This module on interviewing patients about sensitive subjects is geared toward first- or second-year medical students who have had prerequisite training in taking a basic medical history and in general communication skills such as active listening, paraphrasing, etc. Thus, this module can be used as part of a course about medical interviewing and communication skills or as a stand-alone module. if students have received adequate prerequisite instruction in basic medical interviewing, communication skills, and history-taking. Although the content and specific screening questions are different for each of the three sensitive topic areas included in this module, the communication techniques for decreasing patient anxiety and resistance and for improving the reliability of patient self-report are very similar regardless of the nature of the sensitive topic. In addition to the three sensitive topic areas included in this module, these communication techniques are effective for broaching most sensitive topics (e.g., suicidal ideation). The format for this product is: (a) a 1.5 hour interactive lecture using PowerPoint slides, and (b) a 2-hour clinical skills practice session using standardized patients (SPs), although time may vary depending upon the class size, number of SPs, or other logistical considerations unique to individual institutions and settings. There is also the option of using peer role-play in place of SP's if such resources are not available. Although the format noted above describes the manner in which this product was delivered by the author, materials can be delivered in many potential permutations relative to logistical factors, educational preferences (e.g., dividing the lecture in shorter sessions focused on practice of selected skill sets), and/or educational objectives.
This module was piloted using 63, 64 and 65 first-year medical students during the first 8 weeks of the first year during the 2008-09, 2009-10 and 2010-11 academic years, respectfully. Students attended a 1.5-hour lecture focused on talking to patients about sensitive topics, which also included video demonstrations and embedded interactive quizzes.* Students then participated in faculty-facilitated, small groups in which they conducted medical interviews with standardized patients (SPs). Specifically, students in each group took turns interviewing the SPs, with each interview lasting 20 to 30 minutes and consisting of a complete medical history that also included the screenings and specific communication techniques articulated in this module. (Students had previous instruction and practice taking a basic medical history and using basic interviewing and communication skills.)
Following the interview, each interviewer provided a verbal self-evaluation. The interviewer received verbal feedback from the SP, peers, and faculty facilitator, and received written feedback from peers and the faculty facilitator using the Medical Interviewing Checklist (included in this resource).
Preliminary Results of the Pilot:
Students were able to learn and effectively apply communication techniques and screening protocols articulated in this learning module.
Students felt the quizzes embedded in the lecture greatly facilitated their learning for these techniques.
After the first year, the course developer felt that more faculty development was needed for this specialized topic area in preparing them to facilitate the small groups--a brief 30 minute faculty development session articulating the specific objectives and techniques would likely be sufficient. We added this component and it was helpful in standardizing the experience across the small group interviewing activities as well as in coaching students and providing feedback to them following the individual interviews with SPs.
After the first iteration, we found that students needed additional emphasis placed on and reminders about the importance of how to ask questions (the wording and sequence) and not just the fact that they needed to ask about the topic areas. We included reminders for this in the lecturer guide that accompanies the lecture presentation.
Students did well with use of communication techniques for decreasing patient (and physician/provider) anxiety. We have found that students are able to generalize these concepts and techniques to many situations outside of this context, such as for giving bad news or talking to patients who are anxious in general.
Students and SPs indicated there was, perhaps, some overuse of “preparatory statements,” which seemed unnatural at times. However, the statements were necessary to emphasize the use of many different approaches for decreasing patient anxiety. After the first iteration, students were told to "consider" using preparatory statements if they felt their own anxiety increasing or if they felt the patient may feel anxious to discuss certain topics. This seemed to work very well and students continued judicious use of these techniques.
Course developer felt this module might be better placed later in the year, with the first part of the year focusing on basic interviewing skills. In our curriculum, we have made this modification and this has worked well.
Students all passed a detailed clinical skills exam at the end of the block that included the skills covered in this training module on sensitive topics. Students were observed and graded conducting a medical history that included these topics by medical school faculty.
The current product reflects an integration of the valuable student and faculty feedback gleaned from this pilot study.
* An early piloted module included a video demonstration of screening for IPV, alcohol, and drugs and a demonstration of talking to patients about sexual practices and concerns. We hope to revise and add this component in the future so students can observe skilled faculty utilizing these techniques. The video's used in the original iteration of this product are currently under revision and not available at this time.
- To learn communication techniques that decrease patient and physician anxiety and increase the accuracy and specificity of patient self-report about sensitive topics.
- To learn basic screening protocols for assessing alcohol/drug use, intimate partner violence, and sexual practices and concerns.
- To identify and demonstrate understanding of factors that affect the reliability and specificity of patient self-report when asked about sensitive topics.
- To identify, practice, and demonstrate understanding of specific communication techniques that increase the reliability and specificity of patient self-report when discussing sensitive topics.
- To practice and demonstrate understanding of brief, basic, evidence-informed screening protocols for assessing alcohol and drug use/abuse, intimate partner violence, and sexual practices that can be easily integrated into a routine medical history.
None to report.
This project was completed as part of a consortium of medical schools funded by NIDA as Centers of Excellence in Substance Abuse Education.
McBride RB, Christianson CE. Primary care and substance abuse: a model for teaching screening, brief intervention, and continuity of care. Paper presented at: Association for Behavioral Sciences and Medical Education; October 2009; Santa Fe, NM.
McBride RB, Christianson CE. Primary care and substance abuse: a model for teaching screening, treatment and continuity of care. Discussion session presented at; The Society of Teachers of Family Medicine 35th Annual Predoctoral Education Conference; January 2009; Savannah, GA.
Christianson CE, McBride RB. History of sensitive subjects. Invited presentation at the National Institute of Drug Abuse Center of Excellence Physicians Outreach Meeting; February 2009; Bethesda, MD.
Christianson CE, McBride RB, Vari R. Teaching primary care management of substance abuse: A new egg in the “basket of services.” Seminar Session presented at: Society of Teachers of Family Medicine Conference on Families and Health; February 2008; New Orleans, LA.
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