VOL 1, No 3, APRIL 1999

Patient interviews: Learning the physician's art

by Cindy A. Abole, Public Relations

Imagine a patient waiting anxiously within the confines of a cold, sterile physician’s exam room. It’s evident that the patient is nervous, scared and uncomfortable prior to meeting his physician.

The importance of recording a thorough medical history cannot be overstated. It will provide more than 75 percent of the information a physician needs for diagnosis. A successful interview not only communicates information but evokes a skill based on empathy and mutual respect. Like a bridge, the interview strengthens the bond between patient and physician.

As part of the College of Medicine’s (COM) community-based education program, first-year medical students are developing their abilities to take medical histories through exposure to primary care practices. The idea is to allow students to work directly with patients early on in the offices of Lowcountry family practitioners, general internists and pediatricians.

“Traditionally, first-year students are literally bookworms,” said Todd R. Vasko, M.D., a pediatrician and community preceptor. Vasko was referring to the classical medical school curriculum of basic science courses and reaching back to his own experience as a student at the Medical College of Georgia. “As we began rotations, third-year students were forced to integrate what they learned academically with limited people skills. It was a challenging experience.”

The Introduction to Clinical Medicine (ICM) curriculum follows a three-week rotation which features time spent in primary care practices. The program is supplemented by peer debriefing sessions, featured topic sessions and special projects. Each cycle addresses course objectives and fosters more student, faculty and preceptor interactions.

“First-year medical students are starved for practical, patient-oriented activities,” said William J. Hueston, M.D., professor and chairman of the Department of Family Medicine. “I think the long delay between entering medical school and seeing patients fosters some loss of idealism in students. They lose sight of why they are becoming doctors.”

The program is directed by Carolyn Thiedke, M.D., Department of Family Medicine. She has worked with Hueston and curriculum and evaluation coordinator Amy Blue, Ph.D., COM Dean’s Office, in devising its objectives. Colleen Giles, ICM Year I curriculum coordinator, has assisted with coordination of course activities.

“One of the first issues we faced was how to recruit community doctors to participate,” Hueston said. “With 140 students needing teaching, the idea of recruiting became a daunting task.”

Hueston’s idea of alternating students with doctors during three-week cycles would limit the number of participating community physicians to 48 doctors and cut the number of faculty needed for the course by 50 percent.

“We learned how students like being involved in the community,” said Thiedke. “The experience has provided great exposure and practice for students as an introduction to basic patient care. They are also learning the business side of running a private practice.”

First year medical student Luke Bonnett values his improved communication skills enhanced through this program. Bonnett, who is from Rowesville in Orangeburg County, spends more than four hours a month at the office of family practitioner David Albenberg, M.D.

“There are certain elements of my experience in the primary care office that can’t be learned from textbooks,” Bonnett said with a smile.

Albenberg, who is with James Island Medical Care, completed his residency at MUSC in the mid-1990s. He joins other Lowcountry-based physicians who have volunteered to help train the university’s next generation of patient-centered physicians.

“Our preceptor-student relationship is great,” Bonnett said. “Dr. Albenberg allows me to ask lots of questions and often challenges me by reviewing course material and its relevance to his practice.”

In addition to taking patient histories, students arrive at their preceptors' offices with other assignments based upon practice-related issues. These include a list of questions asking students to identify patient demographics, rationale of visits—acute versus chronic problems, information about prescriptions, referrals, etc.

“Early exposure to patients allow students to rekindle the motivation that brought them to medical school,” said Hueston. “By introducing simple topics that we could call the ‘medical infrastructure’ early in the course of their medical school careers, I think we also lay a better foundation on which they can build their future medical knowledge.”

Students have plenty of opportunity to review and practice. When they are not visiting their community preceptors, students meet with faculty preceptors in small group sessions to discuss issues relevant to their clinical visits, review written presentations of an interviewed patient and prepare to conduct an oral presentation.

On another rotation cycle, students attended special topic sessions. Guided by their faculty preceptors, groups of students review assigned readings and are introduced to five patient problems—sleep, addiction, benign pain, sexuality and memory loss. Within the sessions, a standardized patient or actor presents a particular health problem. Three students are selected to practice their medical history taking skills, giving others a chance to observe different interviewing techniques.

“The course uses a helpful text and outside readings,” Bonnett said, referring to special topic session activities. “It provides valuable resources that allow us as students to exhibit positive attributes and let our individual personalities shine.”

The use of standardized patients is not a new concept. Greg Gilbert is one of two dozen contracted actors hired to play the role of a standardized patient. “It’s been a wonderful experience and a practical way to test students,” said Gilbert, who works as a statistician with Center for Clinical Education and Teaching within the College of Medicine. Gilbert’s script prompts him to play a patient suffering from severe headaches. “Sure, sometimes there’s a bit of nervousness in the air between me (as the standardized patient) and the student. But if they play their role professionally, they usually stay focused and do well.”

Another first-year student Natasha Jenkins, 23, gained valuable experience working with Vasko at his West Ashley clinic. Jenkins, originally from Eutawville, conducted pediatric medical interviews and was busy learning the challenges associated with operating a busy clinical practice.

“I realize that I’m limited in what I can contribute on my visits,” said Jenkins. “I’ve learned a lot from Dr. Vasko just by observing his sensitive and attentive approach with his patients.”

As a new program, feedback from participants becomes essential. Midway through the course, students were able to respond to a formative mid-course evaluation regarding small-group interaction. A confidential peer assessment was used to identify and reinforce positive aspects and behaviors, plus facilitate program improvements.

In late spring, ICM organizers will gather volunteer preceptors for an informal reception. As a gesture of appreciation, preceptors will be presented with a letter of thanks and certificate which can be applied towards a future tuition-free Continuing Medical Education course offered at the university.

“As students acquire skills early on, they learn to build upon them,” Thiedke said. “So when it comes to the time when students arrive on the ward during their third year, they can concentrate on getting to the business at hand. They aren’t distracted with the task of learning the basics of communication.”

Students help shape future of medical education

The voice of students at MUSC is helping define medical education for the next millennium.

Students currently serve on several important College of Medicine committees. Their presence on the Curriculum Coordinating Committee is yet another example of how students have a role in contributing to the future course for education in the College of Medicine.

Julie Iannini, left, and Michelle Hudspeth, third and fourth year students, respectively, joined the Curriculum Coordinating Committee (CCC) in January 1999 to represent the views of their fellow students.

“We value their perspective on the existing curriculum,” said Victor Del Bene, M.D., associate dean dean for students.

As planned change occurs in the undergraduate curriculum, “student input on courses and methods of teaching hasbeen very beneficial,” said CCC chair David Garr, M.D., associate dean for primary care.

The experience of serving on the Curriculum Coordinating Committee has been valuable to Hudspeth, who plans to pursue a career in academic medicine. She begins a pediatrics residency at Johns Hopkins in July. After Hudspeth graduates, another student representative will be appointed to the CCC.

“The faculty members of the curriculum committee have been very receptive to our concerns and ideas,” Iannini said.

Hudspeth and Iannini agree that the curriculum changes are making great strides toward fostering coordination between courses and eliminating duplication.

“I think the changes being planned will greatly benefit current and future students,” Hudspeth said. “It’s impressive to see the amount of energy and planning that has gone into this effort so far, and the dedication that they (CCC members) have to medical student education.”

Videotaped interviews offer chance to practice taking medical histories

Although unpopular with some students, videotaped interviews provide extra practice opportunities for conducting medical histories.

ICM II student Natasha Jenkins, eases into a conversation with standardized patient Robert Siudzinski as she practices her interview technique.

CCET’s Shana Caprorossi, monitors and records Jenkins’ real-time progress inside the program’s audio/video room.

ICM II students must perform an eight minute videotaped interview with a standardized patient. Small-group preceptors observe and critique each student from an enclosed viewing area.

Following the interview, the preceptors meet with the student to provide immediate feedback on their performance. Students take the videotape home and complete a self-critique which accounts for 20 percent of the program grade.

“We’ve received nothing but positive feedback on the program,” Thiedke said.

“Over time, I’ve seen some unbelievable improvement in students on their patient presentations and communicative abilities.

The interviews are solid and polished, confirming my thoughts that the students have really got it.”

Standardized patients test the art of medicine

Third-year medical student Aneita Rashford examines a standardized patient.

The use of standardized patients — that is, healthy persons trained to simulate sick ones — in the licensing process for physicians is one step closer to becoming a reality.

After evaluating data collected in the Standardized Patient Research Project, last month the Executive Board of the National Board of Medical Examiners (NBME) gave the go ahead to begin the incorporation of standardized patients.

Fourth-year medical students in the year 2001 likely will become the first to be responsible for successfully completing Step II A and Step II before receiving licensure.

While traditional board examinations test students’ knowledge and reasoning ability, an exam using standardized patients tests “the art of medicine,” according to Victor Del Bene, M.D., associate dean for students. “Step II A will evaluate the other incredibly important dimension of medicine — the ability to interact with and educate the patient.”

The MUSC Center for Clinical Evaluation and Teaching (CCET) is one of 36 testing sites nationwide collecting data on the use of standardized patients. Participation in the project is a natural extension of the center’s role at MUSC.

The center already trains standardized patients for MUSC student evaluations based on cases created by MUSC professors. These tests deal with specific skills in particular areas such as physical diagnosis, surgery or medicine. The NBME test will examine a more global range of skills.

“Standardized patients for the NBME project are designed to test students’ expertise as generalists by incorporating elements required in many different clinical disciplines,” Del Bene said.

Because of the high-stakes nature of board exams, the training process NBME standardized patients must undergo is much more intensive than the preparation of MUSC standardized patients.

“Training for ‘standardization’ is comprehensive and rigorous,” said CCET interim director Imogene Smith, EdD. Each NBME patient case is detailed in a comprehensive training manual including videotapes that model the “ideal” patient demeanor. NBME patient cases have been developed during the past 10 years through the course of the Standardized Patient Project. All training materials are kept strictly confidential.

Since July 1998, when she joined the CCET staff as a full-time patient trainer, Maura Carey has trained eight patients for four NBME standardized patient cases (two patients per case). Standardized patients must learn the case’s current medical history, symptoms that the condition would cause them to possess, medications, past medical history, prior illness and family history.

They must also know the occupation, education and personal habits, such as taking vitamins, smoking or drinking, of the person detailed in the case. Standardized patients are not just actors for the examination; they are also trained to record what happens during the encounter.

Carey works closely with patients to prepare them for the different kinds of student-physician personalities they may encounter.

“To ensure quality control, representatives from the NBME work with trainers at different test sites,” Smith said. “ A standardized patient at MUSC must represent the 'sick' patient and evaluate students in the same fashion as a standardized patient for the same case in another part of the country.”

To determine the effectiveness and realistic portrayal of the patient case, two groups of MUSC residents recently evaluated the standardized patients for consistency. And on April 1, 10 third and fourth-year students participated in a mock NBME exam with the patients, similar to the structure of Step II A.

Ultimately, students taking the exam will see between six and 12 patients, spending 15 minutes with each patient. Each interaction will be recorded on video to be reviewed if questions arise.

Results of MUSC’s evaluation by the NBME will determine the CCET’s progress to the next phase, where additional standardized patients will be trained. Eventually, Carey said, the CCET hopes to become an NBME testing site for medical students in South Carolina and beyond.

“Our participation in the Standardized Patient Research Project has allowed us to tap into the knowledge and expertise of NBME,” Del Bene said. “It’s a great resource for further developing our own standardized patients.”

Clinical Practice Exam to identify physician strengths, weaknesses

Beginning this summer, fourth-year medical students will take yet another exam—but not for a grade.

The Clinical Practice Exam (CPX), is designed to identify students’ strengths and weaknesses as physicians. It anticipates the use of standardized patients in the USMLE Step II A exam, also known as “the Boards.”

During the last week in July and the first week in August, each student will see eight patients, spending 15 minutes with each patient.

“The experience will be similar to what a physician would encounter in a clinic environment during their first year of residency training,” said Imogene Smith, EdD., interim director, Center for Clinical Evaluation and Teaching. Their performance on the CPX will help students determine what they need to focus on in their final year of medical school.

“It’s not an exam to penalize, but to eventually provide students with a ‘prescription’ of strengths and weaknesses. The fourth year is a perfect time to ‘shore up’ weaknesses before licensure and specialty residency training,” Smith said.

“The CPX will be very beneficial to students—the more you are exposed to this type of format the better you are prepared for it,” said Aneita Rashford, a third year medical student.

Victor Del Bene, M.D., associate dean for students, plans to recruit faculty mentors for students who need to improve their skills in certain areas.

Continuing Medical Education

Conferences:

May

21—23 Advanced Endoscopy Update Wild Dunes Resort This conference is designed for gastroenterologists/surgeons already performing endoscopy techniques, as well as GI nursing and technical staff.

27—29 New Drug Update Sheraton Hotel Recent developments in the pharmacotherapy of common problems in primary care will be discussed.

28—31 Medicine in the Vocal Arts Westin Francis Marion Hotel This course is designed for otolaryngologists, speech pathologists and vocal professionals who wish to further their understanding of vocal mechanisms and voice disorders.

May 31—June 1 The Art of Donor Oocytes Charleston Place Hotel This symposium will focus on the technology of ooctye donation in assisted reproductive technology.

June

June 2—5 Cardiology Update for the Primary Physician Charleston Place Hotel The intent of this conference is to bring the most recent advances in cardiovascular disease to the primary physician.

2—5 Orthopedics at Spoleto Mills House Hotel This conference will assist orthopedic surgeons in meeting daily challenges by presenting important key surgical tips and clinical results of primary and revision knee arthroplasty.

7—12 Intensive Review in Family Medicine Kiawah Island Resort Common problems in family medicine and practical approaches to prevention, evaluation and treatment will be reviewed.

For more information on Continuing Medical Education conferences call 876-1925.

Teaching tips

TO HELP LEARNERS build knowledge, encourage them to relate what they are learning to what they already know. For example, you might ask, “Does this patient’s condition remind you of anything you’ve encountered before?” If it does, you can help the learners consider the similarities and differences.

THINK OF USING metaphors while teaching — these help increase students’ understanding and memory of key concepts.

Don't miss this

Upcoming Meetings:

May 7 is the submission deadline for the 1999 Annual AAMC Meeting Group on Educational Affairs Small-Group Discussion Proposals and Mini-Workshop Proposals. For information about submission, visit the AAMC home page at <www.aamc.org>.

June 7 is the submission deadline for the Innovations in Medical Education (IME) exhibit, a part of the 1999 Annual AAMC Meeting on Education Affairs. IME exhibits will highlight innovative ideas in medical education, from instructional design and evaluation of basic science courses to community-based health promotion/disease prevention programs. For more information, visit the AAMC home page at <www.aamc.org>.

If you have an event you would like to see included in Don’t Miss This, please fax it to Kristen Karig at 792-6723, send via e-mail to karigkd@musc.edu, or send via campus mail to Office of Public Relations, attn: Kristen Karig, room 106 Admin. Bldg.

Graduate Medical Education

The Internal Review Committee will be conducting the following Internal Reviews: May—Family Medicine

June—OB/GYN, Pathology and Forensic Pathology.

Committee members are: Jeanne Hill, M.D., program director for radiology; Kerri Kolehma, M.D., PM&R resident; Mark Lyles, M.D., internal medicine; Clay Nichols, M.D., program director for pathology; Franklin Medio, Ph.D., director of Graduate Medical Education; Toya Pound, M.D., OB/GYN resident; and Elizabeth Rittenberg, M.D., PM&R faculty.

The committee has completed 10 reviews since its inception in January 1999.