Teaching medical interviewing. A basic course on interviewing and the physician-patient relationship.

Recent advances in educational theory and methodology have made it possible to teach medical interviewing with as much rigor as other clinical skills. We describe a first-semester, first-year medical student course that effectively teaches basic interviewing skills. This course provides faculty development, small group learning, detailed faculty and student coursebooks, and an interview checklist that delineates specific interviewing skills and content areas, serving as a template for teaching, practice, and feedback. Students have many opportunities for practice in role play and with patients, followed by feedback by self, peers, and faculty. Use of audiotape and videotape reviews enhances the learning experience. This article describes our course, suggests educational principles and standards for the teaching of medical interviewing, and presents educational research demonstrating significant gains in students' skills associated with improvement in standardized patient satisfaction.

Effects of managed care on physician-patient relationships, quality of care, and the ethical practice of medicine: a physician survey.

BACKGROUND: Survey studies have shown that physicians believe managed care is having significant impact on many of their professional obligations. METHODS: Primary care physicians were asked about the impact of managed care on: (1) physician-patient relationships, (2) the ability of physicians to carry out their professional ethical obligations, and (3) quality of patient care. In 1996 we surveyed 1011 primary care physicians in Pennsylvania. The survey group's responses were graded on a Likert scale. Space was provided for respondents to include written comments. The SPSS statistical software (SPSS Inc, Chicago, Ill) was used to analyze the data. RESULTS: The response rate was 55%. Most respondents indicated that under managed care physicians are less able to avoid conflicts of interest and less able to place the best interests of patients first. The majority responded that quality of health care is compromised by limitations in location of diagnostic tests, length of hospital stay, and choice of specialists. A significant minority (27%-49%) noted a decrease in the physician's ability to carry out ethical obligations, to respect patient autonomy, and to respect confidentiality in physician-patient communication. Most physicians expressed that managed care made no impact on ability to obtain informed consent or to provide information. There were small but statistically significant sex differences, with female physicians more negative toward managed care. CONCLUSIONS: Many physicians surveyed believe managed care has significant negative effects on the physician-patient relationship, the ability to carry out ethical obligations, and on quality of patient care. These results have implications for health care system reform efforts.

Love, boundaries, and the patient-physician relationship.

Physicians often use their relationships with patients to promote specific therapeutic goals. Because of their personal histories, values, and biases, patients may react to physicians in ways that inhibit or enhance the relationship. The feelings that are aroused may induce physicians to become overly distant, engendering patient and physician dissatisfaction, or to become overly involved emotionally, which can have serious psychological and clinical consequences. We explore how a balance between clinical objectivity and bonding with the patient is optimal and achievable. The nature and origin of personal boundaries are described. Boundary transgressions on the part of the patient are discussed, and the means of preventing transgressions by both patients and physicians through medical education, the process of self-awareness, and an exploration of family-of-origin issues are proposed. Through attention to communication with patients, the physician can maintain an empathetic yet objective relationship with the patient.

Limits of patient autonomy. Physician attitudes and practices regarding life-sustaining treatments and euthanasia.

BACKGROUND: In making decisions about life-sustaining medical interventions, respect for patient autonomy has been widely advocated, yet little is known about what variables may compete with a physician's ability to honor patient requests in clinical situations. We investigated physician attitudes and behaviors about end-of-life decisions by means of a questionnaire that posed five hypothetical scenarios in which an elderly, competent, terminally ill patient made a request that, if agreed to by the physician, could result in the patient's death. METHODS: We surveyed 392 physicians in Rhode Island and asked them to decide (1) whether or not they would comply with a specific patient request, (2) the justifications they used in making their decision, and (3) whether they had been approached with such a request in their clinical practices. RESULTS: Two hundred fifty-six physicians (65%) responded. Of the respondents, 98% agreed not to intubate the patient in the face of worsening respiratory failure. Eighty-six percent agreed to give the patient a dose of narcotics that could cause respiratory compromise and death to treat his pain adequately. Fifty-nine percent agreed, once the patient was intubated without hope of coming off the respirator, to turn the respirator off. Nine percent agreed to give the patient a prescription for an amount of sleeping pills that would be lethal if taken all at once. Only 1% agreed to give the patient a lethal injection. When they complied with patient requests, physicians cited patient autonomy as the principle most important to their decision making. Physicians who would not comply with patient requests also, paradoxically, often cited this principle but agreed with it less strongly; others cited concerns about the ethical nature of the request, legal questions, and the perception that they were "killing the patient." Sixty-five percent of respondents had been asked by patients to turn off a respirator, and 12% had been asked to administer lethal injections. Twenty-eight percent of respondents indicated that they would comply with requests for lethal injection more frequently if such an action were legal. CONCLUSIONS: Difficult clinical decisions regarding potentially life-prolonging measures are commonly heard in clinical practice. Physicians value the concept of patient autonomy but place it in the context of other ethical and legal concerns and do not always accept specific actions derived from this principle.

Refocusing on history-taking skills during internal medicine training.

Recognizing that skilled history-taking is in danger of becoming a lost art, the American Board of Internal Medicine calls attention to the urgent need for internal medicine residency programs to ensure that these skills are taught and assessed. Although the Board's certification examination contains standardized items that test the physician's ability to use information from a patient's medical history, the written examination cannot assess the physician's ability to elicit that history. The Board believes that history-taking skills will become even more crucial as health care delivery changes, requiring more cost efficiency without sacrificing quality. By highlighting the skills of effective history-taking and strategies for assessment, the Board offers specific recommendations for its promotion as a key element of quality patient care.

Fetal dose from radiotherapy with photon beams: report of AAPM Radiation Therapy Committee Task Group No. 36.

Approximately 4000 women per year in the United States require radiotherapy during pregnancy. This report presents data and techniques that allow the medical physicist to estimate the radiation dose the fetus will receive and to reduce this dose with appropriate shielding. Out-of-beam data are presented for a variety of photon beams, including cobalt-60 gamma rays and x rays from 4 to 18 MV. Designs for simple and inexpensive to more complex and expensive types of shielding equipment are described. Clinical examples show that proper shielding can reduce the radiation dose to the fetus by 50%. In addition, a review of the biological aspects of irradiation enables estimates of the risks of lethality, growth retardation, mental retardation, malformation, sterility, cancer induction, and genetic defects to the fetus.

The future of medical school courses in professional skills and perspectives.

This article looks toward the future of medical school courses in professional skills and perspectives by addressing the extent to which they are a valid model for educating physicians of the 21st century, highlighting what medical educators can learn from the experiences at a sample of four medical schools, and suggesting ways to strengthen this curricular genre. Each of the four courses described in this special feature strives to provide exposure and experience in behavioral science, medical ethics, physician-patient communication, health promotion and disease prevention, physical examination, clinical reasoning, and health services and financing. It is likely that students who will be practicing medicine in the 21st century would also benefit from more attention to personal awareness and professional growth. Several lessons can be drawn from the experiences with these courses: although complex, they are directed by very small groups of faculty; they require large numbers of teaching faculty; it is difficult to establish equal footing with basic science courses; evaluation of students' progress is a major challenge; it is important to clearly articulate course components; the emphasis must extend beyond the first two years; and ongoing student and faculty input is essential. The authors suggest that conducting outcome assessments, creating a more humane culture of medical education, and supporting course faculty are key to a stable future for these courses and a solid education for the students.

Toward creating physician-healers: fostering medical students' self-awareness, personal growth, and well-being.

To restore the "humanism" in medical care, medical education needs to espouse the goal of creating physician-healers. Critical, and often neglected, factors in healing are the personal development and well-being of the healer. Unexamined attitudes and biases and personal stress can interfere with patient care. Personal awareness and well-being can contribute to physicians' using their emotional reactions to patients for their patients' benefit. The authors suggest goals and objectives for medical education that can promote trainees' self-awareness, personal growth, and well-being, and comment on how medical educators might achieve and evaluate these goals and objectives.

Communication skills for preventive interventions.

Effective communication relevant to preventive services and practices has at its basis the physician's skills in not only basic history taking and data collection but also relationship building, facilitation, negotiation, and partnership. These skills, fundamental to doctor-patient communication, are now routinely and systematically taught in many U.S. medical schools. This article defines and examines a communication model for enhancing the provision and adoption of preventive practices in the primary care setting and discusses teaching that model in the medical school context. Within the office visit, broad areas for communication tasks important to providing preventive services are defined as: (1) the medical interview and preventive counseling; (2) working with patients to change unhealthy behaviors, promote healthy behaviors, and enhance adherence; and (3) communication related to office procedures for screening and prevention. Within each of these areas, communication and counseling skills and approaches are defined, and examples of associated prevention activities are provided. Methods for integrating communication skills for prevention into the medical school curriculum are discussed, and examples at Dartmouth, Brown, and MCP Hahnemann medical schools are presented.

An innovative CME program in cardiology for primary care practitioners.

The authors describe an innovative continuing medical education (CME) program they developed to improve the ability of community practitioners to manage common cardiology problems. The program includes an objective structured clinical examination (OSCE) with nine standardized patient (SP) stations. The SPs are trained to use checklists to assess the examinees' clinical skills, and to enter the checklist data directly into computers located within each of the examining rooms. Checklists cover the participants' knowledge of cardiology, and their interviewing, physical-examination, and counseling skills. The computer immediately generates detailed individual reports, which include a skills report, reflecting performance of core skills across all nine stations with group means for comparison, and an omissions report, listing items missed in each case for each participant and, again, comparing the results with group means. Participants review and discuss their performances and then discuss identified learning issues with a cardiologist. The cardiologist also reviews state-of-the-art diagnosis and treatment for the cases presented in the OSCE. Participants have reported having a high regard for the program and have indicated that the program has left them better prepared to deal with clinical cardiology issues.

The psychosocial review of systems.

Psychosocial problems have a significant impact on the course and cost of medical illness. However, many of these areas are generally neglected in medical interviews. This manuscript presents a condensed review of the major psychosocial domains, which together constitute what we term a psychosocial review of systems (PROS). Selected references are provided which document the importance of these areas to medical care, and serve as background reading for further inquiry. The psychosocial areas which are covered include: substance use, stress and life events, subjective views of symptoms, daily activity, social support, sexual concerns, finances, psychiatric history and symptoms, cultural issues, and functional status. The Psychosocial Review of Systems (PROS) can serve as a basic overview for the psychosocial aspects of medical education, and also as a content based instrument which has potential for development as an assessment tool to measure physician competence in eliciting relevant psychosocial data.

Psychosocial aspects of illness.

Medical practice and research today are largely guided by a biomedical model of disease which assumes that disease can be fully accounted for by deviations from the norm of measurable biologic variables. It is suggested that this model has outlived its usefulness. Instead, the biopsychosocial model offers greater understanding of the illness process, and thus has greater utility for the practicing physician. Suggestions are offered for diagnosis and treatment within this biopsychosocial perspective.

The recognition and management of somatization. What is needed in primary care training.

This article addresses the medical education issues associated with teaching primary care residents about somatization. Specific training designed to recognize and manage somatization involves a hierarchical series of five knowledge domains with associated discrete skills. As a foundation, a biopsychosocial model must be embraced by the medical leadership of the training program. Second, because psychosocial stresses play a critical etiologic role in somatization, the ability to identify relevant psychosocial issues during medical interviewing is a fundamental skill. Third, basic psychiatric diagnostic areas (depression and anxiety) must be mastered as a prerequisite for identifying somatization. Specific interviewing and management techniques are reviewed, along with two current programmatic approaches. Finally, the concept of physician countertransference also must be explicitly addressed as part of the curriculum. Without assuring that these building blocks are in place, residents are likely to become overwhelmed by the management of somatizing patients and continue the pattern of frustration associated with these patients.

Anxiety and depression among medical and surgical patients nearing hospital discharge.

Ninety-eight medical and surgical inpatients were interviewed 24-72 hours prior to discharge. Thirty-five (36%) had clinical levels of anxiety and depression as defined by the SCL-90-R, a self-report symptom inventory. Compared with patients with normal SCL-90-R subtest scores, anxious and depressed patients more often had the following characteristics: older age, black race, lower socioeconomic class, a recent previous hospitalization, and impaired functional status prior to admission. Three to four weeks after discharge, 25 of the 35 anxious and depressed patients were again interviewed. Thirteen remained anxious and depressed, while 11 patients had returned to normative distress levels. Older, black, poor inpatients with a recent prior hospitalization and impaired functional status are at high risk for clinical anxiety and depression. Half of those with anxiety and depression may remain anxious and depressed after discharge. Intervention should be considered for these patients.

Domestic violence training program for residents.

Domestic violence is occurring in epidemic proportions in the United States. Recent surveys have shown there is a need for educational programs for health care professionals. This report presents the results of a domestic violence workshop developed to increase knowledge and improve attitudes and skills in working with victims of domestic violence. The results of the workshop, measured by preintervention and postintervention attitude, knowledge, and skills surveys, are promising. There was a significant improvement in knowledge, self-assessed skills, and attitudes after the workshop. Although the full magnitude of the changes was not sustained over time, there was still significant improvement after 6 months in knowledge and attitude. Rates of detection and documentation did not change. Future educational programs will need to address maintaining routine screening for domestic violence in the primary care setting and to highlight more clearly the role of health care professionals in the detection and treatment of domestic violence.

Teaching psychosomatic (biopsychosocial) medicine in United States medical schools: survey findings.

OBJECTIVE: A survey of US medical schools regarding the incorporation of psychosomatic (biopsychosocial) medicine topics into medical school curriculum was conducted. The perceived importance and success of this curriculum, barriers to teaching psychosomatic medicine, and curricular needs were also assessed. METHODS: From August 1997 to August 1999, representatives of US medical schools were contacted to complete a survey instrument either by telephone interview or by written questionnaire. RESULTS: Survey responses were received from 54 of the 118 US medical schools contacted (46%). Responses were obtained from representatives of both public (57%) and private (43%) institutions. Only 20% of respondents indicated that their schools used the term "psychosomatic medicine"; the terms "behavioral medicine" (63%) and "biopsychosocial medicine" (41%) were used more frequently. Coverage of various health habits (eg, substance use and exercise) ranged from 52% to 96%. The conceptualization and/or measurement of psychosocial factors (eg, stress and social support) was taught by 80% to 93% of schools. Teaching about the role of psychosocial factors in specific disease states or syndromes ranged from 33% (renal disease) to 83% (cardiovascular disease). Coverage of treatment-related issues ranged from 44% (relaxation/biofeedback) to 98% (doctor-patient communication). Topics in psychosomatic medicine were estimated to comprise approximately 10% (median response) of the medical school curriculum. On a scale of 1 (lowest) to 10 (highest), ratings of the relative importance of this curriculum averaged 7 (SD = 2.5; range = 2-10). Student response to the curriculum varied from positive to mixed to negative. Perceived barriers to teaching psychosomatic medicine included limited resources (eg, time, money, and faculty), student and faculty resistance, and a lack of continuity among courses. Sixty-three percent of respondents expressed an interest in receiving information about further incorporation of topics in psychosomatic medicine into their school's curriculum. CONCLUSIONS: Results of this survey reveal variable coverage of specific psychosomatic medicine topics in the medical school curriculum and differential use of nomenclature to refer to this field. There is a need for further curricular development in psychosomatic medicine in US medical schools.

Medical interviewing and interpersonal skills teaching in US medical schools. Progress, problems, and promise.

OBJECTIVE: To assess educational practices, problems, and needs in the teaching of medical interviewing and interpersonal skills. DESIGN: Questionnaires sent to curricular deans and introductory course leaders at all US medical schools in 1991. RESULTS: Of 130 programs, 114 deans (88%) and 92 course directors (71%) responded. Respondents indicated some advances since a similar survey in 1977: Virtually all medical schools now offer teaching in medical interviewing and interpersonal skills. More faculty from a greater variety of disciplines are involved in this teaching. Most programs feature observation and feedback of students' interviews with patients, and use a variety of effective teaching methods, including simulated patients and role-playing, both little used in 1977. The majority of schools address students' personal growth through discussion or support groups. However, there are problems. Most schools lack a faculty development process. About half of the introductory courses on medical interviewing take place within physical diagnosis courses, often, it appears, without systematic observation, feedback, and evaluation of student skills. Many programs do not explicitly incorporate certain educational principles into their course designs. As in 1977, there appears to be little coordination or sequencing of teaching interpersonal skills throughout the curriculum in most medical schools. Most deans identified significant barriers to improving teaching. CONCLUSIONS: While a number of educational advances have occurred there is still great variation in the quality and intensity of courses offered in US medical schools. However, the pace of progress bodes well for the future.