Teaching Supplement
Introduction
The student text, Smith’s Patient-Centered Interviewing: An Evidence-Based Method (McGraw-Hill 2012), details the steps involved in medical interviewing, a challenging, complex and ultimately rewarding task for clinicians.1 Teaching interviewing to students can be a demanding undertaking.2–4 Not only must we be expert interviewers ourselves, we must also understand the educational principles required to effectively teach interviewing to others. We may be faced with learners who are busy, sometimes more interested in biomedicine, and who on occasion may view interviewing, particularly patient-centered interviewing, as too “touchy-feely” or as irrelevant to their concerns about becoming “real” doctors. Despite these understandable tensions, we can recall that most students are very interested in interviewing and that they are especially enthused by their first real exposure to clinical medicine. We have an eager, receptive audience for our introduction to the most central skill in medicine—a superb opportunity for establishing a biopsychosocial atmosphere. Most students want to be good clinicians and know that they must be good interviewers to reach their goal.
Our own experiences in teaching interviewing revealed firsthand how difficult it can be. We first had to brush up on our own interviewing skills—and found that feedback on a regular basis was invaluable. Recording interviews in the clinic self-critiquing them and, better yet, having a peer or learner provide feedback has been most useful. The usual standard in medicine of “see one, do one, teach one” does not work very well for improving interviewing skills.
Intensive training for instructors can be useful and has been helpful to all of us. The American Academy on Communication in Healthcare (AACH) [www.aachonline.org] offers an annual course for clinicians to improve their interviewing and teaching skills. AACH also offers a facilitator-in-training (FIT) program, where participants learn small group facilitation skills for teaching the medical interview under the direct guidance of national and international experts. The program usually takes from 3–4 years, according to one’s needs and time available for training, and involves work at the FIT’s home institution and at multiple national sites.
Regular meetings of local groups of instructors can enhance by marshaling the considerable existing expertise that exists in many schools and programs throughout the country. Local training is particularly effective if both medical and mental health professionals are involved and if the work includes personal awareness development. A combination of national and local activities is ideal.
With this backdrop, we want now to describe how one might structure the teaching process for “Interviewing 101.” We do not address advanced interviewing skills involving the integration of personal awareness training with the more mechanical tasks of interviewing, as these have been described elsewhere.5 We do mention some basic personal awareness issues that can be included in Interviewing 101. Teaching will not be effective if it is based on traditional educational pedagogy, that is, didactic lectures, to master cognitive content; nor will only reading the textbook or watching the companion video.6,7 A specific course is required—where the instructor also teaches at behavioral (eg, modeling) and experiential (eg, actual interviewing) levels. Presenting a specific, behaviorally defined model, as the text depicts,1 has been shown to be a particularly effective teaching tool.8,9
Although teaching basic interviewing requires a rather structured approach, we encourage instructors to maintain a balance of learner-directedness within the confines of this structure.9–11 It is critical for learners to: (1) identify course goals as their own (eg, patient-centeredness); (2) identify their own interviewing and self-awareness challenges and devise learning goals and teaching techniques (eg, role play) to address them; (3) lead discussions and provide feedback to each other, taking responsibility for some teaching as well as learning; and (4) assist in directing their own learning (eg, controlling the video playback during critiques). Learner-centeredness actively involves learners, enhances their self-efficacy and creates opportunities for faculty to model the very behaviors they would like to see embodied in learner performance.10,11
Teaching an integrated approach to preclinical students and other new learners, as presented in Chapters 1, 2, 3, 4, and 5 of the textbook1 and in the video,6,7 is outlined here. In essence, the instructor presents the data-gathering and relationship-building (facilitating) skills, then focuses repeatedly upon the first five steps of the interviewing model, next integrates clinician-centered steps (Steps 6–10) of the model, and moves to the end of the interview (Step 11). Virtually all students and residents have been able to learn these skills quickly. The curriculum presented has more sessions than likely are available in some instances, but one can easily modify them to fit the time available, often teaching clinician-centered interviewing in a later semester or year, rather than in tandem with patient-centered interviewing. This teaching supplement does not present guidelines for the end of the Interview (informing and motivating), as these are usually best taught during clinical years. They can be derived easily from the material in Chapter 6 of the textbook.1
Teaching Integrated Patient–Clinician Centered Interviewing to New Learners
While we recommend teaching beginning students the 5-step, 21-substep patient-centered interviewing process and the 5-step clinician-centered interviewing process in one course, the time is not often available, and the patient-centered material is taught in Year 1 (or Semester 1) and the clinician-centered material in Year 2 (or Semester 2). When courses are taught separately, students risk not integrating the two processes. The unfortunate consequence is that they use the last model they observed and practiced, almost always isolated clinician-centered interviewing taught late in the second year. We have found that always beginning interviews with patient-centered practices, then transitioning into the clinician-centered mode for more extensive instruction works well in producing an integrated interview. Doing so provides a review for the learner and also repeatedly demonstrates how the two processes are interrelated and interwoven.
The recommended approach requires 16 weekly sessions (approximately one semester), each of 3 hours duration. Each weekly block consists of: (1) a 1-hour demonstration/lecture in which lecturers discuss material to be introduced in small group sessions; 2) a subsequent 2-hour session for supervised groups of 4–6 learners.
An outline of the proposed 48-hour teaching block for medical students follows and is informed by expert teaching guidelines.12
Session One
Assigned reading: Chapter 1 and Appendix B should be assigned beforehand so that learners are prepared to discuss it.1
Objectives: The learner should understand the following and be able to demonstrate the skills described:
What are human data, and why is this definition important?
Define interviewing.
Why is interviewing the most central of all clinical skills?
Define medicine’s models:
Biopsychosocial model
Biomedical model
Why is the biopsychosocial model superior to the biomedical model?
Define different interviewing skills:
Clinician-centered interviewing skills
Patient-centered interviewing skills
Describe how one transforms multiple bits of personal, emotional and symptom data to a biopsychosocial description of the patient—the patient’s story
Integrated patient–clinician–centered interviewing
What are the different types of needs a patient may have?
Why is an integrated interviewing approach more humanistic and more scientific than an isolated patient-centered or clinician-centered approach?
Describe how one integrates patient-centered and clinician-centered interviewing skills. Which usually comes first? Are they separated or can one go back and forth between them?
Define the content of the interview and describe the unique components of each content item: chief concern (CC), history of the present illness (HPI), other active problems (OAP), past medical history (PMH), social history (SH), family history (FH), and review of systems (ROS). Describe which content usually arises using patient-centered skills and which content usually develops using the clinician-centered skills.
Define the three functions of interviewing (data gathering, relationship building, and patient education) and describe the goals and skills involved in each.
Emphasize the objectives, especially understanding that integrated patient–clinician–centered interviewing elicits multiple bits of symptom, personal, and emotional data that the interviewer, relying on a knowledge base in the basic and social sciences, synthesizes to construct a biopsychosocial description of the patient.
Use role play (using a second instructor or simulated patient for help) to illustrate different patient needs: the usual uncomplicated patient and more troublesome situations such as the unconscious or psychotic patient. Emphasize that present instruction will concern only situations in which no urgent problem exists and where patients are able and want to communicate. Many learners and instructors will tend to focus on the most difficult and complex cases, which also occur least frequently in practice. An important pedagogical principle is to focus on the most basic and routine interviewing tasks.
Demonstrate an isolated clinician-centered interview to show what is to be avoided (see doc.com Module 5 for vignettes of isolated clinician-centered and patient-centered interviewing.)13 Indicate that clinician-centered interviewing will be integrated later.
Perform an integrated patient–clinician–centered interview to show what is expected; include brief examples of the clinician-centered HPI/OAP, PMH, SH, FH, and ROS to orient learners to the totality of the medical interview. Explain the contributions of each of these areas.
Conclude by reviewing why an integrated patient-centered and clinician-centered approach is superior to an isolated clinician-centered approach. Students usually understand the humanistic reasons, but the scientific reasons merit repetition throughout the course, outlined in detail in Appendix B of the text.1 We encourage learners to have the scientific argument at the tip of their tongues and to actively use it with skeptical students, faculty, and others.
Introductions and learners’ reactions to starting their first clinical experience. Facilitate learners’ objective of learning the most important clinical skill they will need (20 minutes).
Review of definitions from objectives (10 minutes).
Instructor briefly demonstrates different patient needs in role play, using a student as the interviewer (15 minutes):
Obvious acute problem (unconscious, massive hematemesis, psychotic, or symptoms of acute heart attack)
Obvious communication problem (demented)
No acute problem and no communication problem—these represent the vast majority of circumstances and are the primary focus of this course. Reassure learners that the entirely clinician-centered process needed for acute problems will be fully addressed in clinical years.
Small group discussion of integrated patient–clinician–centered interviewing, its component processes, and their balance. Learners should be able to define all content components: CC/HPI/OAP, PMH, SH, FH, and ROS (15 minutes).
Instructor demonstrates learners’ initial objective for this teaching block: the complete patient-centered process of HPI with transition into clinician-centered HPI; instructor should review Chapter 3 of the student text beforehand. This is followed by brief examples from the OAP, PMH, SH, FH, and ROS. (30 minutes)
Discuss why the clinician needs to be skilled in using the patient-centered process and what unique humanistic and scientific benefits accrue—see Chapter 1 and Appendix B of the student text. (30 minutes).
Instructors’ Guide
One treats learners the way they will be taught to interact with their patients: respectfully with caring and sensitivity,14,15 considering emotion as well as verbal behavior,16–18 using open-ended and closed-ended inquiry, using relationship-building skills,16–18 negotiating,19–21 giving feedback,22 and setting limits.
Instructors attend to group process, encourage but do not force everyone’s involvement, and allow time for learners to express apprehensions and other emotions about this material. The literature on working with small groups provides important guidelines.23
Instructors from healthcare disciplines other than medicine can ask a clinician colleague about what constitutes an urgent medical problem, the general clinician-centered approach to such a patient, and what is covered in the HPI/OAP, PMH, SH, FH, and ROS; also see Chapter 5 of the student text.
Learners’ Assignment for Next Session
Read Chapter 2 of the student text.1
Be prepared to role play the open-ended and closed-ended skills and the emotion-seeking and empathy skills in the reading assignment.
Session Two
Open-ended skills: six types: silence, nonverbal encouragement, neutral utterances, echoing, requesting, and summarizing
Closed-ended skills: two types: yes/no and short answers
Emotion-seeking skills: two types: direct inquiry and indirect inquiry; the latter uses self-disclosure and also asks about impact on self, impact on others, reasons for the visit, and explanations about causes or mechanisms of a problem
Empathy skills: four types: Naming, Understanding, Respecting, Supporting (NURS)
Brief question/answer session about previously addressed material.
The instructor discusses and demonstrates open-ended, closed-ended, emotion-seeking, and empathy skills, highlighting that these skills are keys to successful patient-centered interviewing. Also remind learners that while these skills are intuitive, they are difficult to perform because they are counter to prior learning and experience.
Demonstrate how the interviewer can use focusing open-ended or relationship-building (emotion-seeking and empathy) skills. Emphasize that this can require interrupting the immediate thread of conversation to return to information gleaned from earlier portions of the interview. Emphasize also that topics not mentioned by the patient should not be introduced by the learners using open-ended requests or emotion-seeking skills. For example, if “job” has not been mentioned by the patient, the student should not say, “Tell me about your job” or “How do you feel about your job.” Being patient-centered in the interview means that the interviewer tries as much as possible not to contaminate the patient’s narrative with her or his own thoughts.
Conduct general discussion and questions about basic skills. Ask if there are any residual questions from the last session. (5 minutes)
Using role play, learners practice open-ended skills, emotion-seeking skills, and empathy skills. Challenge learners to completely avoid closed-ended questions and forecast to them that this will likely be difficult and require practice. The student interviewee can role play either a patient or a third party, for example, family member, lover, caregiver etc.; interviewees are instructed to show moderate levels of emotions and not to “make it too difficult.” (60 minutes)
The instructor then demonstrates the use of facilitating skills, using focusing open-ended skills, emotion-seeking skills, and empathy skills in response to selected patient utterances in two situations: (a) to focus on the patient’s immediate thread of conversation or emotion and (b) interrupting the immediate thread to focus on prior patient utterances or emotion. The intent is to show learners how to open-endedly focus the interview, a skill which they will need to master. Focusing is the key to efficiently developing the narrative thread. New topics should not be introduced when focusing; rather, the focus is on material already raised by the patient. (10 minutes)
Each learner role plays 30 seconds of nonfocused open-ended inquiry (using nonfocusing open-ended skills: silence, neutral utterances, and nonverbal encouragement) followed by 3 minutes of focused inquiry with focusing open-ended skills, emotion-seeking skills, and empathy skills. Learners are instructed to focus on whatever utterances they desire and follow the thread of whatever story emerges—by repeated focusing with the skills. (45 minutes)
Instructors’ Guide
Orient learners to individual skills that are the focus of this session; subsequent sessions will put the skills together into the integrated patient–clinician interviewing process.
Nonfocusing open-ended skills are easily understood and performed. Most teaching time and emphasis will be on the focusing open-ended skills, emotion-seeking skills, and empathy skills.
Review role-play techniques24–26 and anticipate issues that often arise, for example, performance anxiety (in either patient or interviewer role), disdain because “patients” are not “real,” disrupting role play by laughing and otherwise not taking it seriously.
Conduct only one role play (student interviewer and student “patient”) at a time, with others observing, works best. Each non-interviewing learner can be assigned 1–2 specific tasks (eg, watch for silence, identify when open-ended and when closed-ended skills are used, what empathy skills were used, what the focus was) and give feedback to the interviewer—after the instructor initially leads discussion about both participants’ reactions. In role play, give explicit instructions about what the “patient’s” role and script should be; this makes it easier for learners and prevents wasting time; alternatively, the instructor can take the role of the patient, particularly useful at the outset when learners’ anxiety levels are high. Support efforts of learners playing the role of patients; they often are overlooked and stressed about their performance.
Carefully listen and respond empathically to learners’ anxieties about role play. This is a good opportunity for you as the instructor to demonstrate your own facilitating skills.
Learners’ Assignment for Next Session
Read the first parts of Chapter 3 of the student text1: setting the stage for the interview (Step 1) and determining the patient’s agenda and chief complaint (Step 2).
Before the next class, interview a non-patient (spouse, friend) with the objectives of remaining entirely open ended for three minutes, using emotion-seeking skills at least three times, and using empathy skills at least three times. Audio/video record this interview for classroom review during the next session. Jointly critique it (what objectives were, and were not, met) with a fellow learner prior to next session and be prepared to discuss the interview and critique.
Session Three
Welcome the patient.
Use the patient’s name.
Introduce your self and identify specific role.
Ensure patient’s readiness and privacy.
Remove barriers to communication (sit down).
Ensure comfort and put the patient at ease.
Indicate time available.
Forecast what you would like to have happen in the interview.
Obtain list of all issues patient wants to discuss (but avoid detail): symptoms, complaints, specific requests, expectations for visit, probe for additional issues.
Summarize and finalize agenda. Negotiate specifics if too many agenda items.
Review Session Two material in a question/answer format and role-play answers. By this time, it is usually possible to involve student volunteers in role play in front of the large group at the lecture. Repeat demonstration of how to use open-ended, emotion-seeking, and empathy skills to draw out something the patient has expressed verbally or nonverbally (ie, feelings and emotions), including how to interrupt the immediate thread to return to earlier conversation or emotion. Reaffirm that the interviewing student should not introduce new topics. The ability to draw out material introduced by the patient will be a major determinant of the learner’s effectiveness and efficiency.
Indicate that integrated patient–clinician–centered interviewing, to be presented in the next session, begins with two preparatory skills that are this session’s objectives: setting the stage (Step 1) and obtaining the agenda (Step 2). Review and demonstrate the objectives in role play, emphasizing that each component is covered in the order noted, at least for initial training purposes.
Effectively obtaining the patient’s agenda is the most important point. Reassure learners that it sometimes involves interrupting the patient and that respectful interruption can be a valuable patient-centered skill.
Instructor reviews video/audio recordings and experiences with interviews done in the interim. (75 minutes)
Ask about each learner’s experience, always beginning with her or his emotional response, which is key to developing personal awareness of possible interfering personal reactions. Simply getting learners to share emotions at this point is satisfactory; for example, feeling anxious being watched. Acknowledge their anxiety using empathy skills (NURS) and reinforce the importance of sharing of emotions in a safe and supportive atmosphere. In more advanced learning situations, after learners have mastered the integrated patient-centered clinician-centered interviewing method, more active personal awareness work can be guided by your prior work in this area.5
Spend most time on specific skills issues. Highlight expected difficulties (eg, avoiding closed endedness, using all four empathy skills) and successes. Identify specific problems and give feedback about correcting them. Learners should role-play solutions until all can perform the skills.
After the instructor briefly demonstrates, learners role play setting the stage and obtaining the agenda and chief complaint. (45 minutes)
These are Steps 1 and 2 of the patient-centered interview that learners will be working on next time.
Teaching should highlight trouble spots: getting specific agenda items without getting into details and indicating one’s own agenda for time and other needs.
Instructors’ Guide
Begin each critique with an open-ended focus on learners’ emotional responses. You will find that they have much anxiety about their first observed interview, often critique themselves harshly, and worry about how well they did. Give reinforcing as well as corrective feedback, say what specific behavioral change is needed in the next interview, and be supportive and empathic.
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