Preparing Medical Students for the Medical Interview

INTRODUCTION The medical interview is possibly the most important encounter the physician has with a patient, frequently uncovering important clues as to what prompted the patient’s visit. To conduct an optimal medical interview, the physician must be aware of patient behavior patterns and be able to communicate effectively. In a seminal essay written in 1973, George Engel proclaimed, “The keystone around which medical care has evolved over the ages remains the interpersonal encounter between the patient and a physician.”1 He also claimed that the history obtained during the physician-patient encounter remains “the most sensitive and powerful instrument available to the physician.”2 Lipkin et al.3 argued that communication with patients is the core clinical skill for the practice of medicine. Given the importance of the physician-patient encounter and the medical interview, it is not surprising these topics are essential elements of the undergraduate medical education curriculum. In 2005, the AAMC Task Force on the Clinical Skills Education of Medical Students published a monograph outlining recommendations for clinical skills curricula for undergraduate medical education.4 In 2008, the AAMC published a second monograph addressing the clinical skills curriculum and performance outcomes expected for pre-clerkship students.5 In both monographs, the task force members stressed the importance of medical students being able “to engage and communicate with a patient and to build a physician-patient relationship for the purposes of information gathering, guidance, education, and support.”4,5 Multiple authors have reported on the methods and successes of programs to enhance communication and medical interviewing skills.6-11 Although no one program seems to be superior to another, it was apparent that attention to development of these skills was important. The rural regional medical campus of University of Kansas School of Medicine-Salina (KUSM-S) designed a program entitled Preparing Medical Students for the Medical Interview that introduced the students to patterns of human behavior and effective communication techniques, information critical to starting the medical interview. The program introduced medical students to the basic interpersonal communication skills necessary to establish rapport with the patient during the initial moments of the medical interview, including a conversation template to follow for the first two minutes after entering the exam room. The students who completed this introductory program, delivered during the first two weeks of medical school, should be prepared to enter the exam room and create an environment that the patient immediately will perceive as safe enough to discuss their health issues. The program was comprised of four learning activities: (1) Behavior Pattern Awareness (Social Styles), (2) Basic Listening Skills, (3) Recognizing Potential Interviewing Barriers, and (4) The First Two Minutes. This program helped the student navigate the new social encounters of the medical exam room and complemented the techniques of taking a history and performing a physical exam. The total time required to complete this program was approximately three hours, divided into three separate sessions. The first learning activity was covered in the first session. The second, third and fourth learning activities were covered in a second session. The elements of the fourth learning activity (The First Two Minutes) were practiced in a third session. All social encounters between two individuals involve some degree of risk-taking. If one says “Hello” to a passerby, there is the risk that the person addressed will not respond in the manner expected by the initiator of the greeting. Similarly, when patients meet with a medical professional, especially during the first encounter, they must quickly decide if they can trust the care provider enough to take the risk of communicating their concerns. Patient-physician communication can be influenced by socioeconomic status, race, and gender.12-15 The intimate nature of the doctor-patient relationship, and the associated need for trust, requires that the patient be assured that the clinical environment is welcoming and safe. Meaningful dialogue, leading to an understanding of the patient’s health issues, making a diagnosis, and outlining a treatment program, start with a trusting relationship. The decision to trust is frequently made by the patient within seconds of a clinician entering the room.16 The KUSM-S program was developed to raise the students’ awareness of social styles and to introduce basic communication skills that foster empathy and trust. While some medical students may be cognizant of social styles and have developed effective communication skills prior to medical school matriculation, many of their peers were unaware of social styles and needed to hone their communication skills. This program allowed students to learn, or review, then practice effective communication skills, a set of skills that encompasses a variety of verbal and nonverbal techniques. The following four learning activities were designed to aid in acquisition and mastery of those skills.