Carolina at Chapel Hill, Chapel Hill, North Carolina. Supported by grants from the ...... In: Wadsworth M, Robinson D (eds). Studies in everyday medical life.
Teaching the Medical Interview: An Intervention Study SAMUEL M. PUTNAM, MD,* WILLIAM B. STILES, PhD,# MARY CASEY !ACOB, BA,~" SHERMAN A. IAMES, PhD§ TO study the effects of teaching specific interviewing techn / q u e s on verbal behaviors a n d on he~/th outcomes, intern a l medicine residents wor~fng in a screening clinic were assigned to either an exper/mental or a control group. The ent/re clin/c visit w a s audiotaped, transcr/bed, a n d coded according to the Verbal Response/~fede (VRM) system. Res/dents in tile experimental group were taught interv/ewing b e h a v i o r s / p a t i e n t exposition a n d physician explanation) that h a d b e e n found in prev/ous studies to be associated with patient outcomes. Through telephone interviews, patient sat/s/action, compfiance, a n d symptom status were det e r m / n e d for a//patients. Two h u n d r e d a n d sixty-eight interv/ews (156 in the experimental group a n d 112 in the control group) were included in the study. TrQ'ining d/d increase patient exposition and pbysiciun explanation, but did not aHect health outcomes. Residents" attitudes and behaviors during the training are described. Key words: heolth outcomes; medical interviewing; p a t i e n t - p h y s i c i a n relationships; resident education. J GEN INTERN MED 1988;3:38-47.
MANY MEDICAL EDUCATORS a r e i n t e r e s t e d in shifting
t h e e m p h a s i s in r e s i d e n c y t r a i n i n g f r o m a m e c h a n i s tic v i e w of m e d i c i n e w h e r e the p h y s i c i a n is intere s t e d o n l y in p a t h o l o g i c c h a n g e s in tissues to a biop s y c h o s o c i a l v i e w w h e r e the p h y s i c i a n c o n s i d e r s the p a t i e n t s ' u n d e r s t a n d i n g of their illnesses. ~-s T h e b i o p s y c h o s o c i a l v i e w is m o r e p a t i e n t - c e n t e r e d b e c a u s e it e m p h a s i z e s a n o p e n a n d t h o r o u g h e x c h a n g e of i n f o r m a t i o n ( s u b j e c t i v e a s well a s o b j e c tive) b e t w e e n p a t i e n t a n d p h y s i c i a n within t h e m e d i c a l interview. In p r e v i o u s studies, t w o c e n t r a l c o m p o n e n t s of this i n f o r m a t i o n e x c h a n g e w e r e d e fined a n d r e l a t e d to p a t i e n t satisfaction, c o m p l i a n c e , s y m p t o m relief, a n d h y p e r t e n s i v e s ' b l o o d p r e s s u r e control. 4-s W e h a v e c a l l e d t h e s e t w o c o m p o n e n t s patient exposition--patients t a l k i n g a b o u t their c o n c e r n s u s i n g their o w n w o r d s , r a t h e r t h a n g i v i n g " y e s " or "no" a n s w e r s n a n d physician explanation--giving p a t i e n t s o b j e c t i v e m e d i c a l information, in a d d i t i o n to instructions a n d a d v i c e . 4' s
*Department of Medicine. St. Mary's Hospital, Rochester, New York. tDepartment of Psychology,Miami University, Oxford, Ohio. tPsychology Service (116B), Veterans Administration Medical Center, New Haven,Connecticut. §Departmentsof Epidemiologyand psychology,University of North Carolinaat ChapelHill, Chapel Hill, North Carolina. Supported by grants from the National Center for Health Services Research(HS 03040) and the Zlinkhoff Foundation. Address correspondenceand reprint requests to Dr. Putnam: Department of Medicine,St. Mary's Hospital,89 GeneseeStreet, Rochester, NY 14611.
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P r e v i o u s i n v e s t i g a t o r s h a v e r e p o r t e d t h a t training c a n c h a n g e i n t e r v i e w i n g b e h a v i o r s . 9 In o n e study, t r a i n i n g a l s o a f f e c t e d the o u t c o m e of m e d i c a l c a r e . G o l d b e r g et al. s h o w e d t h a t f a m i l y m e d i c i n e r e s i d e n t s g i v e n s p e c i a l t r a i n i n g in i n t e r v i e w i n g imp r o v e d their ability to d e t e c t p s y c h i a t r i c illnesses a m o n g their patients.I° O n t h e o t h e r h a n d , B e n s i n g a n d Sluijs, w h o t r a i n e d six g e n e r a l p r a c t i t i o n e r s in the N e t h e r l a n d s to c r e a t e " o p t i m a l c o n d i t i o n s for the p a t i e n t to e x p r e s s p o s s i b l e p s y c h o s o c i a l p r o b l e m s . . ." (p. 737), w e r e u n a b l e to s h o w a n i m p a c t o n the o u t c o m e of care.~ ~T h e p h y s i c i a n s ' i n t e r v i e w ing b e h a v i o r s did c h a n g e in the d i r e c t i o n s p r e dicted; p h y s i c i a n s w e r e m o r e i n f o r m a t i v e , m o r e e m pathic, a n d l e s s directive. H o w e v e r , t h e r e w a s n o c h a n g e in the a m o u n t of d i a l o g a b o u t p s y c h o s o c i a l issues. M o r e recently, G r e e n f i e l d a n d K a p l a n s h o w e d t h a t p a t i e n t s w h o w e r e t r a i n e d to a s k m o r e q u e s t i o n s a b o u t their i l l n e s s e s h a d b e t t e r o u t c o m e s t h a n u n t r a i n e d p a t i e n t s . 1~ W e w e r e i n t e r e s t e d in c o n d u c t i n g a n i n t e r v e n tion s t u d y to d e t e r m i n e w h e t h e r or not c h a n g i n g the physician's interviewing behaviors would change p a t i e n t o u t c o m e s . Below, w e r e p o r t the results of a t r a i n i n g p r o g r a m for r e s i d e n t s in i n t e r n a l m e d i c i n e d e s i g n e d to e n c o u r a g e p a t i e n t e x p o s i t i o n in the first p a r t of the i n t e r v i e w a n d p h y s i c i a n e x p l a n a t i o n a t t h e e n d of the interview. O u r h y p o t h e s e s w e r e :
1. The training would c h a n g e residents' interviewing behaviors. Specifically, it would increase the frequency of patient exposition in the history segment of the interview a n d the proportion of physician explanation in the conclusion segment. We chose the frequency of patient exposition as the important b e h a v ior b e c a u s e a previous study h a d shown that patient satisfaction w a s correlated with the Irequencybut not the percentage of patient exposition behaviors. 4 In the s a m e study, w e found that beth the p e r c e n t a g e a n d the frequency of physician explanation were correlated with patient satisfaction, but b e c a u s e the association w a s stronger for the p e r c e n t a g e of physician explanation, we chose it a s the important behavior for this study.
2. I n c o m p a r i s o n w i t h p a t i e n t s s e e n b e f o r e t r a i n i n g and in comparison with patients seen by untrained
residents, the patients seen by the residents after their training would a) be more satisfied with the visits, b) be more compliant with the prescribed medical regimens, a n d c) experience greater improvements in symptom status.
JOURNALOFGENERALINTERNALMEDICINE, Volume3 (Jan~Feb), 1988
METHODS Subjects PHYSICIANS
In their second y e a r of training, medical residents at North Carolina Memorial Hospital s p e n d at least two five-week rotations in the medical walk-in clinic. There are four or five residents in e a c h rotation. Residents who h a d rotations b e t w e e n July a n d December 1981 were a s k e d to participatein a study about " p a t i e n t - p h y s i c i a n relationships," which would require that their interviews with study patients be tape-recorded. No other details about the purpose of the study were given, but the experimental groups were told that they would receive a training program h a l f w a y through their rotations. All residents a g r e e d to participate. Because the study required extra time for the training sessions, residents were given $50 worth of books a n d journals in recompense. The months of July, September, a n d November were arbitrarily selected for training. During this time, nine male a n d two female residents, with a m e a n a g e of 28 years, worked in the clinic. During the months of August, October, a n d December, seven male residents a n d one female resident, with a m e a n a g e of 27 years, worked in the clinic a n d received no training. Three of the trained residents h a d a repeat rotation during these months a n d their patient interviews were recorded a g a i n in order to obtain more follow-up data. The residents in the experimental groups were told not to s a y a n y t h i n g about their training, to avoid "contaminating" the interviews of the residents in the control groups. After the study, the residents in the control groups were offered the training. PATIENTS
Patients coming to the walk-in clinic a r e s e e n on a n unscheduled basis for medical problems that a r e not serious e n o u g h to w a r r a n t attention in the emerg e n c y room. Over the six-month period of the study, r e s e a r c h assistants dressed in street clothes went to the clinic practically every day, in both the morning a n d the afternoon, to recruit patients for the study. With the help of the nursing staff a n d c a s u a l conversation with the patients, the assistants s c r e e n e d almost 1,400 patients a n d selected 906 who m e t the following criteria: 1) they were literate, 2) they h a d a h o m e telephone, 3) t h e y h a d not seen the physician they were scheduled to see before, a n d 4) they h a d not previously participated in the study. The patients were a s k e d to participate in a study d e s i g n e d to "improve the quality of patient care in the clinic." They were told that their entire interview with the physician would be tape-recorded, that they would
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complete questionnaires about their illnesses before a n d after the interview, a n d that they would be called at h o m e to a n s w e r more questions. They were a s s u r e d that refusal would not affect their medical care a n d that their doctor would not see their questionnaire responses. Four h u n d r e d a n d eighty patients a g r e e d to participate. Eighty-three patients were found upon closer questioning to be ineligible. Sixty-two interviews were incompletely recorded, either b e c a u s e the physician forgot to turn the recorder back on w h e n s / h e interrupted the e x a m i n a tion to go out of the room, or b e c a u s e s / h e deliberately turned off the recorder to preserve patient confidentiality. Thirty-seven (37) tapes w e r e inaudible. Follow-up d a t a were not obtained for 30 patients b e c a u s e the patients left the clinic before completing the questionnaire or could not be r e a c h e d by telephone for the follow-up interview. Thus, 268 patients, or 56% of the original 480, were included in the final study. In order to c o m p e n s a t e them for the extra time spent in the clinic, the patients' parking fees were paid. Characteristics of patients in e a c h group a r e shown in Table 1.
Procedures AUDIOTAPING
For the residents in the experimental group, at least three baseline interviews per resident were tape-recorded before training b e g a n . The ~ape-recording of interviews b e g a n a g a i n almost immediately after training h a d started a n d continued through the rest of the rotation. For the residents in the control group, interviews were recorded throughout the rotation. Numbers of patients -whose interviews w e r e recorded in e a c h group a r e shown in Table 1. The entire clinic visit w a s recorded on audiotape, using microphones a t t a c h e d to the walls a n d a tape recorder placed out of sight. Before a n d after the interview, the patient filled out questionnaires that took about 15 minutes e a c h to complete. TI~IIVING
The trainer (the first author) w a s a n internist a n d m e m b e r of the Department of Medicine whose major r e s e a r c h a n d clinical interest over the previous ten y e a r s h a d b e e n in medical interviewing a n d related skills. Training consisted of one or two group sessions followed by five or six individual sessions reviewing audiotapes with the trainer. Training time for e a c h resident a v e r a g e d 3.7 hours, of which 62% (2.3 hours) w a s spent in individual sessions. In addition, e a c h resident w a s given a short m a n u a l (copies available from the first author) that described a n d g a v e examples of patient exposition a n d physician
explanation. In the group sessions, the trainer stressed active listening (encouraging exposition) a n d giving thor-
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Putnam et al., TEACHINGTHE MEDICALINTERVIEW TABLE 1 Sample Characteristics* Control Residents
Trained Residents Before Training Residents Female Age (mean) Interviews/resident (mean)
n=11
Patients Female Age (mean) Education (mean) White Chronic illness Symptom status
n = 54 67.7% 34.4 years 12.1 years 39.4% 21.1% 2.8
2 28 years 4.9
After Training n=
11 2 28 years 7.5
n = 102 67.0% 32.0 years 11.5 years 31.7% 27.5% 3.0
First Half Month
Second Half Month
n--8 1 27 years 6.9
n = 8
n = 55 66,4% 31.6 years 12.0 years 54.3% 37.8% 3.0
1 27 years 7.1 n = 57 65.5% 32.6 years 11.7 years 51.0% 26.5% 3.0
*The mean of each patient characteristic was calculated for each physician in each group. The figures are the averages of these means for all the residents in each group. The F statistic was not significant at p
