Videotaped interviewing of non-English speakers: training for medical students with volunteer clients

In a multicultural society such as Australia, with over 20% of its population born overseas, interpreters are often required to facilitate medical interviews. However, where a patient has some proficiency in English, medical interviews are sometimes conducted across the boundaries of culture and language. This is a report of an educational innovation to teach interviewing skills to pre-clinical medical students with the assistance of volunteers of non-English-speaking backgrounds. Pre-clinical students interviewed community volunteers on topics of general life history in a sequence of 16 tutorials. Each student conducted two interviews. Teaching methods included feedback from the volunteers, tutorial discussion facilitated by playback of videotapes, and modelling of skills by the teachers. Evaluations by volunteers and students indicated high satisfaction with the teaching methods and outcomes. Students gained confidence in interviewing people from different cultures. Evaluation of students' pairs of videotapes by an independent rater achieved satisfactory reliabilities and indicated significant gains in inquiry skills and the communication of positive attitudes. Skills in communicating empathy and in using simple language did not improve measurably.     

Subjective and behavioural evaluation of the teaching of patient interview skills

Summary. One aim of the course in general practice and public health medicine during the final year at the University of Sheffield is to help students to develop further their interpersonal communication skills with particular reference to their skills in interviewing patients. During the course students meet twice in small groups with a tutor in order to review audiotape recordings of interviews with patients seen during their general practice attachments. The main activity during these tutorials is group discussion of the interviewer's behavioural options at significant points during the interview. Students also listen individually with a tutor to an interview that they have recorded, discuss this interview and assess it against a set of explicit criteria as part of their summative course assessment. In response to an anonymous end-of-course questionnaire, 85% of students felt that their interview skills had been improved by the teaching and 68% that listening to their own recordings had been the most helpful aspect. During interviews with simulated patients recorded at the end of the course, students asked more open questions, fewer questions referring to physical symptoms, more questions referring to feelings, beliefs or behaviour and fewer questions of a check-list type than during interviews recorded at the start. A number of students also requested examples of specific events during the end-of-course interviews although none had done so at the beginning of the course. All of these changes were statistically significant and were in directions that were consistent with the teaching in the small-group tutorials.     

Behavioural assessment of the effectiveness of a communication programme for medical students

Summary. This study evaluated the effectiveness of a communication programme taught to medical students at the University of Melbourne in their preclinical years. The effectiveness of the programme was assessed by comparing videotaped history-taking interviews completed by a cohort of first-year clinical students in 1986, who had not undertaken the communication programme, with a similar cohort of first-year clinical students in 1992 who had undertaken the programme. The students from the 1986 cohort who had not undertaken communication training in their preclinical course completed their videotaped interviews as part of the experimental evaluation of a consulting skills training programme carried out in 1986-87. A comparison of ratings given by two experimentally naive, independent observers revealed that the 1992 student cohort demonstrated some significantly better skills at questioning and facilitating communication with patients. By contrast, the 1986 student cohort showed significantly greater skills at maintaining relevance in their interviews and greater capacity to explore patients' psychosocial concerns. These data suggest that students acquire the most effective interview skills when interacting with patients during their clinical training.     

The students' view of an innovative undergraduate medical course: the first year at the University of Newcastle,N.S.W.†

An innovative medical course commenced in 1978 in a new medical school at the University of Newcastle. An evaluation of the student response to the first year of this course was carried out. This evaluation aimed to assess how far the students had progressed towards the attainment of the long-term Faculty objectives on which the Newcastle curriculum is based. Students' perceptions of educational innovations were obtained and compared with the Faculty's stated aims. Students felt that they could approach a problem scientifically, in a manner consistent with the Faculty's specified methods. In the area of team work, students had accepted the need for training in team skills as preparation for work after graduation. Students have adapted to the use of objectives, to assessment for competence, and to the marking of one another's papers. These methods had been introduced to facilitate the development of skills necessary for independent and continuing self-education. Patient contact was designated as the greatest strength of the first year. Students expressed concern for patient well-being and the influence of student activities on patients. This indicated that students had progressed some way towards the attainment of the Faculty objective that they should develop an humanitarian approach to patients.     

Student feedback: influencing the quality of teaching in a paediatric module

The aim of this study was to assess the impact of feedback on the quality of tutorials. Students completed structured feedback questionnaires on the perceived usefulness of teaching sessions. They perceived significant differences in the quality of tutorials delivered by experienced and inexperienced teachers (P < 0.01), although the differences tended to become less throughout the year. In the second year, teachers had advice from an experienced tutor in planning the sessions, in addition to receiving feedback from the students. During the second year, the students did not perceive any difference in the usefulness of these tutorials to them. The study showed that the quality of tutorials can be improved by passing structured feedback to the teachers, but that some skills training was also required to completely eliminate perceived differences.     

Self- and peer assessment in a first-year communication and interviewing course

Peer and self-evaluation are crucial in the professional development of physicians. However, these skills must be learned, and there are barriers to their acceptance and successful utilization. To overcome these obstacles, it has been suggested that these concepts should be addressed longitudinally throughout medical education. Therefore, first-year medical students were introduced to peer and self-assessment as part of a videotape review during an interviewing course by having students complete written peer and self-assessments of the interviews. Students' self-assessments were compared with the assessments of peers and faculty. Written evaluations showed peers were more lenient than faculty and students were most critical of their own performances. Students could provide balanced assessments of their peers but were predominately negative regarding their own performances. It appears first-year students are capable of evaluating their peers but have difficulty accurately assessing their own performance. Further interventions are needed to foster self-assessment skills in first-year students.     

A comparison of the interviewing skills of first-and final-year medical students

This study compared the communication skills of randomly chosen first- and final-year medical students. The intention was to follow up previous research, conducted over 10 years ago, into the effects of the medical curriculum on communication skills. It was hypothesized that there would be little improvement in such skills over the period of training, with the possibility that the final-year students might be less caring, empathic and supportive, more directive, and less concerned with psychosocial information. All students interviewed a simulated patient in the role of a mother of a child with cerebral palsy, where the main problems were psychological and social. The interviews were recorded on videotape and analysed by an independent observer for the presence or absence of a set of communication behaviours considered important in facilitating an effective relationship and in the exploration and understanding of the problem. The results failed to support the hypotheses. The final-year students were superior to their juniors on several measures, indicating improvements in relating to the patient in a caring, empathic, facilitative and listening manner. They also elicited more information relevant to the problem. The indications were that these final-year students were more skilled than in earlier studies, suggesting that the general change in attitudes to communications skills and the limited, but increased input into the curriculum may be having effect, even though there remains a need for considerably more training.     

The use of focus group interviews in Asian medical education evaluative research

OBJECTIVE: To evaluate the use of focus group interviews in Asian medical education evaluative research. METHODS: Randomly selected medical students were invited to participate in 30 focus group interviews to provide in-depth data about the effect on their learning of the introduction of early clinical skills. Efforts were made to meet all the students to help them understand the objectives of the focus group. Confidentiality was emphasised and a non-faculty interviewer was recruited for the interviews. RESULTS: The students considered the use of focus groups to be a more meaningful way of collecting students' opinions than other methods, for example structured questionnaire, because it allowed an interactive discussion. They also felt that having an independent non-faculty interview moderator had encouraged them to express their opinions more candidly during the interviews. CONCLUSION: The use of focus group interviews among Asian medical students for evaluative research is practical and efficient.     

A communication skills course for preclinical students: evaluation of general practice based teaching using group methods

Summary. Teaching preclinical medical students about doctor-patient communication gives them an opportunity to develop their interviewing skills prior to their having to elicit lists of symptoms in their clinical years. General practitioners should be among the more efficient interviewers in clinical medicine and therefore able to make important contributions to the teaching of interviewing skills. This paper describes the aims, objectives and methods of the preclinical communications skills course at St George's Hospital Medical School. The contribution of the Division of General Practice and Primary Care to the teaching of interviewing skills in the preclinical course has been evaluated using rapid group methods. Students were asked to identify examples of specific interviewing behaviours in videotaped general practice consultations, and to judge whether the behaviours were helpful or unhelpful in eliciting relevant information from the patient. Students who had been given experience in interviewing patients in small groups led by general practitioners identified significantly more helpful and unhelpful interviewing behaviours in the taped consultations than students who had not received the small-group teaching. Students rated the teaching as relevant and effective in terms of giving insights into the interviewing skills they needed to develop. Group methods of evaluation such as these might prove useful to other medical schools with class sizes of 150 students or more.     

Day surgery: teaching the next generation

The advent of day surgery presents new opportunities and challenges for medical education. The opportunity to see patients pre-operatively and follow them through surgery to discharge on the same day is unique to day surgery. However, with rare exceptions, the development of educational programmes in ambulatory surgical settings is still largely at a rudimentary level. An undergraduate pilot programme was conducted at the University of Adelaide to explore the practicalities, acceptance and educational value of a day surgery programme for final-year medical students. The programme had three components: day surgery patient follow through, practical procedure tutorials and problem-based learning tutorials. It incorporated assessment of practical skills and theoretical knowledge with the use of log books and clinical and practical simulations as important elements in the assessment process. The pilot programme was accepted by all stakeholders and students' perceived significant gains in knowledge and skills. This programme may provide a teaching model that could be adapted for use in other medical schools.     

Cultural diversity in Australian medical education

The present study sought to explore the relevance of cultural dimensions and cultural diversity among overseas and local medical students. The main comparison among the fourth year medical students studied was between Asian origin and Anglophone background students. The measures used included cultural variation, reasons for studying medicine, learning approaches and strategies, patient interaction confidence, and medical practices anxieties. Results indicated cultural differences between the two groups, and relationships between cultural variables and, in particular, reasons for studying medicine, learning approaches and strategies, and patient interaction confidence. Results were interpreted according to Hofstede's(1980, 1986) theory of cultural dimensions as they may apply in the educational setting.     

Influence of context and preferred learning environments: approaches to studying physiology

Summary. One hundred and twenty-eight medical students who had experienced a traditional-style preclinical curriculum completed three self-report questionnaires. Using factor analysis of students' responses this study explores interactions between study orientation, preferences for different kinds of learning environment, and evaluations of the physiology course. Such interactions can provide insight into the reasons why students fail to adopt effective learning strategies. Although many students had the intention to understand, they did not adopt a deep approach. Achievement motivation was strong, test anxiety high, and the course was perceived to be competitive. The meaning orientation merged with the achieving orientation; students were thus performance rather than task oriented. These students perceived the course to have been challenging, as did students within the reproducing orientation and who had ‘surface’ preferences. Students within the non-academic orientation had difficulty coping with the course. The findings suggest that conventional teaching and assessment methods are preventing students from developing appropriate criteria and internal standards for evaluating performance. An illusion of comprehension may prevent students from seeing the need to adopt more effective learning strategies and cause ‘good’ students with the ability to adopt a deep approach to abort the pursuit of deep understanding. Students' preferences and evaluations of teaching and assessment indicate that students within the different learning orientations have different educational needs. The implications for instruction and evaluation are discussed.     

Consulting skills training and medical students' interviewing efficiency

In more traditional medical education, medical students took a patient's medical history by asking a series of sequenced, routine questions, covering presenting medical problem(s); medical history; social and personal history; systems review; and physical examination. Following this process, the student then attempted to derive the patient's medical problems. This inductive problem-solving paradigm may not assist students to prepare for their future interviewing needs, given doctors use a hypothetico-deductive, problem-solving approach when interviewing patients and numerous researchers have developed specialized communication skills training programmes designed to enhance students' interviewing skills. Students given specific consulting skills training have tended to show significantly greater interpersonal effectiveness and improved interview behaviours compared with students who experience traditional patient clerking training. These improvements in interviewing tend to persist over the period of students' medical training. The aim of the present study was to determine whether specialized communication skills training helped students elicit greater quantity and quality of information from patients and if so, whether such information assisted students in improving their diagnostic skills. Videotaped history-taking interviews conducted by students trained in communication skills and untrained (control) students were rated for their interview efficiency. A comparison of ratings given by experimentally naive, independent observers revealed that trained students were more efficient, but took no longer than their control group counterparts to elicit fuller, more relevant information. However, the student groups did not differ in the accuracy or scope of their medical diagnoses. It is argued that students' lack of medical knowledge in this early phase of their clinical training militated against their being able to use their interviewing competence to derive more potentially accurate medical diagnoses.     

Racial differences in accuracy of self-assessment of sexual maturation among young black and white girls.

PURPOSE: To examine the validity of maturation self-assessments and to investigate the association between race and validity of self-assessments among young black and white girls. METHODS: Self-assessments and examiner-assessments of areolar and pubic hair development using line drawings were compared at three visits among a cohort of 11- to 14-year-old girls enrolled in the National Heart, Lung, and Blood Institute's Growth and Health Study. Accuracy rates and kappa coefficients were calculated to measure the agreement between girls and examiners. Logistic regression models were used to assess the racial differences in the accuracy of self-assessments while adjusting for possible confounders. RESULTS: Fair to moderate agreement was found between self- and examiner-assessments (areolar self-assessments: adjusted accuracy rates: 60.7-69.9%, kappa: 0.32-0.51; pubic hair self-assessments: adjusted accuracy rates: 57.9-70.7%, kappa: 0.36-0.55). While there were indications of racial differences in the ability to perform self-assessment with black girls tending to self-assess less accurately, most of the differences disappeared after adjusting for nurse-assessed stage. CONCLUSIONS: These findings suggest that self-assessment can substitute for examiner evaluations only when crude estimates of maturation are needed. However, when accurate maturation stage data are required, examiner-assessments are necessary. Because black girls are usually more pubertally advanced and tend to underestimate their development, the value of self-assessment is questionable for assessing populations with young black and white girls. Use of self-assessment might present biased estimates of maturation and confound research findings.     

Residents' perceptions of their teachers: facilitative behaviour and the learning value of rotations

Summary. Despite changes in modern medicine the role of the clinical teacher remains central to medical residents' education and rotations continue to be their dominant educational context. Residents have strong positive feelings for clinical teachers who are perceived as interested in teaching and for those rotations that provide a balance of educational opportunities and patient care responsibilities. Research in residency education has focused on teacher behaviours used to teach medical residents clinical information or patient care skills but has neglected teacher behaviours used to facilitate effective learning relationships with residents. To explore the impact of clinical teachers' use of facilitative behaviours on residents' educational experience, we use concepts stemming from the psychologist Carl Rogers' work previously shown to be associated with positive learning outcomes — empathy, unconditional positive regard, and congruence. These constructs are measured by the use of the four scales of the Barrett-Lennard Relationship Inventory (BLRI) — level of regard, unconditionality of regard, congruence and empathy. Our study measures the correlation between residents' perceptions of clinical teachers' use of facilitative behaviours and residents' evaluation of the learning value of rotations. Thirty-three residents completed the BLRI on a different clinical teacher for each of six monthly rotations. A total of 158 surveys were returned. There were strong positive correlations between three of the BLRI variables and residents' perception of the learning value of rotations. Potential uses of these findings are discussed.     

Educational assessment of general practice experience for psychiatric trainees

Eighteen psychiatric trainees spent 6 months each as general practice trainees. The educational impact of the experience was assessed by a self-assessment questionnaire, a semi-structured interview and a videotaped interview with a psychiatric patient. Each assessment was conducted at baseline and after 12 months. A control group of 14 trainees was recruited from the same rotation. On the self-assessment questionnaire, the study registrars rated their abilities to solve general medical problems significantly improved compared to controls. They had also acquired greater understanding of the limitations of their knowledge and their legal responsibilities towards their patients. The semi-structured interview failed to distinguish between the two groups. Videotapes for rating at baseline and follow-up were available for only 17 of the trainees. Assessment of the tapes used the Maguire Scale and the Interview Behaviour Scale. Neither scale demonstrated any intervention effect. The interviews were all characterized by a preponderance of 'closed psychological' and 'checking-out' questions. It appears that psychiatric trainees' interviewing styles had not been influenced by the experience. This study suggests that psychiatric trainees gain greater confidence in their role as a doctor and greater understanding of the scope and nature of general practice by such an attachment. It is unclear whether or not supplementary interviewing skills had been acquired which were not utilized in the taped interview, which conforms very much to traditional psychiatric examination behaviour. Trainees were reassured that they had increased their knowledge without losing any of their specific professional skills.     

Non-verbal communication: evaluation of a computer-assisted learning package

Summary. A computer-assisted learning (CAL) package was developed on non-verbal communication. Its effectiveness was evaluated by comparing learning based on use of the package with that based on a didactic lecture covering the same topic. A class of 151 first-year medical students was divided into two groups, balanced for gender and home/overseas students. One group was asked to use the CAL package, the other group attended the lecture. Knowledge was assessed one week later by a written test, and reactions to using the CAL package were obtained via a questionnaire. Each group was then allowed and encouraged to use the other resource and then asked about their preferences for type of resource at the end of term. Mean score on the knowledge test was reliably better in the CAL group. In addition, scores increased as the time spent using the CAL package increased: this relationship was highly significant. Use of the CAL package varied from 15 to 120 minutes (median 45). Users reported that it was easy to operate, was an adequate or good resource for learning about the subject, and was a good or reasonable use of their time. After using both types of learning resource half the students judged the CAL package more useful for learning about the subject, and half preferred it to the lecture (the other half had the opposite judgement and preference). This study provides evidence that a CAL package can effectively substitute for traditional didactic teaching in a medical school. Good quality CAL, however, requires substantial resources and high calibre staff to develop and maintain it.     

Videotapes in psychiatry: their use in teaching observation techniques

In order to assess the effectiveness of videotapes in teaching mental state examination, two groups of medical students, one who had received videotape teaching and one not exposed to videotapes, are compared in their ability to observe accurately the mental state during a live interview. Accuracy of observation was assessed by obtaining a measure of the students' ability to shift from an incorrect opinion about a patient to a more accurate assessment following the live interview. Students who had received videotape teaching were able to make more accurate judgements than those who had not. This ability was not related to certain personality attitudes measured, nor to an ability to detect subjective elements in the interview, nor is it reflected in their examination results. The only significant variable found to influence this ability was whether or not the student had received videotape teaching.