Relationship-Centered Care in the Physician-Patient Interaction: Improving Your Understanding of Metacognitive Interventions.

The concept of relationship-centered care was first introduced approximately 20 years ago, but this important concept has not yet been widely disseminated in clinical practice. Relationship-centered care in the health profession focuses on all relevant relationships in health care, not only between health care professionals and patients but also among colleagues, staff members, students, community, and self. This review summarizes the key literature to date on relationship-centered care as it pertains to the physician-patient relationship. Becoming more aware of the physician (self) and patient is a form of metacognition, thinking about what is happening in the moment as physicians and patients come together. Considering the complexity of the physician-patient relationship, we can implement simple metacognitive techniques toward the daily habitual practice of relationship-centered care.

An Advanced Communication Skills Workshop Using Standardized Patients for Senior Medical Students.

Introduction: Medical students often lack training in advanced communication skills encompassing emotionally fraught situations and those in which an intense emotional response is expected. Such skills are required for clinical situations encountered during residency. We created and evaluated an advanced communication skills workshop (ACSW) using standardized patients for senior medical students. The workshop emphasized communication skills for four scenarios-strong emotion, goals of care, medical error, and palliative care assessment-and utilized formative peer assessment and feedback. Methods: We created the four ACSW cases with case-specific communication behavior checklists and a common modified Master Interview Rating Scale in a Capstone Course for senior medical students. In groups of three, students rotated through three of four stations. Each student conducted one of the interviews while the other two completed the checklists and provided verbal feedback. We performed one-way analyses of variance on Likert responses and content analysis on open responses on a post-ACSW survey. Results: Ninety-one students completed the ACSW and survey. Students assigned high value to all four ACSW student roles: interviewer, observer, feedback recipient, and feedback provider. Students rated the experience above average to excellent on nearly all survey items. Open-response themes included "liked the opportunity to give or receive peer feedback" (46%) and "found the checklists helpful" (45%). Discussion: Feasible and well received by senior medical students, our ACSW offers an opportunity to practice and observe advanced communication skills and peer feedback. A peer-assisted, formative learning model, the ACSW efficiently addresses a key aspect of residency preparation.

Assessing Advanced Communication Skills via Objective Structured Clinical Examination: A Comparison of Faculty Versus Self, Peer, and Standardized Patient Assessors.

Construct: The construct addressed in this study is assessment of advanced communication skills among senior medical students. Background: The question of who should assess participants during objective structured clinical examinations (OSCEs) has been debated, and options discussed in the literature have included peer, self, standardized patient, and faculty assessment models. What is not known is whether same-level peer assisted learning can be utilized for formative assessment of advanced communication skills when no faculty, standardized patients, or other trained assessors are involved in providing feedback. If successful, such an educational model would optimize resource utilization and broaden the scope of topics that could be covered in formative OSCEs. Approach: The investigators developed a 4-station formative OSCE focused on advanced communication skills for senior medical students, and evaluated the concordance of assessment done by same-level peers, self, standardized patients, and faculty for 45 students. After each station, examinees completed a self-assessment checklist and received checklist-based assessment and verbal feedback from same-level peers only. Standardized patients completed checklist-based assessments outside the room, and faculty did so after the OSCE via video review; neither group provided direct feedback to examinees. The investigators assessed inter-rater agreement and mean difference scores on the checklists using faculty score as the gold standard. Findings: There was fair to good overall agreement among self, same-level peer, standardized patient, and faculty-assessment of advanced communication skills. Relative to faculty, peer and standardized patient assessors overestimated advanced communication skills, while self-assessments underestimated skills. Conclusions: Self and same-level peer-assessment may be a viable alternative to faculty assessment for a formative OSCE on advanced communication skills for senior medical students.

Twelve tips for running an effective session with standardized patients.

The incorporation of actors as standardized patients (SPs) to help students achieve learning goals across a range of topics has become widespread in medical education. SPs are integrated into formative and summative objective structured clinical examinations by medical educators and by licensing boards for assessment of competence. While SPs are useful for assessment of dynamic skills, they also have significant utility as an engaging instructional method. Few tools in teaching allow for the breadth of instruction, practice, and assessment offered by workshops involving SPs. A simulated encounter with an SP may be a trainee's only opportunity to experience working through a particular clinical scenario in an environment that carries no risk of significant harm. Thus, there is immense potential for educational innovation with SPs. The following Twelve Tips piece provides suggestions for harnessing this potential based on available literature and educational experiences of the authors.

House staff communication training and patient experience scores.

OBJECTIVE: To assess whether communication training for housestaff via role-playing exercises (1) is well-received and (2) improves patient experience scores in housestaff clinics. METHODS: We conducted a pre-post study in which the housestaff for 3 adult hospital departments participated in communication trainingled by trained faculty in small groups . Sessions centered on a published 5-step strategy for opening patient-centered interviews using department-specific role-playing exercises. Housestaff completed post-training questionnaires. For one month prior to and one month following the training, patients in the housestaff clinics completed surveys with CG-CAHPS questions regarding physician communication, immediately following clinic visits. Pre-and post -intervention results for top-box scores were compared. RESULTS: Forty -four of a possible 45 housestaff (97.8%) participated, with 31 (70.5%) indicating that the role-playing exercise increased their perception of the 5-step strategy. No differences on patient responses to CG-CAHPS questions were seen when comparing 63 pre-intervention patients surveys to 77 post-intervention surveys. CONCLUSION: Demonstrating an improvement in standard patient experience surveys in resident clinics may require ongoing communication coaching and investigation of the "hidden curriculum" of training.

Implementing and Evaluating a Four-Year Integrated End-of-Life Care Curriculum for Medical Students.

PROBLEM: Meeting the needs of patients with life-limiting and terminal illness requires effectively trained physicians in all specialties to provide skillful and compassionate care. Despite mandates for end-of-life (EoL) care education, graduating medical students do not consistently feel prepared to provide this care. INTERVENTION: We have developed a longitudinal, integrated, and developmental 4-year curriculum in EoL care. The curriculum's purpose is to teach basic competencies in EoL care. A variety of teaching strategies emphasize experiential, skill-building activities with special attention to student self-reflection. In addition, we have incorporated interprofessional learning and education on the spiritual and cultural aspects of care. We created blended learning strategies combining interactive online modules with live workshops that promote flexibility, adaptability, and interprofessional learning opportunities. CONTEXT: The curriculum was implemented and evaluated in the 4-year program of studies at Yale School of Medicine. OUTCOME: A mixed-method evaluation of the curriculum included reviews of student written reflections and questionnaires, graduating student surveys, and demonstration of 4th-year students' competency in palliative care with an observed structured clinical examination (OSCE). These evaluations demonstrate significant improvements in students' self-reported preparedness in EoL care and perceptions of the adequacy in their instruction in EoL and palliative care, as well as competency in primary palliative care in a newly developed OSCE. LESSONS LEARNED: A 4-year longitudinal integrated curriculum enhances students' skills and preparedness in important aspects of EoL care. As faculty resources, clinical sites, and curricular structure vary by institution, proven and adaptable educational strategies as described in this article may be useful to address the mandate to improve EoL care education. Teaching strategies and curricular components and design as just described can be adapted to other programs.

Training primary care physicians in cognitive behavioral therapy: A review of the literature.

OBJECTIVE: Patients often seek mental health treatment through primary care. Training primary care physicians (PCPs) in approaches to address common mental health concerns may be a useful method for narrowing gaps in care. Cognitive Behavioral Therapy (CBT) is especially applicable in medical settings given its brief, skill-based approach and strong evidence for a number of presenting problems. This paper reviews the current literature on training PCPs in CBT with a focus on PCP-level outcomes. METHODS: We reviewed studies that described and evaluated CBT training programs for PCPs. Of 652 records identified and screened, 33 full-text articles were assessed for eligibility, resulting in 9 articles identified for inclusion. RESULTS: We extracted and report information about study design, participants, intervention and dose, training content, and outcomes (PCP reaction, learning, and performance; patient outcomes). CONCLUSION: There was substantial variability in sample size, methodology, training content and design, and assessment of outcomes, which translated into mixed findings across studies. In order to best assess effectiveness and allow replicability, future studies should provide adequate information about training curricula and assess multiple levels of learning outcomes. PRACTICE IMPLICATIONS: Additional studies are needed to determine whether PCPs effectively implement skills within routine practice after CBT training.

The impact of a faculty learning community on professional and personal development: the facilitator training program of the American Academy on Communication in Healthcare.

PURPOSE: Relationship-centered care attends to the entire network of human relationships essential to patient care. Few faculty development programs prepare faculty to teach principles and skills in relationship-centered care. One exception is the Facilitator Training Program (FTP), a 25-year-old training program of the American Academy on Communication in Healthcare. The authors surveyed FTP graduates to determine the efficacy of its curriculum and the most important elements for participants' learning. METHOD: In 2007, surveys containing quantitative and narrative elements were distributed to 51 FTP graduates. Quantitative data were analyzed using descriptive statistics. The authors analyzed narratives using Burke's dramatistic pentad as a qualitative framework to delineate how interrelated themes interacted in the FTP. RESULTS: Forty-seven respondents (92%) identified two essential acts that happened in the program: an iterative learning process, leading to heightened personal awareness and group facilitation skills; and longevity of learning and effect on career. The structure of the program's learning community provided the scene, and the agents were the participants, who provided support and contributed to mutual success. Methods of developing skills in personal awareness, group facilitation, teaching, and feedback constituted agency. The purpose was to learn skills and to join a community to share common values. CONCLUSIONS: The FTP is a learning community that provided faculty with skills in principles of relationship-centered care. Four further features that describe elements of this successful faculty-based learning community are achievement of self-identified goals, distance learning modalities, opportunities to safely discuss workplace issues outside the workplace, and self-renewing membership.

Addressing mental health issues in primary care: an initial curriculum for medical residents.

OBJECTIVE: Many express concern that modern medicine fails to provide adequate psychosocial and mental health care. Our educational system has not trained the primary care providers who care for most of these patients. Our objective here is to propose a quantum change: prepare residents and students during all years of training so that they are as effective in treating psychosocial and mental health issues as they are medical problems. METHOD: We operationalize this objective, following Kern, by developing an intensive 3-year curriculum in psychosocial and mental health care for medical residents based on models with a strong evidence-base. RESULTS: We report an intensive curriculum that can guide others with similar training interests and also initiate the conversation about how best to prepare residency graduates to provide effective mental health and psychosocial care. CONCLUSION: Identifying specific curricula informs education policy-makers of the specific requirements they will need to meet if psychosocial and mental health training are to improve. PRACTICE IMPLICATIONS: Training residents in mental health will lead to improved care for this very prevalent primary care population.

Passing the torch: a proposed amendment to "A Physician Charter".

A Physician Charter has received widespread attention throughout the medical community since its publication in 2002. The Charter, which lays out three principles and 10 commitments that "reaffirm the fundamental and universal principles and values of medical professionalism …" omits an essential principle and its corollary commitment. That fourth principle, essential to the successful perpetuation of the aims of the Charter, we call the Principle of Generativity: Physicians must contribute to the education and development of the next generation of practitioners in order to ensure that the profession lives on and thrives, grounded in its fundamental professional values. Only by emphasizing our obligation to teach professional values to the next generation of physicians, can we expect to "pass the torch" of the profession.

An evidence-based patient-centered method makes the biopsychosocial model scientific.

OBJECTIVE: To review the scientific status of the biopsychosocial (BPS) model and to propose a way to improve it. DISCUSSION: Engel's BPS model added patients' psychological and social health concerns to the highly successful biomedical model. He proposed that the BPS model could make medicine more scientific, but its use in education, clinical care, and, especially, research remains minimal. Many aver correctly that the present model cannot be defined in a consistent way for the individual patient, making it untestable and non-scientific. This stems from not obtaining relevant BPS data systematically, where one interviewer obtains the same information another would. Recent research by two of the authors has produced similar patient-centered interviewing methods that are repeatable and elicit just the relevant patient information needed to define the model at each visit. We propose that the field adopt these evidence-based methods as the standard for identifying the BPS model. CONCLUSION: Identifying a scientific BPS model in each patient with an agreed-upon, evidence-based patient-centered interviewing method can produce a quantum leap ahead in both research and teaching. PRACTICE IMPLICATIONS: A scientific BPS model can give us more confidence in being humanistic. In research, we can conduct more rigorous studies to inform better practices.

Benefits of teaching medical students how to communicate with patients having serious illness: comparison of two approaches to experiential, skill-based, and self-reflective learning.

Innovative approaches are needed to teach medical students effective and compassionate communication with seriously ill patients. We describe two such educational experiences in the Yale Medical School curriculum for third-year medical students: 1) Communicating Difficult News Workshop and 2) Ward-Based End-of-Life Care Assignment. These two programs address educational needs to teach important clinical communication and assessment skills to medical students that previously were not consistently or explicitly addressed in the curriculum. The two learning programs share a number of educational approaches driven by the learning objectives, the students' development, and clinical realities. Common educational features include: experiential learning, the Biopsychosocial Model, patient-centered communication, integration into clinical clerkships, structured skill-based learning, self-reflection, and self-care. These shared features - as well as some differences - are explored in this paper in order to illustrate key issues in designing and implementing medical student education in these areas.

Assessment of a motivational interviewing curriculum for year 3 medical students using a standardized patient case.

OBJECTIVE: We sought to evaluate a year 3 motivational interviewing (MI) curriculum using a standardized patient case. METHODS: The 2-h small group MI curriculum included a didactic presentation followed by interactive role plays. During a clinical skills assessment at the end of year 3 the MI skills of 80 students who had participated in the curriculum were compared with those of 19 students who had not participated. RESULTS: The standardized patient reliably rated the students on their performance of 8 items. Students who had participated in the MI curriculum were significantly more proficient than nonparticipating students in the performance of 2 strategic MI skills, importance and confidence rulers (ps<.006). The groups did not differ in their use of patient-centered counseling skills or collaborative change planning commonly used in MI. CONCLUSIONS: Third year medical students can learn to use MI skills that specifically aim to enhance patients' motivations for change. PRACTICE IMPLICATIONS: Medical schools should consider providing students with MI training and MI skill assessments using standardized patient cases to help students prepare to counsel patients for behavior change.

A systematic review of curricula on relationships between residents and the pharmaceutical industry.

CONTEXT: Research has demonstrated the potential adverse impact of pharmaceutical company marketing techniques on doctor knowledge and prescribing practices. Lack of experience may make resident doctors particularly vulnerable to pharmaceutical industry influence. Curricula addressing resident-pharmaceutical industry relations have been reported, but there is no consensus regarding the best approach to take. OBJECTIVE: This study aimed to review published curricula that address resident-pharmaceutical industry relations and to assess them for content, validity and outcomes measures. METHODS: Curricula were identified via searches of electronic databases and bibliographies of collected articles. Inclusion criteria required articles to describe an educational curriculum, applied in graduate medical education, on relations between doctors and the pharmaceutical industry. RESULTS: The search identified 9 curricula. Most addressed detailing of residents by pharmaceutical representatives. Two articles described curriculum development. Eight articles included an evaluation component; only 1 included a control group for comparison. Modest improvements were noted in resident confidence, knowledge of guidelines, belief in the potential influence of marketing on behaviour, and self-reported acceptance of gifts. Only 2 evaluations used a validated outcome instrument, and no studies included longterm follow-up. CONCLUSIONS: A limited number of curricula have addressed resident-pharmaceutical industry interactions. Inconsistency in content, application and evaluation methodology prevents any meaningful synthesis of data. Resident attitudes and behaviours may be affected, but the outcome measures used lacked sufficient validity to assess improvements in knowledge and analytic skills. A clearer delineation of the curriculum development process and the use of standardised outcome measures would facilitate the reproduction of positive results at other institutions.

Teaching brief motivational interviewing to Year three medical students.

OBJECTIVES: In 2005, the authors developed and tested a curriculum to teach Year 3 Yale University medical students a behaviour change counselling approach called 'brief motivational interviewing' (BMI). Brief motivational interviewing is a patient-centred approach designed to promote changes in patient behaviour within the time constraints imposed by a busy medical practice. METHODS: Standardised patients/instructors delivered the curriculum within a single 2-hour training episode using a teaching acronym called 'CHANGE' to promote the students' learning. The authors used a pretest, post-test and 4-week follow-up design to assess students' BMI skills (as measured by the Helpful Response Questionnaire), knowledge and attitudes toward the approach. RESULTS: Students successfully increased their use of BMI-consistent behaviours, primarily by increasing the frequency and depth of their reflections and by reducing the frequency with which they incorporated communication roadblocks and closed questions into their responses (all P-values < or = 0.05). Students also showed increases in BMI knowledge, interest in the approach, confidence in their ability to use BMI, and commitment to incorporating BMI skills into their future medical practice (all P-values < or = 0.05). CONCLUSIONS: The findings suggest that Year 3 medical students can learn basic BMI skills and knowledge and develop positive attitudes toward the approach within a relatively short period of time. The authors discuss the study's limitations and future directions for teaching students BMI.

Not the same everywhere. Patient-centered learning environments at nine medical schools.

BACKGROUND: Learning environments overtly or implicitly address patient-centered values and have been the focus of research for more than 40 years, often in studies about the "hidden curriculum." However, many of these studies occurred at single medical schools and used time-intensive ethnographic methods. This field of inquiry lacks survey methods and information about how learning environments differ across medical schools. OBJECTIVE: To examine patient-centered characteristics of learning environments at 9 U.S. medical schools. DESIGN: Cross-sectional internet-based survey. PARTICIPANTS: Eight-hundred and twenty-three third- and fourth-year medical students in the classes of 2002 and 2003. MEASUREMENTS: We measured the patient-centeredness of learning environments with the Communication, Curriculum, and Culture (C3) Instrument, a 29-item validated measure that characterizes the degree to which a medical school's environment fosters patient-centered care. The C3 Instrument contains 3 content areas (role modeling, students' experiences, and support for students' patient-centered behaviors), and is designed to measure these areas independent of respondents' attitudes about patient-centered care. We also collected demographic and attitudinal information from respondents. RESULTS: The variability of C3 scores across schools in each of the 3 content areas of the instrument was striking and statistically significant (P values ranged from .001 to .004). In addition, the patterns of scores on the 3 content areas differed from school to school. CONCLUSIONS: The 9 schools demonstrated unique and different learning environments both in terms of magnitude and patterns of characteristics. Further multiinstitutional study of hidden curricula is needed to further establish the degree of variability that exists, and to assist educators in making informed choices about how to intervene at their own schools.

Spirituality and medicine. A workshop for medical students and residents.

INTRODUCTION: Governing bodies for medical education recommend that spirituality and medicine be incorporated into training. AIM: To pilot a workshop on spirituality and medicine on a convenience sample of preclinical medical students and internal medicine residents and determine whether content was relevant to learners at different levels, whether preliminary evaluation was promising, and to generate hypotheses for future research. SETTING: Private medical school and university primary care internal medicine residency program, both in the Northeast. CURRICULUM DESCRIPTION: The authors designed and implemented a required 2-hour workshop for all second-year medical students and a separate required 1.5-hour workshop for all primary care internal medicine house staff. The workshops used multiple educational strategies including lecture, discussion, and role-play to address educational objectives. PROGRAM EVALUATION: Learners completed optional, anonymous pre and postworkshop surveys with six 5-point Likert-rated statements and space to cite the most useful part of the curriculum and their remaining questions. One hundred and thirty-seven learners participated and 100 completed both surveys. Medical students and residents had increased (all P< or =.002): agreement regarding the appropriateness of inquiring about spiritual and religious beliefs in the medical encounter, their perceived competence in taking a spiritual history, and their perceived knowledge of available pastoral care resources. Medical students, but not residents, had an increase in their perceived comfort in working with hospital chaplains. DISCUSSION: A brief pilot workshop on spirituality and medicine had a modest effect in improving attitudes and perceived competence of both medical students and residents.

Teaching personal awareness.

Educators rarely consider the attitudes that determine whether a learner will use the clinical skills we teach. Nevertheless, many learners and practitioners exhibit negative attitudes that can impede the use of patient-centered skills, leading to an isolated focus upon disease and impairing the provider-patient relationship. The problem is compounded because these attitudes often are incompletely recognized by learners and therefore are difficult to change without help. We present a research-based method for teaching personal awareness of unrecognized and often harmful attitudes. We propose that primary care clinicians without mental health training can follow this method to teach students, residents, faculty, and practitioners. Such teachers/mentors need to possess an abiding interest in the personal dimension, patience with a slowly evolving process of awareness, and the ability to establish strong, ongoing relationships with learners. Personal awareness teaching may occur during instruction in basic interviewing skills but works best if systematically incorporated throughout training.