Medical Education, 1977, 11, 390-393
Medical students talking to patients D . A. A L E X A N D E R , J . D. E . K N O X
AND
A. T . MORRISON
Department of Audio- Visual Aids and Deparfment of General Practice, University of Dundee, Department of Education, University of Stirling, Scotland
Summary
traditional clinical model in history-taking. Their work showed that deficiencies in performance related as much to inadequate inter-personal interviewing skills as to ignorance of clinical facts. Helfer (1970) has provided evidence to suggest that traditional medical training may actually erode students’ inter-personal skills. Opportunities to introduce inter-personal issues involved in the consultation to pre-clinical students occurred when the Behavioural Sciences Course was instituted as part of the third year in a six year curriculum in Dundee. An outline of the components of this course has been published elsewhere (Sheldrake, 1974). The Department of General Practice makes a contribution entitled ‘Clinical Method’, part of which is concerned with introducing students to patients. The present paper describes some of the teaching Key words : *PHYSICIAN-PATIENT RELATIONS ; ‘EDUmethods, analyses students’ perceptions of their exCATION, MEDICAL, UNDERGRADUATE; BEHAVIOURAL periences and discusses some of the issues raised by scrENcEs/*educ; COMMUNICATION; MEDICAL HISTORY this part of the course. TAKING ; VIDEOTAPE RECORDING; SCOTLAND Observations were made of 108 pre-clinical medical students interviewing patients carefully selected by general practitioner tutors, under strict supervision in an audio-visual studio. Videotape replay allowed immediate feed-back to the student, and this was supplemented by direct comment from the patient. The consultations were also used for small group teaching (by CCTV). Although most students viewed the exercise as threatening, they appeared to find it a helpful experience. The method uncovered students with major defects in communicating at the personal level. Detailed analyses of the content of the interviews are being carried out, and will be the subject of a separate communication.
Aims
This part of the Behavioural Science Course does not attempt to provide specific training in interviewing. It aims to provide a background of broad issues, hitherto absent from the curriculum, against which more specific instruction in clinical interviewing can be given later. It also aims: (a) to create awareness of inter-personal skills needed in consultations with patients; (b) to allow the student to find out which skills he may already possess-or lack; (c) to demonstrate the relevance of skills, especially in establishing and maintaining rapport, to obtaining unbiased information from patients efficiently and effectively (converting data into information).
Introduction Direct observation of medical students interviewing patients has drawn attention to the frequent occurrence of deficiencies in history-taking (Anderson et al., 1970; Tapia, 1972; Maguire & Rutter, 1976a). The nature of some of these deficiencies has been more clearly defined by Maguire & Rutter (1976b) working with senior clinical undergraduates: these medical students had previously been taught to use a Correspondence: Professor J. D. E. Knox, Department of General Practice, University of Dundee, 166 Nethergate, Dundee D D I 4DR, Scotland.
390
Medical students talking to patients Teaching methods Preliminary experimental work in 1974 and 1975 with volunteer students suggested that, at the beginning of the third year, it would be a worthwhile experience to provide every student in the course (of 110) with an opportunity to exercise and observe his own and his fellows’ skills. As a routine part of the, Behavioural Sciences Course, each student wou@ interview a selected patient, while closedcircuit television (CCTV) would enable fellow-students and tutor to watch and listen. Every such consultation could be simultaneously recorded on videotape, for further examination. In the Autumn Term of 1976, the class wai organized into twelve groups of about nine, each with a similar fixed proportion of men and women. Groups attended for one hour on three occasions in the term. At each teaching session one third of the group interviewed patients provided by different general practitioners in rotation, applying a simplified and suitably shortened version of a model described by Maguire & Rutter (1976a) -see Appendix I. Five minutes were allowed for each interview, which was conducted in a simulated consulting room in an audio-visual studio. The interview was relayed live on CCTV to the rest of the group, led by a teacher experienced in consulting with patients. Immediately after the interview, before rejoining the group, each student completed a short questionnaire, recording his perceptions of the patient’s problems and of the interview. In privacy, he then watched a replay of his interview. Meantime, issues raised by the interview were discussed by the group, which usually contained the patient’s family doctor. The patients, in their waiting room, also had an opportunity to see the interviews. The session ended with the patients joining the group for discussion of their feelings and observations about what had happened during the interview. When the group dispersed, the patients stayed on for a second session with a different group of students.
Selection of patients Each of eighteen general practitioner tutors working with the Department of General Practice provided in turn three patients, selected by such criteria as: willingness to co-operate (attested by their written consent for the interview to be televised and used for teaching purposes); possessing an out-going person-
391
ality; clinical impairments which are relatively straightforward. No attempt was made to recruit severely ill patients. The following are examples of the kind of patients who co-operated in the exercise. ES: a married lady, aged 50 years, who had suffered from Still’s disease for about 40 years. She graphically illustrated ways in which she had been helped to overcome most of her disabilities. SW: an 8-year-old boy, convalescent from an ill-defined febrile respiratory illness which resolved when he coughed up a peanut. He was accompanied by his mother. AS: a 51-year-old housewife who lived in a state of perpetual anxiety lest she should have a recurrence of a deep venous thrombosis experienced some years previously. GB: a 51-year-old joiner who was recovering from a fractured scaphoid (his second such injury). For each of the patients the tutors filled in a form similar to that used by the students; this provides a synopsis of the family doctor’s view of the problem against which the students’ perceptions may be assessed. The tutors attempted to provide what they regard as easy interviewing situations for the students : the extent to which they met this objective is shown in Table 1. TABLE 1 . Tutor’s rating of the patients (n =53) Rating
No. of patients
No. of interviews _
Easy Difficult Neither Total
36 4 13
53
_
_
~
73 8 27 108
Findings
During the Autumn Term, observations were made on 108 students, each conducting one short interview yith one of the fifty-three patients. Of the 108 students, fifty rated the exercise as difficult: the students’ perceptions of difficulty are tabulated against the tutors’ assessments of the patient as an interviewee in Table 2. As time passed, the numbers of students who rated their interviews as difficult did not change - seventeen in the first, sixteen in the second and seventeen in the third phases of the term. Many factors may influence a student’s perception of difficulty. The situation may in fact be difficult: marked differences in age
~
D . A . Alexander, J . D. E . Knox and A . T. Morrison
392
TABLE 2. Students’ rating of interviews as difficult by tutors’ ratings of patients No. of students’ ratings Tutor’s ratings of patients Total
Difficult Not difficult
Difficult 4 46 50
Not difficult 4 54 58
sex and social class between participants in the consultation are examples of possible factors which might contribute to this. Students’ ratings of interviews as difficult were, however, not related to these three variables. The student’s first interview might be made easier if, for his patient, this is a second or subsequent consultation: at least one of the participants has had an opportunity to become familiar with the procedure and the setting. However, student ratings of difficulty with their interviews did not correlate significantly with this factor. Differences between pairs of students interviewing the same patient were also examined : the findings are not statistically significant at the 5% level. Discussion
Understandably, perhaps, the exercise was seen by the students as something of a threat, yet they did not attempt to avoid the classes. Once they had interviewed a patient, most students expressed a sense of achievement and appeared eager to continue to learn. Although the tutors had taken care to select ‘easy’ patients, about half the class found interviewing difficult. Most students ascribed this feeling to a lack of clinical knowledge. Understandable though this may be, in fact little or no clinical knowledge or diagnostic skill was called for-the patients were themselves conversant with their problems or diagnoses and were seeking opportunities to talk about them. Indeed, they occasionally provided the students with some classical histories, and an additional and incidental bonus was this indirect way of teaching clinical medicine. Fear of making a fool of oneself in front of colleagues was occasionally accompanied by comments on the ‘artificiality’ of the exercise. This criticism loses some of its cogency when it is viewed against the ‘reality’ of the settings and the nature of much of the conventional clinical teaching.
Against the background of the challenge of this exercise, students at this stage did not appear to feel the additional stresses which differences (between them and the patients) in age, sex and social class might be expected to pose. The format of each group’s three teaching sessions remained the same, but new material constantly emerged, and much ground was in fact covered. The later students had the opportunity of seeing others tackle the job. Yet this and the group teaching appeared to have little effect in decreasing the proportion of students reporting difficulty with their first interview as the term progressed. Group teaching is focused upon concepts and attitudes and the interviewing is primarily an exercise in skills; the finding suggests that different approaches to the subject may be combined to complement each other. Most students found five minutes long enough to carry out the task: those who felt the lack of time tended to perform well and, having got into the swing of the interview, felt cheated at breaking off in the middle of an interesting consultation. Despite the difficulties felt by the interviewers, students were observed to perform the set task in an effective way. The content of the interviews is to be the subject of a separate analysis, but in over 80% the students elicited the salient points of the patients’ problems as listed by their family doctors. Students were seen to pick out, from watching their colleagues’ consultations on CCTV, such techniques as the use of open-ended questions, the constructive use of silence and eye-contact. Many attempted to apply these techniques when given the opportunity. The method also showed clearly those students who appear to have major problems of communication at the personal level. Of two such students, one was handicapped by linguistic, language and cultural problems associated with an overseas background, while the second appeared to dislike people. These observations carry implications for student selection, as well as for undergraduate education, and it is suggested that, with some modification, this exercise might be the subject of study at an even earlier stage in the curriculum. Acknowledgments
We are indebted to the many patients and their family doctors who co-operated in this exercise, to Dr A. T. Macqueen, who provided information on
Medical students talking to patients
393
paediatric interviewing skills of freshmen and senior medical schools. Paediatrics, 45, 623. MAGUIRE, G.P. & RUTTER, D.R. (1976a) Training medical students to communicate. In: Communication Between Doctors and Patients (Ed. by A. E. Bennett). Published for the Nuffield Provincial Hospitals Trust. Oxford University Press, London. MAGUIRE, G.P. & RUITER,D.R. (1976b) History-taking foi medical students: &Deficiencies in performance. Lancer, ii, 556. References SHELDRAKE, P. (1974) Behavioural science: medical students’ ANDERSON, J., DAY,J.L., DOWLING, M.A.C. & PETTINGDALI; expectations and reactions. British Journal of Medical Education, 8, 3 1. K.W. (1970). Obtaining a patient’s history of illness. TAPIA,F. (1972) Teaching medical interviewing-a practical Postgraduate Medical Journal, 48, 606. HELFER,R.E. (1970) An objective comparison of the technique. British Journal of Medical Education, 6, 133.
student feed-back, and to Mrs V. Duncan for typing several drafts. This work was carried out during the tenure of a grant from the Leverhulme Trust.
Appendix 1
Clinical method - Introduction to consulting with patients One suggested approach Greet the patient Seat the patient Establish identities-yours and the patient’s State the purpose of the interview Obtain broad information about all presenting problems List the problems and select what appears - both
to you and the patient - to be the important problem Establish: date/time of onset circumstances of onset how problem has developed what has been done so far effect upon life, job, others patient’s views on cause, and what should be done whether any previous similar problems
Medical students talking to patients D . A. A L E X A N D E R , J . D. E . K N O X
AND
A. T . MORRISON
Department of Audio- Visual Aids and Deparfment of General Practice, University of Dundee, Department of Education, University of Stirling, Scotland
Summary
traditional clinical model in history-taking. Their work showed that deficiencies in performance related as much to inadequate inter-personal interviewing skills as to ignorance of clinical facts. Helfer (1970) has provided evidence to suggest that traditional medical training may actually erode students’ inter-personal skills. Opportunities to introduce inter-personal issues involved in the consultation to pre-clinical students occurred when the Behavioural Sciences Course was instituted as part of the third year in a six year curriculum in Dundee. An outline of the components of this course has been published elsewhere (Sheldrake, 1974). The Department of General Practice makes a contribution entitled ‘Clinical Method’, part of which is concerned with introducing students to patients. The present paper describes some of the teaching Key words : *PHYSICIAN-PATIENT RELATIONS ; ‘EDUmethods, analyses students’ perceptions of their exCATION, MEDICAL, UNDERGRADUATE; BEHAVIOURAL periences and discusses some of the issues raised by scrENcEs/*educ; COMMUNICATION; MEDICAL HISTORY this part of the course. TAKING ; VIDEOTAPE RECORDING; SCOTLAND Observations were made of 108 pre-clinical medical students interviewing patients carefully selected by general practitioner tutors, under strict supervision in an audio-visual studio. Videotape replay allowed immediate feed-back to the student, and this was supplemented by direct comment from the patient. The consultations were also used for small group teaching (by CCTV). Although most students viewed the exercise as threatening, they appeared to find it a helpful experience. The method uncovered students with major defects in communicating at the personal level. Detailed analyses of the content of the interviews are being carried out, and will be the subject of a separate communication.
Aims
This part of the Behavioural Science Course does not attempt to provide specific training in interviewing. It aims to provide a background of broad issues, hitherto absent from the curriculum, against which more specific instruction in clinical interviewing can be given later. It also aims: (a) to create awareness of inter-personal skills needed in consultations with patients; (b) to allow the student to find out which skills he may already possess-or lack; (c) to demonstrate the relevance of skills, especially in establishing and maintaining rapport, to obtaining unbiased information from patients efficiently and effectively (converting data into information).
Introduction Direct observation of medical students interviewing patients has drawn attention to the frequent occurrence of deficiencies in history-taking (Anderson et al., 1970; Tapia, 1972; Maguire & Rutter, 1976a). The nature of some of these deficiencies has been more clearly defined by Maguire & Rutter (1976b) working with senior clinical undergraduates: these medical students had previously been taught to use a Correspondence: Professor J. D. E. Knox, Department of General Practice, University of Dundee, 166 Nethergate, Dundee D D I 4DR, Scotland.
390
Medical students talking to patients Teaching methods Preliminary experimental work in 1974 and 1975 with volunteer students suggested that, at the beginning of the third year, it would be a worthwhile experience to provide every student in the course (of 110) with an opportunity to exercise and observe his own and his fellows’ skills. As a routine part of the, Behavioural Sciences Course, each student wou@ interview a selected patient, while closedcircuit television (CCTV) would enable fellow-students and tutor to watch and listen. Every such consultation could be simultaneously recorded on videotape, for further examination. In the Autumn Term of 1976, the class wai organized into twelve groups of about nine, each with a similar fixed proportion of men and women. Groups attended for one hour on three occasions in the term. At each teaching session one third of the group interviewed patients provided by different general practitioners in rotation, applying a simplified and suitably shortened version of a model described by Maguire & Rutter (1976a) -see Appendix I. Five minutes were allowed for each interview, which was conducted in a simulated consulting room in an audio-visual studio. The interview was relayed live on CCTV to the rest of the group, led by a teacher experienced in consulting with patients. Immediately after the interview, before rejoining the group, each student completed a short questionnaire, recording his perceptions of the patient’s problems and of the interview. In privacy, he then watched a replay of his interview. Meantime, issues raised by the interview were discussed by the group, which usually contained the patient’s family doctor. The patients, in their waiting room, also had an opportunity to see the interviews. The session ended with the patients joining the group for discussion of their feelings and observations about what had happened during the interview. When the group dispersed, the patients stayed on for a second session with a different group of students.
Selection of patients Each of eighteen general practitioner tutors working with the Department of General Practice provided in turn three patients, selected by such criteria as: willingness to co-operate (attested by their written consent for the interview to be televised and used for teaching purposes); possessing an out-going person-
391
ality; clinical impairments which are relatively straightforward. No attempt was made to recruit severely ill patients. The following are examples of the kind of patients who co-operated in the exercise. ES: a married lady, aged 50 years, who had suffered from Still’s disease for about 40 years. She graphically illustrated ways in which she had been helped to overcome most of her disabilities. SW: an 8-year-old boy, convalescent from an ill-defined febrile respiratory illness which resolved when he coughed up a peanut. He was accompanied by his mother. AS: a 51-year-old housewife who lived in a state of perpetual anxiety lest she should have a recurrence of a deep venous thrombosis experienced some years previously. GB: a 51-year-old joiner who was recovering from a fractured scaphoid (his second such injury). For each of the patients the tutors filled in a form similar to that used by the students; this provides a synopsis of the family doctor’s view of the problem against which the students’ perceptions may be assessed. The tutors attempted to provide what they regard as easy interviewing situations for the students : the extent to which they met this objective is shown in Table 1. TABLE 1 . Tutor’s rating of the patients (n =53) Rating
No. of patients
No. of interviews _
Easy Difficult Neither Total
36 4 13
53
_
_
~
73 8 27 108
Findings
During the Autumn Term, observations were made on 108 students, each conducting one short interview yith one of the fifty-three patients. Of the 108 students, fifty rated the exercise as difficult: the students’ perceptions of difficulty are tabulated against the tutors’ assessments of the patient as an interviewee in Table 2. As time passed, the numbers of students who rated their interviews as difficult did not change - seventeen in the first, sixteen in the second and seventeen in the third phases of the term. Many factors may influence a student’s perception of difficulty. The situation may in fact be difficult: marked differences in age
~
D . A . Alexander, J . D. E . Knox and A . T. Morrison
392
TABLE 2. Students’ rating of interviews as difficult by tutors’ ratings of patients No. of students’ ratings Tutor’s ratings of patients Total
Difficult Not difficult
Difficult 4 46 50
Not difficult 4 54 58
sex and social class between participants in the consultation are examples of possible factors which might contribute to this. Students’ ratings of interviews as difficult were, however, not related to these three variables. The student’s first interview might be made easier if, for his patient, this is a second or subsequent consultation: at least one of the participants has had an opportunity to become familiar with the procedure and the setting. However, student ratings of difficulty with their interviews did not correlate significantly with this factor. Differences between pairs of students interviewing the same patient were also examined : the findings are not statistically significant at the 5% level. Discussion
Understandably, perhaps, the exercise was seen by the students as something of a threat, yet they did not attempt to avoid the classes. Once they had interviewed a patient, most students expressed a sense of achievement and appeared eager to continue to learn. Although the tutors had taken care to select ‘easy’ patients, about half the class found interviewing difficult. Most students ascribed this feeling to a lack of clinical knowledge. Understandable though this may be, in fact little or no clinical knowledge or diagnostic skill was called for-the patients were themselves conversant with their problems or diagnoses and were seeking opportunities to talk about them. Indeed, they occasionally provided the students with some classical histories, and an additional and incidental bonus was this indirect way of teaching clinical medicine. Fear of making a fool of oneself in front of colleagues was occasionally accompanied by comments on the ‘artificiality’ of the exercise. This criticism loses some of its cogency when it is viewed against the ‘reality’ of the settings and the nature of much of the conventional clinical teaching.
Against the background of the challenge of this exercise, students at this stage did not appear to feel the additional stresses which differences (between them and the patients) in age, sex and social class might be expected to pose. The format of each group’s three teaching sessions remained the same, but new material constantly emerged, and much ground was in fact covered. The later students had the opportunity of seeing others tackle the job. Yet this and the group teaching appeared to have little effect in decreasing the proportion of students reporting difficulty with their first interview as the term progressed. Group teaching is focused upon concepts and attitudes and the interviewing is primarily an exercise in skills; the finding suggests that different approaches to the subject may be combined to complement each other. Most students found five minutes long enough to carry out the task: those who felt the lack of time tended to perform well and, having got into the swing of the interview, felt cheated at breaking off in the middle of an interesting consultation. Despite the difficulties felt by the interviewers, students were observed to perform the set task in an effective way. The content of the interviews is to be the subject of a separate analysis, but in over 80% the students elicited the salient points of the patients’ problems as listed by their family doctors. Students were seen to pick out, from watching their colleagues’ consultations on CCTV, such techniques as the use of open-ended questions, the constructive use of silence and eye-contact. Many attempted to apply these techniques when given the opportunity. The method also showed clearly those students who appear to have major problems of communication at the personal level. Of two such students, one was handicapped by linguistic, language and cultural problems associated with an overseas background, while the second appeared to dislike people. These observations carry implications for student selection, as well as for undergraduate education, and it is suggested that, with some modification, this exercise might be the subject of study at an even earlier stage in the curriculum. Acknowledgments
We are indebted to the many patients and their family doctors who co-operated in this exercise, to Dr A. T. Macqueen, who provided information on
Medical students talking to patients
393
paediatric interviewing skills of freshmen and senior medical schools. Paediatrics, 45, 623. MAGUIRE, G.P. & RUTTER, D.R. (1976a) Training medical students to communicate. In: Communication Between Doctors and Patients (Ed. by A. E. Bennett). Published for the Nuffield Provincial Hospitals Trust. Oxford University Press, London. MAGUIRE, G.P. & RUITER,D.R. (1976b) History-taking foi medical students: &Deficiencies in performance. Lancer, ii, 556. References SHELDRAKE, P. (1974) Behavioural science: medical students’ ANDERSON, J., DAY,J.L., DOWLING, M.A.C. & PETTINGDALI; expectations and reactions. British Journal of Medical Education, 8, 3 1. K.W. (1970). Obtaining a patient’s history of illness. TAPIA,F. (1972) Teaching medical interviewing-a practical Postgraduate Medical Journal, 48, 606. HELFER,R.E. (1970) An objective comparison of the technique. British Journal of Medical Education, 6, 133.
student feed-back, and to Mrs V. Duncan for typing several drafts. This work was carried out during the tenure of a grant from the Leverhulme Trust.
Appendix 1
Clinical method - Introduction to consulting with patients One suggested approach Greet the patient Seat the patient Establish identities-yours and the patient’s State the purpose of the interview Obtain broad information about all presenting problems List the problems and select what appears - both
to you and the patient - to be the important problem Establish: date/time of onset circumstances of onset how problem has developed what has been done so far effect upon life, job, others patient’s views on cause, and what should be done whether any previous similar problems
