Patient-centered Interviewing Research Articles

Yale University School of Medicine

Yale University School of Medicine

Eliciting the patient's perspective: Does experience or type of case make a difference?

Objective Patient-centered interviewing is an increasingly important aspect of medical education. One way to quantify this skill is the Four Habits Model, which helps to organize medical interviewing. The Four Habits are: invest in the beginning, elicit the patient's perspective, demonstrate empathy and invest in the end. In a previous study at our institution, students were competent in all of the habits but “eliciting the patient's perspective” during a standardized patient case. Based on this study, we hypothesized that the students’ poor performance could be related to the type of case or to clinical experience. Methods We placed three “eliciting the patient's perspective” items on the checklist for two standardized patients, one with and one without a clear diagnosis. We planned to compare group performance between cases and semesters of the third year. We hypothesized that students would be more patient-centered earlier in the year and with an ambiguous diagnosis. Results Students were more patient-centered with the ambiguous diagnosis and later in their third year. Patient-centeredness was measured by an eliciting the patient's perspective (EPP) score based on the checklist items. Conclusion Our results provide information that may help guide curriculum development and future study to advance patient-centered interviewing skills.

Patient-Centered Interviewing: Narrative Approach

Patient-centered interviewing is to understand and respond to patient's needs and prefers at the level of patient. For practicing the patient-centered interview, the way of communication should be changed in history taking, explanation, and patient education. Story telling (illness narrative) which composes of 5 dimensions such as abstract, orientation, development (complication), evaluation, and coda is the unique and key way to approach the area of patient's illness experience, values, history of life, social environment (occupation, family relationship), and emotion. Narrative gives information about how a story teller views and expresses the event that he/she experienced before, and information about how a story teller positions the self, the subjects of story, and listener's identities. Narrative competence to listen to a patient's story requires several kind of interview skills at the moment of patient's expression of disease history, including skill for composing story, skill for listening, skill for empathizing, and skill for effective questioning. Collecting patient's illness story is not refi ned to the individual patient. If we listen to the various patients' illness stories, who have the similar disease, and arrange the stories systematically, the patients' illness database can help many patients by the facts in the database and the therapeutic power of the other patients' illness stories.

Talking with patients and peers: Medical students’ difficulties with learning communication skills

Background: Patient-centered communication skills, such as an empathic attitude towards patients and a holistic perspective on health, are difficult to acquire. Designing effective courses requires better understanding of the difficulties that students perceive with learning to talk with patientsAims: The study aimed at exploring students' common difficulties with learning patient-centered communication skills.Methods: Group discussions about student-patient interviews were videotaped and analyzed with regard to issues that students perceived as difficult and to their reflections about these difficulties.Results: The students reported feeling intrusive as they explored the patient's psychosocial situation. They avoided being empathic and felt insecure about coping adequately with emotionally loaded topics. Their difficulties were mainly due to insufficient understanding of the functional relations between psychosocial issues and health conditions. Moreover, students were insecure concerning the function of affective feedback in the diagnostic process. However, the group discussions generated a language for analyzing and structuring interviews that helped develop the students' professional identities.Conclusions: Students experienced moral qualms about applying major aspects of patient-centered interviewing. Instruction in communication skills should aim at filling the students' knowledge gaps and fostering their awareness and expression of emotional perceptions. Long-term relationships with patients could help develop patient-centered communication.

Patient-centered interviewing and student performance in a comprehensive clinical skills examination: Is there an association?

Objective Communication skills, including patient-centered interviewing (PCI), have become a major priority for educational and licensing organizations in the United States. While patient-centered interviewing is associated with positive patient outcomes and improved diagnostic accuracy, it is unknown if an association exists between patient-centered interviewing and student performance in high-stakes clinical skills assessment (CSA) examinations. The purpose of this study was to determine if generic communication skills and patient-centered interviewing skills were associated with students’ overall student performance on a multi-station clinical skills assessment (CSA) examination. Methods This was a cross-sectional study to assess student performance with standardized patients (SPs). We conducted a retrospective review of 30 videotaped SP encounters of Third year medical students (class of 2006) at the University of Kansas School of Medicine. We measured correlations between observed PCI scores, overall CSA scores and CSA interpersonal and communication (ICS) skills scores of student–SP encounters. Results PCI scores, as measured with the Four Habits Coding Scheme, a measurement tool of patient-centered communication, were not correlated with either overall CSA scores or ICS scores. Students’ PCI scores were lower than the ICS scores (57% vs. 85% of correct items). The students performed poorly (30% mean score of correct items) in eliciting patient perspectives, compared to three other domains (Invest in the beginning, Demonstrate empathy, and Invest in end) of patient-centered interviewing. Conclusions Our study failed to demonstrate any association between student performance and patient-centered interviewing skills (PCI) in the setting of a comprehensive in-house CSA examination. Third-year medical students in our study did not practice some elements of patient-centered interviewing. Practice implications Given the increasing importance of patient-centered communication, the high-stakes in-house clinical skills examinations may consider assessing patient-centered interviewing using a more comprehensive and valid checklist.

Talking about Spirituality in the Clinical Setting: Can Being Professional Require Being Personal?

Spirituality or religion often presents as a foreign element to the clinical environment, and its language and reasoning can be a source of conflict there. As a result, the use of spirituality or religion by patients and families seems to be a solicitation that is destined to be unanswered and seems to open a distance between those who speak this language and those who do not. I argue that there are two promising approaches for engaging such language and helping patients and their families to productively engage in the decision-making process. First, patient-centered interviewing techniques can be employed to explore the patient's religious or spiritual beliefs and successfully translate them into choices. Second, and more radically, I suggest that in some more recalcitrant conflicts regarding treatment plans, resolution may require that clinicians become more involved, personally engaging in discussion and disclosure of religious and spiritual worldviews. I believe that both these approaches are supported by rich models of informed consent such as the transparency model and identify considerations and circumstances that can justify such personal disclosures. I conclude by offering some considerations for curbing potential unprofessional excesses or abuses in discussing spirituality and religion with patients.

A Shared Decision-Making Primary Care Intervention for Type 2 Diabetes

The purpose of this study is to test the feasibility of a brief shared decision-making (SDM) goal-setting intervention among individuals with type 2 diabetes. A convenience sample of 58 patients from the University Internal Medicine Resident Clinic was recruited to participate in the study. Outcomes were tested through a pilot test of the intervention and ongoing conversations with clinic nursing staff and physicians. Patient outcomes included preintervention and postintervention hemoglobin A1C (HbA1c), weight and blood pressure levels, preintervention and postintervention patient survey questionnaires, and documented diabetes goals. Most providers indicated that the SDM intervention did not impose major demands. Patient-centered interviewing and an SDM approach to goal setting led to 75.9% of patients having at least 1 diabetes management goal documented in their medical record after intervention. HbA1c level, weight, and diabetes empowerment score showed a trend toward improvement, as did patient ratings of "life disruption from having diabetes." Postintervention perceived knowledge of diabetes and treatments increased significantly (P = .001), as did the mean numbers of documented diabetes management goals (P < .001). An SDM intervention for individuals with type 2 diabetes appears to be feasible and may improve major diabetes outcomes in primary care. SDM workbooks and activities can encourage patients to identify realistic diabetes goals with primary care providers. These results are encouraging. Future randomized trials with larger samples are warranted.

Using patient‐centered interviewing skills to manage complex patient encounters in primary care

To describe effective and efficient patient-centered interviewing strategies to enhance the management of complex primary care patient encounters. Research literature and applied case study analysis. Patient-centered interviewing can enhance effectiveness of care in complex patient encounters. A relatively small investment of time and energy has positive yields in regard to improvements in longer term physiological status, treatment adherence, quality of life, patient-provider working relationship, and patient and nurse practitioner satisfaction. Use of patient-centered interviewing strategies can enhance effectiveness of patient care processes and outcomes while retaining efficiency of patient management.

Communication skills for mobile remote presence technology in clinical interactions

The use of mobile robotic units for teleconsultation means that the clinician's cognitive and attention skills are divided between tele-operation of the robotic unit and the consultation with the patient. We developed a communication guide based on evidence-based patient-centred interviewing and telephone conferencing skills. The communication guide was tested by five trainee surgeons in a pre- and post-test design. Each surgeon completed three simulated patient consultations. After reading the communication guide, trainees completed three further consultations. The trainees rated authenticity, degree of difficulty, familiarity of clinical presentation and confidence in using telepresence to manage the consultations. Their mean scores were 3.0-4.6, 2.2-4.0, 4.4-4.8 and 3.2-4.2 respectively (maximum possible score 5). The simulated patients rated their satisfaction with communication. Their ratings suggested that there were areas for communication skills development with mean scores ranging from 8.2 to 11.4 (maximum possible score = 15). Although we do not yet know enough about communicating with real patients using mobile robotic units, the communication guide appeared to be useful in our simulated interactions.

A practical assessment of physician biopsychosocial performance

Background: A biopsychosocial approach to care seems to improve patient satisfaction and health outcomes. Nevertheless, this approach is not widely practiced, possibly because its precepts have not been translated into observable skills.Aim: To identify the skill components of a biopsychosocial consultation and develop an tool for their evaluation.Methods: We approached three e-mail discussion groups of family physicians and pooled their responses to the question “what types of observed physician behavior would characterize a biopsychosocial consultation?” We received 35 responses describing 37 types of behavior, all of which seemed to cluster around one of three aspects: patient-centered interview; system-centered and family-centered approach to care; or problem-solving orientation. Using these categories, we developed a nine-item evaluation tool. We used the evaluation tool to score videotaped encounters of patients with two types of doctors: family physicians who were identified by peer ratings to have a highly biopsychosocial orientation (n = 9) or a highly biomedical approach (n = 4); and 44 general practitioners, before and after they had participated in a program that taught a biopsychosocial approach to care.Results: The evaluation tool was found to demonstrate high reliability (α = 0.90) and acceptable interobserver variability. The average scores of the physicians with a highly biopsychosocial orientation were significantly higher than those of physicians with a highly biomedical approach. There were significant differences between the scores of the teaching-program participants before and after the program.Conclusions: A biopsychosocial approach to patient care can be characterized using a valid and easy-to-apply evaluation tool.

Preoperative Nursing Assessment of the Surgical Patient

Thorough assessment of the surgical patient begins in the preoperative phase and extends throughout the perioperative experience. Patient-centered interviews gather critical data that contribute to a successful experience and a focused plan of care. Information collected, documented, and conveyed to the surgeon or physician assists in appropriate medical decision making. This article focuses on perioperative nursing assessment tools and discusses issues pertinent to achieving safe delivery of care. A broad overview touches on key topics that deserve exploration and evaluation. This article will hopefully serve as a useful tool that helps direct the decision-making process.

Prior experiences associated with residents’ scores on a communication and interpersonal skill OSCE

Objective This exploratory study investigated whether prior task experience and comfort correlate with scores on an assessment of patient-centered communication. Methods A six-station standardized patient exam assessed patient-centered communication of 79 PGY2-3 residents in Internal Medicine and Family Medicine. A survey provided information on prior experiences. t-tests, correlations, and multi-factorial ANOVA explored relationship between scores and experiences. Results Experience with a task predicted comfort but did not predict communication scores. Comfort was moderately correlated with communication scores for some tasks; residents who were less comfortable were indeed less skilled, but greater comfort did not predict higher scores. Female gender and medical school experiences with standardized patients along with training in patient-centered interviewing were associated with higher scores. Residents without standardized patient experiences in medical school were almost five times more likely to be rejected by patients. Conclusions Task experience alone does not guarantee better communication, and may instill a false sense of confidence. Experiences with standardized patients during medical school, especially in combination with interviewing courses, may provide an element of “deliberate practice” and have a long-term impact on communication skills. Practice Implications The combination of didactic courses and practice with standardized patients may promote a patient-centered approach.

The Prospective Registry Evaluating Myocardial Infarction: Events and Recovery (PREMIER)—Evaluating the impact of myocardial infarction on patient outcomes

More information on the longitudinal care and outcomes of patients after myocardial infarction (MI) is needed to further improve the quality of MI care. The PREMIER study was designed to meet this need. Patients with MI were prospectively screened and enrolled from 19 US centers between January 1, 2003, and June 28, 2004. Consenting patients had detailed chart abstractions of their medical history and processes of inpatient care, supplemented with a detailed, patient-centered interview. Centralized follow-up at 1, 6, and 12 months is being conducted to quantify patients' postdischarge care and outcomes, with a focus on their health status (symptoms, function, and quality of life). In 2003, detailed chart abstractions, devoid of all personal health information, were collected for patients eligible but not enrolled in PREMIER. Of 10,911 patients screened, 3953 were eligible and 2498 enrolled into PREMIER. Few clinically significant differences between the total MI population and those enrolled into PREMIER were observed. Adherence to accepted processes of quality care, such as aspirin and beta-blockers on admission (96% and 91%) or discharge (96% and 93%), was high. One-month follow-up rates were high, with only 9% of patients being lost to follow-up. PREMIER is a novel registry with detailed insights into patients' sociodemographic, clinical, and health status characteristics, as well as detailed monitoring of their inpatient and outpatient processes of care. Ultimately, PREMIER will describe patients' health status outcomes and identify determinants of these outcomes as an important step toward improving MI care.

‘She gave it her best shot right away’: Patient experiences of biomedical and patient-centered communication

Objective Medical educators and researchers recommend a patient-centered interviewing style, but little empirical data exists regarding what aspects of physician communication patients like and why. We investigated patient responses to videotaped doctor–patient vignettes to ascertain what they liked about patient-centered and biomedical communication. Methods We conducted semi-structured interviews with 230 adult medicine patients who viewed videotapes depicting both patient-centered and biomedical physician communication styles. We used a mixed methods approach to derive a “ground-up” framework of patient communication preferences. Results Respondents who preferred different communication styles articulated different sets of values, important physician behaviors, and physician–patient role expectations. Participants who preferred the patient-centered physician (69%) liked that she worked with and respected patients and explored what the patient wanted. Participants who preferred the biomedical physician (31%) liked that she prevented harm, demonstrated medical authority, and delivered information clearly. Conclusions Patients like (and dislike) patient-centered communication for thoughtful, considered reasons that appear grounded in their values and expectations about physicians, patients, and the clinical encounter. Practice implications Better understanding the diversity of patient communication preferences may lead to more effective and individualized care.

Peer assisted learning in patient-centred interviewing: the impact on student tutors

Effective methods for teaching patient-centred interviewing skills are resource intensive. Providing students the opportunity to work in small groups with simulated patients is highly valued and has demonstrable long-term benefits. Expanding cohorts of medical students and diminishing faculty resources led to the implementation of a peer assisted learning (PAL) project in patient-centred interviewing skills. The paper reports the evaluation of a PAL project on student tutors. The methodology included direct and indirect measures of student tutors’ skills in facilitation and patient-centred interviewing. The self-report evaluations strongly suggest that participating in a PAL project has substantial benefits for student tutors that included both interviewing and facilitation skills. Objective measures revealed no change in patient-centred interviewing skills after participating in the project. The study concludes that formalizing PAL may tap a valuable resource within the medical school and provide benefits for student tutors. Careful consideration needs to be given to ways in which student tutors are supported before, during and after the project.

Patient-Centered Attitudes and Communication Skills in Medical Students after Clerkship

Purpose: Patient-centered communication is known to improve patient satisfaction, compliance, doctor-patient relationship, and health outcomes. The aim of this study is to evaluate patient-centered communication skills and attitudes in medical students after their clerkship. Method: To evaluate their communication skills, OSCE was performed on 114 fourth-year medical students who had completed their clerkship. After OSCE, we used structured questionnaires to survey the subjects in assessing attitudes toward communication skill learning and patient-centeredness. Results: The accomplished frequency of patient-centered communication items were as follows: allow patient’s narrative thread (), open-to-closed-ended questions (), discuss psychosocial and emotional factors (), elicit patient’s concerns and perspectives (), discuss how health problem affects patient’s daily life (), express empathy (), negotiate plan of action with patient (), and ask whether patient has further issues to discuss (). The students who did [medical service as extracurricular activity??????????] and were confident with their communication skills performed better patient-centered interviews. There was no significant relationship between medical students’ patient-centered attitudes and patient-centered OSCE scores. Conclusion: Having completed their clerkship, medical students were still unable to perform a good patient-centered interview. Current medical curriculum should teach medical students how to communicate in a patient-centered manner. The education method should focus on behavior change initiatives.

The internal medicine clinical clerkship: opportunities for improvement

We have witnessed a recent explosion of new knowledge in medical education. The use of creative teaching methodologies, curriculum development and the recognition of medical education as a field ripe for research and investigation have occurred at many medical schools in Europe and North America. However, most of this innovation has occurred in the pre-clinical years and very little has been transferred to the clinical setting. The use of comprehensive curricula with goals and objectives, problem-based learning (PBL), a renewed emphasis on physical diagnosis, evidence-based medicine (EBM), patient-centered interviewing, ambulatory education, computer-based learning and new methods of assessment all need to be introduced into the clinical clerkships while ensuring that the majority of learning still takes place through the student–patient interaction at the bedside. By virtue of its traditional excellence in medical education, internal medicine has the opportunity to take the lead in revitalizing clinical education by building on our successful past and leading the other disciplines into the future.

Peer tutoring in patient-centred interviewing skills: experience of a project for first-year students

Peer tutoring is a potentially valuable resource in higher education. There are few published accounts of the impact of peer tutoring in medical education. College-wide experience of peer tutoring together with difficulties recruiting medical teachers for a communication programme led to the development of a peer-tutoring project. This paper reports the impact on first-year medical students of peer tutoring in patient-centred interviewing. After attending a preparatory workshop, third-year medical students co-facilitated their first-year colleagues in a session: Interviewing a Simulated Patient. First-year students completed written evaluations immediately after the session and two months later randomly selected students were assessed in patient-centred interviews. The impact of the peer-tutoring experience was evaluated by comparing these outcomes for students in groups co-facilitated by peer tutors with those who worked in groups facilitated by medical teachers. The eight learning objectives were completely met by more than 56% of students. However, there were statistically significant differences for four objectives with more students in groups facilitated by medical teachers completely meeting these objectives. Although the seven educational techniques used in the session were rated favourably by all students, two were rated as more effective in achieving the learning objectives by students in groups facilitated by medical teachers. Free-text comments revealed no differences between groups. Two months after the session, there were no differences between students in terms of interviewing skills as rated by trained observers and simulated patients, whilst simulated patients were more satisfied with interviews from students facilitated by peer tutors ( p < 0.02). Peer tutors can support the acquisition of basic patient-centred interviewing skills in first-year medical students when contributing to one session of a structured programme. First-year students were receptive and willing to learn from their senior colleagues.

Improving residents' interviewing skills by group videotape review.

Internal medicine residency training programs typically emphasize biomedical learning, but relatively few provide opportunities for residents to improve outpatient interviewing skills or to address challenging patient encounters. Even fewer programs provide resources to assess patient-resident relationship skills. To address these issues, we developed a curriculum that is designed to enhance patient-centered interviewing techniques in residents. At the UCSF-VA PRIME residency program, interns on ambulatory block attend three didactic sessions that introduce basic medical interviewing techniques, including elicitation of patient concerns and mutual agenda setting, biopsychosocial interviewing, and conflict resolution in the patient-physician relationship. These sessions are taught using role-play exercises and interactive, case-based discussions. Second- and third-year residents on ambulatory block participate in an ongoing small-group seminar in which they present videotapes of their interviews with patients. To make these tapes, residents arrange to see patients in a clinic room where a videotape recorder is mounted on the wall. Patients who consent to be videotaped complete a form stating that the tapes are to be used solely for educational purposes. Twice a year, each of our 16 residents selects one encounter that highlights personal learning goals related to interviewing and presents those learning goals with associated videotape clips in a 90-minute seminar. Each seminar is devoted to two residents, who facilitate a discussion of the effectiveness of the interview and solicit feedback about potential methods for improvement. When the seminars were originally developed, we anticipated that this innovative combination of traditional individual videotape review with small-group learning would encourage self-directed learning. Indeed, over the last three years, residents have become more confident with their interviewing capabilities and less self-conscious about showing their own videotaped interviews. As a result, the seminars have unexpectedly evolved into a highly sophisticated series of learning modules, in which residents seek their most challenging patient encounters to videotape and show to the group. Residents have presented complicated scenarios involving critical patient-physician conflicts, somatizing patients, cross-cultural communication difficulties, overzealous family members, patients with substance abuse, and bad-news interviews. These dilemmas represent fundamental management challenges that are difficult to discuss in a more didactic format, and the immediate case-based nature of the interviews makes these often-emotional issues come alive. The group videotape reviews also give residents opportunities to reflect on their own interviewing encounters, to observe other interviewing styles and techniques, and to provide support to their fellow residents after particularly emotional interviews. An ancillary benefit of these exercises is that we have now developed a library of challenging interviews, which are easily accessible for further teaching seminars. Our residents consider this learning experience to be one of the most positive of their residency and valuable for their professional development. Residents report that this small-group seminar series has markedly improved their communication with patients, and they now clamor for the opportunity to present interviewing dilemmas. We believe that similar curricula can be readily instituted at other residency programs.

The biopsychosocial revolution

The biopsychosocial revolution