Academic Psychiatry 28:66-70, March 2004
© 2004 Academic Psychiatry
An Interviewing Course for a Psychiatry Clerkship
Angela Nuzzarello, M.D., M.H.P.E. and
Catherine Birndorf, M.D.
Dr. Nuzzarello is the Associate Dean for Student Programs and Professional Development and Assistant Professor of Psychiatry at the Feinberg School of Medicine, Northwestern University, Chicago, Illinois. Dr. Birndorf is Assistant Professor of Psychiatry and Obstetrics/Gynecology and Program Director for the Payne Whitney Women's Program at New York Presbyterian Hospital–Weill Cornell Medical College, New York, New York. Address correspondence to Dr. Nuzzarello, Office of Medical Education and Faculty Development, Northwestern University Feinberg School of Medicine, 303 E. Chicago Ave., Ward Building 3-130, Chicago, IL 60611-3008; a-nuzzarello{at}northwestern.edu (E-mail).
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ABSTRACT
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Objective: Taking a psychiatric history is a key educational objective in the psychiatry clerkship. Medical students arrive on psychiatry clerkships unprepared for the unique challenges of psychiatric interviewing. This paper describes an interviewing course for psychiatry clerks that combines practice, observation, and feedback in a small group setting. Methods: A quasi -experimental cohort design with medical student self-ratings as the dependent variable. Results: Students’ self-perceived skill in interviewing and differential diagnosis improved more than students who did not have the interviewing course. Students’ self-perceived skills also correlated significantly with the number of times they observed interviews. Conclusion: Clerkship directors in psychiatry should provide students with opportunities to practice interviewing skills, observe interviews, and receive feedback.
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INTRODUCTION
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Medical students are taught the fundamental components of interviewing patients as part of the preclinical curriculum, yet many are unprepared for the challenges of the psychiatric interview. Preclinical interviewing courses are insufficient to meet the needs of clinical students in psychiatry because patients interviewed in the preclinical years often present a limited array of problems and do not portray the types of patients seen in psychiatric services (1). Students need to feel comfortable dealing with more difficult situations such as extremes of emotion or breaks with reality (2). Interviewing skills must be continually developed (3, 4) and integrated in the curriculum (5) because skill, especially empathy, has been shown to decline in the clinical years of medical training (6). Deficiencies in interviewing skill can result in failure by physicians to recognize psychiatric problems in the their medically ill patients (7, 8).
Taking a psychiatric history is a key educational objective in psychiatric clerkships (8) because it is a primary source of diagnostic information and serves as the foundation of the therapeutic relationship. Despite the importance of the interview, medical students often receive little practice and receive only ad hoc feedback on their interviews from psychiatric residents and attendings. Some psychiatry departments offer instruction during their clerkships aimed specifically at eliciting a psychiatric history, although the type and amount of instruction varies widely. The effectiveness of interviewing courses offered on psychiatry clerkships has rarely been documented.
At the Northwestern University Feinberg School of Medicine (NUFSM), unpublished clerkship data collected in 1999 show that 50% of students completing the psychiatry clerkship had not been observed performing an interview and had not received feedback about their interviewing skills. This lack of guidance during the clerkship, combined with poor preclinical preparation, limits the ability of the students to hone their interviewing and diagnostic skills during the psychiatry clerkship. In response to the evaluation data, the clerkship director in psychiatry at NUFSM designed an interviewing course for third-year medical students that combined the three essential elements of effective instruction: practice, observation, and feedback. The course allowed students to practice and observe each other interviewing patients, provide feedback, and develop a differential diagnosis in a small group setting. The course gave students more opportunities to observe interviews and more experience in providing feedback to their peers than in the prior clerkship format.
There are many ways to structure an interviewing course. Shea and Mezzich argue that role playing is the most effective way to practice different methods of handling hostile or uncooperative patients,(9), while Blake and others suggest using standardized patients to practice communication skills (10–12). Programmed instruction using videotapes with opportunities for discussion has been shown to be another useful tool in teaching medical interviewing (13,14). We chose to use psychiatric inpatients for our interviewing course because it was a cost effective and convenient option.
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Course Description
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The interviewing course included four weekly 1-hour sessions with four third-year psychiatry clerkship students and one psychiatry attending preceptor. Two psychiatry attendings volunteered to precept all of the sessions. Students were given an introduction to the purpose and the format of the course. Each session began with a 20- to 30-minute interview of a psychiatric inpatient conducted by one of the students. The interview was limited to 30 minutes to allow ample time for feedback in the 1-hour session. Patients were chosen by the psychiatry attending preceptor and were not familiar with the student interviewer. The attending preceptor explained the purpose of the interview to the patient. Students were directed to elicit a chief complaint, history of present illness, past medical and psychiatric history, family history, social history and mental status examination. Each student performed one interview and observed three interviews during the course.
At the conclusion of the interview, the patient was escorted back to his/her room. Each group member gave written feedback to the student interviewer using a form modified from the one used by Lovett and colleagues (15) (Appendix 1). Students were encouraged to write comments regarding the positive and negative aspects of their colleague’s interview. Verbal feedback was offered in addition to the written comments.
The preceptor moderated the feedback portion of the session (40 minutes). The student interviewer was asked to assess the interview process, beginning with what he/she felt was done well, followed by a reflection of what he/she thought needed improvement. Every student observer was then asked to provide verbal feedback to the interviewer regarding the interview process. Students were given instruction about how to provide feedback (i.e., begin with positive comments and follow with suggestions for improvement).
After discussion of the interview process, the content of the interview was addressed. The discussion began with a student summary of the important facts. A differential diagnosis was postulated by the students who were then asked to provide evidence supporting or refuting each diagnostic possibility. Implications for treatment, including biological, psychological, and social factors were discussed. The feedback provided by the course was purposefully not used in student evaluations in order to minimize performance anxiety.
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METHOD
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We conducted a quasi-experimental cohort study (16) (nonequivalent control group design [17]) to evaluate the outcomes of the interviewing course within the NUFSM psychiatry clerkship. Students selected one of two possible sites for their clerkship, unaware of the interviewing course when they made the selection. Students were then assigned to a rotation within their selected site. The interviewing course was offered on four of the five rotations at one of the sites. Of the four rotations where the course was offered, two were adult inpatient units, one was a geriatric inpatient unit, and one was a consultation/liaison service, all at Northwestern Memorial Hospital (NMH). The two rotations that did not offer the interviewing course were an adult inpatient unit with consultation/liaison experience at a community-oriented affiliate hospital and an ambulatory site at NMH. The sites for the interviewing course were chosen because of accessibility for the attending preceptors. The data were collected between July 1999 and March 2001.
Students in the intervention group received the interviewing course (N=128). Students in the control group (N=91) took the clerkship before the interviewing course was available (N=22) or were assigned to a rotation that did not offer the course (two of six rotations) (N=69). At the conclusion of each clerkship, students anonymously completed a 10-item questionnaire about their experience of receiving feedback on patient interviews during the clerkship. As a human subjects safeguard to protect student confidentiality, no identifying information was on the questionnaire. The first three questions addressed the number of times the student was observed performing an interview, given feedback, and given the opportunity to observe other students interview. A 5-point scale (1=never, 5=four or more occasions) was used. The next five questions, using a 4-point Likert scale (1=strongly disagree, 4=strongly agree), addressed the quality and timeliness of the feedback, whether students believed their skills in interviewing patients and formulating a differential diagnosis improved and whether the amount of feedback received was sufficient. The last two questions addressed the source of feedback (e.g., resident, attending physician, student, or other health professional) and the name of the assigned site and rotation.
Data analysis was performed using the t test to evaluate group differences in self-assessment responses. Correlation coefficients were also computed to assess relationships of self-assessment responses with interviewing experience.
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RESULTS
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Medical student responses to the eight self-assessment items are summarized in Table 1. Statistically significant between-group differences were obtained for each of the items.
Students self-perceived skills in interviewing correlated positively with the number of times they reported being observed performing an interview (r=0.22, p<0.001), received feedback (r=0.33, p<0.0001), and observed other students’ interviews (r=0.22, p<0.001). Students’ self-perceived ability to develop a differential diagnosis correlated positively with the number of times they reported being observed directly performing an interview (r=0.17, p<0.017), received feedback (r=0.46, p<0.0001), and observed other students’ interview (r=0.37, p<0.0001).
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DISCUSSION
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Being observed performing an interview coupled with the opportunity to receive immediate feedback has been shown to lead to an improvement in interviewing skill (18–20) and increased clinical confidence (21). The NUFSM psychiatry clerkship interviewing course provides students with more opportunities to be observed conducting an interview, receive structured feedback, observe other students’ interviews, and provide peer feedback. We are encouraged that structured feedback in a planned course was superior to ad hoc feedback in improving students’ self-perceived skills in interviewing and in constructing a differential diagnosis. Additionally, we believe that providing structured feedback should be a regular component of psychiatry clerkships.
Small group feedback was used as an instructional method because faculty time allotted to teach students is limited as clinical demands grow. Although interviewing a patient in front of others can increase anxiety, it can also serve as a source of motivation for students (15) and prepare students for future clinical presentations. Gask reported that group feedback was as effective as one-on-one feedback (22). This is consistent with our findings that the number of times students observed others perform interviews was positively correlated with perceived improvement in their own skills. This is supported by much empirical research that shows learning can occur by vicarious observation (23).
Students in the intervention group rated the quality of the feedback they received higher than did students in the control group. This could be due to a number of factors. First, the interviewing course was specifically designed to address both specific interviewing skills and the ability to formulate and support a differential diagnosis. Students received feedback both about how to elicit information and how to use the information they obtained. A second factor is that before the course was introduced, much of the feedback students received on their interviewing skills occurred while they were on call with residents. This is regrettable since time is limited during call, and the residents are evaluating students during the on call experience. Students receiving the course may have perceived the feedback as more positive since it was received in a relaxed environment and was not tied to evaluation. Finally, although we did not examine whether faculty feedback was superior to resident feedback, the students may have perceived the feedback offered in the course as more valid since it came from a faculty member.
The course also provided the students with an opportunity to critique peers. Peer review is an essential skill for all medical professionals, as it provides feedback on areas not always addressed by self-assessment or assessment by instructors (24). The students experienced giving and receiving constructive criticism, an often-neglected component of medical education.
One limitation of this study is that students selected clerkship sites. Although students were unaware of the interviewing course when they made their selection and a portion of the control group was at NMH sites, a selection bias may have occurred. Students choosing the "off site" rotation may not have been as motivated to learn as the students selecting the NMH site. Another limitation is that there was not an objective measure of interviewing skill assessment for both groups. This study relied on self-report of skill and knowledge.
Although this study focused on students in a psychiatry clerkship, other clerkships may benefit from promoting feedback on interviewing skills. The small group method of providing feedback increased student exposure to different interviewing styles and provided opportunities to give and receive feedback. Further studies examining whether structured feedback and observation translate to actual improvements beyond self-perception are warranted. Clerkship directors should provide feedback to their students and evaluate the effectiveness of their chosen method. By providing timely and effective interviewing instruction to students, their training and, ultimately, the care of their patients will benefit.
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ACKNOWLEDGMENTS
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The authors thank William C. McGaghie, Ph.D., for his suggestions during manuscript preparation.
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E. H. C. Cardoso Zoppe, P. Schoueri, M. Castro, and F. L. Neto
Teaching Psychodynamics to Psychiatric Residents through Psychiatric Outpatient Interviews
Acad Psychiatry,
January 1, 2009;
33(1):
51 - 55.
[Abstract]
[Full Text]
[PDF]
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ABSTRACT
INTRODUCTION
