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Author: Jonathan Schindelheim, M.D.

Medical Interviewing and the Doctor-Patient Relationship
Fall 2011
J. Schindelheim, MD
Tufts University School of Medicine

Introduction

Medicine is a profession that fuses technical competence with an understanding of human experience and requires the ability to communicate that understanding to patients. It is an interpersonal activity between two people – the doctor and the patient. In addition to the need to collect accurate information necessary to provide competent health care, when the patient feels that the doctor understands and responds reasonably to his or her needs, the interaction is more likely to be successful. That understanding by the doctor includes an appreciation of who the patient is as a person, how they’ve gone about trying to stay healthy, what it’s like for them being ill, their experiences with the health care system and the impact of illness on their life. In addition, all data collected from the patient by the physician in taking a history, laboratory studies, technical competence, use of the computer, the understanding of physiology, etc. must be synthesized, interpreted and then communicated back to the patient in a form that makes sense to the patient. The most brilliant diagnosis and the latest in effective treatment mean nothing, if the patient is not helped to understand its value and to cooperate in its application. The medical interview is the essential tool, the fulcrum around which all these essential aspects of doctoring takes place. It’s the vehicle for the care of the patient.

There are, of course, exceptional interview situations, such as the focused and limited interview necessary to care for a patient requiring acute emergency care. However, even in these circumstances, continued care after the acute episode requires attention to the above aspects of interviewing for the patient and the family. The art of the medical interview is essential to all physicians, no matter what the setting, specialty, or patient. It requires a great deal of study and practice. This course is an introduction to those human experiences which pervade and define the doctor-patient relationship as well as an introduction to the development of the competencies that will make accurate data collection possible.

As first-year students, you are in the unique position of knowing virtually no medicine. You do not have the knowledge from what the patient tells you to synthesize a diagnosis. Your contact with patients has no demand to produce a treatment. You are uniquely free to learn as you begin the lifelong, interpersonal activity of providing effective patient care. As hard as it is to believe you will, over these four years, become increasingly expert at doing this. The task at this stage is not to make a diagnosis but to learn communication skills and how to build an effective doctor-patient relationship. This requires a development of: 1) new skills/techniques - the medical interview is quite different from the other types of interviewing and from usual social interactions 2) the capacity to tap your own human experience in a way that facilitates empathy and maintains your compassion and awareness of your patient’s suffering 3) the capacity to tolerate emotions, both the patient’s and your own, since if not aware of the feelings patients stir within oneself by the interaction, one may avoid crucial aspects necessary to care for the patient or derail the doctor-patient relationship 4) the capacity to organize collected information into a coherent story and present it verbally and in writing to others.

The lecture topics of the course have been chosen to help you develop these skills. Each lecture outlines specific competencies that we want you to acquire. Each week after lecture you will meet in small groups with your section leaders at your assigned interviewing sites to discuss the material of the lectures, your journals, previous interviews and then go to interview patients with whom you will practice the week’s new competencies. By the end of this course you should

  1. have some understanding of the complex mixture of biological, social, and psychological experiences of both the patient and the doctor that effect medical care

  2. have developed competency in the listening and technical skills, detailed in each lecture of the course, that will facilitate communication with patients and the collection of accurate data

  3. have learned how difficult, but important, it is to be able to talk with people about the serious, often frightening, but always deeply meaningful experience of being sick

  4. have learned about your own strengths and weaknesses in dealing with the emotional aspects of providing care

  5. have learned to organize and present in written and verbal format the information you’ve collected.

To facilitate your integration of the experiential and intellectual aspects of the course and to aide in our evaluation of your progress, we would like you to keep a journal (see instructions for Journal). The journal can be an ongoing recording of your learning and must be written each week. It will also serve as a nucleus for group discussion. There are elective readings that will help to clarify and expand on matters related to the lectures. These are for your own edification and are not required.

The faculty and I hope you will find the course a worthwhile framework from which to view the exciting and privileged experience of caring for the patient. As well, we hope that it serves as only a beginning to a lifelong interest in the study of people who feel ill.

Other components of the course include competencies and expected professional attitudes.

Competencies

Professionalism

Shows professional attitudes and demeanor in interactions with patients, peers and faculty

Rapport

Attempts to engage patient, listens attentively, does not interrupt inappropriately; is respectful, humble and non-judgmental

Empathy

Explores patient’s underlying feelings, and validates them by conveying an understanding of them

Medical History

Shows an organized approach to eliciting data, knows what information to collect from each part of the history (CC, HPI, PMH, FH, SH)

Patient-Centered Perspective

Seeks to understand and respect patient’s background, culture, and belief systems

Growth toward Physician Role

Assumes physician role in the doctor-patient relationship

Oral Presentations

Presents clinical material in a coherent, organized, accurate and concise manner

Written Documentation

Translates interactions with patients into coherent, organized, accurate written summaries

Group Participation

Engages in group discussions, interacts respectfully with peers

Constructive Feedback

Gives timely and specific feedback to peers respectfully. Is open to feedback from peers and section leaders

Reflective Practice

Demonstrates thoughtful personal integration of patient interactions through journaling and group participation

Expected Professional Attitudes

Consider this your first clinical rotation—you are now a student doctor in training, and this means that your role of student is different from that of previous student experiences. As a professional, you should approach learning in the course as part of the doctor-patient covenant and show the professional attitude and demeanor that is part of a physician’s role as follows:

  • Be open-minded and not defensive

  • Use appropriate demeanor, language and dress for a medical professional

  • Have humility as well as maturity

  • Adherence to boundaries (no after-interview patient visits)

  • Respect for section leader and peers

  • Follow appropriate channels for conflict resolution

  • Look involved

  • Attend lectures and small group sections (attendance is MANDATORY and will be taken at the start of class with your Iclicker; excused absences must be approved by the OSA)

  • Be on time

  • No talking during lecture or demonstration patient interviews

  • No eating in the lecture hall

  • No wearing of hats in the lecture hall

  • No sitting with legs over the chair in front of you

  • All telephones, beepers, etc. should be turned off during lecture

  • Keep and submit a doctor-patient journal

Small Group Learning Objectives and Structure

Learning Objectives

By the end of the section meetings students will have demonstrated the ability to:

  • Interact respectfully with peers about a clinical interaction.

  • Provide specific feedback to peers that highlights both strengths and areas for improvement.

  • Receive feedback in a non-defensive manner and respond to suggestions.

  • Summarize information collected concisely, construct a coherent, organized and accurate life story, and medical history of the patient, and present it orally to peers.

  • Translate an interpersonal interaction with a patient into a coherent, organized and accurate written summary as described in the journal instructions.

  • Discuss concepts addressed in lectures.

  • Apply lecture topics to encounters with patient/residents.

Small Group Structure

Meetings will consist of:

  • Opening: Group of 2 section leaders and 8 TMS 1s.

    • Discussion of lecture and students’ journal entries from previous week.

  • Interview: Subgroups of 1 Section Leader and 4 TMS 1s.

    • Interviewing of patients/residents with feedback from section leader.

  • Wrap-up: Group of 2 section leaders and 8 TMS 1s. Presentation of interview and discussion.

    • Present Thank You Cards written by students to JCHE residents and Signed

    • Form Letter to hospitalized patients

Medical Interpreter Experience

Each small group will have the opportunity to work with a trained medical interpreter while interviewing a resident at Jewish Community Housing for the Elderly (JCHE). This will allow students to practice their cross-cultural communication skills and review the proper procedure for working with a medical interpreter.

Each small group leader at JCHE will sign their group up to work with the interpreters on a specific date, so that the group can prepare ahead of time. It will be helpful to review the readings on cross cultural communication and medical interpreter use in the syllabus in advance of your group’s session as your small group interpreter experience may occur before the lecture on cross-cultural interviewing.

Student Evaluation

Continuing Feedback

Students will receive weekly feedback on their interviews, journal write-ups and presentations of patients and readings from section leaders and peers.

Practice OSCE

Each group of students will have an opportunity to work with standardized patients during one of the weeks of the JCHE rotations. This is designed to both practice your interviewing and history taking skills as well as to give you experience with standardized patients for the final exam OSCE in addition to many other standardized patient exercises you will experience throughout your medical training.

Mid-Term and Final Evaluation

Section leaders will evaluate student’s performance at the midterm and at the end of the course (See Student Evaluation Form).

At the mid-course change of interviewing site, students will bring the midterm evaluation they receive from their section leader to their new section leader at their new assigned site.

Final Exam

The final exam will consist of an interviewing encounter with a standardized patient at TUSM Clinical Skills and Simulation Center. The standardized patient will evaluate student’s interviewing competencies based on the overall course competencies listed on the syllabus.

Grading

Students must pass the final evaluation and the final exam.

Journal

Why is there a Journal Assignment?

Doctors write. They write progress notes, case presentations, some write in academic journals. Others write narratives of their encounters with patients. This journal is a way for you to begin writing down data gathered from the interview, your observations of patients, as well as your own reactions to the patient and the interview. Learning to write about encounters with patients is an important beginning to establishing yourself in the role of physician.

The journal is also a vehicle for reflection, a way for you to organize your thoughts about your experience. Some of the most important learning physicians do comes not from medical journals but from their experiences. What worked? What didn’t? What else to did you need to know to help the patient? How can I do it better next time? Reflective journaling gives you an opportunity to think in-depth about your experiences and in the process, improve your practice of medicine. Many students re-read their journals as they move through medical school, and find it helpful to see how much they’ve grown since there first days as a medical student.

Your journal is also an avenue for your section leader to get to know you and to facilitate your development into an empathic interviewer and effective physician. Your section leader will provide you with constructive feedback about your journal and base some of your overall course grade on your journals.

Journal Logistics

Email your most recent journal entry only (as an attachment, PC compatible using MS Word) to your section leader each week by Monday 9am, including your name and the date of the interview. This enables your section leader to get feedback to you about your entry by the following Thursday. The format should be no more than one page.

Your weekly journal entry should be written about the person you interviewed. If you did not interview that week, pick one other person whose interview you observed. Please write your journal entry in your own words as this is not meant to be a collaborative effort.

Journal Structure

Medical Data (1/3 page):

  • What is the Chief Concern (CC)?

  • What is the History of Present Illness (HPI)?

  • What is the Social History? (Please include this after week 4 of the course)

  • How, if at all, were you able to practice the specific competencies pertaining to this week’s lectures during this interview?

Life Story (1/3 page):

  • Who is this patient/resident as a person?

  • What did you learn about this person/life story?

Reflection on the Interviewing Process (1/3 page):

  • How did the interviewer begin to establish a doctor-patient relationship and conduct a medical interview? What specifically was done well? What could have been done better?

  • How, if at all, could the patient/resident story affect your relationship with them as their physician?

  • How, if at all, could the patient/resident story affect your perception of yourself and your own relationships?

Student Evaluation Form

Section Leaders Evaluation Form