A Controlled Trial of Educational Strategies to Teach Medical Students Brief Intervention Skills for Alcohol Problems

26, 78–85 (1997) PM960107

PREVENTIVE MEDICINE ARTICLE NO.

A Controlled Trial of Educational Strategies to Teach Medical Students Brief Intervention Skills for Alcohol Problems ANN M. ROCHE, PH.D.,*,1 JOANNE M. STUBBS, B.SC.,* ROBERT W. SANSON-FISHER, PH.D.,† JOHN B. SAUNDERS, M.A., M.D., FRACP*

AND

*Department of Psychiatry, University of Syndey, New South Wales, 2006, Australia; and †Discipline of Behavioural Science in Relation to Medicine, Faculty of Medicine and Health Sciences, University of Newcastle, New South Wales 2308, Australia

heightened by demonstrations of the efficacy of early intervention delivered by medical practitioners [1,2]. However, a diverse range of barriers hinder clinicians’ involvement in their patient’s alcohol problems [3,4]. Prominent among these is lack of appropriate education and training. Inadequate education and training is reflected in poor detection and intervention skills for alcohol problems [5]. Performance deficits may reflect, at least in part, the content and educational strategies employed in many medical curricula [4,6–10]. Input at the undergraduate level has much to commend it given indications that medical practitioners become relatively fixed in their clinical style soon after qualifying [11–13]. However, the basic clinical skills involved in recognition of drug or alcohol problems have been described as being difficult to acquire [14]. Identifying the real problem of presentation and changing the patient’s behavior remains one of the greater challenges facing doctors [15]. Obtaining a substance abuse history, presenting the diagnosis to the patient, and developing motivation for behavior change require well-developed interpersonal and communication skills [16]. Skills training in relation to alcohol problems carried with it a range of difficulties, not the least of which is discomfort with the topic area. The lack of confidence and hesitancy among experienced clinicians has been noted on a number of occasions [17–19]. Warburg et al. have suggested that a successful strategy to influence physicians’ skills and practice behavior is the provision of clinical experience and relevant training [20]. There is also good evidence to suggest that improvement occurs most effectively through the use of expert feedback [21–23] and practice [24]. Unfortunately, these techniques have been used infrequently within medical education [22,25,26] and few comparisons have been made between these approaches and more traditional, didactic training styles. Yet, without attention to alternative forms of training it remains inevitable that clinical skills in this area will remain underdeveloped

Objectives. Comparatively little is known about the most effective educational strategies to train medical students to successfully intervene in their patients’ alcohol problems. The relative effectiveness of two educational programs to teach medical students brief intervention skills for managing alcohol problems was examined. Methods. Teaching took place over 3 hr and was either the traditional didactic teaching program on the principles and practice of brief and early intervention or an interactive program involving a shortened lecture, clinical practice, and small group feedback on clinical performance. Students were assessed on a 10min videotaped encounter with a simulated patient before and after teaching according to how they addressed alcohol-related issues and on their general interactional skills. Results. Performance on alcohol-related issues and interactional skills were significantly improved after teaching, although still poor in terms of clinical performance. A between-groups comparison on pre/ postteaching difference scores indicated interactive training was no more effective than traditional didactic lectures in developing the knowledge and skills needed for a brief alcohol intervention. Conclusion. The need for more detailed teaching sessions on sensitive areas such as alcohol use is indicated. © 1997 Academic Press

INTRODUCTION

Over recent years increased attention has been focused on the underutilized potential for medical practitioners to successfully intervene in their patient’s alcohol-related problems. This interest has been further 1 To whom correspondence and reprint requests should be addressed at Queensland Alcohol and Drug Research and Education Centre, University of Queensland, Edith Cavell Building, Royal Brisbane Hospital, Herston Qld. 4029, Australia. Fax:(07) 3365 5466.

78 0091-7435/97 $25.00 Copyright © 1997 by Academic Press All rights of reproduction in any form reserved.

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and, consequently, underutilized. Hence, it is imperative that studies are undertaken which can test the efficacy of different forms of training. Although some important advances in teaching medical students and medical practitioners about drug- and alcohol-related problems have been made [10,27–30], comparatively little is known of the most appropriate and effective educational strategies to be employed. As a result, much of the literature dealing with drug and alcohol medical education and associated strategies is either descriptive or anecdotal [31]. At best, teaching programs have been based on strategies extrapolated from the generic medical education literature [32–34]. Evaluating Training Programs A common criticism of many evaluations of students’ clinical performance is that they fail to measure the target skills directly, relying instead on indirect measures of student learning, such as written examinations, supervisors’ subjective assessment, attitude change as measured by before-and-after questionnaires, and patients’ satisfaction ratings [35]. An alternative, and more precise, approach is the use of videotaped interviews with simulated patients. Simulated patient encounters are designed to mimic actual trainee–patient interactions with a high degree of realism. Their strength has long been recognized in the extent to which they can closely approximate the presentation of complex physical and psychological clinical material without the fluctuations and variations that occur in real cases [36,37]. A number of medical schools in the United States have incorporated training with simulated patients as part of routine training in drug- and alcohol-related problems [38]. The use of simulated patients has obvious advantages over traditional teaching techniques with real patients. Using traditional methods, educators are constrained by the availability of patients presenting with the problems appropriate and relevant to the students’ learning needs. The difficulties of clinical training in early and brief intervention are further compounded by the fact that suitable candidates for early and brief intervention do not usually present for treatment in major teaching hospitals or other teaching environments to which the medical student may be exposed. Simulated patients provide more effective clinical training and evaluation than do written problem exercises and, furthermore, they provide realistic stimuli against which to calibrate clinical performance [38,39]. Teaching Brief Intervention Skills for Alcohol Problems A combination of the above strategies, i.e., clinical practice and videotaped simulated patient encounters with feedback, appears to offer considerable potential

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for training medical students in early and brief intervention skills for alcohol problems. Maguire et al. have highlighted the efficacy of using a combination of educational strategies and teaching tools including written handouts, practice with patients, video feedback, and tutorial sessions [13]. Seale et al. recently examined the knowledge, skills, and attitudes of medical residents undergoing a substance abuse training program [40]. They used simulated patients and videotaped interviews to assess clinical skills and developed a rating instrument to evaluate overall interviewer proficiency in alcohol-abuse interviewing and intervention skills [41]. That study was an initial attempt to undertake a comprehensive evaluation of a substance abuse training program. However, the principal focus in Seale’s study was the identification and management of alcohol dependence (or alcoholism). No comparable attention has, as yet, been directed toward skills training for nondependent alcohol-related problems. To date, little empirical knowledge exists on the application of methods to train medical students in the basic components of early and brief interventions for alcohol problems. This issue was addressed in the present study. Recently, Sanson-Fisher et al. have encouraged the application of appropriate educational approaches in teaching interactional skills and in dealing with sensitive areas, such as alcohol-related problems [42]. Questions therefore arise as to the relative efficacy of teaching medical students the clinical intervention skills required for a brief intervention for alcohol problems compared with traditional didactic teaching approaches. The present study explored two areas of relatively unchartered waters: (i) techniques for teaching about brief interventions and (ii) the merit of different types of educational approaches. Both issues have received comparatively little attention. The aim of the study was to examine the relative effectiveness of two different educational programs to teach senior medical students brief intervention skills for alcohol problems. The first condition comprised a traditional didactic teaching program on early intervention; the second condition was an interactive program involving practice and small group feedback. METHODOLOGY

Sample Participants in this study were medical students from a traditionally oriented medical school. As part of their usual fifth-year clinical experience students are randomly divided into four educational groups. Within these groups students complete a four-term rotation between various disciplines and it is at this time that they received the bulk of their undergraduate education on alcohol and alcohol-related problems. This pre-

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existing structural arrangement provided a natural and convenient block-randomized design. Students in terms 1 and 2 formed the experimental groups. Students in term 1 received a traditional lecture on drugs and alcohol while students in term 2 were exposed to interactive teaching. Pre- and Postteaching Interviews All students were assessed through two 10-min videotaped interviews. The first interview was conducted in the first week of the term while the second interview was completed within the final 2 weeks of term, approximately 8 to 10 weeks later. Immediately prior to the interview each student was provided with a brief patient profile outlining some details pertinent to the simulated patient they were about to interview. Each student was told to interview patient ‘‘X’’, obtain an alcohol history, and appropriately advise the patient on his or her alcohol consumption. They were instructed not to focus on any other clinical aspects of the patient’s presentation. Students were advised that they had 10 min in which to conduct the interview. A limit of 10 min was chosen as anecdotal evidence indicates that this most closely approximates the time available in an average general practice consultation [43]. Although patient scenarios varied slightly to reflect individual characteristics and personal circumstances, all were restricted to a specified range of drinking- and alcohol-related problems. Simulated patients were mixed in terms of sex, but were predominantly male with an age range of 20 to 48 years. All patients presented as drinking above recommended levels for safe consumption [44]. Simulated Patients Simulated patients were recruited and trained prior to the commencement of the interviews. Each simulated patient was interviewed by up to six students. Simulated patients were informed that the project was intended to provide the students with nonassessable experience in interviewing skills. They were not aware that the interviews formed part of a controlled trial. Teaching Strategies Traditional teaching group. The traditional teaching group received a standard, formal didactic lecture covering theoretical components of the principles and practice of early and brief intervention. This included aspects of the measurement of alcohol intake, assessment of alcohol-related problems and possible dependence, and the appropriate use of early intervention strategies tailored to the needs of the patient [42]. Information on levels of safe, hazardous, and harmful consumption [44] and details pertaining to recent con-

trolled trials on the efficacy of early intervention [45] were provided. The lecture was 3 hr in duration and delivered by one of the professorial staff. Interactive teaching group. The interactive teaching group received input over the same duration, i.e., 3 hr. In this group, 1 hr of formal didactic lecturing was provided presenting, in summary form, the same content as that delivered to the traditional teaching group. This was followed by a small group tutorial session with each group having approximately eight students. In the tutorials students received feedback on their videotaped interviews, completed earlier in the week, from tutors from the academic staff and from the College of General Practitioners’ Family Medicine Programme training scheme. Feedback strategies included those discussed by Maguire et al. and SansonFisher et al. [13,42]. Both the traditional and the interactive groups received a set of comprehensive reading materials which outlined the burden of illness associated with alcohol use, the potential for intervention by medical practitioners, components of a brief intervention, and strategies for instigating behavior change. Rating Schedule In consultation with experts in the field and based on empirically established best practice guidelines a rating schedule was developed to assess students’ performances on the videotaped interviews. The schedule contained 15 sections. Sections 1 to 14 covered components of the interview relating to alcohol and brief intervention techniques. These items examined whether the student satisfactorily accomplished the following tasks: assessed the patient’s drinking status (1 item), level of consumption (3 items), alcohol dependence (12 items), problems associated with alcohol (3 items), and perception of his or her drinking (3 items); educated the patient about safe drinking (3 items); highlighted the association between excess alcohol consumption and health (7 items); advised the patient to modify his or her consumption (6 items); outlined the benefits of cutting down (19 items); expressed confidence in the patient’s ability to reduce consumption (1 item); countered the patient’s self-exemptions (1 item); addressed concerns about changing drinking behavior (2 items); offered behavioral tips for reduction (25 items); and offered written materials and a follow-up visit (3 items). Section 15 consisted of a further 18 items which examined interactional skills. These included opening the consultation, empathy, nonverbal interaction, language, question style, control of the interview, strategies to effect change, concluding the interview, and attempts to summarize. The rating schedule provided a 4-point scoring system with ‘‘Yes’’ indicating that the subject had satisfactorily completed the specified behavior, ‘‘No’’ indi-

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cating that the behavior was either not performed satisfactorily or not performed at all ‘‘Volunteered’’ applying to items where the patient supplied information that preempted the possibility of the student initiating the topic, and ‘‘Not applicable’’ referring to an item which was not relevant to that particular patient. A detailed rater’s manual accompanied the rating schedule, providing explicit details of the schedule and the rating process. Rating of Videotaped Interviews Four independent raters who were naive to the study design and who had no prior knowledge of the content area (to minimize rater bias) were recruited to rate the videotaped interviews. Raters were selected on the basis of their ability to demonstrate consistency and observational accuracy. Raters were instructed to use the manual as a reference throughout the rating process. Tapes were allocated to each rater such that they received a random selection of pre- and postteaching tapes from each of the two groups. Reliability of the Raters A random sample of 10% of the interviews was used to assess the accuracy of the raters against a ‘‘gold standard’’ rater. These reliability checks were undertaken indirectly as there is evidence that raters are reactive to reliability assessment [46]. The k formula was used to calculate agreement as it takes into account the probability of chance agreements [47]. Kappa was judged acceptable when sufficiently large (e.g., >0.6) and significantly different from 0 (P < 0.05). Statistical Analysis Scoring. To score each interview the item response categories were weighted as follows: No 4 0, Yes 4 2, Not applicable or Volunteered 4 1. Summing the item scores in sections 1 to 14 yielded a total score for the alcohol-related items. A total score for interactional skills (section 15) was determined in the same way. A difference score (the difference between pre- and postteaching scores) was calculated for the alcohol-related items and interactional skills. Analysis. All analyses were conducted on the sum of the alcohol-related items and on the total score for interactional skills. Preliminary between-groups comparisons on the preteaching scores were conducted using Mann–Whitney U tests to ensure there were no preexisting differences between the groups. In addition, a within-groups analysis using the Wilcoxon matched-pairs signed-rank test assessed pre- versus postteaching scores to identify changes in performance after the teaching intervention. The primary outcome of interest, that is, the differential effect of teaching

strategy on performance, was examined using a Mann– Whitney U test on difference scores. Predictors of outcome were assessed using regression techniques to determine which of the following variables predicted the greatest change in outcome: sex, teaching group, preteaching mean score, and posttest interactional skill scores. RESULTS

Table 1 outlines the number of students who recorded an interview in each of the study conditions. Percentage participation rates and retention rates at posttest are presented in brackets. Four students in each of the two groups did not complete the preteaching interview. In most instances, this was due to the student’s absence on the day or at the time of recording. No student refused to participate in the interviews. Performance on Alcohol-Related Items Students’ scores on the patient interviews were calculated using the rating schedule and weights described above. Pre- and postteaching mean scores, according to teaching condition, are shown in Table 2. Preteaching performance scores were low on the alcohol-related items among students in both teaching groups. Mean preteaching mean scores were only 26 and 27 for the traditional and interactive teaching groups, respectively, of a possible total score of 178. An examination of the mean total score for alcohol-related items revealed no significant between-group difference in interviewing performance before the teaching intervention as expected (Mann–Whitney z 4 −0.94, NS). A pre/post within-groups analysis revealed that performance on alcohol-related items significantly improved after the teaching intervention. This improvement was evident in both the traditional teaching (Wilcoxon z 4 −4.93, P < 0.0001) and the interactive teaching (Wilcoxon z 4 −4.47, P < 0.0001) conditions. However, a comparison of difference scores revealed that the mean improvement among students in the traditional teaching group was not significantly different from the mean improvement among students in the interactive teaching group (Mann–Whitney z 4 −0.34, NS). Interactional Skills Mean pre- and postteaching interactional skills scores for students in both teaching conditions are disTABLE 1 Subjects Recruited and Retained by Study Condition

Traditional teaching group (term 1) Interactive teaching group (term 2)

Pretest

Posttest

58/62 (94%)

55/58 (95%)

57/61 (93%)

56/57 (98%)

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TABLE 2 Mean Performance Scores by Condition

Alcohol-related items Traditional teaching group —term 1 (n 4 55) Interactive teaching group —term 2 (n 4 56) Interactional Skills Traditional teaching group —term 1 (n 4 55) Interactive teaching group —term 2 (n 4 56)

Preteaching

Postteaching

26.25 (12.92)

38.98 (12.37)

27.18 (10.94)

39.88 (16.72)

20.49 (4.68)

22.13 (3.96)

20.59 (3.50)

22.71 (4.54)

played in Table 2. There was no significant difference in general interactional skills between the two groups prior to teaching (Mann–Whitney z 4 −0.27, NS). After exposure to the teaching intervention students in both groups displayed a significant improvement in performance (Wilcoxon z 4 −2.35, P 4 0.02 in the traditional teaching group and Wilcoxon z 4 −2.81, P < 0.005 in the interactive teaching group). A comparison of the pre/post difference score for each group revealed no significant difference in improvement in performance according to teaching condition (Mann–Whitney z 4 0.10, NS). Regression Analysis Multiple regression analyses were carried out with sex, teaching condition, preteaching total score on alcohol-related items, and postteaching interactional skills score included in the regression equation. Students’ preteaching total score on alcohol items and postteaching interactional skills score were the only variables which made a significant contribution to the equation (t108 4 2.13, P 4 0.035 and t108 4 5.69, P < 0.0001, respectively). These variables accounted for approximately 27% of the variance (R2 4 0.27) in the postteaching total score on alcohol-related items. Rater Reliability Overall, approximately 70–75% of the k’s on each of the items on the rating schedule were above the acceptable level of agreement of 0.6. DISCUSSION

The present investigation represents one of the first studies to examine the comparative effectiveness of different educational strategies for teaching medical students the skills required to deliver a brief intervention for nondependent alcohol problems. A block-randomized controlled trial compared the impact of traditional didactic teaching with small group video feedback on the performance abilities of fifth-year medical students. Videotaped interviews with simulated patients

were used to assess performance skills before and after teaching. The student’s ability to take an alcohol history and provide appropriate information to the patient about his or her drinking behavior was assessed. Overall interactional skills were also evaluated. Baseline performance levels of the medical students on the alcohol-related items were particularly low with preteaching mean scores of only 26 and 27, for the traditional and interactive teaching groups, respectively, when a total score as high as 178 was theoretically possible. Realistically, high scores were not anticipated for a number of reasons. The rating schedule used to assess the students’ performances was comprehensive, covering a wide range of issues and topics which could be addressed in a brief intervention interview. However, students were not expected to address every item. For example, although the section which examined whether students assessed whether the patient was alcohol dependent included 12 different items which may have been asked to determine dependence, it was not necessary for the student to ask all 12 items. In addition, students were only allocated 10 min in which to complete the interviews, restricting the amount of information which could possibly be addressed by the student. Preteaching interactional skills were of an acceptable standard among students in both teaching groups. Mean preteaching scores of 20 and 21 (for the traditional and interactive teaching groups, respectively) of a possible total of 36 suggest that students had a sound foundation on which to further develop their skills in interacting with patients. Effect of Teaching on Performance For the didactic and interactive teaching groups a comparison of baseline (preteaching) and postteaching interviews revealed a statistically significant improvement in the students’ clinical performance as measured on the alcohol-related items of the rating schedule. These results are consistent with previous research indicating that the interviewing skills of clinicians and medical students can be significantly improved after a single session of training [48,49]. However, it is important to note that although performance improvements in the present study were statistically significant, in real terms improvements for both groups were marginal as scores were still relatively low. Relative Effectiveness of Didactic Teaching versus Training with Feedback Contrary to expectation and other research [50], interactive skills training in the form of video feedback was found to be no more effective than traditional didactic lectures in developing the knowledge and skills necessary for carrying out a brief alcohol intervention. Simply providing a group of medical students with information over a 3-hr period about brief intervention

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and how it should be conducted appears to have been sufficient for improving performance at postteaching. This suggests that students readily incorporated the information into their repertoire of clinical skills. Offering students critical feedback about their performance in the first of their simulated interviews did not impart any additional skills over the didactic group. In other words, the present results indicate that 3 hr of teaching, whether didactic or interactive, was sufficient to achieve statistically significant, although not necessarily clinically significant, improvements in medical students’ capacity to deliver a brief intervention for alcohol. It may also be contended that students in the didactic teaching group were taught more ‘‘facts and figures’’ about brief and early intervention (because this information was covered in a 3-hr lecture) than students in the interactive teaching group. Consequently, these students had a greater knowledge base from which to instruct the patient about alcohol-related problems and encourage behavior change. In comparison, students in the interactive teaching group received a summary of this information in just 1 hr and thus their knowledge may have been less complete. As such they may have been less likely to score on particular items listed on the rating schedule. A counterargument to this explanation is that the feedback students in the interactive teaching group received about their pretest performance should have had a positive effect on their general interviewing skills and, more specifically, on their ability to address alcohol-related issues with a patient. However, as students did not have the opportunity to conduct further practice interviews they were unable to incorporate the information learned through the feedback session into their interviewing style. Furthermore, because students were not given the opportunity to consolidate this information much of what had been learned through the feedback session may have been forgotten by the time of the posttest interview, thus reducing the potential beneficial effects of feedback. This problem was addressed by Strecher et al. in their trial to train residents to counsel patients about quitting smoking [51]. To be eligible for the study, residents had to see patients at least one-half day a week in an ambulatory care setting, thereby providing them with the opportunity to practice their interviewing skills. In addition, approximately 2 weeks after the initial training session residents attended small group or individual sessions to allow them to discuss their initial attempts at counseling patients. Failure to do this in the present study may have diminished the otherwise superior effectiveness of interactive over didactic teaching. In considering the effectiveness of these two teaching strategies, the issue of cost effectiveness should be addressed. The didactic teaching method only required a suitably qualified/informed lecturer and a lecture

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room. In comparison, the interactive teaching approach necessitated the recruitment and training of simulated patients, tutors (eight were used in the present study) to provide students with feedback on their performance, video equipment for recording and then replaying the videotaped interviews, and a number of tutorial rooms in which all of this could take place. The videotaping of interviews also required some time and a high degree of organizational flexability to arrange, especially for the postteaching interviews which were conducted at a number of different teaching hospitals. Such logistical considerations need to be taken into account in examining whether to incorporate this strategy into the normal teaching program. Sensitivities Surrounding Alcohol Anecdotally, students in the present study generally appeared reluctant to ask the patients about their alcohol use and frequently delayed asking specific questions about it. This was despite being explicitly told that that was their task and that they had only 10 min in which to interview the patient. One student managed to conduct the 10-min interview without once mentioning alcohol. Others appeared uncomfortable at the point in the interview when general topics of discussion had been covered and it was time to raise the question of the patient’s alcohol consumption. Possible discrepancies between the student’s own behavior and the advice which they offer may play a role in such reticence. Directions for Future Teaching and Research Findings from the present study suggest that more intensive training is necessary to increase both the skills and the confidence of young trainee clinicians to achieve a desirable level of performance in relation to interviewing patients about alcohol problems. The results also add further weight to the argument that without adequate training medical students will not be equipped to carry out such interventions when they are in full-time medical practice. Given the extensive body of literature which indicates that medical practitioners are reluctant to raise and deal with alcohol-related problems, the findings from the present study would suggest that the area is of sufficient sensitivity and remoteness from regular clinical work (noting that there are few good role models for young trainees to use as exemplars in this area of health care) that more detailed training is required than previously assumed. Teaching many aspects of health care related to drug and alcohol problems requires sophisticated educational approaches. Developing the skills fundamental to the identification and management of drug and alcohol problems, particularly as they present in primary health care settings (e.g., hospital outpatients, general practice/family practice), and overcoming clinician’s in-

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adequacies in interviewing and communication are essential. The use of intensive, interactive training approaches providing feedback on interviews with simulated patients, although not found to be superior in the present study, still holds substantial attraction as an effective means of developing essential skills in young medical trainees. It may simply be that training programs of a longer duration are necessary to achieve the level of competence required. It is also important to recognize the potential efficacy of different forms of educational input at different stages of teaching. For instance, didactic approaches may in fact be more appropriate at earlier stages of training and experientially interactive approaches later in training. This is an important area which warrants closer investigation through future research. Supplementing interactive teaching with additional programs may increase the effectiveness of training. Doctors participating in the Maguire et al. study agreed that their poor interviewing performance was due to a lack of clear guidance about how to give information and advice to patients either while or since they were medical students [13]. Providing students with a listing of the necessary elements (ie., topics to be addressed) in an alcohol interview and then actually demonstrating these in a ‘‘model’’ interview may give students a more concrete guide to what is expected. It is speculated that the skills imparted through this type of training will also achieve two other important outcomes. It is assumed that the skills impacted will be generalizable to other clinical situations. Support for this speculation is drawn from studies by Stillman et al.: however, further research is needed to examine this hypothesis more closely [38]. In addition, it is argued that the impact of this type of training is such that the confidence of young trainee clinicians will be improved and that the combination of skills acquisition and raised levels of confidence will act synergistically to improve the probability of identifying and intervening in patients’ alcohol- and drug-related problems. Again, this view is speculative and requires further research to determine its veracity. Nonetheless, these areas of potential investigation hold considerable promise and raise important questions to be addressed in the near future. CONCLUSION

Given the potential that exists for alleviating problems associated with excessive alcohol use through interventions provided by medical practitioners, it is imperative that clinicians are not only knowledgable about the techniques that might be effectively used to assist patients to reduce their alcohol consumption but also that they are skilled in the practical application of these techniques. It is suggested that the sensitivities surrounding alcohol use necessitate more intensive

and detailed teaching than is necessary for many other problems. Providing students with the opportunity to practice their interviewing skills and giving them critical feedback on their performance may be a useful strategy for teaching medical students the necessary skills. However, the present study suggests that, when conducted over a 3-hr teaching period, feedback alone is no more effective that traditional didactic lectures. ACKNOWLEDGMENTS Thanks are extended to the medical students and the simulated patients who participated in the interviews and to the tutors who provided critical feedback to the students in the interactive teaching group. Thanks are also offered to Dr. Raoul Walsh for assistance in refinement of the rating schedule, to Ms. Julia Cohen for organization of the simulated patients and videotaped interviews, and to the raters who assessed the videotapes. REFERENCES 1. Babor TF, Grant M, editors. Project on identification and management of alcohol-related problems. Report on Phase II: a randomised controlled trial of brief interventions in primary health care. World Health Organization, 1992. 2. Bien TH, Miller WR, Tonigan JS. Brief interventions for alcohol problems: a review. Addiction 1993;88:315–36. 3. Saunders JB, Hanratty SJ, Burns FH, Douglas A, Reznick RB. Findings from the WHO randomised controlled trial of early intervention for harmful alcohol consumption. Presented to the 10th National AMPSAD Conference; 1990; Sydney. 4. Lewis DC. Putting training about alcohol and other drugs into the mainstream of medical education. JAMA 1989;13:8–13. 5. Reid ALA, Webb GR, Hennrikus D, Fahey PP, Sanson-Fisher RW. Detection of patients with alcohol intake by general practitioners. Br Med J 1986;293:735–7. 6. Lewis DC, Niven RG, Czechowicz D, Trumble JG. A review of medical education in alcohol and other drug abuse. JAMA 1987; 257:2945–8. 7. Banks A, Waller TAN. Drug misuse: a practical handbook for general practitioners. Oxford: Blackwell Sci., 1988. 8. Glass IB. Substance abuse and professional education: a topsdown or bottoms-up approach? Br J Addict 1988;83:999–1001. 9. Brewster JM, Single E, Ashley MJ, Chow YC, Skinner HS, Rankin JG. Preventing alcohol problems: survey of Canadian medical schools. Can Med Assoc J 1990;143:1076–82. 10. Roche AM. Drug and alcohol medical education: evaluation of a national programme. Br J Addict 1992;87:1041–8. 11. Byrne PS, Long BEL. Doctors talking to patients. London: H. M. Stationery Office, 1976. 12. Sackett DL, Haynes RB, Taylor DW, Gibson ES, Roberts RS, Johnson AL. Clinical determinants of the decision to treat primary hypertension. Clin Res 1977;24:648. 13. Maguire P, Fairbairn S, Fletcher C. Consultation skills of young doctors: I—benefits of feedback in interviewing as students persist. II—most young doctors are bad at giving information. Br Med J 1986;292:1573–8. 14. Kamien M. Still groping. Aust Drug Alcohol Rev 1986;5:85. 15. Evans BJ, Kiellrup FD, Stanley RO, Burrows GD, Sweet BA. Communication skills training for increasing patients’ satisfaction with general practice consultations. Br J Med Psychol 1987; 60:373–8. 16. Goldstein MG. A faculty development model for a curriculum in

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