Teaching the Medical Interview: Methods and Key Learning Issues

in a Faculty Development Course

David S. Hatem, MD1,2, Susan V. Barrett, MS3, Mariana Hewson, PhD1,4, David Steele, PhD1,5,
Urip Purwono, Drs, MS, MSc3, and Robert Smith, MD1,6
1
American Academy on Communication in Healthcare (DSH, MH, DS, RS), Chesterfield, MO, USA; 2Division of General Medicine (DSH),
University of Massachusetts Medical School, Worcester, MA, USA; 3Office of Medical Education (SVB), University of Massachusetts Medical
School, Worcester, MA, USA; 4Department of Medical Education, Cleveland Clinic (MH), Cleveland, OH, USA; 5Department of Family
Medicine and Rural Health and the Office of Medical Education, College of Medicine, Florida State University (DS), Tallahassee, FL, USA;
6
Department of Medicine, Michigan State University (RS), Lansing, MI, USA.

OBJECTIVE: To describe the American Academy on learning with experienced course participants. Per-
Communication in Healthcare’s (AACH) Faculty Devel- ceived teaching and self-awareness skills changed the
opment Course on Teaching the Medical Interview and most when compared to other skills.
report a single year’s outcomes.
DESIGN: We delivered a Faculty Development course on KEY WORDS: medical interview; physician–patient relations; faculty
Teaching the Medical Interview whose theme was development; educational methods.
relationship-centered care to a national and interna- J Gen Intern Med 22(12):1718–24
tional audience in 1999. Participants completed a DOI: 10.1007/s11606-007-0408-9
retrospective pre-post assessment of their perceived © Society of General Internal Medicine 2007
confidence in performing interview, clinical, teaching,
and self-awareness skills.
PARTICIPANTS AND SETTING: A total of 79 partici-
pants in the 17th annual AACH national faculty
development course at the University of Massachusetts
Medical School in June 1999.
R esearch has indicated patient-centered practices im-
prove patient health outcomes,1 satisfaction,2–4 adher-
ence to therapy,5,6 and decrease malpractice claims.7 Whereas
these studies did not directly evaluate interviewing practices,
INTERVENTION: A 5-day course utilized the principles
many agree that patient-centered interviewing will produce
of learner-centered learning to teach a national and
these outcomes. Recent data demonstrate that systematic
international cohort of medical school faculty about
patient-centered methods are effectively learned8 and that
teaching the medical interview.
integrating this learning into patient care practices is associ-
MEASUREMENTS AND MAIN RESULTS: The course ated with improved outcomes.9
fostered individualized, self-directed learning for parti- Although the medical interview is commonly taught in most
cipants, under the guidance of AACH faculty. Teaching US and Canadian medical schools,10,11 and communication
methods included a plenary session, small groups, skills and provider–patient relationships are receiving in-
workshops, and project groups all designed to aid in creased attention from certifying bodies,12,13 the need for
the achievement of individual learning goals. Course faculty development for teachers of these skills is criti-
outcomes of retrospective self-assessed confidence in cal.12,14–17 In this era when patients’ experiences of care are
interview, clinical, teaching, self-awareness, and control used as a marker of individual and organizational performance,
variables were measured using a 7-point Likert scale. it is likely that the need for skills in teaching the medical
Participants reported improved confidence in interview, interview to a broad range of learners will increase.18–20 A recent
clinical, teaching, and self-awareness variables. After Cochrane Review underscored the need for clear descriptions of
controlling for desirability bias as measured by control teaching methods for those developing communication skills
variables, only teaching and self-awareness mean programs.21
change scores were statistically significant (p<.001). To date, much of the published literature has focused on the
teaching of skills pertaining to a single task of the interview,
CONCLUSIONS: The AACH Faculty Development
such as screening for domestic violence,22 and delivering bad
course on Teaching the Medical Interview utilized
news.23 One recent study implementing a broad curriculum in
learner-centered teaching methods important to insure
the third year at three US medical schools showed encouraging
changes in medical students’ communication skills as a result
This study was presented in part at the 23rd annual meeting of the
Society of General Internal Medicine, Boston, MA, May, 2000. of the implemented curriculum.24 Methods used to achieve
Received June 19, 2006 these skills included lectures, workshops, demonstrations,
Revised February 28, 2007 role-play involving student–student, student-standardized pa-
Accepted September 24, 2007 tient, and student–patient interactions, as well as ward
Published online October 20, 2007 teaching rounds.25

1718
JGIM Hatem et al.: Teaching the Medical Interview 1719

The American Academy on Communication in Healthcare sures.29 We contacted course participants before the course,
(AACH, formerly the American Academy on Physician and and asked them to formulate learning goals for the course in
Patient or AAPP) is focused on teaching the medical interview. writing. These were submitted to the course director, and
Whereas its courses have had great success as measured by distributed to participants’ small group faculty who worked
participant satisfaction and personal testimony, there are no with learners most closely during the 5-day experience.
peer-reviewed publications focused on teaching methods. Out- A course schedule is seen in Table 1.
comes of the courses have been published only in the early Course time over 5 days was 35.5 hours, with slightly more
years of the AACH experience before communication skills than 60% in small groups (22 hours) divided between skills
were widely taught.26,27 work and personal awareness work (in proportions negotiated
Our aim is to provide a clear, practical, and systematic with groups but approximately a 50–50 split). The remaining
description of the AACH’s 17th annual Faculty Development hours were devoted to lecture (1.5 hours), workshops
course on Teaching the Medical Interview. We will describe in (4.5 hours), project groups (6 hours), and course logistics/
detail the novel methods used so that educators can use these announcements (1.5 hours).
principles in designing curricular interventions and faculty We utilized multiple teaching methods to achieve learning
development activities for experienced participants. We also objectives. A Plenary lecture by a national figure to highlight
report this course’s learning outcomes. the relationship-centered care course theme (Jon Kabat Zin,
PhD, lectured on Embodying the Hippocratic Calling: The
Healing Power of Remembering to be Present).
Workshops were offered and participants attended up to 3
METHODS workshops selecting from a menu of workshops including
several on: 1) teaching methods, techniques, and models, 2)
The Faculty Development Intervention
challenging interactions, and 3) theme-related workshops.
The course, titled Expanding the Center: Moving From Patient- Table 2 has a full list of workshops.
Centered to Relationship-Centered Care, sought to describe the Workshops had an introduction of concepts, experiential
concepts of relationship-centered care (a concept that suggests skill-building activities, and reflection to reinforce learning,
the centrality of physician–patient, physician–physician, and allowing participants to work on a focused skill over a short
physician–community relationships to health care)28 and period of time. Although not all workshops dealt directly with
explored its implications for how the medical interview is patient communication skills, they did address applying the
taught and practiced. We advertised to specialty societies principles and skills of relationship-centered care to work
involved in Primary Care education, through educational list (Building a Relationship-Centered Academic Department,
serves, and to past course participants both nationally and Clinician to Clinician communication) and home (Medical
internationally. Marriages).
The course focused on development of discrete interviewing, Small group sessions focused on interview, clinical, teach-
clinical, teaching, and self-awareness skills. We developed this ing, and self-awareness skills. In these small groups, partici-
course based on principles of learner-centered learning, which pants engaged in skills practice and reflected on their skills
suggests that learning is most effective when learners are able through self-assessment, peer and faculty assessment, and
to formulate learning goals, describe clear, measurable, be- feedback. Reflection on skills was broadened to include
havioral objectives, choose learning methods to achieve these discussing personal responses to patients, patient care, and
objectives, and evaluate whether objectives have been met teaching, and the possible effects these reactions have on
through formative (feedback) and summative evaluation mea- encounters. The faculty-to-participant ratio of 1:4 for these

Table 1. Course Schedule

Day 1 Day 2 Day 3 Day 4 Day 5

8:00 Announcements
8:30 Workshops Plenary Workshops Workshops Learning Groups
9:00
9:30 Learning Groups
10:00 Project Group Presentations
10:30 Learning Groups Learning Groups
11:00 Learning Groups
11:30
12:00
12:30
1:00 Course Reflection/Evaluation
1:30
2:00
2:30
2:45 Break
3:00 Break Break
3:15 Project Brainstorming
3:30 Project Group Project Group
4:00 Project Group
4:30
1720 Hatem et al.: Teaching the Medical Interview JGIM

Table 2. Workshop Selections

Day 1 Workshops Day 3 Workshops Day 4 Workshops

Teaching Methods Teaching Methods Teaching Methods

Learner-centered Learning Learner-centered Learning Learner-centered Learning
Feedback Feedback Feedback
Patient-centered Interviewing Patient-centered Interviewing Patient-centered Interviewing
Competency-based Interview Three-function Model of Interviewing Three-function Model of Interviewing
Curriculum
Standardizing Standardized Patients
Challenging Interactions Challenging Interactions Challenging Interactions
Motivational interviewing Somatization Working with the Addicted Patient
Breaking Bad News Alliance and Adherence in Health Behavior counseling Working with Members of the Addicted Family
Family Interviewing Somatization
Theme-Related Theme-Related Theme-Related
Clinician–Clinician Communication Building Relationship-centered Departments Mutual learning between Doctor and Patient
Curricular Approaches to Personal Medical Marriages Meditation/Mindfulness in the Interview
Awareness
Meditation/Mindfulness in the Interview Narratives of Relationship
Mutual learning between Doctor and Patient
Meditation/Mindfulness in the Interview

small groups allowed for knowledge and skills acquisition Whereas a typical session described above took approxi-
tailored to established needs of small-group members. Small mately 2 hours (20 minutes set up of task and group
group sessions are described in greater detail below. participant roles, 30 minutes interview with self-assessment
Project groups took place in which the entire cohort of course from interviewer, 20 minutes of other group feedback and
participants brainstormed ideas for projects, then formed 13 reactions from interviewer with lessons learned, 20 minutes of
project groups utilizing a modified Delphi technique, a common feedback to the participant facilitating the feedback session,
technique used to build consensus and prioritize group inter- followed by 15 minutes of final lessons, and 15 minutes of
ests.30 Project group criteria included that more than 1 individ- planning for the next session), the course schedule allowed for
ual was interested in the topic, individuals committed to working large portions of the day to be designated as learning groups so
on the project during the course, and each group committed to a that if tasks took shorter or longer times, there was flexibility
presentation of their work at the end of the course. Three built into the schedule. In subsequent sessions, faculty
meetings of project groups took place. Project groups embody worked with other group members on their learning needs,
the concepts of learner-centered learning in action: learners thus ensuring that all individuals had an opportunity to work
organized according to their own interests, and by the end of the on their own learning needs during the week.
week produced an outcome in the form of a presentation to all In some small group sessions, termed Personal Awareness
course participants that met agreed-upon learning goals articu- groups, participants discussed challenges they faced in teach-
lated by group members during their meetings. ing and patient care encounters (and sometimes their personal
life) to examine how these issues affected their communication
with patients, colleagues, or teaching performance. For exam-
Small Group Sessions
ple, 1 course participant reflected on his challenges with a
In the first small group session, learners articulated and dying patient, and through gentle probing, came to realize that
refined their learning goals and objectives, facilitated by course his own discomfort with death was a contributor to this
faculty. Throughout the course, faculty worked closely with difficulty. Methods utilized to facilitate personal awareness
their small groups to ensure that focused learning objectives groups included challenging case discussions, based on
were met. For example, 1 small group session consisted of methods or Balint groups,32 discussing family of origin33 and
having a participant work on the interviewing skill of talking its effect on communication, as well as more open-ended
with patients at the end-of-life in a role play with 1 of the other discussion based on methods advocated by Carl Rogers.34
group members taking on the patient role. Another course
participant worked on delivering feedback, whereas the final
Program Evaluation and Analysis
member also worked on end-of-life skills through focused
observation of the role play. Once the interaction took place, We used a retrospective pre-post design for course evaluation.
the interviewer provided a self-assessment of his interview Participants completed a 29-item evaluation immediately after
followed by feedback from the “patient”-participant, other the course that assessed their skill level at two points: before
group members (with special attention to the group member (retrospective pretest) and after (posttest) the course.35–37 The
who was working on end-of-life skills in the observer role), and questionnaire assessed participant confidence in using inter-
faculty. The post-interview feedback facilitated by the group view (10 items), clinical (3 items), teaching (7 items), and self-
member focused on improving her feedback skills. Faculty awareness skills (3 items). Six items, designated control
then facilitated a portion of the session to ensure that the variables, were not formally or systematically taught during
group member working on delivering feedback received input the course and were included to provide a measure of
on her skills of facilitating a feedback session. These activities desirability bias.35,38 Questionnaire responses were on a
underscored the importance of experience and reflection to Likert scale of 1 to 7, with anchors of 1=not at all confident
reinforce learning.31 and 7=completely confident. The evaluation instrument out-
JGIM Hatem et al.: Teaching the Medical Interview 1721

lining all four subscales and the control variables is included Further analysis using a paired t test after adjusting for the
as Appendix. average of the control variables’ pre/post difference demon-
Demographic variables were gathered including gender, age, strated that only teaching and self-awareness mean change
years teaching in a medical school, years teaching the medical scores were statistically significant (p<.001). Figure 1 reflects
interview, and the number of prior AACH courses attended. the mean change scores with their respective confidence
Descriptive statistics were computed for demographic vari- intervals, after accounting for desirability bias.
ables. Paired-samples t tests were used to assess if mean There was no significant effect of years of practice, gender,
change scores were different across skill category. Additional t or age on the 4 skill variables, except the personal awareness
tests were performed to assess pre/post mean differences in variable where the training increased personal awareness most
confidence in utilizing skills before and after adjusting for in older female participants (51 years and older; p<.01).
desirability bias as measured by the control variables. The Results for the reliability analysis showed a high alpha for
adjustment was calculated by subtracting the average of the the overall scale (pre = 0.93, post = 0.93) and 3 of the 4
pre/post mean difference of the control variables from each subscales: interview (pre=0.88, post=0.86), teaching (pre=
skill category post measure. Reliability analysis was conducted 0.88, post=0.90), and self-awareness (pre=0.84, post=0.82).
on all questionnaire items (excluding the control variables) and Clinical skills pre and post were lower (pre=0.58, post=0.61).
the four subscales using Cronbach’s alpha as the measure. These alpha levels suggest that evaluation responses mea-
Linear regression was used to determine whether participant sured participants’ confidence and changes were not because
demographic variables predicted post-course skills assessment. of different interpretations of the questionnaire content.
One additional outcome is that some project groups contin-
ued to work after the course, and this led to the publication of
scholarly work.39,40
RESULTS
Seventy-nine participants took part in the course. Approxi-
mately one-half of the sample (52%) was 45 or younger, 54%
DISCUSSION
were male. Forty-six percent were first-time course partici-
pants, 28% attended 1 prior course, and 26% attended 2 or The AACH’s 17th annual Faculty Development course demon-
more prior AACH courses (see Table 3). strated that, guided by needs assessment of learners’ goals, a
Participants had been practicing medicine an average of faculty development intervention can be designed to meet
14 years, with a mean of 8 years teaching medical school, and diverse needs of a national and international group of partici-
6 years teaching the medical interview (data not shown). Partici- pants with a broad range of experience teaching the medical
pants were from the United States and 4 additional countries, interview. We used teaching methods that allowed participants
were predominantly physicians, although 15 (20%) were educa- to form specific goals and objectives and take concrete steps to
tors trained in social work, psychology, and education. achieve them during the course. In contrast to a self-study
Sixty-five participants (82%) completed course evaluations. process, our program emphasized the importance of small
Initial analysis indicated statistically significant changes in group learning and the teacher–learner relationship to ensure
mean scores of participants’ confidence in interview (mean learning. The importance of goal-setting, observation, guided
pre=5.0, Standard deviation or SD 0.8, post=5.6, SD 0.6; reflection, and feedback based on participant goals in the
p<.001), clinical (pre=4.1, SD 0.9 post=4.8, SD 0.9; p<.001), learning process has been described as critical in teaching
teaching (pre=4.1, SD 0.9 post=5.2, SD 0.8; p<.001), self- communication skills41 and in developing expertise with
awareness (pre=4.3, SD 1.1 post=5.5, SD 0.8; p<.001) skills complex learning tasks.42 More than half of the participants
and control variables (mean pre=4.4, SD 1.1, post=5.0, SD 0.9; in this faculty development program had previously attended a
p<.001). Scores in interview skills demonstrated the smallest similar AACH course. The extent to which these experienced
change, although the participants rated their interview skills learners influenced the learning of others is unknown, but
highest of all categories before the intervention. may have been significant given our emphasis on small-group
learning and shared experiences.
There are other medical interview teaching interventions
that have demonstrated success, but these are typically with a
single skill set22,23 with undergraduate medical students25,43
Table 3. Descriptive Characteristics of Course Participants
or at single institutions.8,9 Our teaching that utilizes learner-
Demographic Characteristic N % centered teaching methods requires a faculty well versed in
teaching communication skills, but also adept at modifying his
Gender or her teaching to specific participant learning needs. This
Male 31 54
Female 26 46
results in a course that ultimately has no “standard” curricu-
Age lum, but whose process embodies the learner-centered princi-
29–35 14 23 ples it seeks to teach.29
36–40 8 13 Our teaching intervention produced clear outcomes in
41–45 10 16
perceived skills for a faculty development program, while
46–50 16 26
51 or greater 14 23 overcoming common sources of bias. We observed improvement
AAPP Experience in two broad skill areas: teaching skills and self-awareness
No prior course 28 46 skills, consistent with our focus on teaching and skills unique to
One course 17 28 the AACH model, self-awareness. Smaller changes in interview-
Two or more courses 16 26
ing and clinical skills were not statistically significant.
1722 Hatem et al.: Teaching the Medical Interview JGIM

Figure 1. Change in pre/post skill categories after accounting for desirability bias

The presence of feelings related to encounters have been Whereas prior curricular interventions have stressed the
demonstrated to potentially affect performance in the medical importance of insuring buy-in and fitting curricular interven-
interview,44,45 providing a rationale for including content tions into an already existing context,25,26 our intervention
related to self-awareness in this faculty development interven- assessed and met learners’ needs over a relatively short period
tion. In addition, reflection promoting self-assessment, self- of time. The process by which faculty rapidly and repeatedly
awareness, and learning is felt by many to be integral to assessed learning needs and took steps to meet them is
professional training,46 teacher development,46–49 and for important in allowing learners to meet their learning goals
learners to effectively learn patient-centered interviewing and objectives.29 This approach requires significant invest-
skills.45,50 A recent article stems from AACH work and ment in small group sessions and skilled faculty who can teach
describes how personal awareness can be taught by teachers the material pertinent to the medical interview, while being
without specific psychological training.51 flexible enough to meet individual learner’s needs. This
Whereas a recent review points out the limited correlation of framework parallels the one derived empirically by Fryer-
physician self-assessment compared to observed measures of Edwards who broke down this teaching process into the
competence,52 three studies directly related to our subject following steps: 1) identifying a learning edge (setting goals),
matter and evaluation methods show a positive correlation. 2) proposing and testing hypotheses (trying new skills), and 3)
Smith8 demonstrated that improvement in resident attitudes calibrating learner’s self-assessments (feedback and evalua-
of self-efficacy in interviewing skills was accompanied by tion).41 Educators running faculty development programs
improved skills performance with both real and simulated should consider adapting their methodology to allow individual
patients. Williams and Deci53 demonstrated that the use of learners to establish their own learning goals and objectives
learner-centered teaching methods for interviewing skills led to and choose methods that allow for their achievement during
increased self-assessed perception of learner competence and their programs.
improvement in interview skills at 6 months as assessed by This course, with its emphasis on and commitment to
standardized patient interviews. Hewson’s faculty development learner-centered learning, skills practice, and reflection for
interventions demonstrated positive correlations between par- skills improvement provides a unique approach to faculty
ticipant’s self-assessed retrospective pre-post teaching skills development and could serve as a model for other faculty
evaluations, and improved teaching evaluations by lear- development efforts, especially those with the goal of dissemi-
ners.54,55 This suggests that the improved self-efficacy we nating the practice of health care relationships and communi-
observed could be similarly paralleled by improved skills. cation that integrates best medical practices with patients’ and
Several faculty development programs have used experien- clinicians’ values, needs, and choices, the mission of the AACH.
tial teaching methods like our course and demonstrated that
faculty development in teaching skills related to the medical
interview were improved as assessed by videotape analysis of
Conflict of Interest: None disclosed.
teaching,56 and that interview skills of students improved after
being instructed by teachers trained to teach the medical
Corresponding Author: David S. Hatem, MD; Division of General
interview.57
Medicine and Primary Care, University of Massachusetts Memorial
This paper has broader implications for educational pro- Medical Center, Benedict Building A3-140, 55 Lake Ave. N, Worcester,
grams with experienced national and international audiences. MA 01655, USA (e-mail: [email protected]).
JGIM Hatem et al.: Teaching the Medical Interview 1723

8. Smith RC, Lyles, JS, Mettler MA, Stoffelmayr BE, et al. The
APPENDIX effectiveness of intensive training for residents in interviewing: A
randomized controlled study. Ann Int Med. 1998;128:118-126.
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