Residency training in interviewing skills and the psychosocial domain of medical practice

Identifying core curricular components for behavioral health training in internal medicine residency: Qualitative interviews with residents, faculty, and behavioral health clinicians

OBJECTIVE

Behavioral health services frequently delivered by primary care providers include care for mental health and substance abuse disorders and assistance with behavioral risk factor reduction. Internal medicine residencies in the United States lack formal expectations regarding training in behavioral health for residents. This qualitative study aimed to determine learners' and teachers' perceptions about appropriate behavioral health curricular components for internal medicine residents.

METHOD

Focus groups and interviews were conducted with the following individuals from the Duke Outpatient Clinic: residents with continuity practice (n = 27), advanced practice providers (n = 2), internal medicine attending physicians (n = 4), internal medicine/psychiatry attending physicians (n = 2), and behavioral health clinicians (n = 4). A focus group leader asked regarding residents' successes and challenges in managing behavioral health issues and about specific learning components considered necessary to understand and manage these behavioral health conditions. Transcripts were coded using an editing analysis style to identify central themes and concordance/discordance between groups.

RESULTS

Regarding mental health management (Theme 1), residents emphasized a need for better care coordination with specialty mental health, while attendings and behavioral health clinicians gave priority to residents' skills in primary management of mental health. Residents, attendings, and behavioral health clinicians all emphasized advanced interviewing skills (Theme 2) with subthemes: eliciting the patient's perspective, managing time in encounters, improving patients' understanding, and patient counseling.

CONCLUSIONS

Internal medicine residents, attendings, and behavioral health clinicians may differ significantly in their perceptions of primary care's role in mental health care. Future internal medicine behavioral health curricula should specifically address these attitudinal differences. Curricula should also emphasize interview skills training as an essential component of behavioral health learning.

Psychosocial Factors in Older Patients 'Medical Encounters

This article reviews the literature and presents some new preliminary findings on physician-older patient communication about psychosocial issues in primary care medical visits. The authors examine the importance of psychosocial talk in medical encounters, the barriers to these discussions, and the prevalence and specific content of psychosocial discussions in primary care medical encounters. The research suggests that the preponderance of talk in the medical encounter is biomedical, with little attention to psychosocial topics. The differential attention to the biomedical sphere may be more common and more problematic with the elderly. A research agenda in three areas is proposed. Investigations are needed on: (a) the determinants, outcomes, and nature of physician-older patient communication about psychosocial issues; (b) the psychosocial factors that are problematic in older patients' lives and have relevance for their medical care; and (c) the psychosocial issues that arise when the older patient is sick or disabled.

Bioterrorism training in U.S. emergency medicine residencies: has it changed since 9/11?

OBJECTIVES

To assess the change in prevalence of bioterrorism training among emergency medicine (EM) residencies from 1998 to 2005, to characterize current training, and to identify characteristics of programs that have implemented more intensive training methods.

METHODS

This was a national cross sectional survey of the 133 U.S. EM residencies participating in the 2005 National Resident Matching Program; comparison with a baseline survey from 1998 was performed. Types of training provided were assessed, and programs using experiential methods were identified.

RESULTS

Of 112 programs (84.2%) responding, 98% reported formal training in bioterrorism, increased from 53% (40/76) responding in 1998. In 2005, most programs with bioterrorism training (65%) used at least three methods of instruction, mostly lectures (95%) and disaster drills (80%). Fewer programs used experiential methods such as field exercises or bioterrorism-specific rotations (35% and 13%, respectively). Compared with other programs, residency programs with more complex, experiential methods were more likely to teach bioterrorism-related topics at least twice a year (83% vs. 59%; p = 0.018), to teach at least three topics (60% vs. 40%; p = 0.02), and to report funding for bioterrorism research and education (74% vs. 45%; p = 0.007). Experiential and nonexperiential programs were similar in program type (university or nonuniversity), length of program, number of residents, geographic location, and urban or rural setting.

CONCLUSIONS

Training of EM residents in bioterrorism preparedness has increased markedly since 1998. However, training is often of low intensity, relying mainly on nonexperiential instruction such as lectures. Although current recommendations are that training in bioterrorism include experiential learning experiences, the authors found the rate of these experiences to be low.

Role modeling humanistic behavior: learning bedside manner from the experts

PURPOSE

Humanistic care is regarded as important by patients and professional accrediting agencies, but little is known about how attitudes and behaviors in this domain are taught in clinical settings. To answer this question, the authors studied how excellent clinical teachers impart the behaviors and attitudes consistent with humanistic care to their learners.

METHOD

Using an observational, qualitative methodology, the authors studied 12 clinical faculty identified by the medical residents enrolled from 2003 to 2004 as excellent teachers of humanistic care on the inpatient medical services at four medical universities in the United States (University of Minnesota Medical School, Emory University, University of Rochester School of Medicine, and Baylor College of Medicine). Observations were conducted by the authors using standardized field notes. After each encounter, the authors debriefed patients, learners (residents and medical students), and the teaching physicians in semistructured interviews.

RESULTS

Clinical teachers taught primarily by role modeling. Although they were highly aware of their significance as role models, they did not typically address the human dimensions of care overtly. Despite the common themes of role modeling identified, each clinical teacher exhibited unique teaching strategies. These clinical teachers identified self-reflection as the primary method by which they developed and refined their teaching strategies.

CONCLUSIONS

Role modeling is the primary method by which excellent clinical teachers try to teach medical residents humanistic aspects of medical care. Although clinical teachers develop unique teaching styles and strategies, common themes are shared and could be used for the future development of clinical faculty.

The effect of physician solicitation approaches on ability to identify patient concerns

CONTEXT

Studies showing that physicians often interrupt the patient's opening statement assume that this compromises data collection.

OBJECTIVE

To explore the association between such interruptions and physician accuracy in identifying patient concerns.

DESIGN

This study replicates the Beckman-Frankel methodology and adds exit interviews to assess physician understanding. The authors audiotaped a convenience sample of 70 encounters and surveyed both parties following the visit.

SETTING

A community-based ambulatory clinic.

PARTICIPANTS

Internal medicine residents (77%) and attending physicians and their adult, English-speaking patients who were primarily low income and ethnic minority.

OUTCOME MEASURE

The Index of Understanding measures patient-physician problem list concordance. It is the percentage of patient problems, obtained on exit, that the physician correctly identifies.

RESULTS

In 26% of the visits, patients were allowed to complete their agenda without interruption; in 37% the physicians interrupted; and in 37% no inquiry about agenda was made in the first 5 minutes. Neither physician experience nor their assessment of time pressure or medical difficulty was associated with these rates. Exit interviews showed no significant difference in Index of Understanding between those involving completion of agenda (84.6%) and those involving patient interruption (82.4%) (P=.83). But when the physician did not solicit an agenda, the concordance was 59.2%, significantly lower than either the completion (P=.014) or the interruption group (P=.013).

CONCLUSION

Interruption as defined by Beckman-Frankel does not curtail ability to identify patient concerns, but failure to ask for the patient's agenda associates with a 24% reduction in physician understanding.

Teaching the psychosocial aspects of care in the clinical setting: practical recommendations

Communication skills and the psychosocial dimensions of patient care are increasingly taught in medical schools and generalist residency programs. Evidence suggests they are not reinforced or optimally implemented in clinical training. The authors present the product of an iterative process that was part of a national faculty development program and involved both experts and generalist teachers concerning teaching psychosocial medicine while precepting medical students and residents in clinical settings. Using scientific evidence, educational theory, and experience, the authors developed recommendations, presented them in workshops, and revised them based on input from other experts and teachers, who gave feedback and added suggestions. The results are practical, expert consensus recommendations for clinical preceptors on how to teach and reinforce learning in this area. General skills to use in preparing the trainee for improved psychosocial care are organized into the mnemonic "CAARE MORE": Connect personally with the trainee; Ask psychosocial questions and Assess the trainee's knowledge/attitudes/skills/behaviors; Role model desired attitudes/skills/behaviors; create a safe, supportive, enjoyable learning Environment; formulate specific Management strategies regarding psychosocial issues; Observe the trainee's affect and behavior; Reflect and provide feedback on doctor-patient and preceptor-trainee interactions; and provide Educational resources and best Evidence. The preceptor-trainee teaching skills that are recommended parallel good doctor-patient interaction skills. They can be used during both preceptor-trainee and preceptor-trainee-patient encounters. Important common psychosocial situations that need to be managed in patients include substance abuse, depression, anxiety, somatoform disorder, physical and sexual abuse, and posttraumatic stress disorder. For these problems, where high-level evidence exists, specific psychosocial questions for screening and case finding are provided.

Teaching the teachers: national survey of faculty development in departments of medicine of U.S. teaching hospitals

OBJECTIVE

To determine the prevalence, topics, methods, and intensity of ongoing faculty development (FD) in teaching skills.

DESIGN

Mailed survey.

PARTICIPANTS

Two hundred and seventy-seven of the 386 (72%) U.S. teaching hospitals with internal medicine residency programs.

MEASUREMENTS

Prevalence and characteristics of ongoing FD.

RESULTS

One hundred and eight teaching hospitals (39%) reported ongoing FD. Hospitals with a primary medical school affiliation (university hospitals) were more likely to have ongoing FD than non-university hospitals. For non-university hospitals, funding from the Health Resources Services Administration and >50 house staff were associated with ongoing FD. For university hospitals, >100 department of medicine faculty was associated. Ongoing programs included a mean of 10.4 topics (standard deviation, 5.4). Most offered half-day workshops (80%), but 22% offered > or =1-month programs. Evaluations were predominantly limited to postcourse evaluations forms. Only 14% of the hospitals with ongoing FD (5% of all hospitals) had "advanced" programs, defined as offering > or =10 topics, lasting >2 days, and using > or =3 experiential teaching methods. These were significantly more likely to be university hospitals and to offer salary support and/or protected time to their FD instructors. Generalists and hospital-based faculty were more likely to receive training than subspecialist and community-based faculty. Factors facilitating participation in FD activities were supervisor attitudes, FD expertise, and institutional culture.

CONCLUSIONS

A minority of U.S. teaching hospitals offer ongoing faculty development in teaching skills. Continued progress will likely require increased institutional commitment, improved evaluations, and adequate resources, particularly FD instructors and funding.

Inter and intra individual variations in physicians' verbal behaviour during primary care consultations

It is well established that most medical interviews in primary care are characterised by a scarcity of patient-centred interventions and a predominance of doctor-centred behaviours. Less information is available on the intra- and inter-individual variability between the physicians' use of these categories. The study aimed to examine the impact of physician, physician's attribution of emotional distress, patients' GHQ-12 status and gender on the frequency of doctor and patient-centred verbal behaviours. A matched pair design involved six General Practitioners (GPs) and 238 patients. GPs'speech was classified using nine main categories derived from the Verona medical interview classification system (VR-MICS/D). Frequencies of the behaviours were calculated as percentages of total utterances per interview. Parametric and non-parametric ANOVAs were performed with GHQ-12 score, GP attribution of psychological distress, gender, and the six GPs as main factors. GPs varied in their use of the various interviewing behaviours. GHQ-12 status had no impact on GPs' interview behaviour, while GPs' distress attribution was associated with an increase of closed psychosocial questions and a decrease of closed medical questions. Within comparisons showed that each GP tended to change very little and only as a function of attribution: four out of six GPs increased closed psychosocial questions with patients they thought to be distressed. Patients' gender did not significantly alter GPs' interviewing behaviour. The variability in the use of specific verbal behaviours among GPs indicates a highly individualised approach and the lack of a common interview strategy. The fact that GPs' interviewing styles did not change according to patient characteristics, such as emotional distress, but only according to attribution further indicates that GPs untrained in communication techniques tend to use a predominant doctor-centred approach to the medical interview.

Rehabilitation-specific communication skills training: improving the physician-patient relationship

OBJECTIVE

Evaluate the effectiveness of a rehabilitation-specific communication skills training program for physicians.

DESIGN

Three groups of rehabilitation patients were interviewed 3 mo after discharge, one group before and two groups after implementation of a communication skills training program. The setting was a free-standing rehabilitation hospital with a residency training program. A total of 245 patients who had been discharged from the rehabilitation hospital participated in the study. A communication skills training program that was designed specifically for physicians and patients in the rehabilitation setting was used as an intervention. Patients' perceptions of the extent to which physicians accomplished 18 communication tasks highlighted by the training program were gauged in a structured telephone interview.

RESULTS

Participants interviewed after the training program was implemented more strongly agreed that their physicians accomplished the communication tasks assessed than did patients interviewed before the training program began. On 14 of 18 items, the differences were statistically significant (P < 0.05).

CONCLUSION

Specialty-specific communication training can improve physician communication skills.

Considerations in using tumor markers: what the psycho-oncologist needs to know

Tumor markers are measures of biological features of a cancer. By revealing important biological aspects of the tumor, tumor markers can be useful in staging patients, predicting cancer outcomes, and guiding treatments. The psychological consequences of using tumor markers are virtually unknown. In this review article, we draw on clinical studies involving the psychological impact of risk information, screening, prognostic information and surveillance of cancer. Such studies may be helpful in considering possible psychological reactions to tumor marker information in clinical practice.

Psychosocial training in U.S. internal medicine and family practice residency programs

PURPOSE

Competence in the psychosocial aspects of medical care is necessary for primary care physicians to function effectively. This study investigated the psychosocial training internal medicine and family practice residents receive in U.S. programs.

METHODS

In 1996, program directors of all U.S. internal medicine (IM) and family practice (FP) residency programs were surveyed regarding the format, content, and quantity of psychosocial training provided in their programs, their opinions on topics related to psychosocial training, and demographics of their programs.

RESULTS

The response rate was 61%. Ninety-nine percent of FP and 62% of IM program directors reported requiring at least one psychosocial training experience. Family practice programs required an average of 352 hours (SD +/- 175; range 27-2,664) of psychosocial training compared with 118 hours (SD +/- 272; range 0-1,050) for IM programs. Most IM and FP program directors expected residents to achieve at least basic competency in virtually all psychosocial topic areas; however, FP programs provided a greater range of psychosocial experiences. FP program directors most often identified psychologists and IM program directors most often identified internists as providing the most psychosocial training in their programs. Both IM and FP program directors considered lack of curricular time to be the main obstacle to development of psychosocial training.

CONCLUSION

Residents' competence in psychosocial areas is important to both IM and FP program directors. However, content and time devoted to psychosocial training vary considerably both within and between program types.

Breaking bad news--development of a hospital-based training workshop

The skills required to break bad news have been written about extensively and are taught in medical schools. Recent initiatives have concentrated on improving the skills of doctors and nurses in senior positions, who act as role models for their junior colleagues. A multiprofessional learning situation can be a threatening environment, in which colleagues may worry about exposing some of the weaknesses in their knowledge and skills regarding communication with patients. We describe the initiation, running, and evaluation of successful training workshops on breaking bad news in a large British district hospital.

The effects of communication skills training on patients' participation during medical interviews

Recent models of physician-patient communication emphasize information exchange in promoting partnership. Although considerable attention has been given to physicians' information exchange, little research has examined patients' communication contributions. The purpose of this research was to test the effectiveness of a training booklet designed to enhance patients' communication skills in information exchange. A nested design was used, such that 25 physicians each saw six patients, two patients in each of three communication skills interventions (i.e. trained, informed, control). The dependent variables included several discourse categories designed to assess patients' information seeking, provision, and verifying. Results indicate that trained patients engaged in more effective and efficient information seeking, provided physicians with more detailed information about their medical condition, and used more summarizing utterances to verify information they received from physicians. Additionally, dyads consisting of trained patients demonstrated a more patient-controlled style of communication than did dyads consisting of informed or untrained patients.

An educational intervention using the Agency for Health Care Policy and Research Depression Guidelines among internal medicine residents

OBJECTIVE

To determine if a brief educational intervention utilizing the Agency for Health Care Policy and Research (AHCPR) Depression Guidelines would effect improved recognition of depressed patients, as well as improved attitudes and knowledge, among Internal Medicine housestaff.

METHOD

This was a randomized trial of an educational intervention for Internal Medicine residents. All patients attending the resident clinics were screened using the Center for Epidemiologic Studies Depression Scale. Persons scoring greater than 16 constituted the prospective cohort. Three hundred eighty-four patients were screened for entry into the study. Of 160 persons meeting the entry criteria, follow up was available on seventy-two (60%). Residents were randomly assigned to receive the educational intervention which consisted of three sessions where the residents received copies and instructions about the AHCPR depression guidelines and the use of a case-finding instrument for depression.

RESULTS

Non-recognized patients had milder symptoms of depression than did recognized patients. The presence of depressive symptoms was strongly related to measures of health status. Only seven of the seventy-two patients were identified as depressed and this was distributed equally between the two groups of residents. Intervention residents showed sustained improvement regarding depression criteria and the use of screening instruments at six months.

CONCLUSIONS

A brief educational intervention effected changes in resident attitudes and knowledge regarding the care of depressed patients. Residents recognized patients with greater depressive symptoms than those with milder symptoms.

Breaking bad news. 3: Encouraging the adoption of best practices

Steps to encourage clinicians to adopt the best practices for communicating bad news to patients are outlined. First, official, credible guidelines endorsed by key organizations or professional bodies, giving a clear message about the components and importance of the best practices, must be produced. Second, the guidelines should be disseminated; publication in journals or mailing to clinicians is unlikely to be sufficient. Third, clinicians should be provided with feedback on whether their performance meets established standards. This requires acceptable systems to collect valid and reliable performance data. Fourth, clinicians need contingencies for providing best practice care. Fifth, barriers to improvement should be explored and strategies to address them, including interactional skills training, implemented. Continuous quality assurance, commitment, and evaluations will help clinicians use the best practices for breaking bad news to patients.

Medical residents evaluate their medical school training in psychosocial care

A questionnaire was sent to all 77 general medical residents at one teaching hospital (18 primary care and 59 the traditional program), to investigate retrospectively their psychosocial training in medical school. 62 complete surveys (81%) were returned. The training was rated good by 62% of the residents and important for psychosocial practice by 45%. In ambulatory settings, supervisors were rated as supporting the doctor-patient relationship (79%) and spending time on psychosocial problems (65%). In inpatient settings, spending time on psychosocial problems was not widely supported (36%). Training to interview was rated far from optimal by 49% of the residents. Psychosocial attitudes in residency did not have substantial correlations with training. In the choice of residency program, what distinguished residents in primary care from those in the traditional program was the positive ratings given their supervisors' psychosocial orientation, but not the supervisors' nor the residents' psychosocial competency or weeks spent in training. In sum, the two most potent influences on psychosocial orientation appear to be positive role models and the clinical setting.

Refocusing on history-taking skills during internal medicine training

Recognizing that skilled history-taking is in danger of becoming a lost art, the American Board of Internal Medicine calls attention to the urgent need for internal medicine residency programs to ensure that these skills are taught and assessed. Although the Board's certification examination contains standardized items that test the physician's ability to use information from a patient's medical history, the written examination cannot assess the physician's ability to elicit that history. The Board believes that history-taking skills will become even more crucial as health care delivery changes, requiring more cost efficiency without sacrificing quality. By highlighting the skills of effective history-taking and strategies for assessment, the Board offers specific recommendations for its promotion as a key element of quality patient care.

Psychiatric training in medicine residencies: current needs, practices, and satisfaction

The purpose of this study was to determine the current level of psychiatric training in internal medicine residencies, satisfaction with this training, and perceived need, if any, for more training. Surveys were mailed to all training directors of accredited primary care (N = 178) and categorical (N = 410) internal medicine residencies in the United States; 110 primary care (62%) and 238 categorical (58%) training directors returned the surveys. Seventy-five percent of categorical and 66% of primary care training directors thought their program should spend more time on psychiatric disorders. For all categories of psychiatric disorder, training intensity was greater and satisfaction with training higher in the primary care programs, but less than half of the directors were satisfied with their current level of training, e.g., 33% of categorical and 47% of primary care directors were satisfied with their residents training concerning depression. Training in somatoform disorders, psychotropic drugs, and office psychotherapy were most frequently identified as deficient. The most favored additions to the curriculum were psychiatric consultants in medical clinics and on medical wards. Although most outpatient care for psychiatric disorders is given by primary care physicians, internal medicine training directors perceive current levels of training in their residencies as inadequate. Innovative collaborations between medicine and psychiatry departments will be necessary if treatment of psychiatric disorders in primary care is to be improved.

The advanced clinical skills program in medical interviewing: a block curriculum for residents in medicine

OBJECTIVE

This study sought to demonstrate whether an intensive block curriculum would lead to learning of basic medical interviewing skills by first year residents in medicine.

METHOD

Pairs of brief clinical interviews done before and after a four week block program in medical interviewing were rated using the Rhode Island Hospital Interview Checklist (RIC). The data were analyzed using the McNemar Test to look for possible improvement following the course.

RESULTS

Of the nineteen categories measured, fourteen showed statistically significant improvement (p < .05) in Year 1 and twelve in Year 2. Combining the data for the two years gave statistically significant results in sixteen of the nineteen categories.

CONCLUSIONS

An intensive block curriculum in medical interviewing led to a significant degree of learning of basic skills by first year medical residents as judged by interviews done at the end of the block. The intensive approach also allowed for a degree of personal growth and solidification of identity as a physician. These factors can be expected to influence interviewing proficiency as well.

Evaluation of a training program for improving adherence promotion skills

A workshop for improving the adherence counseling skills of health professionals was developed and evaluated. Target audiences have included medical students, nursing students, dietetic interns, and practising nurses and dietitians. Four categories of skills are taught: relationship building, interviewing, problem diagnosis, and behavioral intervention. Teaching methods include faculty demonstration, participant rehearsal, and group and individual feedback. The Adherence Promotion Training (APT) workshop has been offered as a 3- to 5-day intensive course and as a semester-long elective. A reliable coding system was developed to assess these skills from videotaped provider-patient interactions. A standardized patient task was given to 60 subjects before and after participation in the adherence counseling skills workshop. Videotapes were coded by trained raters, who were masked to whether the tape came from before or after the workshop. Significant short-term improvements were observed in all four core skills. This uncontrolled evaluation suggests that the Adherence Promotion Training program is a promising way to enhance the ability of health professionals to care for nonadherent patients.

The efficacy of intensive biopsychosocial teaching programs for residents: a review of the literature and guidelines for teaching

OBJECTIVE

To review research evaluations of intensive biopsychosocial training programs for nonpsychiatry residents, and determine whether this research showed sufficient rigor and consistent beneficial impact to allow initial research-based teaching guidelines.

DATA SOURCES

An English-language literature search used MEDLINE (1966-93), Psychological Abstracts (1967-93), and Educational Resource Information Clearinghouse (1966-93) as well as bibliographic reviews from prominent peer-reviewed articles and consultation with an expert.

STUDY SELECTION

From among several hundred articles about biopsychosocial training, only 12 studies met the selection criteria: at least 100 contact hours of training for nonpsychiatry residents and an evaluation of efficacy.

DATA EXTRACTION

The three authors independently assessed these 12 studies and made a consensus decision based on explicit criteria. Successful and unsuccessful programs were distinguished from among those classified as quasi-experimental or experimental to identify programs of sufficient rigor to meet the study objective; success was defined as learning beyond knowledge and residents' acceptance of teaching.

DATA SYNTHESIS

Four successful quasi-experimental or experimental programs showed the following uniquely beneficial features: 1) protected time for residents; 2) teaching that was required, structured, multidimensional, and balanced between learner-centered and teacher-centered approaches; 3) teaching methods that used normal as well as psychosocially disturbed patients, nonpsychiatrist teachers, and special teaching techniques; and 4) inclusion in the curriculum of interviewing, interpersonal skills, doctor-patient relationship, and patient education. Two unsuccessful quasi-experimental or experimental programs were unidimensional and unstructured, and used predominant or isolated teacher-centered approaches. Features found in both successful and unsuccessful programs were experiential teaching, psychiatrist and other mental health professional teachers, use of disturbed patients, training to manage patients' psychosocial problems, teaching directed toward knowledge acquisition, teaching about treatment, and university affiliation.

CONCLUSIONS

Four rigorously studied, successful programs showed a common pattern of intensive biopsychosocial teaching that produced, in aggregate, improvement in residents' knowledge, attitudes, skills, and self-awareness. Although there is need for more definitive research, these data are sufficiently compelling and consistent to provide initial, research-based teaching guidelines.

The psychosocial review of systems

Psychosocial problems have a significant impact on the course and cost of medical illness. However, many of these areas are generally neglected in medical interviews. This manuscript presents a condensed review of the major psychosocial domains, which together constitute what we term a psychosocial review of systems (PROS). Selected references are provided which document the importance of these areas to medical care, and serve as background reading for further inquiry. The psychosocial areas which are covered include: substance use, stress and life events, subjective views of symptoms, daily activity, social support, sexual concerns, finances, psychiatric history and symptoms, cultural issues, and functional status. The Psychosocial Review of Systems (PROS) can serve as a basic overview for the psychosocial aspects of medical education, and also as a content based instrument which has potential for development as an assessment tool to measure physician competence in eliciting relevant psychosocial data.

Efficacy of a one-month training block in psychosocial medicine for residents: a controlled study

STUDY OBJECTIVE

To determine the efficacy of a comprehensive, one-month psychosocial training program for first-year medical residents.

DESIGN

Nonrandomized, controlled study with immediate pre/post evaluation. Limited evaluation of some residents was also conducted an average of 15 months after teaching.

SETTING

Community-based, primary care-oriented residency program at Michigan State University (MSU).

SUBJECTS

All 28 interns from the single-track MSU residency program during 1986/87-88/89 participated in this required rotation; there was no dropout or instance of noncompliance with the study. In the follow-up study in 1989, all 13 available trainees participated. Of 20 untrained, volunteer controls, ten were second/third-year residents in the same program during 1986/87 and ten were interns from a similar MSU program in Kalamazoo, MI, during 1988/89. TEACHING INTERVENTION: An experiential, skill-oriented, and learner-centered rotation with competency-based objects focused on communication and relationship-building skills and on the diagnosis and management of psychologically disturbed medical patients.

MEASUREMENTS AND MAIN RESULTS

The two subsets of the control group were combined because residents and training programs were similar and because means and standard deviations for the subsets were similar on all measures. By two-way analyses of variance (group x gender), the trainee group showed significantly greater gains (p less than 0.001) on questionnaires addressing knowledge, self-assessment, and attitudes; a mean of 15 months following training, there was no significant deterioration of attitude scores. All trainees were also able to identify previously unrecognized, potentially deleterious personal responses using a systematic rating procedure. Residents' acceptance of the program was high.

CONCLUSIONS

Intensive, comprehensive psychosocial training was well accepted by residents. It improved their knowledge, self-awareness, self-assessment, and attitudes, the latter improvement persisting well beyond training.

An evaluation of residency training in interviewing skills and the psychosocial domain of medical practice

Competent use of interviewing skills is important for the care of all patients but is especially critical, and frequently deficient, in meeting the needs of patients experiencing emotional distress. This study presents an evaluation of a curriculum in communication and psychosocial skills taught to first-year medical residents. A randomized experimental design compared trained and untrained residents' (n = 48) performances with a simulated patient presenting with atypical chest pain and psychosocial distress. Evaluation was based on analysis of videotapes, simulated patient report of residents' behaviors, and chart notation. Trained compared with untrained residents asked more open-ended questions and fewer leading questions, summarized main points more frequently, did more psychosocial counseling, and were rated as having better communication skills by the simulated patient. The use of more focused and psychosocially directed questions, and fewer leading and grab-bag questions, was associated with more accurate diagnoses and management recorded in the medical chart. However, no significant difference was found in the charting practices of trained versus untrained residents.

Use of an outpatient medical record audit to achieve educational objectives: changes in residents' performances over six years

OBJECTIVE

To evaluate the effectiveness of a process whereby a faculty-resident committee annually audits outpatient record keeping and preventive care practices and provides feedback to resident physicians.

DESIGN

Pre- and postfeedback audits with interventions and observations repeated over six consecutive academic years.

SETTING

The adult primary care practice of housestaff in a university-affiliated hospital.

SUBJECTS

All 139 physicians in an internal medicine residency program from 1981-82 through 1986-87, of whom 37 were present for three consecutive years.

INTERVENTION

Each year, residents were given individualized, detailed, typewritten feedback based on audits of their outpatient records.

MEASUREMENTS AND MAIN RESULTS

Each resident physician had a minimum of four (mean 5.2) outpatient records per year audited against standards for record-keeping practices and the provision of preventive care. Overall performance scores for each resident audit improved from a mean of 39.7 +/- 12.3 (SD) in 1981-82 to a mean of 58.5 +/- 14.1 (SD) in 1986-87 (possible range 0 to 100, observed range 9.4 to 86.6). The overall performance scores of individual residents, who received two cycles of feedback, improved an average of 11.5 (95% confidence limits 7.6, 15.3), from a mean of 48.4 +/- 11.4 (SD) during their first year of residency to 59.8 +/- 13.9 (SD) during their third year. General (primary care) and traditional-track residents improved at similar rates, although mean performance scores were consistently higher for general than for traditional-track residents. Analysis of variance revealed that all changes and differences were statistically significant.

CONCLUSIONS

An ongoing chart audit and feedback system can be associated with improvements both in the performance of individual residents and in the long-term performance of a residency program.