Medical Education 1990, 24, 243-250
Teaching psychiatric interview skills to medical students L. M. LOVETT, A. C O X t & M. ABOU-SALEH
Department ofPsychiatry, University ofLiveTool and tDepartment of Child and Adolescent Psychiatry and Psychology, Royal Livevpool Children’s Hospital
Summary. 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 ofbasic 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 smallgroup discussions in the presence of a 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.
Introduction Communication skills are essential to good medical practice; they are the means of both diagnosis and therapy. History-taking contributes more to diagnosis of most medical patients than physical examination and laboratory investigation (Hampton et al. 1975), and the interview may form a large part, if not all, of the treatment process (Balint 1964). The price of poor communication skills can include poor compliance (Ley & Spelman 1967; Ley 1982), patient dissatisfaction (Reynolds 1978) and an increase in incidence of litigation (Carroll & Monroe 1979). Exposure to patients during clinical practice is not sufficient to ensure that these skills develop through a process of hopeful osmosis. O n the contrary, these skills can often deteriorate rather than improve (Hefner 1970). The last 15 years have seen an increasing awareness of students’ deficiencies in interviewing (Maguire & Rutter 1976a). In spite of this, little coordinated time is devoted to undergraduate teaching of this subject (Crisp 1986), although there are notable exceptions (Maguire & Rutter 1976b). The situation is even more parlous for teaching of postgraduates (Kerr 1986). Teaching methods which have been used include direct observation and feedback of students’ interviewing behaviour, videotape feedback, role-play presentation of illustrative patient interviews and didactic teaching (Wakeford 1983). These all have their advantages and drawbacks. The value of videorecording and feedback is well established (Maguire et al. 1978; Goldberg et al. 1980). However, although these
Key words: *teaching/*methods; *interview, psychological: *clinical competence; clinical clerkship; psychiatry/*educ; physician-patient relations; England Correspondence: D r L. M. Lovett, Department of Psychiatry, University of Liverpool, P O Box 147, Liverpool L69 3BX.
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techniques may help to maintain skills (Maguire et al. 1986, 1989) they can compound problems by focusing too much on the interviewer’s mannerisms and appearance (Carrol & Monroe 1979). Indeed, some research suggests that instructions which include explicit statements of interview skills with demonstrations and handson experience are more effective (Hatter et al. 1977). Maguire demonstrated that the most important aspect of acquiring information was studying and discussing a printed hand-out (Maguire & Rutter 1976~).In another study medical students’ interview training with psychiatric patients produces benefits evident in interviews with physically ill patients 4-6 years later (Maguire et af. 1989). In Liverpool University Medical School interviewing techniques are specifically addressed in a behavioural sciences course during the first 2 years, and in the clinical years during a fourthyear general practice attachment and a fifth-year psychiatry attachment. In this paper the teaching package used during the introduction to the psychiatry attachment is described. It is designed around the constraints of limited time on the curriculum and limited availability of patients. Also outlined are lessons learnt from the evolution of this package and the student’s experiences of this. The package, conducted in the form of workshops, emphasizes the following teaching methods: teaching underpinned by hand-outs; ‘hands-on’ experience of interviewing in front of small groups ofpeers; peer feedback using checklists which focus on different aspects of interviews; facilitation of small-group discussions in the presence of a facilitator to enable the students to share their experience and to distil specific aspects of interviewing techniques. Objectives include the following: to introduce students to psychiatric patients in a controlled environment, with the aim of overcoming their apprehension about interviewing this patient population; to reinforce students’ knowledge of basic interviewing skills which could be generalized to all patients; and to introduce students to particular skills required in taking a psychiatric history and mental state examination.
The emphasis of these workshops was on how to control an interview and how to elicit facts and feelings effectively. Clinical teaching of interview skills Students receive some instruction on basic communication skills during their fourth year (second clinical training year) when they are attached to the Department of General Practice. At this stage they are asked to role-play doctorpatient interviews which are videotaped and later discussed. The psychiatric interview teaching package described in this paper takes place when students are in their fifth year (final year of training). It occurs during a I-week introductory teaching block which is organized by the academic department and is preparatory to a &week psychiatric clinical attachment. There are about 140 students in each year and one quarter attend each of the four blocks which occur every year. Each block takes about 35 medical students. During the teaching block, students receive a comprehensive hand-out on interview skills and an introductory lecture. The hand-out and lecture emphasize the nature of the doctorpatient relationship and basic interactive issues such as room arrangement, non-verbal communication and dress, thereby reinforcing the instruction which students received whilst in their fourth year on the general practice attachment. Role play is used in the lecture to get these points across and to warm up the students in preparation for interviewing psychiatric patients in the t w o e h o p s which follow: one the same day and one later in the week. Thus, the experience of role-play in the fourth year is extended to an experience of real-life interviews in the fifth year. Before interviewing the patients, students are also given individual hand-outs as aides-mimoire. These detail appropriate targets for the mental state examination, family and personal history.
The Workshops The format of each workshop is explained in detail below. The first workshop occurs immediately following the introductory lecture and role-play. The students are assigned to pre-arranged groups of four.
Teaching psychiatric ititerview skills Workshop 1: (2 hours)
(1) Student (A) interviews a patient for 20 minutes on the subject of the presenting complaint, in the presence of three peers and a facilitator. (2) Student (B) then immediately interviews the same patient for 20 minutes concentrating on the mental state examination. The patient then leaves, although where appropriate, the patient is first invited to comment on how he/she felt about the interview as a consumer. (3) The students fill in their check-lists; these are used as a spring-board for a short discussion in the presence of a facilitator (20 minutes). (4) Two groups then pair and a spokesperson from each initiates discussion by feeding back the group’s experiences in the presence of a facilitator. Points arising are discussed and evaluated (35 minutes).
Workshop 2: (2Y2 hours)
(1) A 30-minute plenary session begins this workshop, which recapitulates on the experiences of the previous workshop by asking each spokesperson to announce what the group learnt. Any particular problems are discussed and a short introduction is given on aspects of the agenda for that day. Each student group interviews a different patient to the one interviewed at the first workshop. (2) The first student (C) interviews on the family o r personal history, having spent a brief period checking out the main presenting problems. Student (D) then concludes with a mental state examination. Stages (3) and (4)are the same as in the first workshop. As indicated above, the student group is divided into subgroups of four. Each student has the experience of interviewing a patient in front of three peers and a facilitator, a senior psychiatrist, who is usually a Consultant but on occasions a Senior Registrar. This is achieved through
having two interviews in sequence with the same patient at each ofthe two workshops. The task of the interviews is explained carefully to the students before each workshop. The two interviews during the first workshop concentrate on the presenting complaint and mental state examination, whilst in the second workshop interviews focus on personal/family history and mental state. There is therefore a considerable emphasis on the mental state examination, which two students from each group are expected to conduct. The interviewing students are given an aide-mimoire for each of the different areas covered to assist them during the interview since, a t this stage in their training, students have minimal experience ofthe psychiatric history and examination. Before the interview, the students are also given specially devised check-lists, which are carefully explained to them, to score their interviewing colleagues on their techniques. There are three types of check-list and all students have the opportunity to score each type over the three sessions in which they are not interviewing; the students who are interviewing fill in a self-assessment form at the end of the interview. These check-lists concentrate on three major aspects of interviewing: elicitation of facts, elicitation of feelings and control ofthe interview (Appendix). In addition there is a global assessment scoring sheet. The aim of this procedure is to focus the students’ attention at each workshop on different aspects of the interview process. Students are told that those conducting the sessions are not interested in their specific scores but they are to use their observations at the ensuing discussion. The first interviewing students are given the responsibility to fetch the patients and arrange the interview room as they want. Following the interviews there is a short discussion where a student-spokesperson encourages comments from the observing students on the interviewing students’ techniques. The facilitator, who is a senior psychiatrist, summarizes the problems and successes encountered by the interviewing students. In the final discussion period, when two groups report together, each group is asked to discover the experience of the other group. The facilitators then help focus discussion on interviewing techniques.
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Lessons derived during development of the workshops The evolution of these workshops, before reaching their final form, has highlighted particular points about them which appear to be successful. Initially only one interview was devoted to the mental state examination instead of two. Increasing the emphasis on the mental state was in recognition of its fundamental importance in psychiatry and was welcomed by the students since it provided them with more supervised experience of acquiring this skill before starting on their psychiatric attachment. This shift in emphasis, in order to improve students’ ability to examine mental state, has occurred at other teaching centres as well (Rosen 1984). In the early development of the workshops, a different patient was interviewed for each of the four aspects of history-taking, i. e. presenting complaint, personal history, family history and mental state. It was found that it was more economical and that more was learnt by making more use of the same patient on one occasion and switching the interviewers than by splitting the psychiatric interview into four parts using different patients. In this way, students could build up a more comprehensive and meaningful view of the patient. Finally, the presence of a facilitator at each workshop was found to be crucial to maximize the benefits of the ‘hands-on’ experience of interviewing through guidance of the ensuing discussion period.
Topics commonly encountered during discussion of interviewing techniques Stages 3 and 4 ofthe workshops allowed time for discussion. It was found that certain problems and issues typically arose and warrant comment. Elicitingfacts Emphasis was put on open, accurate and non-leading elicitation of facts in the ‘factual’ observer check-list. In the introduction and in discussion, students’ attention was focused on gathering historical information and information about the nature of the patient’s current relation-
ships. Attention was drawn to the importance of life-events, particularly in relation to new or changing symptomology. In general, they performed these tasks well. The main difficulties arose from leading or omitting to summarize and feed back to the patient. Students sometimes felt embarrassed at admitting that they did not understand and were reluctant to ask the patient to go over some aspect of the history again. They needed to be taught the value of eliciting detailed descriptions of behaviour and events.
Eliciting feelings Students found it particularly difficult to explore carefully the patient’s feelings and opinions about problems. This was highlighted when they needed to address sensitive issues such as sexual behaviour and experiences; students, however, also felt embarrassed and did not know what to do when patients cried or got angry. Several students felt that they had failed if they provoked their patient to cry and, in a separate questionnaire (unpublished), expressed this as their major fear in interviewing a psychiatric patient. Sensitively directed discussions help students to learn how interviewers may experience feelings similar to those of the patient and that they may avoid topics about which they themselves feel uncomfortable. Students discovered for themselves that certain techniques could be very helpful in the area of eliciting feelings such as attention to non-verbal cues, flexibility with a preparedness to return to difficult issues later, open questions, pacing and silences. Where appropriate, students were introduced to more subtle methods ofeliciting feelings (Cox 1989) such as reflection and interpretations.
Controlling the interview Students used different methods in starting the interview. Most were good at introducing themselves and orienting the patient. Seating arrangements varied in accordance with personal preference and limitations imposed by the interview rooms. However, the majority of students did give attention to those aspects of the interview.
Teaching psychiatric interview skills
The most difficult problem to emerge was how to control the garrulous patient in order to complete the task in the given time. This was highlighted in some interviews where the patient was mildly hypomanic. They learnt that there was a place for changing topic and closed questioning in order to gain control. In contrast reticent patients might need open questioning to get them talking. Other techniques such as verbal interruption and eye aversion were discussed.
Students’ feedback on this teaching The students were asked to answer a questionnaire at the end of the course. All students thought that the workshops had been a valuable experience and all found the experience of learning by peer review to be useful. Students found the ‘hands-on’ experience of interviewing a patient preferable to watching a psychiatrist interview in a 3:l ratio. In addition certain comments and suggestions were made. Students liked the use of a spokesperson to feed back on the interview, since this reduced the embarrassment of the student who had been interviewing. They requested that these workshops should occur earlier in their training and asked for their continuation during the subsequent psychiatric attachment. Attendance was invariably well sustained, those few unable to attend the second session often giving specific apology.
Discussion The objectives of the teaching package included reducing students’ apprehension of interviewing a psychiatric patient, reinforcing their basic interviewing skills and introducing them to taking a psychiatric history and carrying out a mental state examination. T o meet these aims certain techniques were used such as peer review, check-lists to focus on particular aspects of interviewing, and facilitated discussion about interviewing techniques in the presence of a senior psychiatrist. Reports from previous years suggested that motivation to attend and apprehension about interviewing would be particular
problems. Therefore, the workshops were set up to deal with these difficulties in two: hands-on experience and peer review. The active involvement of all students in interviewing psychiatric patients engages them in an effective learning process which students themselves found valuable. Other teachers have also found that students rate actual interviews with patients more highly than other teaching strategies, such as didactic teaching and role-play (Knox & Bouchier 1985). Simulated patients have been used instead of real patients to teach communication skills to general practitioner trainees and medical students (Hannay 1980; Whitehouse et al. 1984; Schofield & Arntson 1989). The problem with this teaching approach is that it fails to provide an opportuntity to correct preconceptions which students may have about psychiatric patients. In general, students expressed their pleasant surprise at how most of the psychiatric patients they interviewed seemed ‘ordinary’. When they were difficult or unusual the peer group was invariably supportive. Most studies using simulated patients appear to use them to depict general medical problems. Even Bird & Lindley (1979), in a psychiatry refresher course for GP trainees, used role-play of a patient with an alcohol problem. T o act convincingly a patient with hypomania or schizophrenic psychoses is a demanding task. The mental state examination is a very important part of the teaching package. It is essential that the verisimilitude of the interview is not undermined by an artificial patient who constructs an inaccurate mental state. Peer involvement increases motivation, since the success of the exercise is dependent on the participation of all four members of the group. It was noticeable that students were reluctant to let down other group members through non-attendance, Peer review was deemed to be useful by the students and in general it was seen as a supportive and constructive exercise. However, some students found that performing in front of their peers increased anxiety, and other students found it difficult to give constructive feedback. Pendleton (Pendleton et al. 1984), who has written extensively on doctor-patient communication and its relationship to diagnosis and treatment, has stressed that for feedback to be an effective teaching stratagem, participants should
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evaluate in a constructive manner. He has suggested ground rules which ensure this happens. One role of the senior psychiatrist who attends the workshops is to encourage helpful feedback. In addition, the psychiatrist explains to students that this teaching procedure of observation and feedback is one which they are likely to encounter in examinations, where clinical skills are often observed, and in later practice where peer review or audit is becoming an expected part of professional life. Apart from having an important role in ensuring that feedback is constructive, the senior psychiatrist can ensure that students do not concentrate their feedback only on a discussion of the patient’s pathology but also attend to the techniques of interviewing and show their feelings about these. In this way, students are made more self-conscious about the process of interviewing and are deterred from concentrating wholly on content. There are clearly limitations to the teaching methods employed. Although the package provides only a brief training experience it may, a t first sight, appear to have extensive resource implications. Overall requirement for one year is for senior psychiatrist involvement in 75 half-day workshops. However, this teaching load is spread over the total consultant body and interested senior registrars and occurs in 4 separate weeks through the year. This has proved to be a manageable arrangement. In addition, it should be emphasized that early involvement of senior psychiatrists in teaching interviewing techniques to students who are attached to them during their subsequent placement gives weight to such training and helps trainers to provide continuity of education. Although the teaching package described here can have only a limited function in upgrading interviewing skills, some teachers have demonstrated how very brief training can be effective through concentrating on specific skills, if these are known to be appropriate to the situation (Bird & Lindley 1979) The mental state examination is the most difficult psychiatric interviewing skill to acquire and this justifies maximum emphasis on this aspect during the teaching programme. In ideal circumstances, there would be focused training throughout the subsequent psychiatric placement.
Acknowledgements The authors would like to thank all the facilitators who participated in this Workshop, and to thank Mrs A. Kershaw for typing this script.
References Balint M. (1964) The Doctor, the Patient and his Illness. Pitman Medical, London. Bird J. & Lindley P. (1974) Interviewing skill: the effects of ultra-brief training for general practitioners. A preliminary report. Medical Education 13, 349-55. Carroll J.G. & Monroe J. (1979) Teaching medical interviewing. Journal of Medical Education 54, 498. Cox A. (1989)Eliciting patients’ feelings. In: Communicating with Medical Patients (ed. by M. Stewart & D. Roter), pp. 96-106. Sage, Newbury Park. Crisp A.H. (1986) Undergraduate training for communication in medical practice. Journal ofthe Royal Society ofMedicine 79, 568. GoldbergD.P., SteelJ.J., Smith C. & Sprireg L. (1980) Training family doctors to recognise psychiatric illness with increased accuracy. Lancet ii, 521-3. Hampton G.R., Harrison M.T.G., Mitchell J.R. A,, Prichard J.S. & Seymour C. (1975) Relative contributions ofhistory taking, physical examination and laboratory investigations to diagnosis and management of medical outpatients. British MedicalJournal 2, 486-7. Hannay D.R. (1980) Teaching interviewing with simulated patients. Medical Education 14, 246-8. Hatter M.J., Duney C.I., Zakus G.E., Mo0reB.J.. Ott J.E. & Favret A.C. (1977) Interviewing skills: a comprehensive approach to teaching and evaluation. Journal of Medical Education 52, 328-33. Helfer R.E. (1970) An objective comparison ofpaediatric interviewing skills of freshmen and senior medical students. Paediatrics 45, 623-7. Kerr D. (1986) Teaching communication skills in postgraduate medical education.Journal ofthe Royal Society ofMedicine 79, 575. Knox J.D.E. & Bouchier I.A.D. (1985) Communication skills teaching, learning and assessment. Medical Education 19, 285-9. Ley P. (1982) Satisfaction, compliance and communications. British Journal of Clinical Psychology 21, 24 1-254. Ley P. & Spelman M.S. (1967) Communication with the Patient. Staple Press, London. Maguire P., Fairburn S. & Fletcher C. (1986) Consultation skills ofyoung doctors. British Medicaljournal 292, 15734. Maguire P., Fairburn S. & Fletcher C. (1989) Consultation skills of young doctors - benefits of undergraduate feedback training in interviewing. In: Communicating with Medical Patients (ed. by M. Stewart & D. Roter), pp. 124-137. Sage, Newbury Park.
Teaching psychiatric interview skills Maguire G.P., Roe P. & Goldberg D. (1978) The value of feedback in teaching interviewing skills to medical students. Psychological Medicine 8, 695-704. Maguire G.P. & Rutter D.R. (1976a) History taking for medical students: I. Deficiencies in performance. Lancet i, 556-8. Maguire G.P. & Rutter D.R. (1976b) Training medical students to communicate. In: T h e Development and Evaluation o f a Training Procedure in Communications Between Doctors and Patients (ed. by A.E. Bennet), pp. 45-74. Oxford University Press, Oxford. Maguire G.P. & Rutter D.R. (1976~)History taking for medical students. Evaluation of a Training Programme. Lancet ii, 558-560. Pendleton D., Schofield T., Tate P. & Havelock P. (1980) The Consultation. An Approach to Learning and Teaching. Oxford General Practice Series 6, Oxford University Press, Oxford.
Reynolds M. (1978) No news is bad news: patients’ views about communication in hospital. British Medical]ournal 1, 1673-6. Rosen B.K. (1984) Video and interview training at Guys. A U T P Newsletter, 26-8. Schofield T. & Arnston P. (1989) A model for teaching doctor - patient communication during residency. In: Communicating with Medical Patients (ed. by M. Stewart & D. Roter), pp. 138-52. Sage, Newbury Park. Wakeford R. (1983) Skills training in United Kingdom Medical Schools. In: Doctor Patient - Communication (ed. by D. Pendleton & J. Hasler), pp. 233-48. Academic Press, London. Whitehouse C., Morris P. & Maks B. (1984) The role of actors in teaching communication. Medical Education 18, 262-8.
Appendix Techniques of interviewing These questions relate as to whether your colleague was able to elicitfactual material appropriately.
Please put Yes or No. Note: You are the convenor of this session. We would like you to discuss with all your colleagues what you learnt most from today’s session about interview techniques and bring to the plenary session two useful techniques which you have learnt about and two difficulties which you have experienced. Did your colleague: 1. Use OPEN questions? 2. Get a detailed description of an experience relevant to the presented problems or personal history? 3. Explore the consequences of the complaint/problem/experience for daily life? 4. Summarize and feedback his understanding of the patient’s complaints/experiences? 5. Clarify details of the complaints/experiences by direct or closed questions? 6. Ask how the patient tried to solve the problem/deal with an earlier experience?
YesINo YesINo YesINo YesINo YesINo YesINo
Techniques of interviewing Feeling Sheet These questions relate as to whether your colleague was able to elicit appropriately the patient’s expressions of feelings, for example, whether he was sensitive to the emotional experience of the patient.
Please answer Yes or No. Did your colleague: 1. Notice verbal and non-verbal clues to the patient’s feelings? 2. Seek the opinion of the patient about the nature and cause of the problem? 3. Explore how the patient really feels/felt? 4. Show warmth? 5. Show empathy, that is, correctly expressed understanding of the patient’s position/feelings? 6. Explore carefully the patient’s feelings and opinions about significant events or experiences?
YesINo YesINo YeslNo YeslNo YesINo YesINo
Techniques of interviewing Control Sheet These questions relate as to whether your colleague was able to initiate the interview appropriately and then take control of the interview during the next half hour
Please put Yes or No. Did your colleague: 1. Introduce himself/herself? 2. Arrange seating and/or invite the patient to sit down? 3. Orient the patient, i.e. clarify and if necessary explain the reason for the interview?
YesINo YesINo YesINo
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4. Facilitate communication with the patient by listening behaviour, e.g. through posture, gaze, YesINo YeslNo YesINo
nodding and vocal or verbal encouragement? 5. Prevent the patient from repeating hidherself or being verbose? 6 . Conclude the interview with a summary?
Your colleague was self-assured Your colleague conveyed warmth towards the patient Your colleague seemed to understand the emotional situation of the patient Your colleague seemed in control of the interview
Received 17January 1989; editorial comments to authors 21 April 1989; acceptedforpublication 23 August 1989