Description versus evaluation of medical interviews

Tailored opening questions to the context of using medical questionnaires: Qualitative analysis in first-visit consultations

Background

Communication skills required for doctors do not consist of simple uses of particular linguistic forms but include uses that are sensitive to the interactional context. In consultations where the doctors have pre-existing information about their patients, this can complicate the context of problem solicitation. We investigated how doctors tailor opening questions to a context in which they get pre-existing information from a medical questionnaire (MQ) filled out by the patients.

Methods

The data for this study were 87 video recordings of first visits to the department of general medicine at a university hospital in Japan. We qualitatively analyzed doctors' practices in problem solicitation in an opening phase using conversation analysis and triangulated it with quantitative analysis.

Results

Open-ended questions accounted for 26.4% of opening questions. Among the closed-ended questions, 75.0% were confirming questions about symptoms. In cases with open-ended questions, doctors minimized the relevance of the MQ to problem solicitation by giving license to repeat the description from the MQ. In cases with closed-ended questions, doctors highlighted the relevance of the MQ by sharing the MQ. Through these practices, they avoided patients' possible confusion about problem presentation while simultaneously maximizing the possibility of soliciting the patients' narratives.

Conclusions

Doctors adjusted the level of relevance of pre-existing information to problem solicitation through both verbal and nonverbal management of the MQ. It will be useful to instruct such context-dependent practices to improve communication skills in medical school curriculum.

Comparison of communication skills between medical students admitted after interviews or on academic merits

BACKGROUND

Selection of the best medical students among applicants is debated and many different methods are used. Academic merits predict good academic performance, but students admitted by other pathways need not be less successful. The aim of this study, was to compare communication skills between students admitted to medical school through interviews or on academic merits, respectively.

METHODS

A retrospective cohort study. Communication skills at a surgical OSCE in 2008 were assessed independently by two observers using an evaluative rating scale. Correlations, t-tests and multivariate analyses by logistic regressions were employed. Academic merits were defined as upper secondary school grade point average (GPA) or scores from the Swedish Scholastic Assessment Test (SweSAT).

RESULTS

The risk of showing unsatisfactory communicative performance was significantly lower among the students selected by interviews (OR 0.32, CI95 0.12-0.83), compared to those selected on the basis of academic merits. However, there was no significant difference in communication skills scores between the different admission groups; neither did the proportion of high performers differ. No difference in the result of the written examination was seen between groups.

CONCLUSIONS

Our results confirm previous experience from many medical schools that students selected in different ways achieve comparable results during the clinical semesters. However, selection through interview seems to reduce the number of students who demonstrate inferior communication skills at 4th year of medical school.

Measuring patient-centered communication in cancer care: a literature review and the development of a systematic approach

Patient-centered communication (PCC) is a critical element of patient-centered care, which the Institute of Medicine (Committee on Quality of Health Care in America, 2001) promulgates as essential to improving healthcare delivery. Consequently, the US National Cancer Institute's Strategic Plan for Leading the Nation (2006) calls for assessing the delivery of PCC in cancer care. However, no comprehensive measure of PCC exists, and stakeholders continue to embrace different conceptualizations and assumptions about how to measure it. Our approach was grounded in the PCC conceptual framework presented in a recent US National Cancer Institute monograph (Epstein & Street, 2007). In this study, we developed a comprehensive inventory of domains and subdomains for PCC by reviewing relevant literature and theories, interviewing a limited number of cancer patients, and consulting experts. The resulting measurement domains are organized under the six core functions specified in the PCC conceptual framework: exchanging information, fostering healing relationships, recognizing and responding to emotions, managing uncertainty, making decisions, and enabling patient self-management. These domains represent a promising platform for operationalizing the complicated PCC construct. Although this study focused specifically on cancer care, the PCC measurements are relevant to other clinical contexts and illnesses, given that patient-centered care is a goal across all healthcare. Finally, we discuss considerations for developing PCC measures for research, quality assessment, and surveillance purposes. United States Department of Health and Human Services, National Institutes of Health, National Cancer Institute (2006). The NCI Strategic Plan for Leading the Nation: To Eliminate the Suffering and Death Due to Cancer. NIH Publication No. 06-5773.

[Evaluation of the patient centered clinical relationship: analysis of psychometric properties using the CICAA scale]

OBJECTIVE

To analyse the psychometric properties by a scale for evaluating patient centered clinical communication.

DESIGN

Validation and observational study of a measurement tool.

SETTING

Health centres and hospital outpatient clinics.

PARTICIPANTS

Three researchers independently evaluated video recorded interviews of different sub-samples: health professionals (family medicine medical residents, family doctors, specialist care physicians, and primary care nurses), actual patients who consulted for chronic or acute health problems, and standardised patients.

PRIMARY MEASUREMENTS

Dimensionality (exploratory factor analysis), internal consistency (alpha de Cronbach), intra- and inter-observer agreement (Kappa index, intraclass correlation coefficient [ICC], generalisability), sensitivity to change (Student t test) and convergent validity with the GATHA questionnaire (Pearson correlation coefficient).

RESULTS

Six factors have been identified that explain 66.0% of the variance. The overall internal consistency of the test was alpha=0.94. The overall intra-observer agreement, measured with the ICC, varied between 0.94 and 0.97, whilst the inter-observer was between 0.82-0.90. The number of completed questionnaires required for the evaluator to obtain adequate reproducibility (generalisability) varied between 6 and 12. Statistical significance was not obtained when testing the sensitivity to change. The CICAA scale and the GATHA questionnaire had a correlation of 0.67.

CONCLUSIONS

The CICAA scale is a generic patient centered clinical communication evaluation tool that may be used in different clinical contexts and situations, since it has shown to be reliable, valid and efficient.

Considering culture in physician-- patient communication during colorectal cancer screening

Racial and ethnic disparities exist in both incidence and stage detection of colorectal cancer (CRC). We hypothesized that cultural practices (i.e., communication norms and expectations) influence patients' and their physicians' understanding and talk about CRC screening. We examined 44 videotaped observations of clinic visits that included a CRC screening recommendation and transcripts from semistructured interviews that doctors and patients separately completed following the visit. We found that interpersonal relationship themes such as power distance, trust, directness/ indirectness, and an ability to listen, as well as personal health beliefs, emerged as affecting patients' definitions of provider-patient effective communication. In addition, we found that in discordant physician-patient interactions (when each is from a different ethnic group), physicians did not solicit or address cultural barriers to CRC screening and patients did not volunteer culture-related concerns regarding CRC screening.

Assessing validity of standardized patient ratings of medical students' communication behavior using the Roter interaction analysis system

OBJECTIVE

The primary objective of this study is to examine concurrent validity of standardized patient (SP) ratings of second year medical students' communication skills with the Roter interaction analysis system (RIAS).

METHODS

We designed An Integrated Medical Encounter (AIME), to teach second year medical students the link between communication and clinical reasoning with emphasis placed on understanding the connection between biomedical and psychosocial aspects of patient care. We randomized 120 students to intervention (AIME) and control groups (non-AIME). Students completed two post-intervention SP encounters which were videotaped and coded using RIAS. SPs used a 30-item checklist to rate students' communication behaviors.

RESULTS

There were no differences between AIME and non-AIME students in age, ethnicity, gender, or college major; however, more AIME students reported prior health professional work. SPs rated AIME students' rapport-building skills higher (mean [S.E.]: 4.1 [0.15] vs. 3.9 [0.15], p=0.05); however, there were no differences in data gathering, patient education/counseling. RIAS demonstrated that AIME students more frequently used rapport-building statements (60.4 [2.7] vs. 52.1 [2.8], p=0.03).

CONCLUSION

The RIAS confirmed SP ratings of differences in AIME and non-AIME students' rapport-building skills.

PRACTICE IMPLICATIONS

Future studies in medical education should further examine the minimum number of SP ratings needed to effectively evaluate communication skills curricula when resources are limited.

Cultural differences in managing information during medical interaction: how does the physician get a clue?

OBJECTIVE

Consultations of ethnic-minority patients tend to result in poor mutual understanding between doctor and patient, which may have serious consequences for health care. For good communication, physicians have strong devices at their disposal to manage the information, such as agenda-setting and structuring the interview into segments. What are the cultural differences in the managing of information in medical conversation? What is the relation with level of mutual understanding?

METHODS

Data of 103 transcripts of video-registered medical interviews (56 non-Western and 47 Dutch patients) were sequentially analysed, focusing on relevant segments of the medical interview (medical history, diagnosis and conclusion) and on agenda-setting.

RESULTS

Physicians set the agenda and lead the conversation firmly forward, while a considerable number of patients (mainly Dutch) 'put on the brakes'. The majority of the medical conversations was traditional (37%) or cooperative (37%), while another 25% was more or less conflicting or complaintive in nature. Interviews of ethnic-minority patients were mostly traditional or cooperative, while Dutch patients showed a variety of types, especially in cases of poor mutual understanding. Further, conversational symmetry between patient and physician has increased over the years, due to the importance attached to patient autonomy.

CONCLUSION

Physicians receive different conversational clues from Dutch and ethnic-minority patients in case of poor mutual understanding.

PRACTICE IMPLICATIONS

This points to the necessity for physicians as well as patients to become culturally competent.

The Four Habits Coding Scheme: validation of an instrument to assess clinicians' communication behavior

OBJECTIVE

To present preliminary evidence for the reliability and validity of the Four Habits Coding Scheme (4HCS), an instrument based on a teaching model used widely throughout Kaiser Permanente to improve clinicians' communication skills.

METHODS

One hundred videotaped primary care visits were coded using the 4HCS, and the data were assessed against a previously available data set for these visits, including the Roter Interaction Analysis System (RIAS), back channel responses, measures of nonverbal behavior, length of visit, and patients' post-visit assessments.

RESULTS

Levels of inter-rater reliability were acceptable, and the distribution of ratings across items indicated that physicians' modal responses varied widely. Correlations between 4HCS ratings, RIAS, back channel responses, and non-verbal measures provided evidence of the instrument's construct validity.

CONCLUSIONS

The Four Habits Coding Scheme, an instrument that combines both evaluative and descriptive elements of physician communication behavior and is derived from a conceptually based teaching model, has the potential to be of utility to researchers and evaluators as well as educators and clinicians.

PRACTICE IMPLICATIONS

The Four Habits Coding Scheme provides a template for both guiding and measuring physician communication behaviors.

Sequential analysis of the phasing of the medical interview

AIMS

To study an analytical approach towards sequential analysis of the medical interview. An interview phase constitutes the analytical unit. Generally accepted phases of the medical interview are 1) medical history, 2) physical examination and 3) the conclusion segment. While descriptive and prescriptive studies claim that the sequence of the phasing is standard, it is hypothesised that in natural medical conversation the sequencing of the interview is more complex. For the doctor, the sequencing pattern is a powerful device to structure the interview and to manage the interactions within a limited time span. For the patient, especially the conclusion segment will contain more self-selection than other segments. Key concepts are turn taking, topic shift, topic flow, conversational coherence and responsiveness.

METHODS

The data consisted of 800 verbatim transcript pages of 85 medical interviews obtained from general practice. Interplay of theoretical notions and data-driven observations produced a reliable analytical method described in the article. The method enables to study processes of (a)symmetry in medical communication and the ways to deal with problems of misunderstanding.

RESULTS

Results confirmed 1) the asymmetrical character of the interview, 2) the complexity of the phasing, and 3) the existence of several types of interviews.

CONCLUSIONS

The method can be applied for a broad range of research questions.

Patient cues and medical interviewing in general practice: examples of the application of sequential analysis

AIMS

To illustrate how sequence analysis may be applied to the medical interview to: 1. explore how physicians without formal training in communication skills elicit and respond to patient cues and expression of expectations and opinions; and 2. test the hypothesis that physicians' closed ended questions determine the use of subsequent closed ended questions.

METHODS

238 consultations in primary care, coded with the Verona Medical Interview Classification System, were analysed. Lag 1 analysis was applied to study which physician behaviour precedes and follows patient cues. Pattern recognition analysis for five lag sequences was performed to test the occurrence of predefined specific code chains, where a closed and an open ended question were followed either by two closed-ended questions or by two patient facilitating interventions

RESULTS

Patients' cue offers were most likely after facilitative interventions, but not after open-ended questions; physicians were most likely to respond to these expressions with facilitation. Physicians' tendency to use closed ended questions increased after previous closed questions and decreased after an open-ended question.

CONCLUSIONS

Lag sequential analysis and pattern recognition analysis are useful methods to study exploratory and theory driven hypotheses and allow an initial approach to validate the supposed appropriateness of specific physician interventions.