1. The Longitudinal Development of Interpersonal and Communication Skills in the First Year of Medical School
Richard W Pretorius, MD, MPH
Katherine M Mineck, BA
Karen H Zinnerstrom, PhD
Frank T Schimpfhauser, PhD
SUNY AT BUFFALO
STFM 34th Annual Predoctoral Education Conference
Portland, Oregon January 25, 2008

2. RESEARCH QUESTION
Is there improvement in communication and interpersonal skills throughout the four clinical skills exams in the first year of medical school?

3. HYPOTHESIS Skills will improve in a linear fashion over the 4 exams.
High performers will remain high (on average)
Medium performs will show improvement (on average)
Low performers will show improvement (on average)

4. METHOD Cohort study N = 141 first year medical students
Students trained in communication & interpersonal skills in first 2 wks of school
Four 15-minute Clinical Skills Exams in first year: Oct, Dec, March, May
Scoring rubrics
Provided to students with instruction (after pretest)
Modeled after USMLE Part II CS
Analysis with bivariate Pearson correlations and paired sample T-test

5. METHOD RUBRIC COMPONENTS
INTERPERSONAL SKILLS
Rapport
Respect
Listening
Humanism
Partnering
Non-technical language
COMMUNICATION SKILLS
Open ended questions
Nonverbal encouragement
Neutral utterances and continuers
Echoing
Transitional statements
Summary/paraphrasing
Timeline
Organization

6. METHOD RUBRIC COMPONENTS: COMMUNICATION SKILLS
OPEN ENDED QUESTIONS The interviewer starts information gathering with an open-ended question. For areas where the interviewer is required to deal with a large amount of potential information (e.g., HPI, ROS), this is followed by direct and forced-choice questions which will allow him to narrow in on the pertinent positive and negative points that need further elaboration.
NONVERBAL ENCOURAGEMENT Gesture with hand, sympathetic facial expression, lean forward, etc.
NEUTRAL UTTERANCES AND CONTINUERS “Yes,” “I see,” “Really,” “Uh-huh,” “Go on,” “Tell me more”
ECHOING Repeating what the patient has just said using the patient’s same words.
TRANSITIONAL STATEMENTS The interviewer always utilizes transitional statements when progression from one subsection to another, which assure the patient that the information being sought is necessary and important, e.g., “Now I’m going to ask you some questions about your family, because we find that there are certain diseases that occur among blood relatives, and it will help us to know what health risks are in our family”.
SUMMARY (PARAPHRASING) Often used towards the end of the interview or at a midway or transitional juncture. At the end of each major line of inquiry or subsection (i.e., History of Present Illness, Past Medical History), the interviewer summarizes the data obtained in an effort to verify and/or clarify the information or as a precaution to assure that no important data is omitted. At end of present illness, or focused history, the interviewer summarizes.
TIMELINE The interviewer obtains information pertaining to the Chief Complaint and History of the Present Illness in a chronological progression, starting with the first signs and symptoms of current illness and following their progression to the present.
ORGANIZATION The interviewer imposes structure and organization to the interview. The purpose, agenda, intent, plan, and/or expectation for today’s meeting is made clear as the interview unfolds, in a logical progressional order.

7. METHOD RUBRIC COMPONENTS: INTERPERSONAL SKILLS
RAPPORT The interviewer forms a bond with the patient.
RESPECT The interviewer treats the patient with dignity and respect at all times. Affirmative statements (must be genuine and appropriate) are made such as: “You have been through a lot.” “I’m impressed at how you have hung in there.” “You must be a very strong person.”
LISTENING The interviewer listens attentively to the patient; hears what the patient is communicating (both verbal and nonverbal messages); does not interrupt while patient is talking.
HUMANISM The interviewer shows interest in the patient as an individual. The interviewer acknowledges the patient’s uniqueness and special qualities. Normalizing statements are made such as: “That must have been very difficult for you.” “That is a very common way to feel.”
PARTNERING The interviewer encourages the patient to ask questions and to express any concerns. At the end of the interview, the interviewer asks: “Do you have any other questions?” During the interview, the interviewer makes comments such as: “I’m here to help.” “Let’s plan on working on this together.”
NONTECHNICAL LANGUAGE The interviewer communicates using language, concepts and terminology that the patient can understand. Never condescending.

8. METHOD RATING SCALE
Adapted from the Arizona Clinical Interview Rating Scale
5-point Likert scale
8 line item communication skills
Points range from low 0 to high 32.
6 line item interpersonal skills
Points range from low 6 to high 30.

9. METHOD LIKERT SCALE: COMMUNICATION SKILLS
COMMUNICATION SKILLS—32 points possible
0 points
NOT DONE
1 point
DONE POORLY
2 points
DONE
3 points
DONE AGAIN
4 points
DONE WELL
RATING CRITERIA
These skills are objectively measured. There are 2 components: if the skill is done & if it is done effectively. To be done effectively, utilization of the skill further enhance the communication.
Not done.
Poorly or incorrectly done.
Skill done at least once.
Skill done several times.
Results in better communication (e.g. more info) from the patient.

10. METHOD LIKERT SCALE: INTERPERSONAL SKILLS
INTERPERSONAL SKILLS—30 points possible
1 point
POOR
2 points
FAIR
3 points
GOOD
4 points
VERY GOOD
5 points
EXCEL-LENT
RATING CRITERIA
These skills are rated from the perspective of the patient.
The patient develops little to no trust in the examiner.
Inconsis-tently done.
Usually done.
Consis-tently done
Results in a strong trust and confidence in the examiner.

11. METHOD Same 15 faculty used as evaluators for each of the 4 exams.
12 evaluators needed per exam
The interrater reliability is 0.7 at the school’s clinical competency center.
Communication skill:
Range of evaluators’ mean scores = +9
(plus two outliers at -16 & 19)
SD=8.5
Interpersonal skills:
Range of evaluators’ mean scores = -9 to 8
(plus one outlier at 16)
SD=7.0

12. RESULTS Class performance fall mean (0-100) spring mean difference
(% increase)
paired sample T-test
communication skills
68.6
73.7
5.1 (7.4%)
p<0.00
interpersonal skills
77.4
81.5
4.1 (5.3%)
difference (% increase)
8.8 (13%)
7.8 (11%)

13. RESULTS Class performance: pretest done on the
1st day of class in the 1st wk of medical school
pretest (0-100)
fall mean
(0-100)
spring mean
communication skills
34.5
68.6
73.7
interpersonal skills
63.3
77.4
81.5
Communication skills double after instruction but then increase only another 7% with repetition.
Interpersonal skills increase 22% after instruction and then increased another 5% with repetition.

14. RESULTS Pearson Correlation Coefficient Individual student performance
mean fall communication skills
c/w
mean spring communication skills
0.256 (p=0.002)
mean fall interpersonal skills
0.206 (p=0.014)

15. RESULTS Gender differences women men communication skills fall 70.4
65.9
4.5 (7%)
spring
75.0
71.6
3.4 (5%)
interpersonal skills
79.1
74.6
4.5 (6%)
82.4
80.2
2.2 (3%)

16. LIMITATIONS Each clinical exam limited to 15 minutes.
Clinical exams structured to be done comfortably in 15 minutes.
Time pressure was an issue for some students (~10%).
New interview skills added to fall semester exams—PE skills to the spring.
Copious (4 or 5 pages) of pre-exam instructions given. Special practice sessions provided.
Multi-tasking was an issue for some students (~10%).

17. DISCUSSION
Communication and interpersonal skills improve by a small increment (7 and 5%) over the course of a 9-month academic year.
10 to 15 years of continued improvement would be required for doubling of skill competency
There is a significant but modest correlation of individual student performance across multiple exams.
Students perform better (by 12%) on interpersonal skills than communication skills.

18. DISCUSSION
Women perform better then men (about 5%) on both communication and interpersonal skills.
Communication and interpersonal skills:
are complex techniques
are influenced by context
improve after initial instruction but then only slowly with repetition