Self Efficacy of Communication Skills in Difficult Patient Encounters: An Interdisciplinary Collaboration Rachel Bramson, M.D., M.S. Kimberly L. van Walsum, Ph.D. Angela Heads, M.A.

Background Rachel Bramson, M.D. Family & Community Medicine, Texas A&M System HSC COM Director, Preceptorship Program Kim van Walsum, Ph.D. Office of Medical Education, Texas A&M System HSC COM Counseling Psychology Post Doc Angela Heads, M.A. Counseling Psychology Doctoral Student Family Medicine Graduate Research Assistant

Background Collaborators: A Department of Family and Community Medicine & A Counseling Psychology Program in a Department of Educational Psychology Beneficiaries Students in both programs receive didactic instruction and supervised skills practice All involved learn from interdisciplinary collaboration

Study Goal and Questions This intervention was designed to increase M2 medical students’ knowledge, skills and self-efficacy in conducting a medical interview Specifically, Breaking Bad News of cervical cancer Which elements of interviewing experience predict pre-intervention self assessments of skill in medical interviewing? What is the effect of interventions on self assessments of skill in medical interviewing, by level of experience?

Participants 68 M2 students in the OC Cooper Preceptorship Program

Methods Participants completed pre-intervention questionnaires on prior medical interviewing experience, and self assessments of skill in medical interviewing. All participants attended a lecture on BBN using EPERC videos and materials. All participants completed a videotaped SP interview. All participants were debriefed by Ph.D. students from counseling psychology trained in Interpersonal Process Recall.

Instruments Medical Interviewing Experience Scale Pre and Post Intervention Self Assessment of Medical Interviewing Skills

Medical Interviewing Experience Scale Through expert consensus, we developed 11 possible variables that may predict medical students’ early confidence in their medical interviewing skills Medical students assessed their level of experience on these 11 variables using a 6 point Likert scale

Medical Interviewing Experience Scale 11 experience items included ratings of Prior training in medical interviewing Prior training as EMT, nurse or PA Training in job interview skills Paraprofessional counselor training/camp counselor/hospital volunteer Experience watching medical interviews Immediate family member who is a physician Experience as a hospital patient

Pre Intervention Self Assessment of Medical Interviewing Skill Medical students reported their level of agreement with 15 statements about medical interviewing 6 point Likert scale 6 items were negatively phrased and were reversed coded during analysis Examples: (+) “I think I have the skills and knowledge to conduct an excellent medical interview.”; (-) “I do not like dealing with people exhibiting strong emotions.”

Results Which elements of interviewing experience predict pre- intervention self assessments of skill in medical interviewing?

Predictors of Pre-Intervention Self Assessment of Medical Interviewing Skills Hierarchical Regression in 5 steps Steps: 1.Experience watching others interview 2.Step 1 + physician family member 3.Step 2 + experience as a hospital patient 4.Step 3 + training as healthcare provider 5.Step 4 + prior specific training in medical interviewing

Predictors of Pre-Intervention Self Assessment of Medical Interviewing Skills ModelRR2R2 R 2 change Sig F change

Predictors of Pre-Intervention Self Assessment of Medical Interviewing Skills The best model (high explanatory power with fewest variables) was Model 3 Model 3 explained 31% of the variance in medical students’ pre-intervention confidence in medical interviewing Model components were: Lots of experience watching others medical interviews An immediate family member who is a physician Extensive experience as a patient in a hospital

Results What is the effect of interventions on self assessments of skill in medical interviewing, by level of experience?

Does self efficacy in interviewing vary with experience level? Pretest In analysis, we divided students into low, medium and high experience groups We selected the items from the Self Assessment of Medical Interviewing Skills Scale that were related to confidence I feel confident I can conduct an excellent medical interview I have the skills and knowledge necessary to… I do not feel confident in my interviewing skills (reverse scored) I will know how to conduct myself in a medical interview Sum of these variables = confidence/self efficacy in interviewing skills Same assessment items were analyzed for M2 students’ post-intervention self assessments of confidence/self efficacy in medical interviewing

Change in Self Efficacy in Medical Interviewing by Experience Level

M2 students with low experience (n=12) improved M2 students with moderate experience (n=46) did not change M2 students with high levels of experience (n=10) declined Standard deviations for low and mod experience groups did not change, but for the high experience group SD tripled in size (from SD =.91 to SD = 2.96). Apparently highly experienced students encountering a difficult medical interview in a formative evaluation have a more extreme and possibly a disconfirming experience.

What effect did our interventions have on M2s’ self efficacy in difficult medical interviews? Data on pre-post differences in confidence by experience level were analyzed with a repeated measures ANOVA Categorical variable = Level of Experience Time 1 = pre-intervention self assessment of confidence Time 2 = post-intervention self assessment of confidence The pre-post differences were not statistically significant

Did our M2 students find the BBN intervention valuable? Intervention = Workshop in Breaking Bad News using EPERC materials 20 minute videotaped interview with SP in which student informs patient of cervical cancer diagnosis 1 hour review with doctoral student in counseling psychology trained in Interpersonal Process Recall

Did our M2 students find the BBN intervention valuable? Most students agreed or strongly agreed that the intervention helped them improve their general skills in medical interviewing 6 point Likert scale 1 = Strongly Disagree 6 = Strongly Agree

Did our M2 students find the BBN intervention valuable? Most students agreed or strongly agreed that this intervention helped them improve their skills in breaking bad news to patients 6 point Likert scale 1 = Strongly Disagree 6 = Strongly Agree

Potential Lessons About Teaching Skills for the Difficult Medical Interview At least early in medical training, students prior level and type of experience is important to their self assessment of interviewing skill Particular types of experiences lead to high levels of confidence in interviewing Interventions may disconfirm self perceptions for students with high levels of experience and confidence Interventions should be experiential, highly personalized, supportive, and iterative

Potential Lessons About Interdisciplinary Collaboration in Teaching Communication Skills Collaborators must respectfully address their differences in professional cultures and languages prior to team teaching Model interdisciplinary collaboration and respect Build on the strengths of differing perspectives Non physicians need understanding of constraints on physician time and resources Collaboration leads to rich curricula!