British Joiirnal of Medical Ediicarion, 1972, 6, 125-1 32

A procedure for training for general practice A. MORRISON and M. CAMERON-JONES Department of Education, University of Dundee

Current interest in the preparation of medical undergraduates and trainee doctors for work in general practice is resulting in a great deal of exploratory work on teaching, assessment, and evaluation techniques which might be used in complementary ways to extend the range and improve the effectiveness of existing training (Hinz, 1966; McCarthy and Connella, 1967). In a two-day workshop during a conference on ‘Training the teachers’ held at the University of St Andrews in April 1971, groups ofexperienced general practitioners used various forms of small group discussions, tutorials, and role-playing to identify methods of teaching appropriate to different areas and objectives of training, and to prepare themselves as potential trainers.

This report, based on video-tape recordings made at the St Andrews workshop, concen- trates upon the use of role-playing as part of a procedure for the training, assessment, and evaluation of trainers and trainees in the doctor- patient interview.

Role-play ing Role-playing has several merits as a training technique, and has been widely used in industrial/ management training and in the preparation of school teachers, as well as in medical education (Rarney, 1968). 1 Where training is concerned with professional

and social skills in dyadic or group situations, role-playing may approximate to real situa- tions which might be closed to the trainer or trainee.

2 I t allows the abstraction of particular com- ponents from real situations, and the speci- fication of certain types of performances in which individuals are to be trained.

3 It demandsdirect behaviouralactivityfrom the trainee and does not depend on assumptions

sometimes underlying other techniques - such as the lecture - that what trainees are told will be translated into appropriate behaviour.

4 In conjunction with observation and record- ing techniques, it is possible to provide fairly immediate analysis of the trainee’s perform- ‘ance and feedback of advice. Moreover, if the performance is recorded on video tape the trainee can see and hear for himself what went on and provide himself with corrective advice. These aspects of role-playing have been discussed by Adler and Enelow ( 1 966) and Sclare and Thomson (1968).

5 Video tapes of role-playing sessions may subsequently be used by trainers to make systematic analyses of the performances of trainees (as done for actual interviews by Barbee, Feldman, and Chosy [ 19671 and/or of skilled practitioners (as done by Davis [I968], again for actual interviews). Such video tapes may also be used for demonstration within introductory programmes of training.

However, there are further considerations. 1 The role-playing situations require credi-

bility and must have some validity for the real situation into which the trainee is going.

2 The need for the purchase and constant availability of technical facilities, and for relatively intensive staffing with trainers experienced in the procedure, may make recorded role-playing more expensive than other training methods.

3 Much of the effectiveness of role-playing may depend upon the parallel development of assessment and evaluation procedures. For assessment many procedures may be used; evaluation is much more difficult. Langsley and Aycrigg (1970) suggest that it may be unrealistic to accept one model physician, one

125

126 A. Morrison and M. Camrron-Jones

criterion of appropriate performance, in the varied kinds of doctor-patient interviews which are carried out in general practice. Finally, its effectiveness as a training method depends upon the ability of the trainer to analyse the performances of trainees and to give appropriate advice: ie, trainers must themselves be taught how to train.

None of these matters provides problems great enough to rule out the fairly extensive use of role- playing, but they do mean that a great deal of work is required before role-playing becomes a practicable part of a normal training programme.

4

Patient-simulated interviews The role-playing sessions at the St Andrews workshop took the form of patient-simulated interviews in which the ‘doctor’ was an experi- enced general practitioner and the ‘patient’ an amateur actor or actress who had been briefed to assume the role of a patient with particular problems and/or symptoms. A ‘consulting room’ was made in a temporary studio and in this setting the interview, approximately 5 minutes in length, was recorded on video tape and simul- taneously televised to small groups of medical colleagues in a number of viewing rooms. These observers were given brief check-lists to use as guides to different aspects of the interview, and then were able after the performance to discuss what they had seen and heard.

The subsequent objectives of this pilot study have involved later replays of the video-taped interviews. These aims concern the development of an appropriate observation schedule with which to record objectively different aspects of the performances of the ‘doctor’ and the ‘patient’; the use of the observation schedule to produce comparative records of the interviews; and a consideration of how the schedule might be used within a training programme for trainee general practitioners. ,,

Systematic observation and recording The use of systematic observation schedules is not new in medical training. But many of the schedules discussed in the literature (Hinz, 1966; Barbee et al, 1967; Davis, 1968) still require the observer to judge and to rate (on an n-point-scale) the degree to which the subject exhibits certain behaviours. A more objective schedule, such as the PIA scale (Adler and Enelow, 1966) differs

from a rating schedule in requiring the observer simply to record, within the appropriate category, each interactional event when it occurs.

These latter types of schedule are being in- creasingly used in training situations, eg, i n teacher training (Flanders, 1968), since they can yield a fairly objective and detailed record of aspects of behaviour, separating the recording of acts from evaluation. They may also provide the trainer and trainee with a permanent record which can be analysed and may form a basis for advice to the trainee. Such schedules cannot hope, for practical purposes, to present comprehensive sequential records of all aspects of the verbal and non-verbal behaviour of individuals in situations of rapid and highly diverse interaction. Therefore, even when an attempt is made to design an observation schedule which is objective, prior decisions have to be made as to what it seems most useful for particular purposes to observe and record, and the desire for detail has to be weighed against the ability of observer-trainers to use the schedule skilfully and reliably, especi- ally where such observers are relatively untrained in observation techniques, and where the need is for a record which can fairly readily be analysed and given back promptly to the trainee.

These points were borne in mind when the observation schedule was developed for the patient-stimulated interview (PSI) and the schedule thus consists of 10 numbered categories. The observer-recorder is required to follow the interview (or the video tape of it), entering on a record sheet the appropriate category number for each distinctive verbal contribution made by the ‘doctor’ or the ‘patient’. The categories used are presented with examples in Table I .

The PSI observation schedule describes the doctor-patient interview as an interpersonal exchange in which both parties have the goals of eliciting and emitting information. Since the instrument is intended primarily as an assessment device for doctors, 7 of the 10 categorized verbal events apply to doctor-behaviour. Categories 1 - 4 (social facilitation) describe social behaviour, the kinds of actions employed by the doctor to initiate the encounter with a patient (I) and to maintain the encounter (2, 3, and 4) until the desired information is gained from the patient: these categories describe the doctor keeping the patient in play, encouraging the patient to pro- vide the necessary information from which the

A procedure for training for general practice 127

Table 1. Categoriesjbr observations and recording of verbal behaviorrrs of doctors andpatients during interviews

Curegories Exutnples

Doctor Soricil fncilirntiuri I Salutation

2 3 4 Professional control 5 Command

6 7

Patient 8 Symptom ‘I’ve got this pain’ 9 10 Questioning

General forms of greeting and parting. ‘Good morning’; ‘Sit down’;

‘I understand’; ‘Yes, Yes’; ‘hmm, hmm’; ‘You did quite right’ General, unspecific. ‘So then you felt’; ‘Tell me what happened’ Developing what has been initiated. ‘Go on’; ‘A funny tingling sensation’

‘You must go home’; ‘Bring your boy-friend and we’ll talk about it’;

‘Do you wake up early?’; ‘Does this happen in the morning? Informing the patient. ‘1’11 write you a prescription’; ‘You’ll be in hospital

‘How are you?’ Reassurance of patient Invitation/initiation Encouragement

‘Take this’ Direct question Problem resolution

for a week’

Problem-related expression Family, work, social problems; reference to related others Direct questions - requests - demands. ‘Can I have a line (certificate)?;

‘What will happen to the children?’

doctor’s diagnostic hypotheses are to be derived. Categories 5-7 (professional control) are cate-

gories of professional role behaviour, and describe the doctor attempting hypothesis-con- firmation (6), managing the patient ( 5 ) , and informing the patient (7) of his diagnosis and/or intended actions.

Two of the patient-categories describe 3he patient as the donor in the doctor-patient infor- mational exchange (8and9).The last category (10) describes direct attempts by the patient to elicit information or to obtain ‘sick lines’, prescriptions, further appointments, etc from the doctor.

The schedule describes dyadic events for which there is verbal evidence. I t describes interpersonal processes. It does not attempt an evaluation of a doctor’s diagnostic skill. While the 10 chosen categories of the PSI schedule seem to yield descriptions (scored records) which have face validity, no other claim is made for their relevance or exhaustiveness.

The recording sheet. Starting with a plain sheet of paper, the, category numbers for the verbal contributions of doctors and patients are entered one after another down the sheet, forming a set of columns of numbers representing the moves made during the interview. For example:

1 6 4 9 9 6 9 9 9 9 9 2 9 9 10 2 4 andsoon.

The result is a record, in time sequence, of different kinds of verbal behaviours, and trainer and trainee could work directly from this to get a general impression of the frequency of different verbal acts and their order. However, there is a considerable advantage in taking the analysis a stage further. Using a blank 10x10 matrix, adjacent pairs of observations can be entered into the cells of the matrix, the first number of each pair being used to locate the row and the second the column, eg, in the sequence of numbers 1 3 3 8 8, the adjacent pairs are 1 and 3, 3 and 3, 3 and 8,s and 8. The first pair would then be used to record a tally at the cell intersected by row 1 and column 3.

Once all the paired observations have been entered, column totals can be calculated to show the frequencies of different behaviours of the ‘doctor’ and the ‘patient’. Other interpretations can be obtained from such a matrix, such as the tendency for any one type of behaviour to persist and the tendency for certain behaviours to precede or follow others. A complete illustration taken from one of our interviews is shown in Figs. 1 and 2, giving the completed matrix and totals (Fig. 1) and a frequency histogram (Fig. 2).

This procedure has been adapted from one now in fairly common use in the study of school teachers. It is simple to operate, and if observa- tion sessions are brief (eg, 5 minutes) the matrix can be quickly prepared for inspection.

Such a procedure does not, of course, provide a word-by-word record; its purpose is to provide a quantitative record of objectively classified

128 A. Morrison and M . Cameron-Jones

1

2 1 1 1 3

1 2 3 L 5 6 7 8 9 1 0

1 1

2 7 1 1 4 8 3 1 0 3 7 7 Fig. 1. Example of a niatrix of observations and the totals.

behaviours. Nevertheless, the record, if used by the trainer i n conjunction with a video-tape play-back of a training session, could identify, for example, the ‘questioning’ content of an interview, and the trainer could then concentrate upon the appropriate part of the play-back to analyse and comment upon the actual use, content, and form of questions.

Observation records of general practitioners Having developed the systematic observation procedure just discussed, we were able to analyse the video tapes of our experienced doctors. Used for this purpose, the schedule has yielded a com- parative display of the verbal interactions of different doctors with different kinds of ‘patients’, and has given, therefore, a valuable, if indirect, exemplification of consulting-room behaviour. Additionally, however, by analysing and record- ing the behaviaur of experienced practitioners, we may have obtained what is in some respects exemplary material for the guidance of trainers. Of course, this can only be a start to the whole question of what are to be regarded as skilled performances by doctors, yet i t is a necessary step at this stage in studies of doctor-patient interviews to rely upon an assumption of an association between experience and skill - an assumption for which Langsley and Aycrigg (1970) provide some empirical, if indirect, sup-

Social Professional facilitation control by by doctor doctor

Fig. 2. Exaniple oJ’ a histogram drriverl from rrialrix of observations.

port - especially in default of other adequate criteria of skilled performance. , Before we look at some of the results of the observation procedure it is necessary to describe the themes of the PSIS done at the St Andrews workshop and to look at the briefings given to ‘doctors’ and ‘patients’ before interviews and video taping.

PSI themesl. The situations outlined below are all based on actual patients, and were selected because they gave opportunities for the display of some of the following skills.

(1) Forming interpersonal relationships, estab- lishing rapport under difficult circumstances, and the use of interview techniques. (2) The ability to gather information and to concentrate on what is relevant to the ‘reality problem’. (3) The ability to identify significant problems from the data presented, and to seek appropriate solutions. (4) The ability to be clinically effective with

~ ~~~ ~

‘We wish to thank Professor J . Knox for this section on the pdtirnt roles. Detdils of dII the situations used dre avdilablc from him.

A procetlrrre /or training /or general practice 129

inadequate data. ( 5 ) Clinical acumen in recog nizing the probable diagnosis.

The situations were so chosen and the actors were so briefed and rehearsed that as the inter- view developed the need for physical examination became less marked, ie, the situations were related more to life problems than to physical diseases.

Eight situations were prepared. They were labelled ‘Sandy’, ‘The positive cervical smear’, ‘The angry woman’, ‘Frances’, ‘The cough bottle’, ‘The bus driver’, ‘Aches and pains’, and ‘The salesman’. They represented various matters, for example, the issuing of prescriptions, a demand for a certificate of unfitness for work, imparting information on a positive result of a routine smear test, and the prescribing of an oral contraceptive to a 17-year-old schoolgirl.

The situation of ‘The angry woman’ is given here as an illustration.

‘The angry woman’ is in her late 40s; she is highly aggressive, ostensibly because her teenage daughter whom she had sent earlier in the day to collect her prescription (for tranquillizers) had been ejected by the receptionist because the teenager turned up with a rowdy gang. Briefing: medical record of frequent attendances, with a brief note of the episode described above. Aim: to demonstrate the experienced general practi- tioner coping with aggression and his skill in eliciting under difficult circumstances the relevant additional social history (not given here); a test of interpersonal relations.

From the complete set of observation records for the 16 interviews, two have been chosen and are shown in Fig. 3 to illustrate the kind of findings that can be obtained. These show the records for two experienced doctors with the same patient.

Results oj’PSIs. By analysing all 16 of the PSIS we were able to describe the characteristics of our experiepced practitioners - without, of course, evaluating them. Tables 2 and 3 show patterns of behaviour identified by the observa- tion records.

These results are presented only to demonstrate the kinds of information yielded by the schedule. What is needed for research and training pur- poses is the same comparative procedure with larger numbers of doctors and trainees, together with the comments and evaluations of authorities in the field of general practice. Nevertheless,

these preliminary scores indicate areas of inter- view behaviour where there is very considerable variation - perhaps bearing on doctor-skill and certainly upon patient differences. Table 2, for ex- ample, indicates that the major variations existed on such aspects as direct questioning, problem resolution (informing patients), and reassurance. This Table also shows very large variations in the broad content of patients’ expressions.

Such variations in behaviour, it might be argued, are well known. But until they are pre- sented in such precise numerical form, for large number of doctors and patients in many inter- view situations, it may not be possible to discover the co-variants of the differential frequency of these behaviours, ortolist the behavioural compo- nents which would define a skilled performance in any particular type of general practice interview.

A small study conducted after the St Andrews conference, and using 14 of the video-taped inter- views as stimulus material, suggested that even shortly after completing their training, young general practitioners might not agree on how a skilled interviewing performance is to be defined. In this study, five (and later in the day, four) trainee practitioners were asked to suggest, immediately after viewing each interview, the appropriate percentage distribution, for that interview, of social facilitation by the doctor, professional control by the doctor, and patient acts. Their prescriptions for skilled performance showed a wide variability (measured by SD), the widest variability (mean SD of 10.5) occurring for the amount of social facilitation they judged it appropriate for the doctor to display, and the lowest variability (mean SD of7.5) for the amount of patient acts they judged appropriate. This study seemed to suggest the need for agreed and/ or validated performance criteria if medical training is to include increased instruction about appropriate behaviour in dyadic situations such as the interview (Dudley, 1970).

A suggested training procedure Of course, the interviews described in this report were conducted by experienced GPs, but similar records could be obtained for interviews con- ducted by trainees. If used for teaching trainees, such interview records would form the second stage of a training procedure modelled upon one in use in teacher training (Allen and Ryan, 1969) in which :

I30 A. Morrisoil uird M. Carnerott-Joirc2s

40

30

A 6 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 0 9 10

- 40 - - -

30 - -

1 27 2 0 3 15 4 3 18 36 3 0 15 8 2 0 15 14 11 46 0

Fig. 3. Observation record matrices and frequency histogranis for two patient-simulated interviews ('The angry women')

1 The trainee cyries out the interview. 2 Observations are made andanalysed as above. 3 The record is commented upon by the trainer

and discussed with the trainee. 4 The trainee is, perhaps, asked to conduct a

further interview, during which he takes into account both the observation recordofhispre- vious behaviour and advice from the trainer on any desirablemodification to becarriedout.

The use of an observation record, whether of this or another form, is an important component

in the procedure, although it is commonly lack- ing in training situations. 1 It provides the trainer with an objective record

of what went on and therefore he is not dependent upon recalled impressions in which performance and evaluation are confused.

2 It allows the trainee to see a record of how he behaved, so that he is not dependent solely upon what the trainer says he did. I f the trainee is advised to modify his behavi- our, then a comparison can be made of records

3

A procediire for training Jbr gwrrul prurticc 131

Table 2. Analysis of doctor-patient behaviour based upon observations of 16 patient-simulated interviews Rntio of social

tion to doctor to fudi ta- Ratio of Symp-

tom- Probbm- Patient- profes- patient Invita Direct Problem related related

simulated sionul beka- SuIuta- Remsur- tionlini- Entour- Corn- question- rcsalu- expres- expres- Question- interviews control‘ viour2 tion3 unce riarion agcment mund inn tion sion sion ing

‘Sandy’ 0.25 1.20 2 7 1 I 4 8 31 0 37 7 ‘Sandy‘ 0.32 1.10 I 12 I 0 3 16 20 0 39 7 ‘The positive 0.50 I .80 1 16 3 2 0 19 23 26 7 2 cervical smear’

‘The angry woman’

‘The angry woman’

‘The angry woman’

‘The angry woman’

‘Frances’ ‘The cough

bottle’ ‘The bus

driver’ ‘The bus driver’

’Aches and pains’

‘Aches and pains’

‘Aches and pains’

‘The sales-

‘The sales- man’

man’

0.60 1.10 1 13 7 0

0.86 0.94 1 13 7 2

0.49 1.60 I 18 1 0

0.91 0.91 1 19 I 2

0.26 1.20 2 4 2 3 0.27 1.10 I 9 I I

0.92 1.30 1 19 0 6

0.32 I.SO 1 7 3 4

1.30 1.00 1 I6 I 10

0.30 0.79 I J 2 3

0.52 0.75 I 10 J I

0.36 1.10 I 7 3 2

0.65 0.74 I 14 I’ 1

3 13 17 3 42 I

0 13 12 10 41 0

2 10 29 12 24 2

0 16 8 7 44 1

0 29 1 5 I I 31 I 0 37 4 10 36 0

0 27 I 31 12 0

1 16 28 30 9 0

0 16 5 30 19 0

0 22 12 23 32 0

I 12 I S 46 1 1 0

3 19 16 33 12 I

0 15 1 1 40 16 I

‘This is calculated from number of social facilitation acts divided by number of professional control acts. A low ratio indicates relatively high professional control. ‘This is calculated from number of doctor acts divided by number of patient acts. A low ratio indicates relatively high patient contribution in the interview. JFigures in this and remaining columns arc percentages of total number of acts. They are approximations to a total 100%.

Table 3. Means and ranges of measiires over the 16 patient-simrtfated interviews

Mmtr Rrtttgc uf rotio rcctius

Ratio of social lacilitation to 0.49 0.2s-1.30 professional control behaviour

behaviour Ratio of doctor to patient 1.10 0’74-1.80

Careguries of cloctur belraviuiir I Salutation 2 Reassurance 3 lnvitation/initiation 4 Encouragement 5 Command 6 Direct questioning 7 Problem resolution

7 ; (rtrttgef

2 (1-2) 12 (4-19) 3 (0-71 2 (0-10) I (0-4)

18 (8-29) I5 (1-31)

of two or more training sessions to discover what changes, if any, were achieved.

The amount and kind of change may be pre- cisely specified : the observation record, itself capable of affording a precise numerical descrip- tion of a trainee’s behaviour, is thus a potentially valuable assessment device. The evaluation of a trainee’s performance in consultation is a much more complex matter and demands validated criteria. Observation records are not in them- selves evaluations but they may provide part of the evidence necessary for the development of a sound evaluation procedure, since they provide trainers with obiective information on the con-

C(rtryurirs i i / p i t t i e ~ t t hrhct viiitir

10 Questioning

tents of consultations of different kinds. Unti l we IY (0-46) 26 ,9-44) have this information, coupled with expert 2 ( s 7 ) opinion on more or less effective performances,

8 Symptom-related expression 9 Problem-related exprcssion

I32 A. Morrison otrd M . Carnerotr-Jotlcs

then evaluation by the trainer can be based upon little more than his own general impressions, derived from personal experience, of what he thinks effective or ineffective. Such a basis for evaluation is probably inadequate, since trainers disagree among themselves on what to look for in a performance, on how to weigh up the im- portance of different components, and on the conclusions they reach.

Summary This paper examines a possible procedure for use in training for general practice. Video-tape recordings were made in a simulated consulting room of experienced general practitioners indi- vidually interviewing amateur actors or actresses who had been briefed to assume the roles of patients with particular problems and/or symp- toms. Subsequently, the recordings were replayed, and the ‘doctor’s’ and ‘patient’s’ performances analysed against an observation schedule which records objectively the frequencies of various kinds of behaviour. Findings from the observa- tional records are presented here, together with discussion of the use of the combined role-playing and behaviour-recording technique as part of a training programme.

We wish to thank Professor J. Knox and D r J. Lawson, Mr and Mrs D. Alexander, and all the doctors at the St Andrews Workshop who took part in the patient-

simulated interviews. Particular mention should be made of the excellent work done by the actors and actresses who played the patient roles.

This project was made possible by a grant from the Education Foundation of the Royal College of General Practitioners, t o which we are indebted.

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