1. Qualitative Analysis of Student- Patient Interviews in Underserved Clinics William B. Shore, MD Jessica Muller, PhD George Saba, PhD UCSF-Family and Community Medicine STFM: 2008-Predoctoral Education Conference

2. Presentation Objectives  Introduce study  Describe challenges encountered so far  Identify very preliminary findings  Discuss with audience their experiences with video analysis/checklists  Discuss with audience potential implications of findings for curricula in doctor-patient communication

3. Background  All students in required 3 rd Year Family & Community Medicine clerkship assigned to clinics in urban underserved communities  Minimal opportunity to observe students directly with patients  Implemented program where all students video-record one interview & review recording with a faculty member for formative feedback (HRSA grant)  Students & faculty find this a valuable teaching intervention

4. Communication Research  Analysis of video recorded interactions can improve students’ communication skills  Evidence that improved communication skill can positively influence health outcomes  Studies use different frameworks for coding communication behaviors  Standardized patients often used to rate patient-physician communication skills  Few studies focus on vulnerable populations (Roter 2004; Saba 2006; Schillinger 2004; Fiscella 2007; Clark 2008; King 2007)

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

6. Research Questions  What verbal and non-verbal communication patterns do 3 rd year students use when working with medically underserved patients in community clinics?  Do these communication patterns promote or discourage positive patient-centered interactions?

7. Methods: Phase One  After IRB approval, obtained consent from students on Family Medicine clerkship to review their taped interviews  Selected 10 video recordings from students at 4 sites for Phase One (3 at underserved sites, including FHC and 1 at UCSF Faculty practice clinic)  Reviewing recordings to develop checklist of communication behaviors  Beginning to identify emerging themes and conduct thematic analysis

8. Challenges of Research so far 1. Obtaining approval from IRB  Wanted assurance that review of video recording by researchers would not affect course evaluations/residency applications

9. Consent Form “ We will make every effort to assure that your choice to participate or not participate in this study will have no impact on your clerkship evaluations or residency selection. We will also make every effort to assure that the viewing of your video recording by the researchers will have no impact on your clerkship evaluation or residency selection.”

10. Challenges 2. Recruiting students  30 students (of 67) consented to participate in the study during the first 2/3 of this academic year 3. Technical Issues  Student sets up camera to minimize impact on preceptors  Some tapes w/out sound  Camera in wrong position; difficult to visualize facial, non-verbal communication

11. Challenges 4. Developing a meaningful checklist to get at communication behaviors  Items that particularly address underserved or vulnerable populations  Yes/no or scale  Frequency of behavior

12. Checklist Categories  Greets Patient  Elicits Patients’ Health Concerns/Perspective  Sets Agenda  Listens Actively  Responds to Patient’s Emotions  Explains Diagnosis, Meds & Treatment Options  Demonstrates Sensitivity to Context  Engages Patient  Closes Interview  Demonstrates professional Behavior  Overall Assessment

13. Example of Checklist Category: Sensitivity to Context  Asks about patient’s use of social services (Medicaid, home health)  Asks about access/barriers to care (housing, money, transportation, immigration issues)  Asks for contextual information (occupation, neighborhood safety, access to grocery store)  Asks follow-up questions to clarify  Uses minimal jargon  Checks for comprehension  Acknowledges patient’s cultural values & practices in relation to health concerns

14. Preliminary Results  Nothing egregious  Notable for what is absent from interviews  Follow-up questions e.g., most did not check to see if patients understood their explanations  Did not elicit patient’s explanatory model  Did not explore barriers to access to care  Did not stop writing notes during interviews

15. Next Steps  Develop a code book  Hire & train research assistant to review & code video-recordings  Review 100 recordings in 2007-08  Analyze data  Publish findings & present conclusions at future STFM conferences  Develop curriculum changes to address issues identified in study

16. Further Questions  Are these realistic expectations?  How to use the results of this study with our preceptors?

17. This project is supported by  HRSA-Grant #D56HP00042  UCSF-Instructional Improvement Grant

18. References  Clark NM et al. The clinician-patient partnership 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.