Ruth B. Hoppe

The Patient's Story: Integrating the Patient- and Physician-centered Approaches to Interviewing

Patients produce biopsychosocial stories that integrate material from the medical and personal aspects of their lives. Capturing the personal aspect of the story requires that a patient-centered approach to clinical interviewing complement the equally important physician-centered approach. Patient-centered interviewing actively involves the patient and ensures that his or her perceptions, needs, and concerns are articulated during the physician-patient interaction. In our article, we define patient-centered interviewing and provide a rationale for using it. We also describe how patient-centered interviewing is done, how it is integrated with the physician-centered approach, and how to understand the product of this complementary approach to clinical interviewing, the patients biopsychosocial story.

Comparison of physicians' decisions regarding estrogen replacement therapy for menopausal women and decisions derived from a decision analytic model

Decisions regarding estrogen replacement therapy were obtained from 50 physicians for 12 cases representing menopausal women with systematically varying levels of cancer risk, fracture risk, and symptom severity. Their decisions were compared with a decision analytic model for which each physician provided needed quantities--subjective probabilities, utilities of various outcomes, and weightings of the importance of the outcome categories. The majority of observed decisions were not to treat. By contrast, the decision analysis based on physician-provided estimates indicated that the optimal strategy was either to treat or a toss-up. Sensitivity analysis showed that these conclusions would hold over all possible utilities, over all plausible probabilities of cancer, and so long as symptom relief and fracture prevention were also considered as treatment objectives. The increased probability of early detection of cancer by regular follow-up was systematically incorporated into the decision analysis but apparently neglected in unaided clinical judgment, which follows the principle of minimizing the most important risk, regardless of its probability.

Residents' attitudes towards and skills in counseling: using undetected standardized patients.

Objective:To identify the frequency and quality of certain prevention-oriented counseling skills of resident physicians and to compare these skills with the residents’ attitudes towards and knowledge about primary prevention.Design:Longitudinal descriptive study.Patients/participants:54 PGY-1-3 internal medicine and family practice residents enrolled in three training programs affiliated with Michigan State University’s College of Human Medicine.Intervention:Trainees’ attitudes towards and knowledge about certain prevention activities were captured by an instrument designed for this study using 127 Likert scales. Counseling skills were assessed with one of two standardized patients. Residents were unaware of the simulation, which occurred in their routinely scheduled ambulatory care setting. Audiotapes of the interactions were rated by blinded, independent raters. Residents had strong positive beliefs about the role of primary care physicians in counseling patients, high levels of knowledge about what the counseling should entail, and high self-assessment about the frequency and quality of their own counseling interventions. Skill levles, however, were at or below a level defined as minimally acceptable.Conclusion:Resident physicians’ skill levels, as measured in this study, are inadequate to accomplish routine counseling interventions in the primary care setting. These results suggest that more reliance should be placed on direct observation of physicians, ideally in nonreactive settings, for purposes of drawing conclusions about physician performance. Further, these results have implications for the training of students and residents in the area of counseling for prevention.

Efficacy of a one-month training block in psychosocial medicine for residents : a controlled study

Study objective:To determine the efficacy of a comprehensive, one-month psychosocial training program for first-year medical residents.Design:Nonrandomized, controlled study with immediate pre/post evaluation. Limited evaluation of some residents was also conducted an average of 15 months after teaching.Setting:Community-based, primary care-oriented residency program at Michigan State University (MSU).Subjects:All 28 interns from the single-track MSU residency program during 1986/87–88/89 participated in this required rotation; there was no dropout or instance of noncompliance with the study. In the follow-up study in 1989, all 13 available trainees participated. Of 20 untrained, volunteer controls, ten were second/third-year residents in the same program during 1986/87 and ten were interns from a similar MSU program in Kalamazoo, MI, during 1988/89.Teaching intervention:An experiential, skill-oriented, and learner-centered rotation with competency-based objects focused on communication and relationship-building skills and on the diagnosis and management of psychologically disturbed medical patients.Measurements and main results:The two subsets of the control group were combined because residents and training programs were similar and because means and standard deviations for the subsets were similar on all measures. By two-way analyses of variance (group×gender), the trainee group showed significantly greater gains (p<0.001) on questionnaires addressing knowledge, self-assessment, and attitudes; a mean of 15 months following training, there was no significant deterioration of attitude scores. All trainees were also able to identify previously unrecognized, potentially deleterious personal responses using a systematic rating procedure. Residents’ acceptance of the program was high.Conclusions:Intensive, comprehensive psychosocial training was well accepted by residents. It improved their knowledge, self-awareness, self-assessment, and attitudes, the latter improvement persisting well beyond training.

Women’s and physicians’ utilities for health outcomes in estrogen replacement therapy

Estrogen replacement therapy (ERT) prevents fractures and relieves vasomotor symptoms, but it increases the risk of endometrial cancer. Previous studies and national prescribing patterns show that physicians are conservative in their approach to this therapy. The authors interviewed physicians and perimenopausal women to assess their utilities for the various health outcomes of estrogen replacement therapy. On all outcomes, physicians rated illness episodes followed by recovery as being closer to perfect health than did perimenopausal women. Physicians, in judging which outcomes were most important to women, estimated relief of symptoms above fracture prevention, whereas women rated fracture prevention above symptom relief. These results emphasize the need to assess patients’ utilities directly, particularly when utilities for the outcome of a particular therapy may influence the choice of a therapeutic regimen.

A Survey of Student Assessment in U.S. Medical Schools: The Balance of Breadth Versus Fidelity

Background: Faced with the challenge to develop models of assessment relevant to work of physicians, medical schools have broadened their assessment of medical student competency. Purpose: U.S. medical schools were surveyed to determine the extent to which student assessments have broadened beyond multiple-choice question (MCQ) examinations and preceptor ratings. Methods: A survey mailed to 126 accredited U.S. medical schools asked respondents to indicate the frequency with which a variety of assessment methods were used in each year of the curriculum. Results: Examinations dominated preclinical assessments. Year 3 relied heavily on faculty ratings, live observations, and MCQs. Preceptor ratings were used most in Year 4. Conclusions: A variety of competency assessments currently are used; MCQs remain a core assessment method. Year 3 had the greatest breadth of assessment strategies. The findings suggest that educators continue to be challenged to balance the breadth of competencies sampled with the fidelity of the assessment experience

The patient safety OSCE for PGY-1 residents: a centralized response to the challenge of culture change.

Background: Accreditation and Institute of Medicine mandates require retooling of graduate medical education curriculum and assessment processes. This Objective Structured Clinical Exam (OSCE) focused on patient safety-specific skills important to stakeholders from multiple institutions. Purposes: A 10-station OSCE was designed to assess patient safety-related competencies in new Postgraduate Year 1 (PGY-1) residents. The OSCE emphasized performance of essential skills and teamwork, and it provided early formative feedback to trainees and leadership. Methods: Group nominal process selected 10 final OSCE stations. Two stations were designed to assess team competencies and response to feedback. Two hundred thirty-five trainees enrolled in 64 programs participated during summer 2006. Skill-set aggregation was employed to improve the validity of individual feedback. Results: Significant performance deficits were noted. Trainee and administrator evaluation of the experience was positive. Conclusions: Multi-institutional test development and centralized testing was well received and produced worrisome results. Early assessment can guide the development of task-specific personalized learning plans and systemwide curricular improvement. Further research is needed to determine whether such an effort directed at PGY-1 trainees can improve trainee performance and patient safety.

A course component to teach interviewing skills in informing and motivating patients

In the present study, the authors implemented and evaluated a course component to teach three types of interviewing skills: giving information to patients, handling emotions on the part of patients, and motivating patients. The authors developed a seven-week course for second-year students that included identification and demonstration of explicit interviewing skills, practice with simulated patients, and feedback in a small-group setting. Thirty of the 104 students in the course were randomly selected for evaluation before and after the course. They showed statistically significant increases in their interviewing skills, based on ratings of videotaped interviews with simulated patients after the course, but did not change significantly in self-assessment of their level of confidence in aspects of conducting the interviews.

Enhancement of the Assessment of Physician–patient Communication Skills in the United States Medical Licensing Examination

The National Board of Medical Examiners (NBME) reviewed all components of the United States Medical Licensing Examination as part of a strategic planning activity. One recommendation generated from the review called for enhancements of the communication skills component of the Step 2 Clinical Skills (Step 2 CS) examination. To address this recommendation, the NBME created a multidisciplinary team that comprised experts in communication content, communication measurement, and implementation of standardized patient (SP)-based examinations. From 2007 through 2012, the team reviewed literature in physician–patient communication, examined performance characteristics of the Step 2 CS exam, observed case development and quality assurance processes, interviewed SPs and their trainers, and reviewed video recordings of examinee–SP interactions. The authors describe perspectives gained by their team from the review process and outline the resulting enhancements to the Step 2 CS exam, some of which were rolled out in June 2012.

Acceptance of external funds by physician organizations - Issues and policy options

S everal years ago, the Society of General In te rna l Medicine (SGIM) held a precourse on AIDS at its a n n u a l meeting. After the precourse had been designed, speakers chosen, and topics defined, a pha rmaceu t i ca l company that made a drug used in the t r e a tme n t for AIDS gave an educa t iona l g r a n t to the Society to suppor t , among other th ings , the cost of the precourse. In ensu ing years, this a r r a n g e m e n t created some controversy among the people p l a n n i n g a n n u a l meet ings . Should they ar range ano the r precourse on AIDS in the realistic hope that the company would come th rough aga in with a generous gift? Was it too soon to have ano the r precourse on AIDS? Could mee t ing p l a n n e r s even be expected to objectively decide on the mer i t s of a precourse on AIDS when they knew the a m o u n t of money tha t would be tied to their dec i s ion? Should precourses be