1. Improving Self-Efficacy of Medical Students’ Communication Skills Using the Common Ground Method Rachel Bramson, M.D., M.S., Angela Heads, M.A., Kim van Walsum, Ph.D 1. Forrest Lang, M.D. 2 Robert Wiprud, M.D., Mark English, M.D. Texas A&M University Systems Health Science Center College of Medicine Department of Family & Community Medicine bramson@medicine.tamhsc.edu 1 Alberta Children’s Hospital, Calgary, 2 East Tennessee State University

2. Importance of Effective Communication Skills Effective patient/physician communication skills can be instrumental in improving: –treatment adherence, patient satisfaction, health care outcomes 1991 Toronto and Kalamazoo Consensus Statements* outline key elements for effective patient/physician communication Common Ground Modules cover same topics: –Rapport –Agenda Setting –Information Management –Active Listening - Exploring the patient’s perspective –Feelings - Empathy, exploration –Reaching Common Ground *Simpson, Buckman, Stewart et al., 1991. Doctor-patient communication: the Toronto consensus statement. *Forrest Lang, M.D. and Family Medicine Interview Study Group at Eastern Tennessee State University

3. Importance of Effective Communication Skills Accreditation Council for Graduate Medical Education has outlined expectations for medical residents including an evaluation of interpersonal and communication skills. The United States Medical Licensing Examination includes an assessment of communications competence. A time of transition: curricular guidelines are emerging (eg. Family Medicine Curriculum Resource Project)

4. Methods in Teaching Communication Skills Approaches to training have included: –Lectures, Workshops, Role-plays, Standardized patients, and Videotaped examples of patient/physician encounters What is helpful and what do students prefer? –In a study of training in medical students, WORKSHOPS along with lectures lead to greater gains than lecture only (Evans et al., 1989) –Rees, Sheard and McPherson (2004) found that medical students preferred EXPERIENTIAL methods (role playing with SPs, interviewing real patients) over class lectures. –The use of BENCHMARKS for effective communication along with videotaped SPs is helpful for training and evaluation (Losh, Mauksch, Arnold, et al., 2005; Boyle, Dwinnell & Platt, 2005).

5. Methods in Teaching Communication Skills Variability among Institutions –Methods, curricular time, position, depth of materials –Depends on resources: time, staff, infrastructure, finances, institutional esteem for communication skills This study compares two methods used in communication skills training for second year medical students during two separate years.

6. Study Goals and Questions Our goals were to design and implement an intervention to increase second year medical students’ knowledge, skills and self-efficacy in conducting a medical interview We were interested in finding the effect of interventions on self assessments of skill in medical interviewing, by level of experience

7. Participants In the first cohort, participants were 68 second year medical students in the OC Cooper Preceptorship Program, a required longitudinal ambulatory care course meeting one afternoon a week in community physicians’ offices. In the second cohort, participants were 71 second year medical students in the OC Cooper Preceptorship Program.

8. First Cohort – Methods Communication Skills workshop All Participants: –completed pre-intervention questionnaires: the Medical Interviewing Experience Scale and the Self Assessment of Medical Interviewing Skills Scale. –attended a lecture on breaking bad news with video clips. –participated in small group role plays with grad student giving feedback. –completed a videotaped SP interview (breaking bad news of dysplasia on PAP smear). SP eval. –debriefed by Ph.D. students from Counseling Psychology trained in Interpersonal Process Recall.

9. First Cohort – Methods Medical Interviewing Experience Scale Consisted of 11 experience items: –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

10. First Cohort – Methods Self Assessment of Medical Interviewing Skill Designed to measure self efficacy of medical interviewing skills in medical students. Medical students reported their level of agreement with 15 statements about medical interviewing. –6 point Likert-type scale –6 items were negatively phrased and were reverse 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.”

11. First Cohort Results What is the effect of interventions on self assessments of skill in medical interviewing, by level of experience? In analysis, we divided students into low, medium and high experience groups based on their responses to the Medical Interviewing Experience Scale. We examined selected items from the Self Assessment of Medical Interviewing Skills Scale and summed these to get a self-efficacy score Same items analyzed post-intervention

12. First Cohort Results (Lecture, Grad Student Feedback) Change in Self Efficacy in Medical Interviewing by Experience Level Analysis by repeated measures ANOVA (cat. var. Experience) Pre-post differences not statistically significant

13. First Cohort Results Change in Self Efficacy in Medical Interviewing by Experience Level Low experience (n=12) improved Moderate experience (n=46) did not change 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.

14. Second Cohort – Methods Participants completed the Medical Interviewing Experience Scale and the Self Assessment of Medical Interviewing Skills Scale. Participants took the electronic, independent-study Common Ground Training Modules* (no lecture) All students participated in a workshop: small group sessions with student role plays and faculty giving feedback. All students completed a videotaped SP encounter (adult smoking cessation). SP eval. *Forrest Lang, M.D. and Family Medicine Interview Study Group at Eastern Tennessee State University

15. Second Cohort – Methods The videotapes were evaluated by graduate students in Health Communications, Clinical Psychology and Counseling Psychology trained to use the Common Ground Feedback Form to give feedback and evaluate the medical students. Medical students met again at a later date to review videotapes in groups of four with the graduate student communications trainer who evaluated their videotapes. The Self Assessment of Medical Interviewing Skills Scale was repeated after all training.

16. Second Cohort Results (Common Ground Modules, Faculty Feedback) Change in Self Efficacy in Medical Interviewing by Experience Level Means sig. diff. (<.05, Mpre=64.2, SD=7.9, Mpost=67.7, SD=6.7)

17. Second Cohort Results Change in Self Efficacy in Medical Interviewing by Experience Level Low experience (n=14) improved somewhat (not significant). Moderate experience (n=47) improved significantly. High levels of experience (n=10) stayed the same Standard deviations for the moderate experience group did not change. For the low and high experience groups SD decreased (from SD = 8.35 to SD = 5.61 and SD=6.99 to 4.40, respectively).

18. Summary This suggests that using the Common Ground self- study modules (instead of lecture) and small group interaction with faculty (instead of graduate students) may be responsible for improving medical students’ self-efficacy in communication skills for medical interviewing. Common Ground modules take little faculty time and seem to acculturate students to actively engage in role plays and SP encounters. Qualitatively, students performed better in SP interviews.