“Did I really say that?” Analysis of student-patient interviews in underserved clinics William Shore, MD Jessica Muller, PhD George Saba, PhD Julia Mergendoller, RA University of California San Francisco STFM Vancouver April 26, 2010

Presentation Objectives Describe study Discuss with audience: Experiences with video analysis/checklists Challenges in implementation Potential implications of findings Recommendations for curriculum Additional findings BS: brief review

Background Increasing evidence that improved communication skill can positively influence health outcomes How prepared are medical students to engage in effective communication with patients?

Background Analysis of video-recorded interactions can improve students’ communication skills Studies have used Different frameworks for coding communication behaviors Doctor-patient communication checklists to rate behaviors (Roter 2004; Saba 2006; Schillinger 2004; Fiscella 2007; Clark 2008) GS-review

Background Many of these studies involve standardized patients in simulated settings However, few studies involve vulnerable populations in clinical settings (King & Wheeler 2007) Needed to develop our own checklist for students in MUC’s

UCSF Students 1st & 2nd year ”Doctoring” Course: Foundations of Patient Care Standardized Patients PBL Cases Primary Care Preceptorships Social and Behavioral Science Lectures Small Group Simulated Cases BS: Describe briefly

Family Med. Clerkship Students Required 3rd Year clerkship Most students assigned to clinics in urban underserved communities BS: We wanted to conduct a research study to identify behaviors in “real-time”—i.e, real students, real pts, in real clinic

Clerkship Students Video-recording provides opportunity to directly observe student communication behaviors One video-recording of on-site patient interview required Video review with faculty member for formative feedback required

Our Focus Interviews (excluding PE) recorded on-site at community clinics Interviews conducted with real patients from medically underserved or vulnerable populations.

Research Questions What verbal and non-verbal communication behaviors can be observed in 3rd year student patient visits in community clinic settings? What trends in communication behaviors were demonstrated in the recordings?

Methods IRB approval & student consent obtained 43 item checklist & coding manual developed Video recordings from a 2 year period coded by RA using checklist Rater reliability established & data analyzed While many checklists exist to observe communication behaviors, few exist which capture some of the particular issues important to the care of vulnerable populations. Our checklist was created: Using the Patient-Physician Interaction (PPI) scale. This scale is used as an evaluation of general communication by students at their Clinical Practice Examination in their 4th year. It is also the basis for an interviewing checklist teaching tool in the Foundations of Patient Care course (described earlier) To address the behaviors that are needed in working in community clinics, we then adapted the scale to include items that: Emerged from the recent theoretical work on underserved and vulnerable populations (e.g. context, access, barriers) discussed in King and Wheeler. Concurrent research on assessing cultural competency in medical students (Hauer, Fernandez, Saba) in which faculty experts rated 4th year students Clinical Practice Examinations for general communication skills and skills in cultural competency and identified key dimensions in the latter, not addressed in the former set of behaviors.

Checklist Greets Patient Elicits Patient’s Concerns Expresses interest in patient Faces patient Elicits Patient’s Concerns Uses open-ended questions Asks about impact on home, school, work Expresses empathy

Checklist Sets Agenda Explains Dx, Meds, Tx options Asks patient about role in decision-making Encourages patient questions

Checklist Closes Interview Listens Actively Summarizes discussion Asks for further questions Listens Actively Summarizes patient’s statements Uses verbal & non verbal expressions of interest

Checklist Builds Rapport Validates patient’s behavior Acknowledges & responds to patient’s feelings

Checklist Explores Contextual Factors Cultural/spiritual values Social services use (Medicaid, home health) Access/barriers to care (housing, money, transportation, immigration issues) Family, occupation, lifestyle, diet, exercise Neighborhood safety, access to grocery stores

Checklist Contextual Factors (cont) Checks for comprehension Uses minimal jargon Asks follow-up questions to clarify Explores patient’s cultural/spiritual values

Checklist Demonstrates Professional Behavior Conveys non-judgmental/respectful attitude Dresses & acts appropriately

Global Assessment of Interview Outstanding Adequate Inadequate

Results Obtained consent and reviewed 95/200 recordings over two academic years 9 recordings eliminated with technical difficulties or language 86 recordings analyzed GS

Global Assessment of Interview Outstanding 30% Adequate 44% Inadequate 26%

Contextual Inquiry Social Services: 7% asked Barriers to Care: 6% asked Cultural /Spiritual Values: 13% asked Give you two sets of data, the first are summary findings, then dive down and look at effect of gender

Contextual Inquiry (con’td) Family, occupation, diet, lifestyle, home & neighborhood safety, access grocery stores 51% asked

Language 22/86 interviews had non-English speaking patients. Majority of these in Spanish 1/22 checked for comprehension Almost all of the students referred to these patients in the informal tense “tu”.

Patient negotiation Negotiates agenda 13% Asks preferences about decision-making 3%

Behavior by Student Gender Female (N=40) Male (N=45) Encourages questions 51% 32 % Summarizes patient’s statements 58 33 Asks about barriers to care 9

Behavior by Patient Gender Female patient N=41 Male N=44 Asks if patient has other concerns 53% 32% Shows personal interest in patient 88 71 Expresses empathy 85 66 Reassures patient 81 61 Checks for comprehension 37 19

Student/Patient Gender Pairings Behavior F/F N=25 F/M N=15 M/F M/M N=29 Faces patient 96 % 86 % 67 % 100 % Asks patient what s/he thinks 29 50 54 13 Summarizes patient’s statements 56 60 53 24 Explores cultural values 12 27 7

Limitations Experience at one medical school Students selected patients to videotape Data not available: Ethnic/racial identifiers of students and patients Students or patients who refused to participate

Conclusions Students demonstrate good general interviewing skills Students need additional skills to obtain contextual information from patients in medically underserved communities Gender concordance may be significant in (student) doctor communication

Conclusions Recording students in clinical settings can provide valuable information Further studies to compare students in MUC’s vs. non-MUC clinics

Discussion Your experience: Teaching medicals students communications skills in community clinics On-site recordings of students’ interviews with patients Implications of the findings Next steps: Curriculum development Future research

References Clark NM et al. The clinician-patient paradigm outcomes associated with physical physician communication behavior. Clin Peds 2008; 47(1):49-57. Fiscella K et al. Ratings of physician communication by real and standardized patients. Ann Fam Med 2007;5(2): 151-158. King TE, Wheeler MB (eds). Medical management of vulnerable and underserved populations. New York: McGraw-Hill (Lange), 2007. Roter DR et al. Use of an innovative video feedback technique to enhance communications skills training. Med Ed 2004; 38(2):145-57. Saba G et al. Shared decision making and the experience of partnership in primary care. Ann Fam Med 2006;4(1):54-62. Schillinger D, Davis T. A conceptual framework for the relationship between health literacy and health care outcomes. Pt. Ed & Counseling 2004; 52:315-323 Lang L, McCord R, Havill L, Anderson D. Communication Assessment Using the Common Ground Instrument: Psychometric Properties. Fam Med 2004; 36(3):1 89-98 Fernandez A, Wang F, Braveman M, Finkas BA, Hauer, K. Impact of Student Ethnicity and Primary Childhood language on Communication skill Assessment in a Clinical Performance Examination. J Soc Gen Inter Med. 2007; 22:1155-60

This project is supported by HRSA-Grant #D56HP00042 UCSF-Instructional Improvement Grant David Thom, MD, PhD Director Research-UCSF-DFCM