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.     

Psychological tests to measure the effects of medical education on students'' interpersonal skills

The consulting skills required of medical students and practitioners have been categorized into a number of specific skills, two of which are: students' ability to empathize with the patient; and ability to decode non-verbal cues given by the patient in the interview. Training programmes to improve students' consulting skills are usually evaluated using analysis of students' actual interview behaviours with patients. Broad psychological and personality tests have also been used to measure changes in students' interviewing skills, but have generally not been successful. The hypothesis is advanced that more specific tests of the skills of interviewing, such as non-verbal sensitivity and empathy, would detect changes in students' ability to display these skills. As part evaluation of a consulting skills training programme, clinical students completed psychological tests of empathy and non-verbal sensitivity. Subsequent comparisons between trained and control student groups revealed no clear pattern in test results. These data suggest that specific psychological tests of empathy and non-verbal sensitivity may be no more effective in detecting changes in students' interpersonal skills than global personality measures.     

Training clinical teachers in psychiatry to teach interviewing skills to medical students

To study the feasibility of training all clinical teachers in psychiatry to teach interviewing skills to medical students, 24 (unselected clinicians were assigned to one of four different training methods. They received either experiential or didactic instruction, and their initial teaching sessions were either supervised or unsupervised. A total of 287 medical students subsequently received feedback training from these teachers. While all students showed significant increases in skill after training, those taught by experientially trained teachers showed the greatest gains. Neither supervision nor the teachers' own interviewing skills exerted significant effects on students' performance. It is concluded that with only brief training unselected clinicians can become effective teachers of essential interviewing skills. Feedback training in such skills can, therefore, be incorporated into existing curricula without major disruption of other requirements.     

Teaching interviewing skills to paediatric junior clerks using simulated mothers

In this article a training programme is described for improving interviewing skills of students in the fifth year (junior clerkship) of the medical curriculum. Two interviews with a 'simulated mother' form the core of the programme. The interviews are immediately followed by a feedback session in which the simulated mother discusses the strong and the weak points of the interview. In the feedback she makes use of a checklist with relevant points concerning the content and the process of the interview. Where required the comments are substantiated with fragments of the videotaped interview. In a 2-hour theoretical session, students are told how to prepare themselves for the interview. The learning effects of the training programme using simulated mothers were evaluated in order to determine: (1) the subsequent improvement in interviewing skills; and (2) the effect of the feedback session. It was found that students' interviewing skills improved significantly on the content and the process aspects after one or two interviews. In addition the feedback sessions proved very helpful, although no significant differences were revealed, when comparing the mean group scores for students who had had feedback sessions with the scores for those who had not. The results also revealed that two interviews were insufficient and that the training should include at least three interviews. This was borne out by the large number of students who asked for more interviews with simulated mothers. In the training programme the simulated mothers perform two functions: (1) playing the role of the mother of a sick child; and (2) giving feedback to students regarding their interviewing skills.(ABSTRACT TRUNCATED AT 250 WORDS)     

Teaching psychiatric interview skills to medical students

A teaching package is described for teaching interview skills to large blocks of medical students whilst on their psychiatric attachment. The aims of this package are to reduce students' concerns about interviewing psychiatric patients, to reinforce students' knowledge of basic interviewing skills and to introduce students to the particular skills required in taking a psychiatric history and mental state examination. The package emphasizes the following teaching methods: 'hands-on' experience of interviewing a patient in front of small groups of peers; peer feedback using check-lists which focus on three major aspects of interviewing; elicitation of facts, elicitation of feelings and control of the interview; facilitation of small-group discussions in the presence of senior psychiatrist. The active involvement of all students in interviewing psychiatric patients engages them in the learning process. Peer involvement increases motivation and was deemed by students as a supportive and constructive exercise. The presence of a senior psychiatrist ensures that discussion is focused on the process of interviewing rather than on patient pathology. Ideally this package would precede focused training throughout the subsequent psychiatric placement.     

Do students develop better motivational interviewing skills through role‐play with standardised patients or with student colleagues?

OBJECTIVE: Smoking is the leading cause of preventable death in the USA and reducing the number of smokers by 50% is among the goals of the Healthy People 2010 initiative. Despite its importance, few medical students receive formal training in smoking cessation counselling. Motivational interviewing is a patient-centred, but directive, method of counselling that has been found to be more effective than giving brief advice for motivating smokers to quit. We wanted to determine whether using standardised patients to teach this skill to Year 3 medical students would be more effective than using student role-plays. METHODS: We conducted a randomised, controlled trial of 93 Year 3 family medicine clerkship students at our medical school between July 2003 and July 2004. The control group (n=46) practised motivational interviewing with one another and the intervention group (n=47) practised with standardised patients trained in motivational interviewing for smoking cessation. At the end of the study all the students conducted an interview with a different standardised patient that was videotaped. The primary outcome was analysis by a trained masked evaluator of the quality of a final videotaped interview using the motivational interviewing treatment integrity code (MITI), which assesses the quality of the interview according to 6 different criteria. RESULTS: There was no significant difference between the control and intervention groups in the final analyses of the interviews. CONCLUSIONS: According to MITI scores, standardised patient role-plays are similar in effectiveness to student role-plays when teaching basic motivational interviewing skills for smoking cessation to Year 3 medical students.     

Retention of interviewing skills learned by first-year medical students: a longitudinal study

A pilot interviewing course was offered as an elective to first-year medical students in the spring of 1985. A quasi-experimental pre-test/post-test control group demonstrated that students who took the course exhibited a significant increase in interviewing skills. Subjects, 15 in the experimental group and 11 in the control group, were assessed in each of the following 3 years. Data consisted of five 10-minute videotaped interviews with real or stimulated patients for each subject and subject's responses on a degree of confidence, familiarity and anxiety scale. Interviews were rated on 43 behaviours by two independent coders with a 90% simple agreement. The experimental group did not maintain their scores on interviewing skills and both groups showed a significant decline in nine skills comprising empathy. The only significant difference between the groups in fourth year was on the degree of confidence experienced. While interviewing skills can be learned they decline in the clinical years as students learn medical problem-solving. If medical students are to graduate with their original empathy intact, a follow-up course in fourth year is indicated.     

Medical students as standardized patients to assess interviewing skills for pain evaluation

PURPOSE: The use of medical students as standardized patients in a performance assessment of pain evaluation was studied. METHODS: Fifty-two pairs of second-year medical students participated. One student portrayed a patient presenting with cancer pain and was interviewed by the other medical student. The student-patient then rated the interview using a checklist of pain assessment and general interviewing skills. The interviews were audiotaped and also rated independently. RESULTS: Based on student-patient ratings, 36 (69%) students demonstrated 9 or more of the 11 pain-specific checklist items, compared to 34 (65%) students according to the trained rater. Highly specific pain-related items had higher agreement than broader interviewing skill items. There would be differences in the summary assessments of students depending on which rating data were used. DISCUSSION: Medical students represent a readily accessible resource as patients for clinical simulations. Students tended to overestimate the performance of fellow students, but acting as a standardized patient had educational value, and can be used to extend simulated patient encounters within the curriculum. Further investigation is needed to improve the reliability of the feedback provided by student-patients.     

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.     

Patient preferences and the bedside manner

An interview training model was tested and students' performances compared with patients' preferences and ratings of the students. The model was found to have some effect in improving performance. Students who were rated high in their interviewing skills tended to be rated highly by patients.     

Evaluation of procedural skills training in an undergraduate curriculum

CONTEXT: A substantial proportion of medical students enter their intern year without any basic skills experience. Lack of experience is a significant source of stress for many junior doctors. OBJECTIVES: To evaluate the effect of a basic procedural skills tutorial for Year 3 medical students on their competence in relevant skills at Year 5. SUBJECTS: The control group consisted of 93 medical students who completed Year 3 in 1996. The intervention group consisted of 92 medical students who completed Year 3 in 1997. The intervention group received a practical skills tutorial in Year 3; the control group did not. Both groups were assessed on their practical skills competence during Year 5. METHODS: A 3-hour practical tutorial on injection and suturing techniques was delivered to the intervention group. The effectiveness of the intervention was assessed by self-reported experience of giving injections, inserting sutures and sustaining needlestick injuries, and by teacher-rated competency in four basic procedural skills. RESULTS: Students who received the Year 3 tutorial were significantly more likely to record a satisfactory assessment for their performance in all four basic skills compared with students who did not receive the tutorial. They were less likely than controls to refuse invitations to give injections, but not invitations to insert a suture, during Years 4 and 5. CONCLUSIONS: A single session of formalised teaching in procedural skills in the early stages of a medical degree can have long-term effectiveness in basic skills competence and may increase students' confidence to practise their skills.     

Lectures and skills workshops as teaching formats in a history-taking skills course for medical students

The consulting skills acquired by medical students during their training are an important determinant of their ability to conduct adequate and efficient clinical interviews. These skills comprise: the acquisition of medical knowledge and the ability to apply this; and communication skills required to obtain full, accurate clinical histories from patients and to be able to give to patients the information they need to comply with prescribed regimens. Until recently, consulting skills training has certainly not had a high profile in medical curricula, despite evidence that students do not gain sufficient expertise during their medical training. A history-taking skills course within the Austin Hospital Clinical School, utilizing mass lecture and small-group skills workshops is described. Independent evaluation of students' videotaped interviews with patients, completed before training, after mass lectures and following small-group workshops, showed that students trained in consulting skills demonstrated significant improvements in interview skills and techniques, compared with a similar group of students for whom training followed the more traditional model. Whilst there were some improvements after mass lectures, most significant gains in history-taking skills were obtained following skills workshops. Ongoing evaluation of these students will determine if these short-term improvements in consultation skills persist over their clinical training and internship.     

Impact of a new curriculum on medical students' interpersonal and interviewing skills

OBJECTIVES: In 1998 we reported on the rise and fall of medical student communication skills during the 4 years of medical school. Since then, the University of Connecticut School of Medicine has completed a major curriculum renewal project with an emphasis on early clinical work, lifelong learning and more ambulatory training. The goals of this study were to compare students' interviewing and interpersonal skills in standardised patient (SP) assessments in the old and new curricula and to assess the success of the new curriculum in preventing a decline in student skills in this domain. METHODS: The clinical skills of 202 students were measured longitudinally during encounters with SPs in each of their 4 years of medical school. Students in this study and the earlier study were evaluated using the Arizona Clinical Interviewing Rating (ACIR) Scale. RESULTS: Compared with students from the previous curriculum, students on the new curriculum in this study showed an improvement in ACIR scores. Year 1 mean ACIR scores (1 = poor to 5 = excellent) were, respectively, 3.6 for the old curriculum cohort and 4.0 for the new curriculum group. In Year 4 the mean score for the old curriculum cohort was 3.7 and that for the new curriculum group was 3.8. Students on the new curriculum still showed a decline in ACIR scores from Years 1 to 4, but it was not as severe a decline as it had been previously. CONCLUSIONS: Pre-clinical medical students perform better on measures of interpersonal communication than their clinical counterparts. The students who participated in the new curriculum demonstrated an earlier acquisition of and a less steep decline in interviewing and interpersonal skills during the course of medical school.     

Does ultrasound training boost Year 1 medical student competence and confidence when learning abdominal examination?

OBJECTIVES: Learning to perform physical examination of the abdomen is a challenge for medical students. Medical educators need to find engaging, effective tools to help students acquire competence and confidence in abdominal examination techniques. This study evaluates the added value of ultrasound training when Year 1 medical students learn abdominal examination. METHODS: The study used a randomised trial with a wait-list control condition. Year 1 medical students were randomised into 2 groups: those who were given immediate ultrasound training, and those for whom ultrasound training was delayed while they received standard instruction on abdominal examination. Standardised patients (SPs) used a clinical skills assessment (CSA) checklist to assess student abdominal examination competence on 2 occasions - CSA-1 and CSA-2 - separated by 8 weeks. Students also estimated SP liver size for comparison with gold-standard ultrasound measurements. Students completed skills confidence surveys. RESULTS: Proficiency in abdominal examination technique acquired from traditional instruction boosted with ultrasound training showed no advantage at CSA-1. However, at CSA-2 the delayed ultrasound training group showed significant improvement. Students uniformly underestimated SP liver sizes and the estimates were not affected by ultrasound training. Student confidence in both groups improved from baseline to CSA-1 and CSA-2. CONCLUSIONS: Ultrasound training as an adjunct to traditional means of teaching abdominal examination improves students' physical examination technique after students have acquired skills with basic examination manoeuvres.     

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.     

Improving the psychiatric skills of established general practitioners: evaluation of group teaching

Ten established general practitioners, eight of whom were also trainers, took part in a course designed to improve their psychiatric interviewing skills. Participants were instructed in the problem-based model with audiotape and videotape feedback of real consultations in a group setting. Although those attending were experienced practitioners with a particular interest in the management of psychological problems, evaluation demonstrated a significant improvement in their skills after training. It is suggested that trainers could be trained to provide a similar teaching experience for their own trainees.     

Training and experience of examiners

Variation in the accuracy of examiner judgements is a source of measurement error in performance-based tests. In previous studies using doctor subjects, examiner training yielded marginal or no improvement in the accuracy of examiner judgments. This study reports an experiment on accuracy of scoring in which provision of training and background of examiners are systematically varied. Experienced teaching staff, medical students and lay subjects were randomly assigned to either training or no-training groups. Using detailed behavioural check-lists, they subsequently scored videotaped performance on two clinical cases, and accuracy of their judgments was appraised. Results indicated that the need for and effectiveness of training varied across groups: it was least needed and least effective for the teaching staff group, more needed and effective for medical students, and most needed and effective for the lay group. The accuracy of the lay group after training approached the accuracy of untrained teaching staff. Trained medical students were as accurate as trained teaching staff. For teaching staff and medical students training also influenced the nature of errors made by reducing the number of errors of commission. It was concluded that training varies in effectiveness as a function of medical experience and that trained lay persons can be utilized as examiners in performance-based tests.     

The teaching of interviewing skills: comparison of experienced and novice trainers

During a clerkship in psychiatry thirty-six medical students were randomly allocated to one of three teachers who differed widely in their experience of teaching essential interviewing skills. Each teacher taught two groups of six medical students using videotape feedback and discussion of practice interviews. Independent raters who were blind to the teachers to whom the students had been assigned rated pre and post-training interviews. All three teachers proved effective in teaching interviewing skills and it is concluded that most teachers could probably be taught to carry out this training.     

Promoting diagnostic problem representation

PURPOSE: Problem representation, as mediated by semantic qualifiers (SQs), has been associated with better diagnostic outcomes. The purpose of this study was to assess the effect of training medical students to use semantic abstractions as a means of building problem representations. METHODS: Sixty second-year medical students were assigned to either an intervention group (n = 20) or a control group (n = 40) during 8 months of an Essentials in Clinical Medicine course which used standardized patient-based workshops. Students were trained to transform findings into SQs and to use abstractions to compare and contrast diagnostic hypotheses. Students were assessed using a standardized patient data collection checklist, a post-encounter patient finding questionnaire (PFQ), and case summaries and write-ups. RESULTS: Experimental subjects used over twice as many SQs in their summaries as control group members (1.40 versus 0.63, P = 0.006). The correlation between checklist and PFQ scores was higher for the experimental group than for the control group (r = 0.70 versus r = 0.58, P 0.56). CONCLUSION: A short instructional intervention was successful in promoting the use of SQs and enabled students to recall elicited findings better. This intervention did not enhance data interpretation and diagnostic accuracy. Use of SQs may therefore be a necessary tool for efficient problem representation but one that is insufficient when used in isolation. The naturalistic setting used in this study imposed a number of limitations, implying that further research should test whether instructional efforts should also emphasize recognition of key patient findings and knowledge representation.     

A comparison of computer-assisted instruction and small-group teaching of cardiac auscultation to medical students

Cardiac auscultation is suffering from declining interest, caused by competing diagnostic technology and inadequate training of doctors. Computer-assisted instruction (CAI) supporting graphics and digitized sound could be ideally suited for teaching and sharpening this skill. To evaluate this premise we randomized 35 third-year medical students to 3 hours of seminar teaching plus the use of audiotapes (group 1), the self-use of a MacIntosh-based CAI (group 2), or both (group 3). All students took a pre- and post-test consisting of eight pre-recorded cardiac events and were also assessed for computer anxiety. Although there were no significant differences between pre- and post-tests for each group and among groups, group 1 had a 4.5% deterioration in its diagnostic score compared to the 7.2% and 3.2% improvements of groups 2 and 3 respectively. Group 2 used the CAI significantly more than group 3. We conclude that CAI is at least as effective as seminars in teaching cardiac auscultation to third-year medical students.