ORIGINAL ARTICLE
Medical students’ agenda-setting abilities during medical interviews 1
2
3
3
4
HyeRin Roh , Kyung Hye Park , Young-Jee Jeon , Seung Guk Park and Jungsun Lee
Departments of 1Medical Education, 2Emergency Medicine, 3Family Medicine, and 4Surgery, Inje University College of Medicine, Busan, Korea
Purpose: Identifying patients’ agendas is important; however, the extent of Korean medical students’ agenda-setting abilities is unknown. The study aim was to investigate the patterns of Korean medical students’ agenda solicitation. Methods: A total of 94 third-year medical students participated. One scenario involving a female patient with abdominal pain was created. Students were video-recorded as they interviewed the patient. To analyze whether students identify patients’ reasons for visiting, a checklist was developed based on a modified version of the Calgary-Cambridge Guide to the Medical Interview: Communication Process checklist. The duration of the patient’s initial statement of concerns was measured in seconds. The total number of patient concerns expressed before interruption and the types of interruption effected by the medical students were determined. Results: The medical students did not explore the patients’ concerns and did not negotiate an agenda. Interruption of the patient’s opening statement occurred in 4.62±2.20 seconds. The most common type of initial interruption was a recompleter (79.8%). Closed-ended questions were the most common question type in the second and third interruptions. Conclusion: Agenda setting should be emphasized in the communication skills curriculum of medical students. The Korean Clinical Skills Exam must assess medical students’ ability to set an agenda. Key Words: Communication skills, Standardized patient, Objective structured clinical examination, Undergraduate, Medicine
concerns, and negotiate an agenda in order to enable the
INTRODUCTION
identification of reasons for the patient’s visit to the doctor [2]. Setting an agenda while applying attentive
Agenda setting can be defined as the reaching of a
listening may decrease concerns that could emerge later,
mutual agreement by a patient and doctor regarding what
ensure efficient time management, and minimize the
to discuss during the consultation. Upfront agenda sett-
risks of important problems being missed [1,3]. Agenda
ing is one of the most important factors in the effective
setting should be performed before focusing on a
management of clinical encounters [1]. Doctors are
specific agenda [4].
required to listen attentively, survey all the patient’s
Received: January 30, 2015 • Revised: April 2, 2015 • Accepted: April 13, 2015 Corresponding Author: Kyung Hye Park (http://orcid.org/0000-0002-5901-6088) Department of Emergency Medicine, Inje University College of Medicine, 75 Bokji-ro, Busanjin-gu, Busan 614-735, Korea Tel: +82.51.797.0172 Fax: +82.51.893.9600 email:
[email protected]
The listening skills that should be used in the initial
Korean J Med Educ 2015 Jun; 27(2): 77-86. http://dx.doi.org/10.3946/kjme.2015.27.2.77 eISSN: 2005-7288 Ⓒ The Korean Society of Medical Education. All rights reserved. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
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HyeRin Roh, et al : Agenda setting ability in medical students
stages of a consultation differ significantly from those
Training in communication skills should be persis-
used to gather information. When taking patient history,
tently implemented from undergraduate and extend
facilitation using repetition (repeating the patient’s sen-
throughout the physician’s professional life. To teach
tence), paraphrasing (expressing the patient’s statements
agenda setting, educators should know the students’ skill
in a different way), and interpretation (presenting the
levels (good/poor) across this area of communication.
meaning of what the patient is saying) constitute effec-
However, few studies have reported medical students’
tive listening skills [2]. In contrast, when setting an
abilities regarding agenda setting. In addition, previous
agenda, those techniques, as well as closed questions,
research has not focused on specific agenda-setting
non-interrogative verbal responses, and comments aimed
skills in detail. Furthermore, no research has been con-
at encouraging a patient to speak about a certain topic,
ducted on either the mean time that medical students
constitute interruption when patients are stating their
allocate to patients to complete their opening statements
concerns [4].
or the patterns of interruption by medical students in
Generally, patients have between one and six concerns
patients’ completion attempts.
per visit [1,5], and the first stated concern is not always
Therefore, medical students’ agenda solicitation pa-
the patient’s principal concern [6]. Patients primarily
tterns were investigated using the following research
complete their statements of concern within 60 seconds
questions: (1) How many medical students explore
[4]; therefore, during the initial phase of the interview,
patient concerns and negotiate an agenda? (2) How long
which typically takes 1 minute, it is recommended that
do the students listen attentively at the beginning of the
the doctor postpone diagnostic questioning in favor of
encounter? (3) What type of responses do the students
questions that facilitate open-ended responses and
give after the patient’s initial statement of concern?
repeated prompts to assist the patient in identifying more concerns [1,7]. However, incomplete interviews are common in the
SUBJECTS AND METHODS
medical field [6]. Patients finish their initial opening statement of concern in only 23% to 28% of medical visits [3,4]. The mean time within which doctors allow
1. Participants
patients to complete their opening statements is appro-
The agenda-setting skills of medical students at Inje
ximately 18 to 23 seconds. The most common obstacles
University College of Medicine (Korea) were examined
to statement completion include closed-ended questions,
during the first college semester in 2012. Ninety-five
absence of solicitation (i.e., not asking further about
students in their third year were included. Our medical
patients’ concerns), and the physician’s statements (i.e.,
school has a four-year curriculum for medical degrees.
physicians’ interruption of patient statements and redi-
This comprises 2 years of the preclinical course and 2
rection of patients toward the doctor’s concerns) [3].
years of clinical clerkships. A formal communication
Most redirections (54% to 76%) occur after the first
program for first-year students has been in existence
concern has been stated [3]. The likelihood of returning
since 2012; this means that the students in this study did
to the agenda completion is very low once the focus of
not practice communication under a formal course.
the discussion is on a specific concern [3].
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Korean J Med Educ 2015 Jun; 27(2): 77-86.
Third-year medical students were chosen for two
HyeRin Roh, et al : Agenda setting ability in medical students
reasons. First, there was concern that final-year students
A family medicine doctor was the primary case writer.
are too familiar with the format of the Clinical Skills
He wrote the roles for the standardized patient based on
Examination in the Korean Medical Licensing Exam. It
his experiences with common medical complaints. Two
was assumed that they would be more likely to display
communication skills educators and one standardized
only the behaviors that are evaluated in the exam, even
patient trainer reviewed the script.
though they knew the importance of agenda setting.
Before the video recording, informed consent was
Second, the ability of first- and second-year students to
obtained from both the medical students and the stan-
control the interviews is less likely to be well developed
dardized patients. The medical students were informed
[8]. These students may not have sufficient clinical
that the purpose of the exercise was to assess their
reasoning ability to see a patient within 15 minutes.
communication skills. We obtained approval to under-
Of the 95 medical students who participated in this investigation, one was omitted from analysis due to a missing file. Therefore, the final sample size was 94, comprising 68 male and 26 female students. The average age was 24.40 years (±2.12). There was no age difference between the male and female groups.
2. Standardized patient case development The station is a 15-minute interaction with a 32-yearold woman with abdominal pain. The medical students’ task was to build initial rapport, solicit an agenda, take relevant histories, and perform focused physical examinations.
take this study from the Institutional Review Board Committee of Inje University in Busan, Korea.
3. Data collection and analysis Medical students were video-recorded while interviewing a standardized patient. The segment of the encounter in the current study focused on the solicitation of the chief complaints and current concerns. The identity of the students and interview order were hidden from raters to prevent the halo effect. 1) Evaluation of the tasks for the initiation of the discussion The evaluation form was constructed based on the
The instruction for students before entering the exam
Calgary-Cambridge Guide to the Medical Interview:
room includes the patient’s age, gender, and vital signs,
Communication Process. The focus of the analysis was
and for the student to determine whether the patient had
on the initiation stage of the medical interview, include-
visited the emergency room or not. The instruction did
ing the identification of reasons for consultation. The
not describe the patient’s primary concern. The patient’s
rating form included three tasks for agenda setting; these
initial statement was formulated such that it would take
tasks were rated as yes (1) or no (0) (Appendix 1). Two
40 seconds. There were four concerns that were to be
experienced standardized patients were trained as raters
presented to the doctor within 40 seconds. The patient’s
for 2 hours. The video recordings were independently
first concern, presented in 10 seconds, was about dark-
reviewed and scored using the evaluation checklist. If
colored urine. The second concern was abdominal pain,
the two raters disagreed in their judgment of a medical
presented in the next 10 seconds. Two further statements
student’s performance, the two communication educators
of concern were a headache and a psychosocial concern
reviewed and scored the interview in order to gain
regarding the stomach cancer that the patient’s mother
additional insight and clarity.
had.
IBM SPSS Statistics version 19.0 (IBM Corp., Armonk,
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HyeRin Roh, et al : Agenda setting ability in medical students
USA) was used for descriptive statistics; the data are shown as the mean and standard deviation for the sum
RESULTS
of all task items, as well as frequencies and percentages for categorical data. 2) Timing and content of the medical students’ redirection to the patient’s initial statement
1. Tasks for agenda setting All medical students asked appropriate opening
The duration of the patient’s initial statement without
questions to identify the patient’s problems and concerns.
redirection was measured in seconds, starting from the
However, the students did not screen all of the patient’s
end of the medical student’s soliciting question to the
concerns or confirm the list of concerns before focusing
point of redirection. The time was measured by a
on a specific concern. In addition, none of the medical
research assistant and the exact timing was verified by
students negotiated an agenda with the patient.
two investigators. The interviews in which the medical students solicited the patient’s agenda in the initial stage were transcribed.
2. Timing and content of the medical students’ redirection to the patient’s initial statement
The two investigators reviewed each video recording and
The patient’s 40-second initial statement of their
transcript of the patient encounter. The total number of
concerns was not completed in any of the interviews
patient concerns expressed before interruption was
conducted by the medical students. These students
evaluated. The first, second, and third questions posed
interrupted the opening statement after 4.62±2.20
by the students were coded. The categories and number
seconds. All students interrupted the patient during or
of questions were coded as closed-ended (e.g., “When do
after the statement of the first concern (Table 1). Among
you feel a stomachache?”), elaborating (e.g., “Tell me
all of the responses, the two most common interruptions
more about your stomachache”), recompleters (repetition
were recompleters and closed-ended questions. Two of
or paraphrasing of what the patient said; e.g. “stoma-
the students used more open-ended inquiries to explore
chache”), a statement (e.g., “That sounds serious”), open-
a greater number of concerns after the first interruption;
ended (e.g., “Tell me more” or “Anything else?”), and
however, they used closed questions in response to the
others, as used in previous studies [3,4].
patient’s reply. Among the first interruptions, the most frequent barrier to completion was recompleters (79.8%), followed by closed-ended questions (14.9%). Closed-ended questions were in relation to two issues; namely, onset (n=11) and nature (n=3). One response was classified into the
Table 1. Types of Medical Students’ Responses to the Patient’s Statement of Concerns First responses Type No. (%) Recompleter 75 (79.8) Closed-ended 47 (62.7) Total 94 (100.0)
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Korean J Med Educ 2015 Jun; 27(2): 77-86.
Second responses Type No. (%) Closed-ended 56 (59.6) Statement 18 (19.1) Total 94 (100.0)
Third responses Type No. (%) Closed-ended 54 (57.4) Recompleter 24 (25.5) Total 94 (100.0)
HyeRin Roh, et al : Agenda setting ability in medical students
Table 2. Types of Medical Students’ Second and Third Responses in Case of a Recompleter as a First Question Second response
Third response
Type Closed-ended
No. (%) 47 (62.7)
Statement
16 (21.3)
Recompleter Elaborating
8 (10.7) 3 (4.0)
Open-ended inquiry Total
1 (1.3) 75 (100.0)
Type Recompleter Closed-ended Statement Elaborating Closed-ended Statement Open-ended inquiry Closed-ended Closed-ended Recompleter Closed-ended
No. (%) 20 (42.5) 17 (36.2) 8 (17.0) 2 (4.3) 14 (87.5) 1 (6.3) 1 (6.3) 8 (100.0) 2 (66.6) 1 (33.3) 1 (100.0)
Table 3. Types of Medical Students’ Second and Third Responses in Case of a Closed-Ended First Question Second response
Third response
Type Recompleter
No. (%) 6 (42.9)
Closed-ended
6 (42.9)
Statement Elaborating Total
1 (7.1) 1 (7.1) 14 (100.0)
Type Closed-ended Statement Recompleter Closed-ended Statement Recompleter Closed-ended Closed-ended
No. (%) 3 (50.0) 2 (33.3) 1 (16.7) 3 (50.0) 2 (33.3) 1 (16.7) 1 (100.0) 1 (100.0)
“other” category. The response was, “By the way, what is
interruption, recompleters (42.9%) and closed-ended
your name and how old are you?”
questions (42.9%) were equally used as the second re-
Among the second interruptions, the most frequent was closed-ended questions (59.6%), followed by state-
sponse (Table 3). The most frequently used third response was closed-ended questions.
ments (19.1%). Among the third interruptions, the most frequent was closed-ended questions (57.4%), followed by recompleters (25.5%).
DISCUSSION
When a recompleter was used as the first interruption, closed-ended questions (62.7%) were the second res-
The present study demonstrated the limited agenda-
ponse, and recompleters (42.5%) were the third response
setting abilities of medical students in Korea. The
(Table 2). Moreover, in case of other responses except
students did not explore the patient’s concerns and did
recompleters as the second, students mostly used closed-
not negotiate an agenda. The medical students took
ended questions as the third response.
specific history from patients’ first concern. In addition,
When closed-ended questions were used as the first
the time taken by the students to listen to the patient’s
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HyeRin Roh, et al : Agenda setting ability in medical students
statement was under 5 seconds. Repetition of the
standardized patient complains clearly about one major
patient’s statement was also predominant in the first
symptom in the initial statement. Students are asked to
response; however, closed-ended questions featured
interview the patient—who has a predetermined primary
increasingly in the second and third responses.
concern—within a period of 10 minutes. It is the medical
These findings are similar to those in previous studies
student’s responsibility to gather relevant history, ex-
[3,4]. However, Korean medical students’ competency in
amine specific physical signs, and discuss diagnostic and
setting an agenda proved lower than that of medical
therapeutic plans with the patient. The doctor-patient
students in other countries, as shown by the research.
interaction is assessed, but the items related to the initial
This finding can be partly attributed to Korean culture
stage include only the greeting, introductions, silence,
and Korea’s medical system.
and doctors’ nodding while listening. In the exam, it is
First, in many traditional medical schools in Korea,
assumed that the agenda has already been negotiated;
the teaching of communication skills remains limited in
therefore, the medical students are not required to
duration and scope. Educators have recently developed
explore and set the agenda. The students might acquire
communication education programs [9]; however, these
agenda-setting abilities during their clinical clerkships,
need more time to be more fully established. In addition,
but these cannot be evaluated in the current clinical
some students have exhibited skepticism toward the
skills exam. Consequently, medical students focus on the
learning of communication skills [10]. The situation at
requirements for the exams, including history taking,
Inje University College of Medicine is very similar to
which differs significantly from focused history taking
those in other Korean contexts, as discussed previously.
[2].
That is, formal communication courses had not yet been
However, any improvement strategies including pro-
established and some students exhibited skepticism
longed training, long consultations and/or non-Korean
toward communication education.
cultures cannot guarantee good agenda-setting skills. In
Second, it is common in Korean training hospitals for
a Dutch study, the effect of a 4-year teaching program
physicians, including residents, to have under 5 minutes
was found to be less relevant to the development of
of contact with individual patients. While the fee-for-
students’ exploration of reasons for the medical encoun-
service system is applied for paid doctors, the fee ceiling
ter [11]. Furthermore, in an Australian study, students
is low. Therefore, hospital income depends on the num-
displayed limited improvement during their clerkships,
ber of patients seen by the hospital’s physicians within
as demonstrated by their poor performance in agenda
a certain period. Poor quality and inefficient communi-
setting [12]. Time pressure, medical difficulties, and
cation subsequently occurs between doctors and patients
physicians’ clinical experience were not the causes of the
due to physicians being pressed for time. Korean medical
low frequency of patients’ completion of their opening
students continuously observe short encounters between
statements [13]. Although doctor visits lasting under 15
doctors and patients. Consequently, these students are
minutes are related to poor quality of communication
more likely to allocate short consultation periods to
[14], more time does not ensure better communication
patients and practice time efficiency.
between a doctor and a patient [15]. Young doctors
Finally, a well-defined agenda is presented in the
cannot spontaneously learn the basic communication
Korean National Clinical Skills Exam. In the exam, a
skills in daily clinical work, despite their exposure to
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Korean J Med Educ 2015 Jun; 27(2): 77-86.
HyeRin Roh, et al : Agenda setting ability in medical students
short postgraduate communication skills courses. Conse-
concerns, including about possible diagnoses and pro-
quently, their deficient communication skills persist into
gnoses, their anxieties about the side effects of treat-
their professional lives [16].
ments and unwanted prescriptions, and information
In light of this, how can medical students be
about their social conditions [19]. Therefore, medical
encouraged to improve their ability to set agendas? The
students should be trained to explore these issues and
following four strategies are recommended: highlighting
listen carefully to patients who cannot express their
the importance of agenda setting in encounters with
concerns easily.
patients throughout the curriculum, modification of the
Second, changes in the format of the Clinical Skills
instruction format of the clinical skills exam, faculty
Exam in the Korean National Licensing Exam should be
development, and reform of the Korean healthcare sys-
considered. Medical students’ agenda-setting abilities
tem to be more patient-centered. The emphasis on the
should be assessed. It is recommended that the exam
importance of agenda setting and the clinical skills exam
instructions not indicate the patient’s primary concern.
format is discussed in more detail in the paragraphs
Currently, the instructions on the Medical Council of
below.
Canada Qualifying Examination Part II do not present
First, it is proposed that, over the duration of the
and summarize the patient’s primary concern and agenda
curriculum, medical students be trained to identify and
[20]. This appears to be a more appropriate method of
negotiate the primary concern at the beginning of the
assessing medical students’ ability to take medical history
doctor-patient encounter. In order to make differential
in the real world.
diagnoses during their clerkships, medical students tend
This study has two key limitations. The first limitation
to focus more on medical information [17] rather than on
is that the medical students’ abilities were investigated in
upfront agenda setting. However, the students have little
an exam setting, not in real settings. The second limita-
opportunity to obtain feedback on locating patients’
tion is that only the sentences from the first to the third
hidden agendas or they overuse inefficient closed-ended
question were analyzed. That is, analysis was not con-
questions. Emphasis on agenda setting, with appropriate
ducted on the whole conversation; therefore, it is not
feedback, is desirable. Furthermore, a doctor’s ability to
known whether the medical students ultimately deter-
actively listen optimizes the exploration of reasons as to
mined the patient’s real agenda.
why a patient visits a doctor. It can be expected that, in
In conclusion, Korean medical students have limited
a country such as Korea, where indirect communication
ability to explore patient concerns and to negotiate
is a virtue, hidden agendas are more difficult to
agendas during medical interviews. In addition, they
determine than in countries where direct communication
interrupt the patient’s first statement in within 5 seconds,
is more common.
primarily using recompleters and closed-ended ques-
It would be beneficial to identify the type of patients
tions. In order to improve medical students’ ability to set
who tend not to communicate their agendas easily, or the
agendas, communication skills focusing on upfront
types of agendas that cannot easily be determined.
agenda setting, through active listening, should be
Younger, uneducated, and unmarried patients have been
taught. Moreover, the instruction format of the Clinical
found to be less likely to trust doctors and express their
Skills Exam in the Korean National Licensing Exam
desires [18]. Typically, patients do not express their
should be changed to avoid explicating the patient’s chief
83
HyeRin Roh, et al : Agenda setting ability in medical students
complaint so as to facilitate assessment of agenda-setting
WReN study. Ann Fam Med 2004; 2: 405-410. 6. Baker LH, O'connell D, Platt FW. "What else?" Setting
ability.
the agenda for the clinical interview. Ann Intern Med 2005; 143: 766-770.
Acknowledgements: We thank the large number of academic staff who contributed to the development of this task-based learning outcome in clinical clerkships at Inje University College of Medicine. In particular, we acknowledge the work of the Clinical Education Committee and the Curriculum Committee, the support of the Office of Medicine, and the technical support of the Medical Education Unit. In addition, we thank Dong Hun Kang, Eun Hwa Ok, and Jiyoung Jang for their excellent research assistance. Funding: None. Conflicts of interest: None.
7. Smith RC, Hoppe RB. The patient's story: integrating the patient- and physician-centered approaches to interviewing. Ann Intern Med 1991; 115: 470-477. 8. Bishop JM, Fleetwood-Walker P, Wishart E, Swire H, Wright AD, Green ID. Competence of medical students in history taking during the clinical course. Med Educ 1981; 15: 368-372. 9. Lee YH, Lee YM. Development of a patient-doctor communication skills model for medical students. Korean J Med Educ 2010; 22: 185-195. 10. Ahn S, Yi YH, Ahn DS. Developing a Korean communication skills attitude scale: comparing attitudes between
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HyeRin Roh, et al : Agenda setting ability in medical students
Appendix 1. Rating Form for Assessing Students’ Agenda-Setting Abilities Exploring concerns
Yes
No
1
To screen all of the patient’s concerns
1
0
2
To confirm the list of patient’s concerns
1
0
3
To negotiate an primary agenda before specific history taking
1
0
Timing and contents 4
End time of students’ question inquiring patient’s concern
5
Start time of students’ interruption
6
1st response
7
2nd response
8
3rd response
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Korean J Med Educ 2015 Jun; 27(2): 77-86.
