Kraan, H. F., Crijnen, A. A. M., & Zuidweg, J. (1986). Physicians’ interviewing skills in Primary Health Care: relevance and effects of training programs. In G. J. Visser, J. M. Bensing, B. P. R. Gersons, B. Maoz, & C. Z. Margolis (Eds.), Mental Health and Primary Care – Dutch and Israeli experience (pp. 125–143). NIVEL, Netherlands Institute of Primary Health Care.
The importance of the physicians’ interviewing skills in primary mental health care is underscored by the pivotal role of the physicians’ interviewing skills for diagnosing and treating minor psychiatric syndromes, and the need felt by physicians to improve the communication with their patients. Guidelines for the design of training programs for interviewing skills pertaining to primary mental health care were yielded from our review on how to teach interviewing skills and our study of students’ and residents’ development of skills over the residency program. Evaluation studies showed deficits in the interviewing skills of students/physicians, providing further guidelines to determine the content of the training programs.
In 1869 Tolstoy wrote in his great novel ‘War and Peace’ that the societal function of physicians was not dependent on making the patient swallow substances. In Tolstoy’s opinion, physicians were, however, indispensable and necessary, because they satisfied ‘a mental need for the invalids and for those, who loved them’.
According to Tolstoy, physicians satisfy a mental need for the invalids and for those who loved them
More than hundred years later we still recognize this kind of ’care—giving’ as an important role of the physician. In Tolstoy’s statement the dilemma between the humanistic, holistic versus the reductionistic technological approaches in medicine is also discernible. The conflicting relationship between both approaches, often described as the art and the science of medicine, have not altered much over years, notwithstanding the tremendous growth of knowledge that has taken place, especially in medical technology.
Tolstoy’s ‘satisfying a mental need for the invalid’ – for long considered an art – has also been drastically changed by the scientific development in behavioral medicine and psychiatry. The increased knowledge caused considerable replacement of artistry and craftsmanship in the ‘care—giving’ professions by social technology (DiMatteo and DiNicola, 1982). The ‘mental needs’ of Tolstoy’s days would probably nowadays be called somato-psychic problems and minor psychiatric syndromes, like depression, anxiety and psychosomatics.
Not only the patient, but also the care-giver himself has been subject of study over the last twenty years, often with the aim of improving his competence. According to Fabb and Marshall (1983) different psychological properties or skills are to be discerned that make up together the physician’s competence. In addition to his attitudes towards patients and his own professional role, the possession of knowledge, medical interviewing skills, perceptual and interpretative skills and problem solving skills are considered as discernible dimensions of medical competence. This theoretical distinction makes sense because these competence aspects require their own educational and evaluative approaches.
In this article, we focus on one aspect of competence necessary in Tolstoy’s ‘satisfying a mental need for the invalid’: the physicians’ interviewing skills in primary mental health care. Medical interviewing skills are, according to Schouten et al. (1982), defined as the physicians’ skills, needed in order to exchange information with the patient about diagnosis and treatment.
- First, we justify the choice of this competence aspect.
- Next we examine guidelines for the design of training programs, taking the present program in the Maastricht Medical School as an example.
- Finally, we turn to the evaluation of training programs in medical interviewing skills.
Physician-patient communication plays a major role in primary health care. Several arguments in support of this statement can be found in the literature.
In epidemiological studies, it is found that the prevalence of ‘minor psychiatric syndromes’ is high (20-25%) (Goldberg and Huxley, 1980; Shepherd et al. , 1982). These ‘minor psychiatric syndromes’ encompass mainly depressive, anxiety-related and psychosomatic symptomatology, often in combination with somatic complaints. Although spontaneous remission is also high, 10-25% of these ‘minor cases’ seem to become more seriously or chronically disabling. Johnstone and Goldberg (1976) have shown, that early detection and treatment of ‘minor cases’ result in relief of symptom and psychological pain, without ‘medicalizing’ the illness and with probable cost benefits.
Early detection and treatment of Minor Psychiatric Disorder results in relief of symptoms and psychological pain, without medicalizing the illness
However, in other studies (Goldberg and Huxley, 1980; Goldberg and Blackwell, 1970) it is shown that about 30% of these patients with ‘minor psychiatric syndromes’ are not detected. Golberg et al. (1982) repeatedly found in studies with family practice residents, that their ability to make accurate ratings of psychiatric symptoms (‘detection of cases’) is partly determined by interviewing style, and partly by certain personality attributes. Self-confident, extroverted physicians, aware of their feelings and with high academic ability, tend to make more accurate assessments. In respect of the interviewing style of the physicians it appeared that a more accurate assessment of psychiatric symptoms is achieved by means of directive psychiatric questioning, supportive comments, exploration of social background, sensitivity to nonverbal cues and maintaining eye contact.
For a more accurate detection of psychiatric disorder, general practitioners’ interviewing skills are of paramount importance
In addition to the epidemiological figures of these minor syndromes and the role of the physicians’ interviewing skills in detection and diagnosis, there is another argument for the importance of medical interviewing skills. According to a study of Shepherd and Clare (1982), only 84 of 1530 patients with ‘minor psychiatric syndromes’ were referred to a psychiatric outpatient department and only 47 were admitted. These figures imply that the majority of these patients receive cure and care by their general practitioners. Irrespective of the kind of treatment provided, it is evident that the general practitioners’ interviewing skills are of paramount importance for treatment.
Medical interviewing skills are the basic clinical method in both general practice and psychiatry (Pendleton et al., 1984). Studies have shown the positive halo-effect of adequate interviewing upon other aspects of medical competence in these disciplines:
- Several authors (Goldberg et al., 1982; Elstein et al., 1978; Rutter and Cox, 1981; Giel, 1982) suggest, often on empirical grounds, that the physicians’ interviewing skills determine accurate data collection from the patient and therefore contribute to attaining a more accurate diagnosis.
- Since 1975, Eisenthal, Lazare and coworkers study the use of the so called negotiated approach in initial psychiatric interviews. In this type of consultation, several subjects are negotiable: the problem definition, treatment goals, methods, conditions and so on.
- The negotiated encounter in (primary) mental health care was already proposed by Adolf Meyer in the twenties. Later it was described by Balint (1976), Levinson et al. (1967), Scheff (1968) and others as the most effective consultation model in mental health care.
- Eisenthal et al. (1983) reported two significant antecedents of patient satisfaction as a measure of outcome: the perception of being understood by the other and the participation in the treatment decisions. They showed that both antecedents were largely determined by the physician’s interviewing skills. The study shows the central role of the interviewing skills in the negotiation consultation model.
Physicians’ satisfaction has been shown to be a positive factor in the quality of care provided (Pendleton and Hasler, 1983). A physician interested in psychiatric and psychosocial issues may feel a need to improve his interviewing skills. Training in interviewing skills is a valuable investment of time, when we remember that general practitioners treat the majority of patients with minor psychiatric syndromes themselves. For physicians treating these patients, the ‘general psychotherapy’ of Frank (1975) or the counseling models of Ivey (1983), based on rather ‘simple’ interviewing skills, will be of value (for more information we refer to the literature cited).
General practitioners treat the majority of patients with minor psychiatric syndromes themselves
However, many physicians suffer from low satisfaction in their work, because of communication problems with their patients. A striking example is the phenomenon of ‘somatic fixation’, caused by an unbalanced communication pattern, in which the physician pays too much attention to the somatic aspects of the problem neglecting the psychosocial aspects. These problems often have their roots in deficiencies in the physician’s interviewing skills (Grol et al., 1981).
In somatic fixation, caused by an unbalanced communication pattern, a physician pays too much attention to the somatic aspects of the problem neglecting the psychosocial aspects
Moreover several medical educators have pointed to ‘countertransference’, that is broadly defined as feelings about the patient, that are incompletely recognized and disturb the physician-patient communication (Ekstein and Wallerstein, 1972; Engel, 1977). Some authors consider it as a common phenomenon in physicians (Balint, 1976; Platt et al., 1979), but no data obtained systematically are available on this subject. In a small sample study, Smith (1984) attributed the following interviewing behaviors to countertransference: avoiding certain topics (e.g. suicidal thoughts, loneliness), controlling the patient (changing subjects, inappropriately interrupting, etc.), attempts to be pleasing, detachment (avoiding to relate with the patient about emotional topics), etc. Besides these overt behaviours, he found on the emotional level indirect evidence for countertransference as fear of causing harm, fear of affect, feelings of inadequacy, strict biomedical orientation, over-identification with the patient.
From these arguments it not only becomes clear, that deficiencies in interviewing skills play an important role in these difficulties, but also that interviewing skills ought to be taught in conjunction with the elaboration of emotional issues.
In the literature, the adequacy of medical interviewing is correlated with several measures of the ‘immediate outcome of care’:
- Patients’ increased recall of information, provided by the physician on the diagnosis of the problems presented and the rationale of the further management plan (Ley, 1983);
- Increased ‘patient satisfaction’ (a.o. Lebov, 1974). This rather vague variable has been found to be an important intermediate variable for patients’ adherence to advice (Freeman et al., 1971; Ley, 1983; wolf et al., 1978);
- Our own research (Crijnen et al., 1986) has revealed that several dimensions can be discerned in this variable of ‘patient satisfaction’. It was shown that ‘patient satisfaction’ was determined by increased cognitive and emotional insight and by the physician’s facilitation of emotional expression in the patient.
These data underscore the significance of the relation between the physicians’ interviewing skills and immediate outcome of care.
The Dutch Government adheres to a policy assigning the general practitioner a central position in the prevention, cure and care of ‘non-serious’ psychiatric problems (Nota Geestelijke Volksgezondheid, 1984). This type of health care requires more extensive training of the general practitioners’ diagnostic interviewing and skills in counseling and in supportive care.
In an extensive review of the literature, Carrol and Monroe (1980) selected the effective ingredients in training programs for medical interviewing. They formulated recommendations for the design of training programs based on their findings.
These guidelines, which we follow in this section, are:
- Explicit (behavioural) statements of the interviewing skills to be taught;
- A structured teaching program, encompassing the skills to be taught;
- Ddirect individualized feedback;
- Standardized presentation of illustrative, protocolar patient interviews;
- Continuity of training.
Moreover, we add two other guidelines, originating from the experiences of the Maastricht training programs in medical interviewing:
- Integrative teaching of cognitive, behavioural and emotional elements of medical interviewing;
- And the close link between teaching and evaluation.
These seven guidelines for teaching programs will be discussed
The design of instructional programs should include explicit statements of the interviewing skills to be learned and evaluated. At the Maastricht Medical School, the teaching program uses a taxonomy of interviewing skills in primary mental health care. This taxonomy may serve as an overview of interviewing skills, relevant to initial interviews in primary mental health care. Moreover, based on it, an evaluation instrument has been constructed: the Maastricht History-taking and Advice Checklist MAAS-MI General and Mental Health.
The taxonomy consists of seven parts of which the first five contain skills pertaining to process and content of the different phases in those interviews. The last two parts deal with process skills. We give an overview of these seven parts, accompanied by a few examples of interviewing skills (for the complete taxonomy we refer to the appendix).
Exploring Reasons for Encounter
This is the patient-centered phase of the interview. By means of mainly open-ended questions, good listening and other active, facilitative behaviour, the physician collects information about the problems and symptoms from the viewpoint of the patient: emotional impact of the problem, causal attributions, attempted solutions, reactions from the patients’ primary group and so on. The result of this phase ought to be a statement by the patient about the help he desires from the physician.
The skills in this part of the checklist are derived from the work of Schouten et al. (1982), Byrne and Long (1976) and Pendleton et al. (1984).
Examples of items:
- Asks the patient why (s)he presents this problem at this particular moment.
- Asks the patient to give her/his opinion about the causes of the problem.
History-taking
During this phase the physician has to make an in-depth exploration of the main problem(s) within a psychiatric frame of reference. This exploration pertains to factors which aggravate or alleviate the problems/symptoms, history of the symptoms, previous treatment, relationship between somatic complaints and psychosocial problems, and so on.
The skills grouped in this part of the taxonomy stem from the work of Schouten et al. (1982) and MacKinnon et al. (1971).
Examples of items:
- Explores somatic aspects in the mental health problem
- Explores which factors decrease and/or eliminate the complaint/problem.
Psychiatric examination
In this phase of the interview the physician deals with the systematic exploration of symptoms and impairment in function accompanying psychiatric disorders which are important to primary care, like affective disorders, anxiety disorders, psychosomatic and somato-psychic disorders, substance abuse and psychoorganic syndromes, etc.
The skills in this part of the taxonomy come from the work of Goldberg et al. (1982) and Giel (1982).
Examples of items:
- Examines symptoms of affective disorders:
- disturbances in mood and affect
- biological features
- disturbances of thought
- suicidal ideation and behaviour
– Examines disturbances in memory:
- immediate recall
- recent (short-term) memory
- remote memory.
Socio-emotional exploration
This phase deals with the exploration of a broad domain of social and interpersonal functioning, professional functioning, family life, sexual functioning, traumatic events during childhood, developmental issues.
The skills in this part of the taxonomy are derived from several primary care oriented diagnostic classification systems of mental health problems, compiled in a review by Lipkin and Kupka (1982).
Examples of items:
- Asks for perspectives and aspirations in life.
- Asks for social support.
Presenting Solutions.
In this phase the physician is concerned with providing information about the problem presented (diagnosis, causal relations problems/symptoms, prognosis), negotiation about the problem definition and possible solutions, giving concrete advice (further exploration, treatment plan, referral). The skills pertain especially to the process and less to the content of the solution which is, of course, mainly determined by the character of the problem.
The skills in this part of the taxonomy stem from the work of Eisenthal et al. (1983), Stimson and Webb (1975), Ley (1983).
Examples of items:
- Asks the patient for his expectations about help.
- Checks if the patient has a different point of view on the problem definition and/or proposal for help and discusses any difference of opinion.
Structuring
This part of the taxonomy gives a summary of the physicians’ skills in structuring the phases of the interview: in announcing and closing a phase of the interview, in controlling the sequence and timing of the phases, in opening and in terminating the interview.
The skills described in this part of the taxonomy are to some extent discussed by Schouten et al. (1982).
Examples of items:
- Concludes the phase of Exploring Reasons for Encounter with a summary.
- Starts the phase of Presenting Solutions with information about diagnosis /problem definition.
Basic Interviewing Skills
Following Hess (1969), we make within these basic interviewing skills a theoretical distinction between Interpersonal Skills and Communicative Skills. Interpersonal skills refer to interviewing behaviour, which contributes to establishing patient rapport, trust and acceptance. They are important for patient compliance and satisfaction (Korsch et al., 1968; Hulke et el., 1976). These effects are attributed to several interviewing skills: showing empathy, warmth and concern, active listening, facilitative behaviour, instillation of positive expectations, selfdisclosure.
Communicative skills promote the information flow between physician and patient. These skills are related to structuring the interview (see above) and the use of appropriate techniques of questioning, providing information and giving advice.
Examples of items:
- Explores the patient’s feelings during the interview.
- Facilitates the communication with the patient.
According to this guideline the interviewing skills to be taught should be grouped in a teaching program with clear objectives. Several examples of thoroughly elaborated programs are encountered in the literature. Lipkin et.al. (1984) describes such a program for primary care internal medicine. It has four general objectives: patient-centered interviewing and treatment; biopsychosocial approach to clinical reasoning and patient care; personal development of humanistic values; psychosocial and psychiatric medicine. Each general objective is expressed in requirements of knowledge, skills and attitudes.
Another well-known program with a well-defined, hierarchical list of interviewing skills is the micro-counseling program of Ivey (1983). In this hierarchy ‘attendant behaviour’ (appropriate eye contact, attentive body language, following the patient’s topic of interest) and client observation skills should be mastered, before the student proceeds to the ‘basic listening sequence’ (open and closed questions, facilitation, paraphrasing, summarization and reflection of feelings). After attainment of a reasonable level in this skill, gradually more complex skills like reflection of meaning, focusing, influencing skills, confrontation, sequencing and structuring the interview and skill integration are learned. The necessity of mastering ‘easy’ before more complex skills, is the educational rationale and the ordering principle of this program.
Crucial variable in the design of interviewing programs is the provision for direct observation and feedback. Despite this platitude, it is nevertheless common in clinical teaching for interviewing students/residents not to be directly observed and commented on by their supervisor. In training programs feedback by video is a useful device, but the use of this technology may sometimes complicate the situation more than help it. During videotape replay students tend to pay a lot of attention to other aspects of the consultation, for instance problem-solving aspects, peculiarities of the case presented or their own physical appearance on the screen.
In their review, Carrol and Monroe (1980) conclude ‘that standardized presentations of patients may be more effective for teaching clinical interviewing then live, spontaneous demonstrations of patient interviews’. It seems likely that for demonstration purposes, recorded or edited interviews via film or videotape would be more efficient to illustrate certain skills than live, unrehearsed interviews. A ‘spontaneous’ interview may fail to exhibit expected interview behaviours, therefore a series of such demonstration interviews may exhibit only a limited range of relevant interviewing skills.
Programs of interview training should have continuity through curricula or post-graduate training. The reason for this stems from our knowledge about the ‘natural history of interviewing skills’. Several authors (Heifer, 1970; Scott et al., 1975) report on the development of the students’ interviewing skills, when no formal training is provided during the medical curriculum. These studies show a general pattern of an increasing directiveness in the interviewing style, yielding more factual, organic information. However, ‘human aspects’ receive increasingly less attention: students show a decreased tendency to use open-ended questions and to give reassurance, support and empathy less often. Consequently, it has become evident that training programs were needed to counteract these deteriorating tendencies in the interviewing style of students and physicians.
Proponents of ‘confluent education’ and ‘experiential learning’ (a.o. Rogers, 1957) stress integration of cognitive, behavioural and emotional (attitudinal) elements during learning processes. The attitude of the physician towards patients and their problems, determine to a large extent the interviewing skills. Nevertheless, some critical remarks should be made. Ajzen and Fishbein (1980) made an extensive study of the relationship between an individual’s attitude and his behaviour. They concluded that the prediction of an individual’s future behaviour (like interviewing skills) from his present attitudes has a low to moderate reliability. Situational factors (such as time restrictions, external pressures, unexpected incidents during the consultation hour) and the external norms (for instance, the influence of the belief that prestigious colleagues would or would not perform a certain behaviour) lower the degree to which behaviour is determined by attitudes.
Nevertheless in training programs attention should be paid to the physicians’ attitudes and other emotional aspects, like (minor) countertransference reactions. As stated in the introduction, the physicians’ attitude to caring has remained a basic condition in his profession.
Physicians’ attitude to caring has remained a basic condition in their profession
The ‘second stream education’ at the Maastricht Medical School may serve as an example of an integrated program for physician-patient communication in the broadest sense. This program, with a small group teaching format, runs parallel to the ‘main stream’ of the first four years ( the ‘thematic blocks’ of the curriculum).
It consists of four parts, integrated into one teaching program:
- Structured training courses in interviewing skills during the first four years of the curriculum. The skills are taught according to a hierarchy in complexity (like in Ivey’s micro-counselling method, mentioned earlier) and according to the students’ needs born in clinical situations. The teaching format is a highly structured program with use of videotapes, that show each skill separately and in context. The courses consist further of role playing and exercises with videotapes presenting ‘critical incidents’ in demonstration interviews.
- Interviews with simulated patients, where students may act as ’physician’ and as ‘critical observer’. Several students will interview the same patient, in such a way that the videotaped interviews can be compared. These interviews are reviewed by peers, students and experts. Not only the interviewing behaviour but also other aspects of competence (diagnostics, treatment plan) are discussed.
- Students have clinical experience in health care throughout their curriculum. Experience with actual patients may be subject of discussion within the small group. The emotional impact on the students by the patient and his problem gets attention. Problematic interviews caused by deficient skills or countertransference get attention. When a student has mastered an adequate interview technique, as he has shown in the past with simulated patients, the difference between a problematic interview with a ‘real’ patient and his usual interviews with simulated patients may be a strong learning experience (Smith, 1984).
- Attitude-development.
Students’ experience in health care practice, in interviews with simulated patients, but also experience with colleagues and educators can be further explored by the group. Attention is paid to the students’ emotions, underlying norms and values towards patients and health care systems.
The main focus in this part of the program is on the behaviour of the student, interacting with patients. These interactions are analyzed using the models of Leary (1957), and with techniques of value clarification (Simon et al., 1978).
The same format may be implemented in the future training of general practitioner-residents, which will be extended to two years.
Evaluation should be closely connected with training programs for two mean reasons:
- To assess the effects of an entire training program (program evaluation). Independent variables in the program evaluation may be the content and objectives of the training program, the teaching format and methods, or the time investment of educators and students. The dependent (outcome-) variable in these studies are the (increased) level of interviewing skills of the students/physicians.
- To assess the progress of individual students on various types of interviewing skills as a result of a training program. Furthermore, specific weakness may be pointed out to individual students in order for them to make corrections in their interview behaviour (formative evaluation).
Data from both sources should be used continuously to adapt the training program. In the next section we will go more deeply into the results of the evaluation of our students and general practitioner-residents.
The Maastricht History-taking and Advice Checklist (MAAS) was used to assess students’ and residents’ levels of interviewing skills. The MAAS is based on the taxonomy of interviewing skills in primary health care, described in the previous section and in the appendix. The seven parts of the taxonomy constitute the item domain of seven corresponding subscales.
Evaluation studies with undergraduate medical students and residents in general practice yielded data for the assessment of their pattern of growth in these seven types of skills during the years of study. From these findings some specific recommendations for training programs are derived.
These seven growth patterns are the result of the integrated training programs described in the previous section:
Exploring Reasons for Encounter
Young medical students tend to listen to patients’ stories, concerns, emotions and opinions about their illnesses. Later during their medical study, they display these skills to a lesser extent or lose them completely, unless the training program pays attention to them. The reason for this fall in the collection of patient-centered information is the students’ preoccupation with the diagnostic process and their concern not to miss a single detail in their patients’ medical history.
Our training program gives sufficient attention to the patient-centered information. The same development holds for the residents in general practice, who originally mastered these skills, but easily tend to neglect or ‘forge’ them under pressure (time, patients with serious life-threatening problems, demanding patients). The training should be aimed to preserve these skills pertaining to the patient-centered phase of the interviewing, which are extremely important in mental health problems.
History-taking
The skills in this phase grow during the undergraduate curriculum and become more efficient during the residents training, because they ask less questions but yielding more relevant and accurate information. In case of obvious mental health problems, some interviewers tend to neglect the somatic aspects during this phase. The result is sometimes a kind of counterpart of ‘somatic fixation’, also called ‘psychosocial fixation’ (Grol et al., 1981).
Psychiatric examination
From our studies it became evident that students and residents neglect systematic questioning on symptoms and on psychological functioning. For instance, questions about depressive symptoms, antecedents and consequences of anxiety and phobia or objective assessments of complaints about memory impairment are often incomplete or totally omitted. They frequently touch on many of these subjects, but don’t probe more thoroughly or feel inhibited about asking more directive and closed questions. It looks as if mental health problems force future physicians into a non-directive, counseling style, which is contrary to the more directive questioning, necessary during this phase of the interview (Goldberg, et al., 1982). Attention to these aspects appears to be a necessary component of training programs in primary mental health care.
Socio-emotional exploration
Often residents in general practice don’t distinguish this phase of the interview from the phase Exploring Reasons for Encounter. As the style of the latter should be marked by open-ended, non-directive questioning with the patient frequently taking the lead, residents continue this style during the Socio-emotional Exploration that therefore often lacks systematic orderliness. Residents and students often explore – following the patients’ flow of thoughts and emotions – pertinent and problematic areas of life in depth.
Students and residents in Primary Care are reluctant to explore ‘difficult’ emotional and relational areas
However, they neglect sometimes to go into other areas of life, not spontaneously brought up by the patient, like emotional aspects in human relationships. They are reluctant to go into these difficult areas for the patient, which may be loaded with shame and guilt. But neglecting strong areas of patient functioning may also be a result of this lack of ‘broadness’ in socio-emotional exploration. These points should be an issue of concern in interviewing training programs.
Presenting solutions
In case of mental health problems, students and residents often tend to lose themselves in vague formulations while informing patients about the nature of their problems. The explanation to the patients themselves of their complaints in terms of stressful life-events/circumstances or underlying emotional conflicts is often superficial or totally omitted. The same often holds for the information about the rationale of the treatment plan. The negotiation process during consultation may be hampered by a deficient provision of information on the part of the physician. Data from our studies show considerable growth in these skills as a result of training (Kraan et al, 1986), making this part of the interviewing program of great value.
Another argument for careful attention to this phase of the interview comes from the fact that general practitioners devote the bulk of the time during their short interviews to this Presenting Solutions’ phase.
Structuring
Students learn easily to structure the medical interview on somatic problems, as a result of the training program. However, in cases of mental health problems, students and residents in general practice don’t structure the interview very much. Opening and termination procedures of the interview are rather easily learned. However, the distinction between non-directive patient-centered parts (Exploring Reasons for Encounter; some parts of the Socio-emotional Exploration) and systematic, physician-centered parts (History-taking, Psychiatric Examination) is often not sharply drawn in introductory statements and closing summaries.
Emotional exploration during the phase of Presenting Solutions (Schouten et al., 1982) is also often neglected or contaminated by the collection of new information, which should take place earlier during the interview. Although more difficult to learn than somatic problems, interview training programs in primary mental health should pay attention to these rather complex skills of Structuring.
Basic Interviewing Skills
Earlier we made the distinction between Interpersonal Skills and Communicative Skills. In our studies (Kraan et al., 1986) it was found that the net effect of the integrated Maastricht training program can be at best summarized as inhibiting in both types of skills. This decline, in the Interpersonal Skills especially, was described earlier as the ‘natural history of interviewing skills’.
The Communicative Skills likely improved as a result of the more behavioural approach in the skill training part of the program (Goldstein, 1973; Ivey; 1983). The interpersonal skills are favorably influenced by the Attitude-development part of the training program.
Although this differential effect of the Maastricht training program on interpersonal and communicative skills has not empirically been confirmed, we still recommend, particularly for residents in general practice, the earlier described integrative training approach.
Moreover, we found in our studies (Kraan et al., 1986) that residents show great variations in level when using the following complex interpersonal and communicative skills: focusing, summarization of emotions, content and process, confrontation, interpretation, self-disclosure (Bremer, 1973; Ivey, 1983). Although not so easily trainable, these skills should be improved in residents deficient in these skills, because of their importance to primary mental health care.
The importance of the physicians’ interviewing skills in primary mental health care is underscored by several arguments:
- The pivotal role of the physicians’ interviewing skills for diagnosing and treating minor psychiatric syndromes;
- The need felt by physicians to improve the communication with patients in general and the present Dutch health care policy, allotting general practitioners a greater responsibility in mental health care.
Reviewing the literature and applying results of our evaluation research has yielded guidelines for the design of training programs for interviewing skills pertaining to primary mental health care. Because explicit behavioural statements of interviewing skills to be learned is a necessary prerequisite we designed a taxonomy of skills. It was used as the base to construct an evaluation instrument to measure the physicians’ skills in initial interviews, called the MAAS-MI General and Mental Health This instrument is of value in the close connection between training and evaluation, which is needed to assess the progress of individual students and to study the effects of entire training programs.
Training should be structured in a way that the interviewing skills will be taught according to clear objectives and proven educational methods. Direct observation and feedback as well as standardized presentations of illustrative patient interviews appeared to be decisive in the teaching methods. Further it is an important educational rationale to integrate behavioural and cognitive elements with emotional aspects. Emotions foster or hamper (e.g. countertransference) the physician in using the proper interviewing skills.
Evaluation studies showed deficits in the interviewing skills of students/physicians, providing further guidelines to determine the content of the training programs. Under external pressure students/physicians seem easily to neglect the collection of patient-centered information, failing to detect the essential request for help. Further some reticence is observed to ask for somatic information, when mental health problems are obvious. Often a lack in flexibility of interviewing styles is observed, preventing the physician from changing from a non-directive to a more directive style, necessary in the interview phases such as Psychiatric Examination and some parts of Socio-emotional Exploration.
Finally, without training some Basic Communicative and Interpersonal Skills (e.g. reflection of emotions, summarization, checking of provided information) show a tendency to decrease. Complex communicative and interpersonal skills, like confrontation, interpretation, self disclosure should be taught, because of their importance for primary health care.
