Engaging patients as teachers of clinical interview skills

Abstract

Aims and Method

To engage patients as teachers of psychiatrists in training and non-consultant career grades, for the purpose of enhancing doctors' understanding of the patient point of view and of the complexity of the doctor–patient relationship. Patients have been engaged as teachers in a recurrent cycle of ‘Basic Interview Skills' workshops and the views of the doctors about this initiative have been elicited through a brief anonymous and confidential questionnaire.

Results

Thirty-six psychiatric senior house officers (SHOs), general practitioners, Vocational Training Scheme SHOs in psychiatry, and staff grade and trust doctors in psychiatry have participated in four cycles of workshops. Five patients have engaged in the workshops as teachers, alongside the clinical tutor. Questionnaire feedback indicated some specific criticisms of a number of participants and dissatisfaction by a small minority of doctors, but the overall evaluation of the experience was positive.

Clinical Implications

Engagement of patients as teachers of psychiatrists in training and other new doctors in mental health services is desirable, feasible and welcomed by most doctors. With due attention to the legitimate sensitivities of participants, the practice of engaging patients as teachers of doctors working in psychiatry could be generalised in training schemes and services across the country.

The Royal College of Psychiatrists first published ‘Guidelines for Psychotherapy Training as Part of General Professional Psychiatric Training’ 10 years ago (Grant et al, 1993).

First year objectives of training include the following:

1. • the ability to interview the patient in a manner that elicits the required information

2. • to be aware of and describe the importance of non-verbal communications from the point of view of the patient

3. • to understand the various ways in which the patients may view their illness

4. • to understand and practice the principles of supportive counselling

5. • to be aware of the complexities of the doctor-patient relationship

The local psychiatric education committee in Barnet Mental Health Services, north London, considered it appropriate to engage patients as experts in teaching doctors to understand the point of view of patients with mental illnesses and develop empathic skills.

The idea of learning from the patient is one that has been around for some years (Casement, 1985). Indeed, the NHS Executive Mental Health Task Force User Group (1994) published a ‘training pack for mental health service users working as trainers, speakers and workshop facilitators’. The Mental Health Foundation (2000) has developed a user-led research programme around the idea of the ‘patient as expert’. The Department of Health (2001) has recently launched the ‘expert patients programme’ in recognition of the knowledge that people with chronic disease have to contribute to disease management.

This paper reports on the engagement of patients from a local mental health services users’ group, ‘Barnet Voice for Mental Health’, in delivering some of the first year objectives through a basic clinical interview skills workshop. The participants’ evaluation of this training experience is also presented. The teaching of communication skills to doctors is widely reported (Maguire, 1990; Novack et al, 1992; Benbassat & Baumal, 2001) and the use of ‘patients as teachers’ is growing (Kelly & Wykurtz, 1998; Skog et al, 2000). The literature on the ‘involvement of users and carers in the training of psychiatrists’ (Crawford & Davis, 1998), however, is extremely limited.

Method

In response to the College guidelines, the clinical tutor set up a weekly workshop on ‘Basic Clinical Interview Skills’ in 1993. All new trainees in the Charing Cross General Professional Training Scheme in Psychiatry (Northern Sector) are expected to attend regularly, on a weekly basis, during the first 6 months of their training. The duration of each session is 1.5 hours, and this time is protected from clinical duties. Attendance is also open to Vocational Training Scheme (VTS) trainees and new staff grade and trust doctors within Barnet Mental Health Services who, after discussion with their clinical supervisor or consultant, consider that they might benefit from such an experience.

The cycle of workshops is repeated every 6 months. Four workshop leaders deliver training in a number of broad areas, namely basic interview skills, elementary psychodynamic concepts, interviewing in groups or with families and cultural considerations in the psychiatric interview. This paper focuses on only some of the basic interview skills sessions conducted by the clinical tutor (myself). These constitute approximately 60% of the total number of workshops.

Topics covered in the tutor's workshops include the ‘Three Function Model of the Medical Interview’ (Bird & Cohen-Cole, 1990), assumptions prior to the interview, expectations and feelings prior to the interview, getting the interview started, moving on and terminating the interview. Seminar-type sessions are complemented by sessions where opportunities for role-play are offered.

Representatives of Barnet Voice have contributed to basic interview skills sessions since 1999. They contribute to approximately two-thirds of the sessions conducted by the tutor and take the leading role in the second and third sessions. In the second session, trainees are invited to consider what expectations their patients might have of them in view of their professional status. This is achieved through inviting the trainees to reflect on what they might expect themselves from a visit to another professional (e.g. bank manager). In the third session, the Barnet Voice representatives invite the trainees to imagine the feelings of patients as they approach a psychiatric interview. They also invite them to reflect on their own feelings and how they might affect their conduct in the interview.

Barnet Voice representatives make an active contribution to other sessions through observations and comments in discussion and role-play. The tutor asks them not to take part in the role-play themselves, but contribute their thoughts on the role-play that the trainees and tutor have participated in. Their experience as witnesses and potential contribution as expert patients is emphasised. A total of five different Barnet Voice individuals, working in pairs, have contributed.

Evaluation

Participating doctors were informed that this was a new initiative that would later be evaluated. Thirty-four junior doctors, who participated in four different cycles of workshops during the years 1999-2001, were paired to evaluate their experiences through confidential questionnaires. They consist of 24 psychiatric trainees, six Vocational Training Scheme trainees and four staff grade/trust doctors. Twenty-six of the 34 doctors returned completed questionnaires. None of the doctors repeated the workshop cycle. For reasons of confidentiality, it is not possible to distinguish between the different groups of doctors in terms of responses.

Evaluation was achieved through a simple questionnaire. The respondents were asked to give an overall rating of their experience of being taught or trained by Barnet Voice representatives. They were also asked to answer, in print, three specific questions (see below). The total length of the questionnaire was one side of an A4 sheet of paper.

On a scale of 10 to 1, where 10 is ‘excellent’ and 1 is ‘terrible’, the modal response was 8. Eighteen out of the 26 respondents rated the quality of these workshops at 9 or 8. Four trainees gave scores of 7 or 6. Three trainees gave a score of 5 and one a score of 3.

Workshop participants were asked the following questions:

1. • What have you found helpful about the patient/user involvement in clinical interview skills training?

2. • How can patient/user involvement in clinical interview skills be improved?

3. • What have you found unhelpful about patient/user involvement in clinical interview skills training?

In response to the question ‘what have you found helpful about the patient/user involvement in clinical interview skills training?’, they indicated that they found patients had a genuinely different perspective to contribute. They found it helpful to hear about this perspective directly from them. They also indicated that patients were able to give vivid messages about their concerns, and to impress trainees and other doctors with the fact that they have active memories of their treatment while psychotic. They indicated that it helped them to develop empathy and realise that patients are able to play an active role in indicating choices and contributing to decision-making. In short, participants appear to have appreciated the vivid exposition of patient experiences, memories and points of view.

In response to the question ‘how can patient/user involvement in clinical interview skills be improved?’, trainees indicated that they would have welcomed the involvement of a greater number of patients as they believed this would have given them a greater range of experience and opinion. A number indicated that they would have liked the patients to take a direct part in the role-play. There was also a suggestion that current, acutely ill in-patients on the wards might be invited to contribute to the workshop. In summary, participants appear anxious to ensure that the input they receive is broadly representative of the diverse experiences and preferences that different patients have.

Perhaps of most interest to the reader might be the answers to the question ‘what have you found unhelpful about patient/user involvement in clinical interview skills training?’ One participant answered pointedly ‘Barnet Voice’. Another indicated that s/he found ‘overtly democratic values in the treatment process’ unhelpful. A third perceived ‘clashes between users and doctors’, while another complained that there was ‘the underlying feeling that the user attitudes and expectations are necessarily valid or reasonable in practical terms’. There were complaints that ‘the users’ representatives tended to forget that it was a training programme for students, emphasising their own agenda, spending more time than required over it’. Concern was expressed that ‘Barnet Voice patient participants [were] expressing personal experience unrelated to and of no relevance to patient involvement in interview skills, for example patient profiles and intimate personal details’. In summary, some participants appear to have perceived the ‘Barnet Voice’ contribution as threatening and insensitive to their own emotional needs.

Discussion

The present report has a number of limitations. The responses from different grades of doctors participating in the workshop have not been distinguished in the analysis. No control group has been used. There are no prospectively collected data on the impact of the present training on the psychiatrists’ clinical practice. Participants state that their experience has helped them understand the patient point of view better, but would objective evaluation support this? A more extensive study would be needed to address such issues, but anecdotal feedback both from participants and colleagues suggests it is likely be the case that the workshops are having a favourable impact on daily practice.

Another limitation is that I have acted in multiple capacities in relation to the participants. I have acted as workshop leader/teacher, clinical tutor/assessor with responsibility for recommending suitability for the MRCPsych examination and as evaluator of the workshop itself. Obviously, this raises concerns about the reliability and validity of the data. Although an attempt was made to ensure honest responses through ensuring confidentiality of the feedback, it is possible that respondents did not honestly report their opinions.

The above limitations notwithstanding, it appears both desirable and possible to engage patients/users as teachers in clinical interview skills training in psychiatry. Their engagement might assist in achieving some of the first year objectives of the psychotherapy training guidelines of the Royal College of Psychiatrists. There is increasing emphasis on ‘engaging patients in medical decision-making’ (Crawford & Davis, 1998; Kravitz & Melnikow, 2001), and it is hoped that engaging patients in teaching psychiatrists in the early stages of their training or working in services will enhance their preparation for such practice. Recent developments in this area are congruent with the objectives set out in the College Psychotherapy Training Guidelines (Grant et al, 1993). Barnet Voice members consistently express positive regard about the present initiative and consider it to be a flagship project among their activities.

Our findings, that patients may successfully contribute to interview skills training of psychiatrists, complement and extend the findings of Crawford and Davis (1998) that patients can successfully contribute to psychiatric training through lecturing on an MRCPsych course. Present findings seem to go further, in that they refer to experiential learning beyond simple instruction through lectures.

Despite the overall positive evaluation of this initiative, a number of trainees have expressed significant reservations and criticisms. The objection to overtly democratic values is a case in point. Another example is one trainee's comment about ‘clashes between users and doctors’. Similar concerns are highlighted in the paper by Crawford and Davis (1998), which refers to discussions at the Patients and Carers Liaison Group of the Royal College of Psychiatrists, although they considered such concerns ‘misplaced’.

I recognise the difficulties of dealing with trainees’ feelings and am available to be consulted outside of workshop sessions. A small number of workshop participants have made use of such availability. In addition, I, in my role as coordinating tutor/programme director, review the trainees’ experience in face-to-face reviews of progress towards the end of the their training placement in their current post and, usually, also towards the end of their next training post.

I accept that if it was the case that patients made inappropriate remarks, it is my responsibility as workshop leader to address relevant concerns, both inside and outside the workshop group situation. My group psychotherapy and teaching in medicine training has alerted me to such issues. Where appropriate, such criticisms recorded by the participants have been taken on board. For example, the rationale for including Barnet Voice representatives in the workshop is made explicit during the first workshop session. Special emphasis is given to ensuring that trainees understand that the presence of Barnet Voice representatives in training is not intended to highlight criticism of the medical profession in general or the workshop participants in particular. Emphasis is laid on using these witnesses to help prepare for future practice rather than examine other doctors’ or mental health professionals’ past practice.

The results of the feedback questionnaires are made fully available to Barnet Voice participants. The workshop participants understand that this is necessary in order to modify and fine-tune the experience for future work-shops. The purpose of making feedback available is to assist Barnet Voice in being able to phrase their interventions in a way that is most effective in influencing the attitude and behaviour of the doctors and enhancing their future relationships with their patients. As a result of feedback from a number of workshop participants, Barnet Voice have advocated that they directly take in role-play, and this is currently being tried out.

Trainees (and other colleagues) may be sensitive to the developments proposed in this paper and it is important to emphasise explicitly that the intention is not to criticise but to improve practice.

Finally, Skog (2000) have suggested that older people with dementia may act as ‘teachers’ to nurses specialising in dementia care, through a year-long attachment of the nurse to an individual patient. Such initiatives may also be appropriate to the training of psychiatrists but are beyond the scope of this paper.