- Email: [email protected]
The Professionalizing Impact of an Interviewing Course
The Professionalizing Impact of an Interviewing Course CARROLL BRODSKY, Ph.D., M.D. AND DAVID RICHMAN, M.D.
Medical school courses on interviewing and communication skills share much the same fate as instructions on how to live, interact, or raise children, for the teaching of skills that people believe should "come naturally" and that touch fundamental aspects of their self images, is likely to produce extreme emotional reactions. A discussion of the goals and techniques of such a course can do much to clarify the problems and dynamics encountered in similar situations.l. 2. 4. 10·13 Students entering medical school are well prepared for such courses as biochemistry and physiology but are quite unprepared to talk with patients and assume a professional role with all its multifaceted demands. A course on communicating with patients can be of help to medical students on several levels-informing them of the general issues and problems encountered in professional contact, teaching them how to assist patients to relate their histories fully and freely, and preparing them to receive and absorb this information. Students must develop new templates for communication and new conceptual categories with which to process and retain the information obtained. The medical educator must assist his students to modify their existing patterns of learning and interacting so they can synthesize the new with the old. The educator must also provide an opportunity for students to confront and work through those emotional reactions that impede communication with patients. Finally, he must try to equip students with techniques for evaluating their own performance so that they can continue to develop techniques of self-evaluation when they are no longer supervised. When should such a course be taught? If it is taught early in the curriculum, the student lacks the medical knowledge necessary to engage in the diagnostic and treatment process. If it is taught later, the student is already so fixed in his manner of relating to patients that he experiences difficulty in altering his approach to communicating and interviewing,1i even when his deficiencies are apparent to him or when they are pointed out to him by his teachers or classmates. In the fall of 1969, the University of California School of Medicine at San Francisco reorganized its Dr. Carroll Brodsky is Professor of Psychiatry at the University of California School of Medicine, San Francisco; Dr. David Richman is Assistant Clinical Professor of Psychiatry, University of California School of Medicine, San Francisco. Jan.lFeb.lMarch. 1976
curriculum to include in the first year a required course in communication skills dealing mainly with interviewing and history taking (see Table I for a summary of similar courses). Clinical faculty and students alike had recognized deficiencies in history-taking techniques and a lack of concern and responsiveness by students and house staff when interviewing patients. 3 The quality, validity, and comprehensiveness of the information obtained by student interviewers were limited and distorted because the students would not permit patients to talk or would encourage them to narrate only those things the students wanted to hear which was believed to be immediately relevant to the symptom complex. 2 Frequently, students assumed the roles of judge, minister, parent, or, even worse, social critic, with a resulting alienation of the patient. The faculty hoped that the course would help to produce physicians who would be more sensitive and humane in their dealings with patients. 8 As a rule, first year medical students seemed to identify with their patients far more than did fourth year students or house officers. Some first year students, for example, objected to the term "the patient," and many beginning students objected to any use of patients for teaching purposes, despite the obvious practical value this would have for their own learning of clinical medicine. First year medical students often showed a distinct anti-physician bias, describing physicians as heartless, mercenary, and concerned only with their own welfare, and were convinced they would treat their own patients diflerently.3 Thus, it seemed that students would be far more positively influenced by a course given during the early, impressionable months of their medical education, and it was hoped that the experience would continue to influence them during the remainder of their medical education and beyond into practice. FORMAT OF THE COURSE
Most medical educators agree that students should be exposed to a variety of role models during the course of their training}' 8. 9. 10. 12 Here we attempted to achieve this by having an experienced clinician give a brief talk and then, in front of the entire class, interview a patient whom he had not seen previously. The clinician described his interview philosophy, giving the students the opportunity to learn something about the interviewer himself, as well as to acquire technical knowledge. Following this, the students questioned the clinician and presented their own reactions. After a 21
PSYCHOSOMATICS
short intermission, the class reassembled in groups of approximately ten students each, for a ninety minute meeting with an instructor who stayed with the group for the entire twelve weeks of the course. During the small group meetings the first hour's demonstration was further discussed and then a student would interview a patient for 20 to 30 minutes. This was followed by a general discussion in which the group evaluated the interviewer's technique and the positive and negative aspects of the interview and discussed their impressions of the patient, the doctor-patient relationship, and whatever else they considered to be of importance. The students were provided with written material on technique, on the evaluation of interviews, and on problem patients, together with a list of suggested reading. Variations included the use of role playing in which students would interview each other, and the presentation of videotapes of students in the class interviewing patients, which were shown to the assembled class and then discussed. 13 OBSERVATIONS
Our conclusions are based on observations both in the large group and in the small groups, on numerous interviews with individual students, and on data from official course evaluations conducted by the Dean's Office. Students approached learning to interview in many different ways and continued to develop these differing patterns during the twelve weeks of the course. Variation was considerable within each group, and each successive freshman class reflected somewhat different shared attitudes toward dealing with patients. Much more striking than this variability, however, were the learning processes that clearly and regularly recurred. Role, Purpose, and Privilege At the outset of each semester students eagerly and anxiously posed a number of questions: "What is the purpose of the course?" "What are we supposed to find out from patients?" "How can we conduct an interview with no medical knowledge?" The discussion of procedural matters, the explanation of goals, and the furnishing of outlines and guides designed to assist beginning interviewers did little to allay anxiety or dispel perplexity. It soon became evident that questions about what the course was "supposed to accomplish," and what the students were "supposed to ask" the patients, were not worrying students nearly as much as the question "Who and what am I in relation to the patient?" The focus of the question was on role, especially on the legitimacy of assuming a new role. It bore most immediately on whether or not the beginning student has the right to ask a patient personal questions. Some students wanted to assume the role of the graduate physician immediately, but most were opposed to this and insisted on identifying themselves to the patient as beginners. They identified with the patients, whom 22
they thought would be harmed by exposure before an audience of students and faculty. Later, some students related these feelings of their own anxieties about performing before the group, with the risk of appearing incompetent and foolish. Some students felt that only to the extent that a physician can provide a patient with practical and immediate aid does he have the right to confidential information. Although it gradually became evident that the chance to speak of their illnesses to interested and sympathetic listeners was in itself often pleasing and helpful, the concern about in some way harming patients persisted. In the early interviews, the fear of intruding, confusion about role, and lack of experience, coupled with self-consciousness about performing in front of the group, combined to immobilize 2 some students. Unable to make sense of the unfamiliar information about the patient's symptoms and burdened by the above mentioned concerns, the student would end the interview early, announcing that he had run out of questions. These early experiences generated the discussion, thought, and self-examination needed to advance the students into the next phase of the developmental process.
The Search for a Nuclear Issue By the third or fourth class meeting, the students would reveal a need to develop early in the interview a clear idea of a single, central problem in the patient's history around which to organize further lines of questioning. They had not yet conceptualized a style that could assist the patient to develop a description of one symptom chronologically, and then to deal similarly with his other symptoms and their effects until an organized and coherent history emerged. Rather, the students would ask a series of leading questions that tended to limit the patient and discourage his elaborating a free and spontaneous account of his illness that might contain the very cues needed by the interviewer to direct his questioning most productively. Without such cues, the students soon felt lost and groped for some single idea around which to structure their inquiry. The awkward silences that frequently arose at such moments increased the interviewer's anxieties. Not trusting the patient to point the way, and feeling burdened by the responsibility for conducting a "successful" interview, the student would ask questions at random. Despite these difficulties, the students managed to elicit great amounts of information. This confronted them with the problem of developing mechanisms to cope with and process this new information, itself an identifiable stage in learning to interview. Problem Situations and Coping Styles The students' problems with allowing their patients Volume XVII
INTERVIEWING COURSE-BRODSKY AND RICHMAN
to speak freely fell into identifiable clusters. 2 The most obvious and most frequently encountered difficulty was a simple information overload. As the patient unfolded a long, elaborate, and complex history, the student would begin to feel overwhelmed as he tried to register, record, organize, and evaluate the information. Identification and empathy with patients led many students to try to divert them from fully disclosing the life-threatening, painful, disabling, or disfiguring nature of their illnesses. Some of the students later commented that the patients had caused them to recall their own past illnesses, their own fears of becoming seriously ill or disabled, or illnesses affecting family or friends. Students were visibly more uneasy and cautious than usual when speaking with patients with terminal illnesses such as metastatic cancer or advanced cardiac disease, and later expressed surprise when, during the group discussion, they "learned" that the patient was approaching death. They were often noticeably affected when patients discussed problems in the areas of sex, family relationships, marriage, finances, or work, and some would display heightened anxiety and make obvious efforts to discourage patients from elaborating their problems. The students' reactions to the life styles, behavior, and values of some patients also constituted a regularly occurring problem. This usually took the form of a student's displaying anger, disapproval, or disbelief. Reactions were most marked when a student was dealing with a patient from a background, socioeconomic class, or ethnic group that was different from his own. A similar hindrance to learning about the patient resulted from exaggerated approval of a patient's life style. During the first year of the course (1969), when the social scene was somewhat more disrupted than it is at present, young, rebellious, anti-social patients would evoke applause from the class; students were more eager to discuss the life styles and social philosophies of these patients than to explore what had brought them to the hospital. The students found it diffcult to see how their own personal values, moralistc attitudes, and biases intruded inappropriately during an interview.
Adaptive Efforts Students used a number of techniques to attempt to influence their patient to limit, edit, and otherwise withhold a complete description of their symptoms, feelings, and reactions. They conveyed their uneasiness by means of body movements, facial expressions, and tone of voice, indicating that there was something to fear in proceeding openly in the interview. Closedended questions, phrased to invite only a very brief reply or a "yes" or "no" response, frequently were employed at such points. Often, when a subject was discussed that aroused discomfort in the student, he Jan.lFeb.lMarch, 1976
would simply ask another question, diverting to a different subject. Another technique was to try to predetermine a patient's response by phrasing the next question to suggest a desired answer, for example, "I guess that went away after a while, didn't it?" In general, students were not aware that their interviewing styles could inhibit communication. They were astonished when an experienced interviewer, by providing a patient with only two directives: "Tell me all about your illness," and "Tell me all about yourself," learned a great deal about the patient's social, psychological, and biological history and status. They found it difficult to believe that they had "trained" their patients to restrict the amount and nature of verbalizations to limits that would be emotionally tolerable to the students. Assimilation of Role and Technique The interplay of emotional and technical factors was striking as students developed their interviewing skill. Effective techniques for phrasing productive questions, for perceiving the necessary cues to guide the direction of further inquiry, and for investigating symptoms thoroughly and clearly were not acquired and assimilated by most students until they began working through the personal emotional impediments described above. As students began to identify themselves as physicians, they became less concerned with the problem of privilege in questioning patients, and began to .conduct interviews that yielded appropriate medical information and were therapeutic. By conducting and observing interviews of a large number of patients they became aware of the range of possible events that can arise in a medical interview, and this reduced the fear of the unknown. As they heard a variety of patients describe the development of their illnesses, desensitization to the more frightening aspects of somatic disease occurred. As they became less emotionally affected by identification, they were able to listen more freely and to help patients relate their histories. DISCUSSION
Most authors who describe interviewing courses for first year medical students tend to be enthusiastic about the results. On the basis of yearly surveys of student evaluations and extensive discussion with the faculty members who taught in the large and small groups, we too are enthusiastic, while student reaction to the course ranged from strong enthusiasm to labeling it a total waste of time. We found that students gained awareness, technical skill, and freedom in communicating with patients, as was confirmed by faculty members of later clinical courses, who could compare the performance of students who had completed the interviewing course with that of previous students who had not taken this course. The course served other vital functions. In a tur23
PSYCHOSOMATICS
bulent academic year when, because of new admission policies, one quarter of the freshman class came from minority groups, this course was the only one in the curriculum to provide a forum in which students could discuss significant issues concerning relationships among themselves and between physician and patient. Questions were raised, for example, as to whether a white physician could ever understand a black patient, and as to whether one could treat someone whom one hated. Students from minority groups challenged the health care system to deal with the problems of impoverished minority patients' not finding ready access to medical care, or being afforded inferior treatment. Women medical students identified themselves as a spe-
cial minority group and raised their concerns about not being taken seriously by certain patients, especially joking, flirtatious men and doting elderly women. A number of women students had begun to expect patronizing responses from the patients they interviewed after being mistaken by them for nurses and meeting with surprised embarrassment on informing these patients that they were medical students or student physicians. They understood that such behavior was a part of the long tradition of the "male physician", at least in the United States, and were tolerant though hopeful that their increasing numbers in medicine would change the stereotype. They were less accepting of male faculty members who made jokes about women physicians and
TABE I Stated Purpose
Methods
The College of Human Medicine, Michigan State University April, 1971 Freshman Course
To acquire the skills necessary for good professional relationships with patients, overcome anxieties in confronting patients, adopt a comfortable professional self·image.
Students do 5 interviews. Actors simulate patients. Videotapes of interviews are replayed and discussed in small groups. Instructors are trained in a workshop prior to the course.
2
University of Southern Calif., School of Medicine August, 1967 Freshman Course
To change disease orientation of students, teach doctor-patient relationship, increase sensitivity to and perception of interpersonal events and patients' problems. increase student-faculty contacts.
Small groups meet weekly for 12 weeks. Each student interviews weekly and discusses his results for 90 minutes in a small group. Two instructors per group.
4
Marquette School of Medicine October, 1968 Sophomore Course
To teach interview skills, encourage an accepting, nonjudgmental attitude toward patients, understand the doctor-patient relationship.
Small groups meet weekly for 12 weeks (4 hours per meeting). Each student interviews at the bedside then discusses the interview in the smaIl group. A tutor interviews patient and the group discusses this interview.
10
Howman-Gray School of Medicine October, 1971 Freshman Course
To increase awareness of interaction between student and patient, to develop operational skills in interviewing, to develop patient cooperation and trust.
Weekly 2 hour meetings. Lectures and panels on interviewing principles, faculty demonstration interviews, student role-played interviews and discussion of these in small groups. Then students interview patients with discussion following. Didactic seminars on special topics. Students write up reports on their patients.
11
Cornell Medical College December, 1969 Elective Freshman Course
To enhance interpersonal sensitivity, empathy, and selfawareness, to promote emotional development, creativity, and authenticity in students, to improve communication among students and faculty, to lessen stresses of medical education.
Group seminars (10 students and a resident psychiatrist) using discussion, role-playing, exploration of group process and students' behavior in the group, information on human behavior given by instructors.
12
University of Oklahoma, School of Medicine December 1969
To teach the skills necessary for successful interviewing.
Students interview actors, role-playing patients, small group discussion is based on videotape playbacks, a descriptive manual with programmed instructions is furnished, faculty does demonstration interviews, group discussion of filmed interviews and student write-ups.
Reference
24
School and Date of Publication of Reports
Volume XVII
INTERVIEWING COURSE-BRODSKY AND RICHMAN
who seemed to believe that they should be restricted to the specialities of pediatrics and psychiatry. The early opportunity to share experiences on problems of common interest effected a considerable reduction of tension and opened a dialogue which continued in other classes and in special seminars organized by the students. Many students resented the course, however, for the very reasons the faculty considered it important, namely, because it strove to establish professional role models, because it discussed appropriate modes of interaction between physician and patient to safeguard the patient's rights and freedom, and because it made a definite effort to initiate the student into that vague entity called the medical profession. Attempts to define behavioral standards to those students who were highly ambivalent about any discipline, who were often antiprofessional in their attitudes, and hostile to those already in the profession, inevitably were unpopular. The evaluation of a course such as this has important implications for the medical anthropologist and medical educator. Medical education, unlike the liberal education of undergraduate colleges, prepares the student for a field that not only requires specific specific skills and techniques but also is, in a sense, an institution in itself. It possesses its own hierarchy, rituals, rites of passage, and has, both in popular literature and in formal professional codes, definitely prescribed patterns of behavior that are recognized and shared by practitioners and ancillary personnel. Changes in these patterns tend to reflect trends of change in the broader culture. Thus, medical educators must concern themselves with changes in students entering medicine and in their attitudes toward being initiated into the values of the existing culture. From listening to conversations among first year medical students and from extensive talks with them about their attitudes toward medicine and their own futures, the authors have concluded that there is a pronounced decrease in the number who want to follow existing patterns of members of the medical profession. Fewer students see themselves entering traditional private practice. They are, however, uncertain about how they do want to practice. They tend to take future security for granted, having been raised on the notion that there will never be enough physicians and that medicine will always be allocated enough wealth for them never to worry about their income. They assume that opportunities of many sorts will be available-they can work in medical programs in foreign countries or domestically with disadvantaged people, they will be in part doers, in part leaders, they will have the option of deciding which roles they will perform. The resentment that these students feel toward any course or program designed to structure a professional self-image or Jan.lFeb.lMarch, 1976
to inculcate principles designed to help them match their behavior to that of their predecessors must be recognized, allowed for and dealt with in the format and timing of such courses, the value of which seems unquestionable. In a period of rapid social change, when values and institutions have lost the clarity and impregnability they possessed in more tranquil times, a course such as the one described enables beginning medical students to gain insight into their own psychological mechanisms and to acquire certain specific skills, both of which are essential to conducting a complete and productive interview. It also introduces them to the range of professional role behavior of physicians so that they can consider these thoughtfully and deliberately and begin the conscious and unconscious development of their own professional roles. 350 Parnassus, Brodsky).
San
Francisco,
California
94117
(Dr.
REFERENCES 1. Jason, H., Kagan, N., Werner, A., Elstein, A.S., and Thomas J.B.: New approaches to teaching basic interview skills to medical students. Am. J. Psychial. 127: 1404, 1971. 2. Pollack, S. and Manning, P.R.: An experience in teaching doctor-patient relationship to first-year medical students. J. Med. Edllc. 42:770, 1967. 3. Pollock, S. and Michaea, W.B.: Changes in attitudes of medical students towards psychological aspects of the doctor-image and the doctor-patient relationship. J. Med Edllc. 40:1162,1965. 4. Bernstein, L., Headlee, R., and Jackson, B.: Changes in "acceptance of others" as a function of a course in the doctor-patient relationship. J. Med. Edllc. 43: 1093, 1968, Abstract. 5. Barbee, R.A. and Feldman, S.E.: A three year longitudinal study of the medical interview and its relationship to student performance in clinical medicine. J. Med. Edllc. 45:770,1970. 6. McGuire, F.L.: Psychosocial studies of medical students. J. Med. Edllc. 41 :424, 1966. 7. Funkenstein, D.H.: The learning and personal develop· ment of medical students and recent changes in universities and medical schools. J. Med. Edllc. 43:883, 1968. 8. Mendel, W., and Green, G.: On becoming a physician. J. Med. Edllc. 40:266, 1965. 9. Mene, W.G.: Medical identity: change in conflict in professional roles. J. Med Edllc. 46:58, 1971. 10. Hayes, D.M., Hutatf, L., and Mace, D.: Preparation of medical students for patient interviewing. J. Med. Edllc. 46:863,1971. 11. Cadden, J.J., Flach, F., Blakeslee, S. and Charlton, R.: Growth in medical students through group process. Am. J. Psychial. 126:862, 1969. 12. Froelick, R.E.: A coun;e in medical interviewing. J. Med. Edllc. 44: 1165, 1969. 13. Cline, D.W., and Garrard, J.N.: A Medical Interviewing Course: Objectives, Techniques, and Assessment. Am. J. Psychial., 130:574-578, 1973. 25
Medical school courses on interviewing and communication skills share much the same fate as instructions on how to live, interact, or raise children, for the teaching of skills that people believe should "come naturally" and that touch fundamental aspects of their self images, is likely to produce extreme emotional reactions. A discussion of the goals and techniques of such a course can do much to clarify the problems and dynamics encountered in similar situations.l. 2. 4. 10·13 Students entering medical school are well prepared for such courses as biochemistry and physiology but are quite unprepared to talk with patients and assume a professional role with all its multifaceted demands. A course on communicating with patients can be of help to medical students on several levels-informing them of the general issues and problems encountered in professional contact, teaching them how to assist patients to relate their histories fully and freely, and preparing them to receive and absorb this information. Students must develop new templates for communication and new conceptual categories with which to process and retain the information obtained. The medical educator must assist his students to modify their existing patterns of learning and interacting so they can synthesize the new with the old. The educator must also provide an opportunity for students to confront and work through those emotional reactions that impede communication with patients. Finally, he must try to equip students with techniques for evaluating their own performance so that they can continue to develop techniques of self-evaluation when they are no longer supervised. When should such a course be taught? If it is taught early in the curriculum, the student lacks the medical knowledge necessary to engage in the diagnostic and treatment process. If it is taught later, the student is already so fixed in his manner of relating to patients that he experiences difficulty in altering his approach to communicating and interviewing,1i even when his deficiencies are apparent to him or when they are pointed out to him by his teachers or classmates. In the fall of 1969, the University of California School of Medicine at San Francisco reorganized its Dr. Carroll Brodsky is Professor of Psychiatry at the University of California School of Medicine, San Francisco; Dr. David Richman is Assistant Clinical Professor of Psychiatry, University of California School of Medicine, San Francisco. Jan.lFeb.lMarch. 1976
curriculum to include in the first year a required course in communication skills dealing mainly with interviewing and history taking (see Table I for a summary of similar courses). Clinical faculty and students alike had recognized deficiencies in history-taking techniques and a lack of concern and responsiveness by students and house staff when interviewing patients. 3 The quality, validity, and comprehensiveness of the information obtained by student interviewers were limited and distorted because the students would not permit patients to talk or would encourage them to narrate only those things the students wanted to hear which was believed to be immediately relevant to the symptom complex. 2 Frequently, students assumed the roles of judge, minister, parent, or, even worse, social critic, with a resulting alienation of the patient. The faculty hoped that the course would help to produce physicians who would be more sensitive and humane in their dealings with patients. 8 As a rule, first year medical students seemed to identify with their patients far more than did fourth year students or house officers. Some first year students, for example, objected to the term "the patient," and many beginning students objected to any use of patients for teaching purposes, despite the obvious practical value this would have for their own learning of clinical medicine. First year medical students often showed a distinct anti-physician bias, describing physicians as heartless, mercenary, and concerned only with their own welfare, and were convinced they would treat their own patients diflerently.3 Thus, it seemed that students would be far more positively influenced by a course given during the early, impressionable months of their medical education, and it was hoped that the experience would continue to influence them during the remainder of their medical education and beyond into practice. FORMAT OF THE COURSE
Most medical educators agree that students should be exposed to a variety of role models during the course of their training}' 8. 9. 10. 12 Here we attempted to achieve this by having an experienced clinician give a brief talk and then, in front of the entire class, interview a patient whom he had not seen previously. The clinician described his interview philosophy, giving the students the opportunity to learn something about the interviewer himself, as well as to acquire technical knowledge. Following this, the students questioned the clinician and presented their own reactions. After a 21
PSYCHOSOMATICS
short intermission, the class reassembled in groups of approximately ten students each, for a ninety minute meeting with an instructor who stayed with the group for the entire twelve weeks of the course. During the small group meetings the first hour's demonstration was further discussed and then a student would interview a patient for 20 to 30 minutes. This was followed by a general discussion in which the group evaluated the interviewer's technique and the positive and negative aspects of the interview and discussed their impressions of the patient, the doctor-patient relationship, and whatever else they considered to be of importance. The students were provided with written material on technique, on the evaluation of interviews, and on problem patients, together with a list of suggested reading. Variations included the use of role playing in which students would interview each other, and the presentation of videotapes of students in the class interviewing patients, which were shown to the assembled class and then discussed. 13 OBSERVATIONS
Our conclusions are based on observations both in the large group and in the small groups, on numerous interviews with individual students, and on data from official course evaluations conducted by the Dean's Office. Students approached learning to interview in many different ways and continued to develop these differing patterns during the twelve weeks of the course. Variation was considerable within each group, and each successive freshman class reflected somewhat different shared attitudes toward dealing with patients. Much more striking than this variability, however, were the learning processes that clearly and regularly recurred. Role, Purpose, and Privilege At the outset of each semester students eagerly and anxiously posed a number of questions: "What is the purpose of the course?" "What are we supposed to find out from patients?" "How can we conduct an interview with no medical knowledge?" The discussion of procedural matters, the explanation of goals, and the furnishing of outlines and guides designed to assist beginning interviewers did little to allay anxiety or dispel perplexity. It soon became evident that questions about what the course was "supposed to accomplish," and what the students were "supposed to ask" the patients, were not worrying students nearly as much as the question "Who and what am I in relation to the patient?" The focus of the question was on role, especially on the legitimacy of assuming a new role. It bore most immediately on whether or not the beginning student has the right to ask a patient personal questions. Some students wanted to assume the role of the graduate physician immediately, but most were opposed to this and insisted on identifying themselves to the patient as beginners. They identified with the patients, whom 22
they thought would be harmed by exposure before an audience of students and faculty. Later, some students related these feelings of their own anxieties about performing before the group, with the risk of appearing incompetent and foolish. Some students felt that only to the extent that a physician can provide a patient with practical and immediate aid does he have the right to confidential information. Although it gradually became evident that the chance to speak of their illnesses to interested and sympathetic listeners was in itself often pleasing and helpful, the concern about in some way harming patients persisted. In the early interviews, the fear of intruding, confusion about role, and lack of experience, coupled with self-consciousness about performing in front of the group, combined to immobilize 2 some students. Unable to make sense of the unfamiliar information about the patient's symptoms and burdened by the above mentioned concerns, the student would end the interview early, announcing that he had run out of questions. These early experiences generated the discussion, thought, and self-examination needed to advance the students into the next phase of the developmental process.
The Search for a Nuclear Issue By the third or fourth class meeting, the students would reveal a need to develop early in the interview a clear idea of a single, central problem in the patient's history around which to organize further lines of questioning. They had not yet conceptualized a style that could assist the patient to develop a description of one symptom chronologically, and then to deal similarly with his other symptoms and their effects until an organized and coherent history emerged. Rather, the students would ask a series of leading questions that tended to limit the patient and discourage his elaborating a free and spontaneous account of his illness that might contain the very cues needed by the interviewer to direct his questioning most productively. Without such cues, the students soon felt lost and groped for some single idea around which to structure their inquiry. The awkward silences that frequently arose at such moments increased the interviewer's anxieties. Not trusting the patient to point the way, and feeling burdened by the responsibility for conducting a "successful" interview, the student would ask questions at random. Despite these difficulties, the students managed to elicit great amounts of information. This confronted them with the problem of developing mechanisms to cope with and process this new information, itself an identifiable stage in learning to interview. Problem Situations and Coping Styles The students' problems with allowing their patients Volume XVII
INTERVIEWING COURSE-BRODSKY AND RICHMAN
to speak freely fell into identifiable clusters. 2 The most obvious and most frequently encountered difficulty was a simple information overload. As the patient unfolded a long, elaborate, and complex history, the student would begin to feel overwhelmed as he tried to register, record, organize, and evaluate the information. Identification and empathy with patients led many students to try to divert them from fully disclosing the life-threatening, painful, disabling, or disfiguring nature of their illnesses. Some of the students later commented that the patients had caused them to recall their own past illnesses, their own fears of becoming seriously ill or disabled, or illnesses affecting family or friends. Students were visibly more uneasy and cautious than usual when speaking with patients with terminal illnesses such as metastatic cancer or advanced cardiac disease, and later expressed surprise when, during the group discussion, they "learned" that the patient was approaching death. They were often noticeably affected when patients discussed problems in the areas of sex, family relationships, marriage, finances, or work, and some would display heightened anxiety and make obvious efforts to discourage patients from elaborating their problems. The students' reactions to the life styles, behavior, and values of some patients also constituted a regularly occurring problem. This usually took the form of a student's displaying anger, disapproval, or disbelief. Reactions were most marked when a student was dealing with a patient from a background, socioeconomic class, or ethnic group that was different from his own. A similar hindrance to learning about the patient resulted from exaggerated approval of a patient's life style. During the first year of the course (1969), when the social scene was somewhat more disrupted than it is at present, young, rebellious, anti-social patients would evoke applause from the class; students were more eager to discuss the life styles and social philosophies of these patients than to explore what had brought them to the hospital. The students found it diffcult to see how their own personal values, moralistc attitudes, and biases intruded inappropriately during an interview.
Adaptive Efforts Students used a number of techniques to attempt to influence their patient to limit, edit, and otherwise withhold a complete description of their symptoms, feelings, and reactions. They conveyed their uneasiness by means of body movements, facial expressions, and tone of voice, indicating that there was something to fear in proceeding openly in the interview. Closedended questions, phrased to invite only a very brief reply or a "yes" or "no" response, frequently were employed at such points. Often, when a subject was discussed that aroused discomfort in the student, he Jan.lFeb.lMarch, 1976
would simply ask another question, diverting to a different subject. Another technique was to try to predetermine a patient's response by phrasing the next question to suggest a desired answer, for example, "I guess that went away after a while, didn't it?" In general, students were not aware that their interviewing styles could inhibit communication. They were astonished when an experienced interviewer, by providing a patient with only two directives: "Tell me all about your illness," and "Tell me all about yourself," learned a great deal about the patient's social, psychological, and biological history and status. They found it difficult to believe that they had "trained" their patients to restrict the amount and nature of verbalizations to limits that would be emotionally tolerable to the students. Assimilation of Role and Technique The interplay of emotional and technical factors was striking as students developed their interviewing skill. Effective techniques for phrasing productive questions, for perceiving the necessary cues to guide the direction of further inquiry, and for investigating symptoms thoroughly and clearly were not acquired and assimilated by most students until they began working through the personal emotional impediments described above. As students began to identify themselves as physicians, they became less concerned with the problem of privilege in questioning patients, and began to .conduct interviews that yielded appropriate medical information and were therapeutic. By conducting and observing interviews of a large number of patients they became aware of the range of possible events that can arise in a medical interview, and this reduced the fear of the unknown. As they heard a variety of patients describe the development of their illnesses, desensitization to the more frightening aspects of somatic disease occurred. As they became less emotionally affected by identification, they were able to listen more freely and to help patients relate their histories. DISCUSSION
Most authors who describe interviewing courses for first year medical students tend to be enthusiastic about the results. On the basis of yearly surveys of student evaluations and extensive discussion with the faculty members who taught in the large and small groups, we too are enthusiastic, while student reaction to the course ranged from strong enthusiasm to labeling it a total waste of time. We found that students gained awareness, technical skill, and freedom in communicating with patients, as was confirmed by faculty members of later clinical courses, who could compare the performance of students who had completed the interviewing course with that of previous students who had not taken this course. The course served other vital functions. In a tur23
PSYCHOSOMATICS
bulent academic year when, because of new admission policies, one quarter of the freshman class came from minority groups, this course was the only one in the curriculum to provide a forum in which students could discuss significant issues concerning relationships among themselves and between physician and patient. Questions were raised, for example, as to whether a white physician could ever understand a black patient, and as to whether one could treat someone whom one hated. Students from minority groups challenged the health care system to deal with the problems of impoverished minority patients' not finding ready access to medical care, or being afforded inferior treatment. Women medical students identified themselves as a spe-
cial minority group and raised their concerns about not being taken seriously by certain patients, especially joking, flirtatious men and doting elderly women. A number of women students had begun to expect patronizing responses from the patients they interviewed after being mistaken by them for nurses and meeting with surprised embarrassment on informing these patients that they were medical students or student physicians. They understood that such behavior was a part of the long tradition of the "male physician", at least in the United States, and were tolerant though hopeful that their increasing numbers in medicine would change the stereotype. They were less accepting of male faculty members who made jokes about women physicians and
TABE I Stated Purpose
Methods
The College of Human Medicine, Michigan State University April, 1971 Freshman Course
To acquire the skills necessary for good professional relationships with patients, overcome anxieties in confronting patients, adopt a comfortable professional self·image.
Students do 5 interviews. Actors simulate patients. Videotapes of interviews are replayed and discussed in small groups. Instructors are trained in a workshop prior to the course.
2
University of Southern Calif., School of Medicine August, 1967 Freshman Course
To change disease orientation of students, teach doctor-patient relationship, increase sensitivity to and perception of interpersonal events and patients' problems. increase student-faculty contacts.
Small groups meet weekly for 12 weeks. Each student interviews weekly and discusses his results for 90 minutes in a small group. Two instructors per group.
4
Marquette School of Medicine October, 1968 Sophomore Course
To teach interview skills, encourage an accepting, nonjudgmental attitude toward patients, understand the doctor-patient relationship.
Small groups meet weekly for 12 weeks (4 hours per meeting). Each student interviews at the bedside then discusses the interview in the smaIl group. A tutor interviews patient and the group discusses this interview.
10
Howman-Gray School of Medicine October, 1971 Freshman Course
To increase awareness of interaction between student and patient, to develop operational skills in interviewing, to develop patient cooperation and trust.
Weekly 2 hour meetings. Lectures and panels on interviewing principles, faculty demonstration interviews, student role-played interviews and discussion of these in small groups. Then students interview patients with discussion following. Didactic seminars on special topics. Students write up reports on their patients.
11
Cornell Medical College December, 1969 Elective Freshman Course
To enhance interpersonal sensitivity, empathy, and selfawareness, to promote emotional development, creativity, and authenticity in students, to improve communication among students and faculty, to lessen stresses of medical education.
Group seminars (10 students and a resident psychiatrist) using discussion, role-playing, exploration of group process and students' behavior in the group, information on human behavior given by instructors.
12
University of Oklahoma, School of Medicine December 1969
To teach the skills necessary for successful interviewing.
Students interview actors, role-playing patients, small group discussion is based on videotape playbacks, a descriptive manual with programmed instructions is furnished, faculty does demonstration interviews, group discussion of filmed interviews and student write-ups.
Reference
24
School and Date of Publication of Reports
Volume XVII
INTERVIEWING COURSE-BRODSKY AND RICHMAN
who seemed to believe that they should be restricted to the specialities of pediatrics and psychiatry. The early opportunity to share experiences on problems of common interest effected a considerable reduction of tension and opened a dialogue which continued in other classes and in special seminars organized by the students. Many students resented the course, however, for the very reasons the faculty considered it important, namely, because it strove to establish professional role models, because it discussed appropriate modes of interaction between physician and patient to safeguard the patient's rights and freedom, and because it made a definite effort to initiate the student into that vague entity called the medical profession. Attempts to define behavioral standards to those students who were highly ambivalent about any discipline, who were often antiprofessional in their attitudes, and hostile to those already in the profession, inevitably were unpopular. The evaluation of a course such as this has important implications for the medical anthropologist and medical educator. Medical education, unlike the liberal education of undergraduate colleges, prepares the student for a field that not only requires specific specific skills and techniques but also is, in a sense, an institution in itself. It possesses its own hierarchy, rituals, rites of passage, and has, both in popular literature and in formal professional codes, definitely prescribed patterns of behavior that are recognized and shared by practitioners and ancillary personnel. Changes in these patterns tend to reflect trends of change in the broader culture. Thus, medical educators must concern themselves with changes in students entering medicine and in their attitudes toward being initiated into the values of the existing culture. From listening to conversations among first year medical students and from extensive talks with them about their attitudes toward medicine and their own futures, the authors have concluded that there is a pronounced decrease in the number who want to follow existing patterns of members of the medical profession. Fewer students see themselves entering traditional private practice. They are, however, uncertain about how they do want to practice. They tend to take future security for granted, having been raised on the notion that there will never be enough physicians and that medicine will always be allocated enough wealth for them never to worry about their income. They assume that opportunities of many sorts will be available-they can work in medical programs in foreign countries or domestically with disadvantaged people, they will be in part doers, in part leaders, they will have the option of deciding which roles they will perform. The resentment that these students feel toward any course or program designed to structure a professional self-image or Jan.lFeb.lMarch, 1976
to inculcate principles designed to help them match their behavior to that of their predecessors must be recognized, allowed for and dealt with in the format and timing of such courses, the value of which seems unquestionable. In a period of rapid social change, when values and institutions have lost the clarity and impregnability they possessed in more tranquil times, a course such as the one described enables beginning medical students to gain insight into their own psychological mechanisms and to acquire certain specific skills, both of which are essential to conducting a complete and productive interview. It also introduces them to the range of professional role behavior of physicians so that they can consider these thoughtfully and deliberately and begin the conscious and unconscious development of their own professional roles. 350 Parnassus, Brodsky).
San
Francisco,
California
94117
(Dr.
REFERENCES 1. Jason, H., Kagan, N., Werner, A., Elstein, A.S., and Thomas J.B.: New approaches to teaching basic interview skills to medical students. Am. J. Psychial. 127: 1404, 1971. 2. Pollack, S. and Manning, P.R.: An experience in teaching doctor-patient relationship to first-year medical students. J. Med. Edllc. 42:770, 1967. 3. Pollock, S. and Michaea, W.B.: Changes in attitudes of medical students towards psychological aspects of the doctor-image and the doctor-patient relationship. J. Med Edllc. 40:1162,1965. 4. Bernstein, L., Headlee, R., and Jackson, B.: Changes in "acceptance of others" as a function of a course in the doctor-patient relationship. J. Med. Edllc. 43: 1093, 1968, Abstract. 5. Barbee, R.A. and Feldman, S.E.: A three year longitudinal study of the medical interview and its relationship to student performance in clinical medicine. J. Med. Edllc. 45:770,1970. 6. McGuire, F.L.: Psychosocial studies of medical students. J. Med. Edllc. 41 :424, 1966. 7. Funkenstein, D.H.: The learning and personal develop· ment of medical students and recent changes in universities and medical schools. J. Med. Edllc. 43:883, 1968. 8. Mendel, W., and Green, G.: On becoming a physician. J. Med. Edllc. 40:266, 1965. 9. Mene, W.G.: Medical identity: change in conflict in professional roles. J. Med Edllc. 46:58, 1971. 10. Hayes, D.M., Hutatf, L., and Mace, D.: Preparation of medical students for patient interviewing. J. Med. Edllc. 46:863,1971. 11. Cadden, J.J., Flach, F., Blakeslee, S. and Charlton, R.: Growth in medical students through group process. Am. J. Psychial. 126:862, 1969. 12. Froelick, R.E.: A coun;e in medical interviewing. J. Med. Edllc. 44: 1165, 1969. 13. Cline, D.W., and Garrard, J.N.: A Medical Interviewing Course: Objectives, Techniques, and Assessment. Am. J. Psychial., 130:574-578, 1973. 25