Evaluating human communication is an extraordinarily complex process. Analyzing a two-way interaction--which most primary care consultations are--involves a wide variety of possibilities that require at least a minimum of systematization.
During the last three decades the clinical interview has been investigated in depth, as shown by the amount of information produced both in the English-speaking world1 and in Spain. A clear example of such interest in Spain is the creation of research teams such as the COMCORD Group, whose members authored the study this editorial deals with.
The study carried out by Roger Ruiz and colleagues, who evaluated how the communication profile of residents in family and community medicine developed during a 1-year period, is based on three fundamental elements:
Training in clinical interviewing.
Multiple interviews with standardized patients.
Evaluation of the interviews with the GATHARES questionnaire.
Training in clinical interviewing, although described succinctly in this article, is an element of capital importance. One of the best known studies in Spain is based on a biopsychosocial model that has been systematized in a semistructured interview that facilitates the exploration and resolution of a wide variety of situations in primary care.
The development of a 20-hour course in clinical interviewing, although it facilitates the incorporation of different communication skills (especially those related with narrative support), has not determined how much influence such training has in situations involving real patients, or whether the changes in the trainee are maintained with time or tend to disappear. In the study that concerns us, it appears that instead of improvements in skills related with psychosocial exploration and negotiation with the patient, the opposite was seen, although in overall terms the differences were small and their actual impact on patient health is not known. Paradoxically, an earlier study in Spain with three programmed patients and a sample of 16 physicians reported results that in some aspects were the opposite: improved quality of communication at the expense of performance on some tasks, associated with a selective loss of biomedical information which was not recorded in the patient´s chart.
Although the course on clinical interviewing included in the family medicine curriculum in Spain is recognized to be necessary, it may be insufficient to produce the desired changes. In this connection formulas for the teaching of clinical interviewing are being developed and applied (in the context of family medicine) which incorporate those elements of quality most widely accepted internationally, and that make it possible to identify, test and evaluate specific communication skills. This has been done through a process of prior training of tutors and the use of specific methods (videotaped recordings of simulated interviews, role-play with standardized patients, and structured exercises). One of the most successful of the different approaches is the analysis of actual interviews with problem-based interviewing methods, in which the trainee physician receives intensive feedback centered on his or her training needs.2
Other teaching options for related areas of interest, some based on similar methods, have been used for several years to train family physicians and nursing professionals in Spain. Some relevant examples are the family interview, brief systemic therapy, emotional self-control, the motivational interview, problem-solving therapy, and a method to improve psychodiagnostic ability.
Work in Spain with standardized patients (actors trained to interact according to a series of set behaviors based on how the trainee physician acts) started within the context of courses in interviewing skills, and was further developed to evaluate medical students3 and residents in family medicine, internal medicine and pediatrics. This approach has also been used to evaluate the clinical capacity of family physicians as a way to certify, in a clearly objective manner, their skills in history-taking, physical examination, interpersonal communication and chart notation. There is an active group of experts in Spain involved in the training of standardized patients, the design of instruments to evaluate clinical competence, and the implementation of these tools in field studies. The experience gained in these areas is helping to build a culture of evaluation of the care-providing skills of Spanish physicians (especially those in primary care) through the so-called Objective, Structured Evaluation of Competence (OSCE) (evaluación de la competencia objetiva estructurada).4 In addition, a guide to the implementation of the ACOE instrument has been published by the Clinical Competence Training and Evaluation Group of the Health Studies Institute (IES, Institut d´Estudis de la Salut).
Although the use of standardized patients involves hard work (to train the actors, maintain an appropriate level of competence, and find the time and means to cover the costs), we now know that they are a key element in training with carefully controlled clinical situations. The well-designed, unvarying stimulus provided by a standardized patient makes it possible to compare performance in different professionals, and to establish standards for the quality of care.
Another point that merits comment centers on the use of an instrument that makes it possible to measure communication. Since the 1950s and 1960s, many instruments have been developed to evaluate clinical interviews from the standpoint of different explanatory models. Some instruments are aimed more at measuring cognitive elements, others aim to measure behaviors, and a minority are designed to analyze emotional aspects. In all cases the main question that must be asked regarding these testing instruments is whether they fulfil the requirements aptly summarized by Kraan et al.5: a) orientation toward an underlying interview-based model, b) well-defined communication skills and the methods used to measure them, c) adequate interobserver, intra-observer and intercase reliability, shown before the instrument is used, d) documented content validity, e) well-designed items and scoring system, and f) usable for both training and evaluation.
The GATHA-RES questionnaire, developed from the earlier GATHA-BASE instrument (the subject of a PhD thesis by J.A. Prados) is one of the few instruments that, as a result of several years´ rigorous methodological work, satisfies all the above requirements.6 The GATHA-RES questionnaire is now probably the most widely recommended instrument for evaluating clinical interview performance in primary care settings, particularly if formal communication elements are to be measured.
Finally, the main findings that Ruiz Moral, Rodríguez Salvador and colleagues report in this issue raise several questions: how long, on the average, should the interview last in order to obtain information on situations that are prototypical in primary care? Can a threshold duration be specified such that shorter interviews can be assumed to clearly diminish the quality of care? Although it might be felt that excessively short interviews lead to worse quality care, the present study in evidence-based medicine raises additional questions. In terms of clinical practice, how many excess errors would be made as duration of the consultation decreases? What would their associated patient morbidity and mortality be? What repercussions would the situation have on the physician´s health? How many new cases of chronic stress or surmenage (burnout), anxiety, or depression would appear? In economic terms, how much absenteeism results from constant time pressures and shortages? How many unneeded complementary examinations and referrals result from the desire to end the consultation on time? What are the real costs of this situation, in monetary and human terms? Ethical issues raised by the findings suggest a number of questions: Is it ethically censurable to work under such conditions? Who is responsible for their consequences? As regards health care management, who is responsible for changing the situation? Those firms that contract health services? Representatives of the colleges of physicians and medical associations? Scientific societies? The Ministry of Health, members of parliament, or those responsible for allocating the national budget? Perhaps the Public Ombudsman? Or none of the above? What about the World Health Organization? These questions will need to be answered by consensus among the responsible parties, if such can be identified.
Which variables in the clinical interview predict the best performance scores and the best outcomes? A study designed to compare groups of interviews in which specific items related with communication skills were included or omitted might provide relevant information.
In view of the decisive influence of the tutor´s profile on learning communication skills, it would be useful to discuss the features of the most useful program possible for training the trainers in clinical interviewing, in the light of previous experience in this area within the Spanish Society of Family and Community Medicine. Our current knowledge about different methods of training in clinical interviewing (in both undergraduate and graduate education) brings to mind the question: which method would yield the best results when evaluated a posteriori with (for example) the ACOE instrument or standardized patients?
Several studies have noted the importance of a contextualized approach to patient´s demands during consultation; the results of such of an approach are increased patient satisfaction, compliance with treatment, and better health outcomes for some chronic diseases. However, two studies based on a survey of patients and physicians, published in Atención Primaria by Torío Durantez and García Tirado, found that an approach based on the consulter´s experience appeared not to be relevant, whereas maintaining a good relationship with the patient and providing quality information were found to be important.
Undoubtedly, both visions contain some truth; the findings probably reflect as many factors as there are types of patient, and the prevailing culture of medicine (eg, the health care model used, availability of resources, time per interview, prior training, and expectations of those involved in the consultation). Further studies are needed to identify (as far as possible) which patient profiles and which physician profiles would benefit the most from the patient-centered or the physician-centered approach. It should not be forgotten that the key issue lies fundamentally in obtaining both objective and subjectively perceived results for health.
