, data gathering and patient education/counseling. • Identify effective communication techniques for rapport building and data gathering. • Demonstrate analyzing communication behaviors and giving constructive peer feedback.
Introduction to Clinical Reasoning
• Create a problem list for a patient. • Demonstrate elements of clinical reasoning through the construction of a differential diagnosis using an organ systems based approach and categories of medical disease through a mnemonic VINDICATE.
Introduction to the Psychosocial History and Cultural Competence
• Identify components of the psychosocial history. • Demonstrate awareness of how socio-cultural factors impact patients, physicians, and clinical encounters. • Integrate psychosocial history taking with clinical reasoning/ problem solving.
Integrating Communication Skills and Clinical Reasoning
• Demonstrate integration of communication skills and clinical reasoning during history-taking. • Demonstrate skills to elicit and provide feedback with respect to interviewing. • Utilize knowledge of epidemiology and pathophysiology of disease to rank order a differential diagnosis.
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Educational Methods
Skill Areas Addressed
• Self-reflection • Didactic • Videotape review poor rapport building and data gathering • Case-based questions Role-play: low back pain in a patient concerned about cancer • Self-reflection • Didactic • Videotape review of a clinician’s thoughts during a medical interview • Case-based questions Role-play: cellulitis in a diabetic patient
Communication Skills • Data gathering • Rapport building/partnership
• Self-reflection • Didactic • Videotape review of a cross-cultural, crossgender sexual history • Role-play: hypertensive, diabetic patient with medical non-adherence • Self-reflection • Standardized patient interview: acute onset of HIV in a person with recent IV drug use
Communication skills • Data gathering • Rapport building/partnership • Patient education and counseling Clinical reasoning • Problem list generation
Communication Skills • Data gathering • Rapport building/partnership Clinical Reasoning • Problem list generation • Hypothesis generation
Communication skills • Data gathering • Rapport building/partnership • Patient education and counseling Clinical reasoning • Problem list generation • Hypothesis generation
Table 2. AIME: An Integrated Medical Encounter Curriculum Overview (continued) Session Learning Objectives Educational Methods Reasoning Through A Differential Diagnosis
• Define and practice using pretest probability using researched knowledge of epidemiology and pathophyisiology. • Re-rank differential diagnoses using supportive data. • Select appropriate diagnostic studies. • Present sensitive information to a patient.
• • • •
Introduction to Shared Decision Making
• Identify principles of and rationale behind shared decision making. • Demonstrate phrases that can promote shared decision-making.
• • • •
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Self-reflection Didactic Case-based questions Role-play: presenting an HIV positive test result to a patient
Self-reflection Didactic Case-based questions Videotape review of a failure to elicit patient preferences for care • Role-play: subacute headache in a patient concerned about having a brain tumor
Skill Areas Addressed Communication skills • Patient education and counseling Clinical reasoning • Hypothesis generation • Diagnostic test selection Communication Skills • Data gathering • Rapport building/ partnership • Patient education and counseling Clinical reasoning • Problem list generation • Hypothesis generation
Table 3. Communication Skills Items As Rated by the Standardized Patients.
*
Data Gathering 1. Information elicited in an organized manner 2. Asks clear, unambiguous questions 3. Uses vocabulary at the level of patient understanding 4. Listens carefully without interruptions, allowing sufficient time for a response 5. Uses restatement, reflection and clarification to verify information and indicate active listening Establishing Rapport 1. Demonstrates respect by avoiding critical or judgmental comments or expressions 2. Greets patient warmly 3. Demonstrates courteous and professional behavior 4. Treats patient on the same level without patronizing 5. Conveys a sensitive and caring attitude 6. Demonstrates interest in the patient 7. Demonstrates respect for privacy and confidentiality 8. Makes comfortable eye contact 9. Displays a range of facial expressions that are consistent with the content of speech 10. Displays an open, receptive, interested posture 11. Demonstrates respect for personal space Patient Education and Counseling 1. Uses clear, organized explanations 2. Provides enough information to answer questions 3. Encourages questions 4. Discusses options and helps patient decide what to do 5. Encourages patient to give opinions about treatment plans† *Rated on a five-point scale of: 1=poor, 2=adequate, 3=good, 4=very good, 5=excellent, unless otherwise indicated. † Rated on a five-point scale: 1=strongly disagree, 2=disagree, 3=neutral, 4=agree, 5=strongly agree.
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Table 4. Baseline Student Characteristics, Self-rated Proficiency, and Application of Communication and Clinical Reasoning Skills.
Baseline Characteristics Age Male gender, % College major, % Science Non-science Both Previous interviewing experience, % Previous medical training, %† Self-rated proficiency of skills, median (IQR)‡ Communication Skills Using verbal and nonverbal cues Encouraging questions from patients regarding health/illness Eliciting patients’ beliefs about health or illness Eliciting patients’ expectations for tests or treatment Clinical Reasoning Skills Creating a problem list Using methods to develop a differential diagnosis§ Narrowing differential diagnoses based on information gathered Video Viewing of a Clinical Encounter Recognition of Physician Communication Behavior, % Data Gathering Agenda setting Interrupting the patient Use of medical jargon Eliciting beliefs about illness Establishing Rapport Appropriate eye contact Expression of empathy Patient Education and Counseling
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AIME Students (n=59)*
Non-AIME Students (n=60)*
24.4 years 50.8
24.1 years 50.0
66.1 11.9 22.0 66.1 33.9
76.7 13.3 10.0 48.3 16.7
4 (3-4) 3 (3-4)
4 (3-4) 3 (3-3)
3 (2-3) 2 (2-3)
2.5 (2-3) 2 (2-3)
2 (1-3) 2 (2-3) 2 (2-3)
2 (1-3) 2 (1-2) 2 (2-2)
27.6 37.9 8.6 36.2
35.0 41.6 11.7 35.0
87.9 72.4 NR¶
88.3 76.7 NR¶
Table 4. Baseline Student Characteristics, Self-rated Proficiency, and Application of Communication and Clinical Reasoning Skills (Continued) AIME Students (n=59)*
Non-AIME Students (n=60)*
Video Viewing of a Clinical Encounter Clinical Reasoning Skills, mean (SD) Problem List Problems listed History of present illness items Psychosocial history items Differential Diagnoses Diagnoses listed Supporting factors for the correct diagnosis Refuting factors for the correct diagnosis
5.9 (1.2) 2.4 (0.8) 2.6 (0.7)
5.8 (1.1) 2.3 (0.8) 2.6 (0.6)
4.4 (1.1) 2.1 (1.7) 0.15 (0.44)
4.3 (1.0) 1.8 (0.8) 0.06 (0.24)
Diagnostic Thinking Inventory, mean (SD) Total score Flexibility in thinking Structure in memory
149.3 (15.5) 78.6 (8.2) 70.7 (9.1)
145.3 (14.8) 77.2 (9.0) 68.1 (8.0)
* Data available for 119 of 121 students. † p=0.04 by chi-square analysis. ‡ Median and interquartile range (IQR) for ratings of proficiency: 0=no exposure, 1=familiar with concept, 2=can perform skill somewhat, 3=can perform skill well, 4=can teach to other students. § p=0.01 by Wilcoxon rank-sum test. ¶ Not rated.
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Table 5. Comparison of Communication and Clinical Reasoning Skills Using Standardized Patient Encounters with Students Who Did and Did Not Receive the AIME (An Integrated Medical Encounter) Curriculum.
Communication Skills Interpersonal Score Ratings† Overall interpersonal score Data gathering Establishing rapport Patient education and counseling Clinical Reasoning Skills Problem List Problems listed History of present illness items Psychosocial history items Differential Diagnoses Diagnoses listed Supporting factors for the correct diagnosis Refuting factors for the correct diagnosis Diagnostic Thinking Inventory Overall score Flexibility in thinking Structure in memory
AIME Students mean, (SD)
Non-AIME Students mean, (SD)
P-value*
3.74 (0.40) 3.73 (0.50) 4.11 (0.49) 3.06 (0.64)
3.63 (0.47) 3.64 (0.44) 3.95 (0.51) 3.00 (0.73)
0.17 0.33 0.08 0.62
8.4 (2.3) 5.7 (1.6) 0.37 (0.40)
7.5 (2.3) 4.8 (1.7) 0.17 (0.24)
0.05 0.01 0.002
4.1 (1.2) 2.2 (0.7) 0.36 (0.45)
3.9 (1.0) 2.0 (0.9) 0.44 (0.40)
0.30 0.36 0.41
151.9 (18.7) 78.9 (9.7) 72.9 (9.1)
150.0 (18.5) 77.4 (9.0) 72.6 (8.0)
0.60 0.42 0.86
* All comparisons were made using t-tests except for comparisons of psychosocial history items and supporting and refuting factors for the correct diagnosis. These comparisons were made using the Wilcoxon rank-sum test. † Interpersonal Score Ratings scale: 1=poor, 2=adequate, 3=good, 4=very good, 5=excellent.
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