1. “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

2. 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

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

4. 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

5. 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

6. 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

7. 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

8. 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

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

10. 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?

11. 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.

12. 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

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

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

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

16. 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

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

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

19. Global Assessment of Interview
Outstanding
Adequate
Inadequate

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

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

22. Contextual Inquiry Social Services: 7% asked
Barriers to Care: % 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

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

24. 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”.

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

26. 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

27. 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

28. 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

29. 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

30. 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

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

32. 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

33. 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):
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):
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:
Lang L, McCord R, Havill L, Anderson D. Communication Assessment Using the Common Ground Instrument: Psychometric Properties. Fam Med 2004; 36(3):
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:

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