Evidence-based guidelines for teaching patient-centered interviewing
Introduction
It has been proposed that physicians, allied health professionals, and students integrate patient-centered approaches into their interviews and relationships with patients if they want to be most scientific and humanistic [1]. Integration avoids the singular disease focus of isolated doctor-centered interviewing and makes the patient as a person the primary interest. Compelling data support integrating patient-centered [2], [3], [4], [5], [6] with doctor-centered approaches: increased patient satisfaction [7], [8], [9] and compliance [8], [9], [10], decreased law suits [11], [12] and doctor-shopping [13], and, most importantly, improved health outcomes [14], [15], [16]; e.g., lower glycohemoglobin levels in diabetics [14].
Much training, however, remains focused narrowly on biomedicine, with well-known dangers of diminishing the personhood of the patient. Nevertheless, educators have had at least two understandable explanations for not changing this focus [17], [18]. First, there previously were no behaviorally-defined descriptions of how one actually conducted a patient-centered interview, step-by-step, from beginning to end. Second, most interviewing recommendations in texts and elsewhere, patient-centered or otherwise, had little or no research data to support their recommendations.
One of the authors (RCS) took advantage of a rich patient-centered interviewing literature [2], [3], [4], [5], [6] and synthesized its parts into a unified, complete interview that described exactly what behaviors were required by new learners, step-by-step [1]. Our group then studied the effectiveness of training in this systematic patient-centered interviewing method in 63 PGY1 residents [17]. Using a randomized, controlled design, we found significant improvement in trained residents’ knowledge, attitudes, self-confidence, skills in interviewing patients and dealing with relationships, skills in managing and communicating with somatizing patients, and skills in educating patients; there also were consistent trends towards improvement in patient outcomes [17].
This paper provides a template for teachers who wish to follow our approach for teaching patient-centered interviewing and provider–patient relationship skills. While the supporting research has been published earlier [17], we present here the first description of our actual training program. We propose that this curriculum can provide evidence-based guidelines for teaching patient-centered interviewing to physicians, allied health professionals, and students.
Section snippets
Theoretical background
In formulating the specific, behaviorally-defined patient-centered method and the teaching program, our overarching theoretical base was general system theory [19], [20], [21], [22], [23], [24] and its medical derivative, the biopsychosocial model [25], [26], [27], [28], [29], [30], [31]. To operationalize this guiding model of medicine, we relied upon a rich base in patient-centered medicine [1], [2], [3], [4], [5], [17], [32], [33], [34], [35], [36], [37]. To be patient-centered means
Goals
Our goals were twofold: that trained residents be willing as well as able to use an integrated patient-centered and physician-centered approach. This required a focus on attitude as well as skill development [38], [39], especially important because negative attitudes toward patient-centered approaches are common and problematic [38], [40], [41], [42], [43], [44], [45], [46], [47].
Basic patient-centered interviewing method
We believed that the patient-centered dimension of interviewing, which places the patient’s needs foremost [1], [2], [3], [4], [5], [6], was the most essential skill and that the physician–patient relationship was a central but often ignored aspect of interviewing [48]. Using a behaviorally explicit, step-by-step method [1], our teaching focused on the usually unfamiliar patient-centered process because residents already were familiar with doctor-centered interviewing to make disease diagnoses.
Influencing attitudes
Facilitating attitudinal changes required a safe, respectful setting. Residents’ openness and expressivity was fostered, appropriate to the situation, by teachers’ self-disclosure and sharing of their own vulnerabilities and uncertainties.
Critiquing interviewing and patient management skills
Following directly observed resident-patient interviews (usually inpatients), critiques occurred in a conference room, lasted approximately 30 min, and typically began with inquiry about the resident’s personal reaction to the patient as part of self-awareness work. After a few minutes, the resident would be asked for a self-assessment of her/his success with whatever skills were being addressed. Then, resident colleagues provided feedback. We encouraged residents to give feedback in
Teachers
Teachers were from four departments: communication (PhD), family practice (PhD in psychology), psychiatry (DO), and medicine (MD). All had training in psychosocial medicine. Faculty held regular monthly meetings and also met 1–3 times weekly on an ad hoc basis to discuss residents’ progress, problems and feedback, and to make necessary adjustments. Faculty were funded for this project which required 24 resident contact hours weekly for 6 months; i.e., a total of 0.3 FTE per year was required to
Specific conduct of the training
We trained a total of 63 first year primary care residents, 3–4 at a time, on a required 1 month rotation where the only competing duty was residents’ regular half-day clinic. One week prior to the rotation, residents received a letter that explained the rotation, encouraged them to begin thinking about learning objectives, and asked them to complete a preliminary learning agreement. At the initial orientation session, extensive introductions and much discussion of residents’ own objectives
Comment
Three behaviorally-defined patient-centered interviewing methods (basic interviewing, somatization management, patient education) and other aspects of psychosocial training were shown to be effective in a previously reported randomized controlled trial [17]. This article provides a template for those wishing to teach these evidence-based patient-centered methods to residents. Because first year residents are similar to many students, post-residency physicians, nurse practitioners, physician
Acknowledgements
We wish to acknowledge the decisive support we received from the Fetzer Institute in Kalamazoo, Michigan. Without their unflagging interest and ongoing encouragement, this work would not have occurred. We also acknowledge the strong, enduring influence of the biopsychosocial programs at the University of Rochester and of the American Academy on Physician and Patient. We also thank many people at Michigan State University who supported this program in so many ways from its inception, especially
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Dr. Marshall is now in the Department of Social and Behavioral Health, Texas A&M University, College Station, TX 77843.