LI""ARY

M317: C‘ {are

University

‘w

 

 

This is to certify that the

thesis entitled

THE EFFECTS OF TEACHING INTERVIEWING SKILLS AND
AFFECTIVE SENSITIVITY TO FAMILY MEDICINE
RESIDENTS: A PILOT STUDY

presented by

Belinda Rose Novik

has been accepted towards fulfillment
of the requirements for

Ph. D. Counseling Psychology

degree in

 

./ x
/,

l Major profess

Date February 27, 1978

 

0-7639

© 1978

BELINDA ROSE NOVIK

ALL RI GHTS RESERVED

THE EFFECTS OF TEACHING INTERVIEWING SKILLS AND
AFFECTIVE SENSITIVITY TO FAMILY MEDICINE
RESIDENTS: A PILOT STUDY

BY

Belinda Rose Novik

A DISSERTATION

Submitted to
Michigan State University
in partial fulfillment of the requirements

for the degree of

DOCTOR OF PHILOSOPHY

Department of Counseling, Personnel Services,,

and Educational Psychology

1978

ABSTRACT

THE EFFECTS OF TEACHING INTERVIEWING SKILLS AND
AFFECTIVE SENSITIVITY TO FAMILY MEDICINE
RESIDENTS: A PILOT STUDY

By
Belinda Rose Novik

The purpose of this study was to evaluate the
effectiveness of Interpersonal Process Recall (IPR) as a
teaching mode for training in interviewing and affective
sensitivity for Family Medicine residents. All the resi-
dents in the Duke-Watts Family Medicine Program (n=33)
were given a thirty-two hour version of IPR.within a one-
year period. This was a pilot study done to test the
feasibility of IPR in this setting and to analyze the
effectiveness of IPR within the design constraints imposed
by the setting.

The residents served as their own controls. Pre
and post resident-patient interview measurements were
taken with the Counselor Verbal Response Scale, Affective
Sensitivity Scale, a chart audit of the number of benzo-
diazepin prescriptions (minor tranquilizers) written by
the residents before and after training, and a chart audit
of the affect words and other statements on patient charts

which might indicate that personal-social issues had been

discussed in the interview. (The shortened form "affect
words" will be used to describe all of those statements

hereafter.) In addition, the CVRS (the resident-patient
interview rating) was taken at a point in time when half
of the residents had received IPR training and half had

not received the training.

It was hypothesized that physicians would be more
likely to note affect words and other statements indicative
of a personal-social interview on their patients' charts
after IPR training than before training. Because these
physicians would be more able to respond as therapeutic
agents themselves, it was also hypothesized that they
would prescribe less benzodiazepins after training in IPR
than before training.

It was hypothesized that residents trained in IPR
would increase their Affective Sensitivity Scale scores
and that they would have better basic communication skills
after training. The final hypothesis was that the CVRS
would discriminate between those residents who had IPR
training and those who did not. ‘

Analysis of the data was performed using both
parametric t tests and non-parametric Wilcoxon matched
pairs signed-rank test, and the Mann-Whitney U-test
statistics. No difference in the results was found be-
tween the two types of statistics. The non-parametrics

supported the findings of the parametric statistics in all

cases. A correlation analysis on the measurement instru-
ments was also performed to determine the relationship
between them.

Results of the study indicated that residents did
improve significantly in their basic communication skills
in patient interviews. Also, a subgroup of the residents
(the third-year class) decreased their prescription fre-
quency of benzodiazepins significantly pre-to-post train-
ing in IPR. It was also found that the affective subscale
of the CVRS did discriminate between those residents who
had IPR training and those who did not at the time of the
testing. There were no significant changes in the number
of affect words written by residents on patient charts or
on the Affective Sensitivity Scale. The Affective Sensi-
tivity Scale Form D has since been found not to correlate
well with other measures of affective sensitivity and has
been redone by its authors. The chart audit needs further
development and validation. Implications of the study and
recommendations were discussed in detail.

The results of this pilot study indicate that IPR
did have a significant impact on the residents of the
Family Medicine program and that it was a viable teaching
mode for basic communication skills and affective sensitiv-
ity. It may have an impact on prescribing practices of
third-year residents, but this observation needs to be

examined in a future study.

To my family,
friends,
and teachers--
For their love,
trust, and
wisdoma

ACKNOWLEDGEMENTS

I wish to thank all of the people at the Duke-
Watts Family Medicine Program for their consistent support
and cooperation in this endeavor. Special thanks go to
Dr. William J. Kane for his commitment to this research,
and to Dr. James Moore, for without his encouragement and
expertise, this project would never have been started.

Dr. James Bobula was especially helpful with evaluation
‘methods. I also wish to thank Bob Miller for his technical
assistance and emotional support.

My thanks, too, to all the residents who, with
varying degrees of apprehension and excitement, watched
themselves, taught me, and allowed me into their private
worlds. Their enthusiasm for learning and tolerance for
the difficult times made teaching a delight. Although not
individually named, they were the foundation upon which
this research was built. I hope that what we have learned
together will be of help to others.

I am especially indebted to Martha Absher who not
only edited this paper, but taught me how to edit, and to
Katie Glazier for her help in preparing this manuscript.

For their support on my committee, I would like to
thank Dr. William.Farquhar, Dr. Ralph Kron, Dr. John

Schneider, and Marsha Worby.

iii

Finally, I would like to thank Dr. Norm Kagan for
his encouragement, generous feedback, and guidance through-

out this study and throughout my graduate education.

iv

TABLE OF CONTENTS

Page
LIST OF TABLES . . . . . . . . . . . . . . . . . . . vii
Chapter
1. THE PROBLEM . . . 1
Statement of the problem . 1
Need for the Study . . 2
Definition and Discussion of Terms 6
Behavioral Science. . . 6
IPR- The Teaching Tool . 6
Theoretical Considerations . . 9
The Doctor- Patient Relationship.
A Model. . . . . . . . 9
How IPR Checks Distortion . . . . . . 12
Hypotheses . . . . . . . . . . . . . . . 14
Summary. . . . . . . . . . . . . . . . . 16
Overview . . . . . . . . . . . . . . . . l6
2. REVIEW OF THE LITERATURE. . . . . . . . . . 17
Teaching Interviewing Skills to Medical
Personnel . . . . . . . . . . 17
Summary and Discussion . . . . 34
Family Medicine: Roles, Needs, and
Training. . . . 36
Establishing Family Medicine as a
Specialty . . . . . 36
Definition of Family Medicine . . . . 40
Summary and Discussion . . . . 45
The IPR.Method, Theory, and Research . . 4S
IPR and Psychotherapy . . . . . 4S
IPR and the Training of Para-
professionals. . . . . . . . 48
IPR and Counselor Education . . . . . 50
IPR and General Education . . . . . 55
IPR and the Training of Medical
Interviewers . . . . . . . . . . . . 57
Summary and Discussion . . . . . . . . . 59

3. METHODOLOGY.

The Design. .
The Setting. .
The Subjects .
Hypotheses
Instrumentation . .
Affective Sensitivity Scale.

Counselor Verbal Response Scale:

The Chart Audit. . .
Selection of Raters.
Summary .

4. ANALYSIS .

Number of Subjects .
Hypothesis One (H1)
Results. .
Hypothesis Two (H2)
Results. . . .
Inter- rater Reliability .
Hypothesis Three (H3)
Results. . .
Inter- rater Reliability .
Hypothesis Four (H4).
Results. .
Hypothesis Five (H5 ).
Results. . .
Correlation Analysis.
Summary . . .

5. SUMMARY, RESULTS, AND IMPLICATIONS .

APPENDIX .

Background of the Problem . .
Methodology and Analysis of Data.
Results . . . . .
Conclusions .

Discussion.

The Affective Sensitivity Scale:

The CVRS . .
The Chart Audit. . . .
Discussion of the Correlation
Analysis .
Implications.
Recommendations . . .
Non- -hypothesized Observations.
The Impact of IPR.

BIBLIOGRAPHY .

vi

100
103

103
106
107
108
109
109
112
114

115
119
121

123

126

136

4.10

LIST OF TABLES

Weighed Scores on the Affective
Sensitivity Scale for the Total Group
(Years 1,2, 3). . . .

Unweighted Scores on the Affective
Sensitivity Scale for the Total Group
(Years 1, 2, 3). . . . . . .

Weighted Scores on the Affective
Sensitivity Scale for lst Year
Residents. . . . . . . .

Unweighted Scores on the Affective
Sensitivity Scale for lst Year
Residents. . . . . . . .

Weighted Scores on the Affective
Sensitivity Scale for 2nd Year
Residents. . . . . . . .

Unweighted Scores on the Affective
Sensitivity Scale for 2nd Year
Residents. . . . . . . .

Individual Pre-Post Means (Total Score)
on the Affective Sensitivity Scale .

Individual Means Pre and Post Training
on the CVRS. . . . . . . .

Pre-Post CVRS Scores.

Inter- rater Reliability on the Pre- Post
CVRS Scores. . . . . . . . .

Total Group Scores on the In-Training
Exam Using the CVRS. . . .

Inter-Rater Reliability on the In-
Training Exam CVRS Scores.

Chart Audit Means Pre and Post IPR
Training . . . . . . . .

-vii

Page

126

127

128

129

130

131

83

84
86

89

91

92

94

4.14

4.15

Affect Words Noted Pre and Post IPR
Training on the Chart Audit for Second
and Third Year Residents Combined. . . . 95

Frequency of Benzodiazepin Prescriptions
of Residents Pre-Post IPR Training . . . 97

viii

CHAPTER 1
THE PROBLEM

Statement of the Problem

Of the many drugs, instruments, and procedures
used by the medical profession today, the most frequently
used--and most frequently forgotten--tool is the doctor-
patient relationship. The general question which this
study addressed was this: Can training increase the
therapeutic value of the doctor-patient relationship?
Specifically, the purpose of this project was to evaluate
the effectiveness of Interpersonal Process Recall (IPR) as
the teaching mode for training in interviewing and affec-
tive sensitivity for Family Medicine Residents at Duke
University. Evaluation was in the form of objective
tests, interviews with patients, and diagnosis and treat-
ment plans. The study was based on previous research in
IPR as developed by Norman Kagan, Ph.D., at Michigan State
University, and from the current body of Family Medicine
literature as it relates to medical education.

The next section of this chapter describes the-
need for the study as evident through a brief review of
the literature on the doctor-patient relationship and the

teaching of interview skills. Terms which are either new

or are used in a special sense are then defined. A section
on theoretical perspectives provides a framework for
understanding the communication dynamics of the doctor-
patient relationship, from.which the hypotheses of the
study were developed. A final section reviews the chapter
in summary form and provides an overview of the remaining

chapters.

Need for the Study
Medical literature contained many references
citing the importance of the doctor-patient relationship
and the need for further research and training of physi-
cians in interviewing and affective sensitivity. The
following are a few of the authors who most clearly
describe the doctor-patient relationship and its impor-
tance in the clinical setting.
Bird (1955) considered the doctor-patient relation-

ship a focal point of treatment.

Of all the technical aids which increase the doctor's

power of observation, none comes even close in value

to the skillful use of spoken words--the words of the

doctor and the words of the patient. . . . For these

reasons, the technique of talking must be studied and

developed. It cannot be left to accidental or inci-

dental learning. (p. v.)
A more recent article also supported the teaching of
interviewing skills. Bloch (1973) stated the following
about listening:

The main foci are on the unique nature of the relation

between doctor and patient, the role of empathy, and
a deeper self-awareness in the student. A crucial

facet of achieving this objective lies in the teach-
ing of the interviewing process, particularly the art
and technique of listening to the patient. (p.242)
Bloom (1963) stated that self-awareness is an impor-
tant tool for the physician, and that the meaning of
illness varies.
Each illness, in theory, has a clinical unity: it is
describable according to identifying signs as one
illness or a cluster of illnesses. But the meaning
of illness from the view of the patient is more
variable. It is not capricious, but it is complex.
People perceive illness in different ways.
Clear communication between the doctor and the patient is
critical to the formation of an accurate diagnosis and for
the development of a treatment plan. Turner, Helper, and
Kriska (1974) defined clinical competence as "communication
skill, physical exam skill, and interpersonal skill."
This three-phase model dealt first with the doctor's
ability to communicate clearly to the patient the diagnoses,
medication, and treatment plan in language the patient
could understand, while allowing time for the patient to
verify instruction or ask questions. The second phase,
physical exam skills, was the most closely monitored
segment of training already in existence and the one most
familiar to "old-time" family doctors. The third area,
interpersonal skill, was a somewhat newer addition; its
emphasis was on the therapeutic relationship between ‘
doctor and patient. Until recently, the good intentions

and experience of the practitioner were the only determi-

nants of this therapeutic doctor-patient relationship.

Now it is possible to teach interpersonal skills. Both
affective sensitivity and interviewing skills are domains
necessary for a competency-based approach to family
medicine.

Several authors discussed using the relationship
between doctor and patient as a tool aiding diagnosis and
treatment. Clyne (1972) stated that traditional diagnosis
was said to be illness-centered rather than patient-
centered, and that "the best, most detailed and well-
founded diagnoses are usually presented at clinical-
pathological conferences, after the patient has died." In
contrast, the overall diagnosis, which is patient-centered,
considers the patient's physical and emotional condition
and his relationship with himself and others, including
doctors. Overall diagnosis is useful in that it permits
the deduction of a detailed treatment plan and prognosis.

Loch (1972) listed five situations which the
general practitioner frequently faced:

1. The psychosomatic aspect of illness in its
formative stages, often with the opportunity
to influence the patient's unconscious conflicts
which may be activated at the time.

2. Patients who are in psychological crises

3. Problem patients or the chronically ill

4. Dying patients

5. And . . . "as a result of constant technical
progress, leading to an increase in teamwork,
the general practitioner will soon be the only
doctor with the ability to establish this unique
two-person relationship with his patient."

Loch emphasized the human, emotional side to the doctor-
patient relationship, rather than the clinical, patholog-
ical, or technological sides.

As shown above, there was agreement in the liter-
ature on the need for the doctor to handle interpersonal
encounters with patients adequately, both with regard to
the efficacy of health care and to the process of illness.
Family physicians are often the first, and sometimes the
only physicians to find out about their patients' emo-
tional well-being. Often patients will present their
emotional concerns through physical symptomatology or at
the time of a routine examination. If not blocked by
their own concerns or unfamiliarity about emotional issues,
physicians are in a position to intervene therapeutically
through effective communication, understanding, accurate
empathy, and appropriate listening skills. Family doctors
can thus serve as therapeutic tools in discovering and
dealing with the range of concerns that patients present.

This study applied a specific teaching model
(Interpersonal Process Recall) to the problem of communi-
cation between a physician and a patient. The IPR model

was a development in the field of behavioral science, a

field now applied to many residency training programs.

The next section defines the terms behavioral science and
Interpersonal Process Recall (IPR), preparatory to a

theoretical discussion of communication.

Definition and Discussion of Terms

Behavioral Science

 

Behavioral science, although a term often used in
the literature, has no standard meaning. For the purpose
of this research, behavioral science was defined as that
part of the medical curriculum.concerned with the doctor-
patient relationship, interviewing and interpersonal
skills, affective sensitivity, psychological and psychia-
tric problems and perspectives, and the use of the spoken
word as a therapeutic tool. Behavioral science should not
be confused with behavior modification or behaviorism,

which are subsets of behavioral science.

IPR - The Teaching Tool

 

IPR is a training model which develops skills in
specific interviewing techniques, affective sensitivity,
and self—study through videotape recall. While the IPR
model used in this study offered a structured approach to
the teaching of interviewing and affective sensitivity,
there was some latitude in the actual "content" of the
course. Much of the material was generated by the trainees
as they reflected upon their own perceptions, feelings,

strategies, and ideas. In all of the sessions, trainees

were encouraged to focus on real concerns of a personal
nature, sharing themselves with their peers and instructor.
This level of instruction served to maintain a high level
of interest and motivation in the course as well as to
give the trainees "real" problems to handle. Even in the
cognitive section of the course, examples were requested
from the trainees to make it applicable to their immediate
circumstances. The theoretical viewpoint in the model was
designed to enable the trainees to determine for them-
selves what was relevant to their self-study. Latitude
and permission were given for self-exploration, and a
structural framework was provided which enabled trainees
to form a cognitive and affective base for their inter-
viewing behavior.

There are three basic parts in a complete IPR
course:

1. Basic communication skills are developed through
demonstration, practice, and discussion. The
basic communication skills taught are explora-
tory, active listening, affective, and honest
labeling response modes. Definitions and
examples of the skills can be found in the
appendix.

2. The trainee is acquainted with his/her own
responses to stressful situations through affect

simulation films.

3. Experience is gained through videotaped recall
of interviews with other trainees, patients,
colleagues, and faculty. The video recall
process is the backbone of IPR. In recall,
trainees are encouraged to immerse themselves in
the immediacy of the videotaped interaction and
to relive, in as much detail as possible, the
thoughts, feelings, images, fantasies, strate-
gies, and perceptions that were occurring at the
time of the interview. The facilitator does not
stop the tape to offer criticism or praise, but
rather aids in the self-discovery process through
non-threatening exploratory leads after the
trainee has stopped the tape. Though it seems
a tentative approach for a supervisor, the
potency of the video feedback stimulates much
self-exploration in the recall.

This three-phase course was only slightly modified
in order to facilitate learning by a very small group
rather than a more traditional classroom approach. With
the attention and practice time intensified due to the
small instructor-trainee ratio, the course could be short-
ened slightly in total number of hours without sacrificing
group participation or presentation of material. A thirty-
twofhour version of the course was used for this study.

The IPR method required the instructor to foster an

atmosphere conducive to self-discovery and exploration.
The class sequence for this study can be found in the

appendix.

Theoretical Considerations
The relationship between doctor and patient has
been explored from a diagnostic and treatment perspective.
This section elaborates on the communication dynamics of
the relationship and shows how these dynamics can be

influenced by the IPR method.

The Doctor-Patient Relationship: A Model

 

Several authors pointed out the difficulties in
doctor-patient interactions (Korsch et a1, 1968; Scott,
Donnelly, Hess, 1973; Golden, Johnston, 1967; Snyder,
Lynch, Gruss, 1976). These difficulties were treated as
communication distortions. The causes of distortion in
communication, and how interviewing skill and affective
sensitivity can reduce it are the basis of the following
discussion.

Berlo (1960) and Terwilleger (1968) offered valida-
tion of the premise that distortion is the natural by-
product of interaction. The process of interaction can be
simplified into a four-part conceptual model. This model,
developed by Berlo (1960), clarifies the concept of dis-
tortion. Berlo (1960) designated four components of any

communication system: Sender—Message-Channel-Receiver.

10

The relevance of this model to the medical setting becomes

apparent in the following example.
As sender, the patient tries to tell the doctor-
recerer what is wrong. The patient uses a channel,
perhaps symptomatology or verbal expression, for the
vehicle of the messa e. Distortion can take place
when any of the four component parts of the inter-
action are disturbed. The patient-sender may have
a background, vocabulary, and perceptual field
different from that of the doctor, and for that
reason, the meanings that the patient attaches to
words may be different than the meanings the doctor
attaches to 'those same words.‘

Several articles researched possible causes of
distortion. Snyder, Lynch, and Gruss (1976) interviewed
150 randomly selected patients immediately before and
after their visit with the doctor. Fifty-four percent of
these patients either forgot to mention all their medical
problems or they confused or forgot instructions concern-
ing their diagnosis or treatment. This well-controlled
study also organized the types of problems that patients

had into the following six categories:

1. Misunderstandings about medications
2. Medical problems that were either forgotten or
omitted

3 Misunderstandings about treatment instructions

4. Misunderstandings about diagnosis

5 Misunderstandings about diet instructions

6. Misunderstandings about return appointments
This kind of distortion could have serious medical conse-

quences.

11

A study by Golden and Johnston (1967) reviewed the
ethical implications of distorted communication between
doctors and patients. These ethical implications centered
on this question: Can patients who do not understand what
they are being told be said to have given informed consent
for medical treatment? In the Golden and Johnston study,
transcripts of conversations were evaluated and factors
which contribute to clarity and distortion in communica-
tion were defined. In cases where distortion was evident,
the factors most often cited were inadequate explanation
by the physician and serious illness of the patient. It
appeared that the patient's anxiety over a serious illness
could interfere with the patient's understanding of the
doctor's communication, even when an adequate explanation
was given to the patient. Although their sample size was
not large, an important discovery was made. Ten patients
out of the twenty-five questioned showed definite distor-
tion of what they had been told.

Studies of this kind strongly stated the need for
improved feedback systems between doctor and patients so
that distortion could be detected and modified by addition-
al communication. Some of the consequences of distortion
were seen in examples taken from.the Snyder, Lynch, and
Gruss article.

A 23-year-old woman who was experiencing unwanted

side effects from her newly-prescribed oral contra-
ceptives was told to complete this month's cycle

12

with the pill she was presently taking and then
switch to a new prescription. She misunderstood
and replied, "I'm.to continue taking the same pills
until they are all gone, and then in six months,
I'm to start with this new prescription."
The next example showed the extent to which a patient's
misunderstanding could be carried.
A 28-year-old man looked hesitatingly at the doctor
when asked if he understood the instructions he was
given. The physician sat down and wrote out sequen-
tially all the dietary and medical instructions.
When asked afterwards about what the doctor said,
the patient proceeded to misread most of the instruc—
tions.

Some causes of distortion and examples of it were
cited above. How can Interpersonal Process Recall help
when there is a lack of feedback, unchecked assumptions,
different meanings for words, and information overload?

This question is answered in the following paragraphs.

How IPR Checks Distortion

The most direct opportunity for distortion to be
checked is for the receiver to paraphrase the message to
the sender's satisfaction. This was the aim of the active
listening response mode taught in unit one of the IPR
series. Trainees practiced listening and restating what
they perceived. If this meaning was inaccurate, then the
sender had the opportunity to correct the perception or
modify the statement to make it clearer. The modification
of communication without imposition or loss of face was

encouraged through the facilitating atmosphere of IPR. It

13

is the physician‘s task to create an atmosphere where the
patients are free to ask questions or to restate a treat-
ment plan or medication regime.

The other response modes also encouraged the
patient to tell his/her own story in an atmosphere of
openness which is conducive to feedback. The affect
simulation portion of IPR acquainted the doctor with
stressful interpersonal situations and encouraged him/her
to examine not only the stimuli, but the responses and
messages generated in himself/ herself to this stimuli.

In this manner, the physician was made more sensitive to
the possible meanings that patients may be trying to
communicate, and to the anxiety that may foster distor-
tion. Listening to peers respond to identical stimuli, as
they did in this part of the course, exposed physicians to
the possibility of multiple interpretations of the same
message. This was an invaluable learning situation for
trainees to develop an awareness of the range of possible
meanings, and to learn their own systems for avoiding
certain kinds of patient communications. When a physician
has blocked off certain emotionally charged areas of
communication because they generate personal stress, it
becomes increasingly difficult for the doctor to underStand
the meaning of the patient's message, and important areas
may be overlooked or de-emphasized. The IPR method also

offered video recall of interaction, and allowed the

14

physician to test general principles and to validate
his/her perceptions of interpersonal communication. By
experiencing the distortion, assumptions, and unspoken
questions that inevitably arise when people try to relate
to one another, and by receiving feedback from peers,
trainees could increase their personal awareness and
therapeutic skills.

These were the methods of IPR as they related to
the establishment of a dynamic and distortion-free system
of interaction between a patient and a physician with
respect to the Sender-Messagg-Channel-Receiver model.
This theoretical discussion provided a detailed view of
the doctor-patient relationship and how it could be in-
fluenced by IPR. From this base the hypotheses of the

study can be stated.

Hypotheses*

 

IPR training has been shown repeatedly, in many
different populations, to effect changes in dimensions of
affective sensitivity, use of basic communication skills,
and accelerated progress in psychotherapy. (For a detailed
discussion of IPR literature, see Chapter 2, page 36.)

The group of family medicine residents used in this study
was screened for intelligence, willingness to work with

people, and high scholastic ability as a routine part of

*Formal research hypotheses can be found in Chapter 3.

15

admission to the residency.

It was hypothesized that (1) there would be a sig-
nificant increase pre-to-post IPR training in the basic
communication skills (exploratory, affective, active
listening, and honest labeling response modes) of resi-
dents, and that (2) there would be an increase pre-to-post
training on the Affective Sensitivity Scale as residents
became more sensitive to themselves and more willing to
listen to their patients. It was also expected that (3)
as residents became more self—aware and could deal with
patients on an improved sensitivity and response level,
they would be better able to elicit and to hear patient
concerns, particularly emotional ones, and would respond
to them verbally, fostering an openness which would make
more information available from their patients and thus
improve residents' diagnostic capabilities.

Residents who were less aware of patient concerns
were less likely to record those observations on patient
charts. It was therefore hypothesized that (4) there
would be a significantly greater number of affect words
noted on charts of residents after IPR training than
before training. Finally, with a better understanding of
the dynamics of interaction, there was reason to expeCt
that such physicians would be more likely to see themselves
as therapeutic agents, thus relying less on the use of

minor tranquilizers such as Librium and Valium for their

16

patients. Therefore, it was hypothesized that (5) there
would be significantly less prescribing of these drugs by

residents after IPR training than before.

Summary
This chapter described the purpose of this study,

which was an evaluation of the teaching of interview
skills and affective sensitivity to family medicine resi-
dents. The need for the study was explored, terminology
defined, and theoretical perspectives were provided. From

this background, the hypotheses were developed.

Overview
In Chapter 2, a three-part literature review

examines methods of teaching interview skills, a perspec-
tive of Family Medicine, and the IPR literature. Chapter
3 contains design considerations, sample characteristics,
measurement, experimental design, and the research hypoth-
eses. Chapter 4 contains an analysis of the data, and
Chapter 5 discusses implications and conclusions, presents
recommendations, and summarizes the study. A review of
the relevant studies which serve as ground work for this

research now follows in Chapter 2.

CHAPTER 2
REVIEW OF THE LITERATURE

This chapter consists of three sections, each a
review of the current literature in one of the three focal
areas specific to this study. These focal areas are: (1)
the teaching of interviewing skills to medical personnel;
(2) Family Medicine roles, needs, and training; and (3)
the IPR method, theory, and research, In each section the
material is arranged chronologically, and each section

ends with a summary and brief discussion.

Teaching of Interviewing Skills to Medical Personnel

The literature contained a number of methods for
teaching interviewing skills to medical students and
physicians in residency training or beyond. This section
reviews those methods.

Coleman (1946) stated that it was unfortunate that
the teaching of psychotherapy (the chief tool of the
psychiatrist and one that may be invaluable to the general
physician) was not started at a much earlier period. He
advocated the non-directive, listening approach to psycho-
therapy. Some of his early statements of psychotherapy

served as philosophical groundwork for much of the teaching

17

18

in humanistic psychotherapy found today. For example,
Coleman stated that
The physician presents to the patient the gifts of
time and understanding . . . for the physician, it
implies for himself discipline of feeling, speech,
and behavior, and the control of impatience,
hostility and prejudice.
The teaching of psychotherapy is founded upon individual
supervision with study of interview material. Major
interest is devoted to the reaction of the patient to the
doctor and vice versa. Conference time and case—seminar
time is also included along with individual supervision.
Soon after Coleman (1947) suggested that psycho-
therapeutic skill could counter the authoritarian attitude
fostered in medicine, the skills of psychotherapy began to
be applied to general medicine and medical evaluation.
The Group for the Advancement of Psychiatry (1948) was one
of the first groups to prOpose offering interviewing
training to undergraduate medical students. Whitaker
(1949) described one of the first postgraduate programs in
psychiatry. Doctors were involved in multiple therapy to
promote the "ability to develop a more therapeutic doctor-
patient relationship." Whitehorn, Jacobsen, Levine, and
Lippard (1952) also offered interview training to under-
graduate medical students at Cornell. Gill, Newman, and
Redlich (1954) suggested specific behavioral guidelines

for the interviewer along with listening to audio record-

ings made by the interviewer.

19

Responding to the increasing demand on the part of
physicians for psychotherapeutic skills, Balint (1954)
held case conferences with six to ten doctors, discussing
their day-to-day problems with neurotic patients. He
introduced the "Balint group" consisting of six to ten
practicing physicians who were interested in acquiring
psychotherapeutic skills. Balint asserted that the acqui-
sition of these skills consisted not only of learning
something new, but of a ltmited personality change of the
doctor. The Balint groups focused on the ongoing practice
of the doctor and provided group support, supervision, and
a forum for his or her own personal concerns. Doctors
desiring individual supervision could request it. Balint
emphasized the atmosphere of the group as emotionally free
and friendly.

Engle, Green, Reichsman, Schmale, and Ashenburg
(1957), at the University of Rochester, taught interviewing
skill as part of a clerkship in comprehensive medicine.
The instructors used observations of students' initial
interviews as their mode. Adam (1958) described a compre-
hensive clerkship at Western Reserve University where a
psychiatric consultant was available.

The most effective way to bring about changes in
the way students dealt with emotions and patients, accord-
ing to Werkman (1960), was to "immerse the student in a

new group whose standards represent the attitudes and

20

behaviors he is to learn." Students were encouraged to
participate in interpretive interviews. He discussed the
floundering way students often conducted such interviews
in terms such as appeal to will power, unconscious jealousy
and competitiveness, pussy-footing, retrospective guilt
production, magical solutions, and punitiveness. To avoid
some of these pitfalls, werkman suggested role-playing and
defining the situation for the student more clearly.
Lester, Gussen, Yamamoto, and West (1962) pointed
out student helplessness, anxiety, and hostility as conse-
quences of current teaching methods, and called for the
creation of new, more therapeutic methods. Heine, Aldrich,
Draper, Meuser, Tippett, and Trosman (1962) described a
seventeen-week clerkship at the University of Chicago
Psychiatry Outpatient Clinic where students reported gains
in insight, confidence, and sensitivity. The students
conducted therapy groups under "intensive supervision."
However, the data, although favorable, was not objective.
Pfouts and Rader (1962) at the University of
Southern California School of Medicine described a program
involving case conferences with eight to ten physicians.
Demonstrations were followed by discussion of techniques.
Aldrich and Bernhardt (1963) described a four-year
sequence for teaching psychiatry to medical students that
included a threefold increase in teaching time, seminar

case-study instruction, and longer supervised patient

21

contact. There was no significant difference between
these students and students in the traditional program who
had less teaching time and patient contact. The authors
found that the test instruments, the Problem Cases Test and
the Filmed Interview Test, correlated poorly with instruc-
tors' grades. They called for more practical tools to
measure potentiality in interpersonal relationships.
Enelow, Adler, and Manning (1964) described a teaching
clinic where physicians conducted an interview, watched a
demonstration conducted by the supervisor, and followed it
with discussion. During the course, a shift in the stu-
dents' conception of the physician's role was noted towards
more use of the doctor-patient relationship.

Coggeshall (1965) emphasized the need for medical
schools to turn out increasing numbers of students with
interpersonal skills enabling them to work with a team of
medical specialists, enter into facilitating relationships
with their patients, and relate to patients from.diverse
backgrounds. Coggeshall concluded that "interviewing
skill, constructive interpersonal attitudes, flexibility
of role definition, and understanding of basic human
behavior will be of increasing importance."

Mattarazzo, Wiens, and Saslow (1965) reviewed the
teaching of psychotherapy in medical schools from 1948

through 1963. They discussed mechanical innovations,

22

program description summaries, and conceptual frameworks,
as well as approaches to experimental study and examples
of research in the field.

Matarazzo, Phillips, Wiens, and Saslow (1965) and
Matarazzo, Wiens, and Saslow (1966) measured the interview-
ing behavior of medical students before and after an
eight-week psychiatry clerkship, and examined the effects
of three different methods of supervision. Over three
years, students showed greater improvement each year. The
authors suggested that this improvement corresponded to
improved teaching techniques.

Thurnblad and McCurdy (1967) summarized the medical
school programs supported by the NIMH Human Behavior
Grants during the year 1964-65.

Most of the programs have used large group lectures,
but often supplement these with small group dis-
cussions. Demonstration interviews, films, and
videotapes are utilized. Unstructured student
groups are often used as laboratories of human
behavior and for self-observation. As yet there is
no systematic comparison or evaluation of such
programs. Apparently few if any of them.have become
directly involved with teaching the student himself
how to interview and/or relate to patients, except
as this may be implicit in lectures and "modeling"
during demonstration interviews.

Pollach and Manning (1967) described a course
offered since 1958 at the University of Southern California
where small groups of students met once weekly for twelve
weeks with a psychiatrist and a physician to discuss the
students' forty-five minute interviews which were previous-

ly conducted. This course was given to beginning medical

23

students to offer patient contact and faculty acquaintance.
Through this course, critical incidents and blocks in
doctor-patient communication were explored along with
student defenses used to guard against these situations.
Hastings (1968) described the teaching of psychia-
try "in vivo." The premises of his method were: (1) the
"therapeutic use of oneself" as the fundamental psychiatric
skill, (2) that this skill was of infinitely greater
importance than any scheme of diagnostic classification or
psycho-genetic theory, and (3) that it could be taught
effectively, although acquisition of this skill was left
largely to chance in most medical school curricula. He
described a strategy for the teaching of this skill by
non-psychiatric parsonnel using a multidisciplinary,
hospital-based home-care unit as its teaching laboratory.
The course involved first-year medical students in groups
of five assigned as teams to a staff physician and a
public health nurse. The students spent one afternoon a
week for eight weeks in the program. The student was to
be a "family advocate." Before or after each home visit,
hour-long seminar discussions were held with the physician
and nurse for each group. Home visits were often audio-
taped for replay in the group. This method was expensive
in terms of time, money, and equipment, but the author
justified it by the learning gains of the student concern-

ing cultural differences and societal barriers which were

24

directly experienced and later discussed.

Muslin, Singer, Mueser, and Leahy (1968) described
a course in psychiatric interviewing at the University of
Illinois. The experiential learning model had students
performing interviews over a three-month period with
traditional and video supervision. Teaching and learning
goals were in the areas of (l) observational skills, (2)
collating skills, and (3) data gathering and therapy
skills. These authors also studied the impact of their
training program by rating student interviews against the
faculty responses to filmed interview segments. Cattel's
IPAT Anxiety Scale and the F scale were also criterion
measures. Data from this study indicated that simulated
clinical situations for examinations did not represent a
valid replica of behavior during actual clinical situations.
These authors concluded that the "student's actual perfor-
mance is the only reliable indicator of his learning of
clinical psychiatric skills."

Ornston, Chicchetti, and Fierman (1968) compared
interview behavior of psychiatry residents with that of
experienced psychotherapists. They found that compared to
the experienced therapists, novices used short choppy
questions and explored specific, narrow content areas.

Froelich (1969) stated that " . . . the focus on
family medicine, on comprehensive medicine, and on the

demands of the consumer that he be interviewed with skill

25

and be made to feel that the physician is interested in
him . . . are the forces within our society which direct
that more training be focused upon the skill of interview-

ing. He then proposed a sixty-four hour course for
learning medical interviewing, comprising six steps:
(1) role-playing, (2) use of a programmed manual on ways
of responding, (3) role-playing and programmed patients
using video replay, (4) observation of skilled interviewers,
(5) interviewing live patients, and (6) writing the history.
Bernstein and Dana (1970) developed a four-hour-
per-week course. In the first hour a student interviewed
a patient; in the second, students discussed the interview
with a tutor; the third hour was a demonstration interview;
and the fourth, a discussion period. The Bernstein and
Dana book on interviewing served as a formalized guide,
providing a framework for the conceptualization of the
clinical experience. Instructors provided a point of view
from.which to conceptualize a patient's behavior. Both
nurses and doctors were addressed in an effort to unify
their efforts and reduce the incidence of power struggles
and communication breakdowns. The authors began with the
patient's view of illness and the hospital stay, then
effectively discussed the hidden outcomes of dissatise
faction. In the interviewing sections, the authors

described five different kinds of response categories--

evaluative, hostile, reassuring, probing, and understanding.

26

Besides the discussion of the response modes, a section on
"Conditions for Effective Interviewing" dealt with such
concerns as attentiveness, rapport, and freedom from
interruption, as well as psychological privacy and emotion-
al detachment.

Kimball (1970) suggested an interviewing course at
Yale University School of Medicine specifically designed
to teach students working with a preceptor by the use of
alternating demonstrations and didactic instruction. He
also included trial-and-error exercises which were set up
in a stepwise fashion progressing from.a five-minute
patient interview through a forty-five minute interview.
Each step was monitored by the preceptor and a small peer
group; discussion followed. The students' interview
responsibilities increased at each stage. Subsequent
special sessions were added to deal with certain types of
patients. This approach sought to integrate a multi-
faceted approach to patient care, taking into account
social as well as biological concomitants to the patient's
illness.

Suess (1970), of the University of Mississippi
Medical Center, encouraged students to videotape their
patient interviews for personal replay. Students were
also rated by faculty. Suess presented a rationale for
the use of video:

Videotape is a good medium for objective study of the
interview process and also offers the possibility of

27

self-confrontation and observation of what actually
happened . . . Although the student may have a theo-
retical orientation which tends to mold his therapeu-
tic behavior and posture, the videotape recorder is
not bound by such restrictions and can faithfully
document the here-and-now process of the therapeutic
interaction in a non-preferential fashion . . . When
viewing the videotape, the student is an observer
only, with the opportunity to concentrate fully on
the objective data from either himself or the patient

and to review by multiple replays . . . This self-
discovery becomes more acceptable when it is a result
of one's own experience and observation . . . Since

the videotape recording contains so much perceptual
data, a fifteen-minute segment of an interview
contains sufficient information for adequate viewing
and evaluation. As in most therapeutic sessions,
more material is produced in fifteen minutes than can
be exhaustively dealt with in several weeks.
This self-confrontation process can be used with the
student alone, with a supervisor present, with the peer
group, or with the patient also present in any of those
conditions. The students and teachers involved in this
process all reported student interviewing gains when these
methods were employed.

Adler, Ware, and Enelow (1970) described a study
of a programmed instructional method with ten simulated
medical interviews and group supervision. In the pro-
grammed interviews, students selected among alternative
actions of the interviewers and got immediate feedback of
either approving or disapproving explanatory remarks by
the narrator. This was compared with a form of group ~
supervision where each student video-interviewed a patient

and a discussion of the videotape was held by the group.

The goal was to teach a non-interrogative interviewing

28

style. The authors concluded that the programmed instruc-
tion was superior to the group supervision in producing
certain behavioral changes and in changing attitudes of
the learners.

Metarazzo (1971) stated that historically there
had been little psychotherapy or interview training outside
of psychoanalytic institutes; however, after World War II,
most medical schools instituted three-year residency
programs.

Stoeckle, Lazare, Weingarten, and McGuire (1971)
reported on the use of videotaped recordings of student
interviews with outpatients. These interviews served to
stimulate the students' interest in their skill and roles
as doctors, and to clarify issues distinct to community
medicine. These diffuse goals were attempted in a course
that took place over two three-hour sessions a week for
eight weeks. A student videotaped a patient and returned
the next week for a follow-up evaluation session. This
follow-up conference was attended by a psychiatrist and
the students' peers. Both students and faculty felt the
course to be successful in increasing the students' inter-
est in social-psychological issues. Problems encountered
in the course centered around some students' fear of being
videotaped. Also, some students learned well from their
own videotapes, but not from.videotapes of other students.

There was a curious drop-off of student interest after the

29

fourth week. The authors believed that the use of video-
tape in the general education of medical students was
limited.

Enelow and Swisher (1972) in their book stated,
"We are interested in what data to get, how to get it, and
how to synthesize these data into an understanding of the
patient's total situation." Their book discussed the
nature, process, and theory of medical interviewing.
Their focus was not on what information to get from the
patient, but on facilitating the communication between
professional and patient. Specific techniques such as
opening the interview, silence, confrontation, questions,
support and reassurance, and avoiding biased questions
were described. Along with a discussion of the Problem-
Oriented Record, there were chapters on emotional and
behavioral responses to illness and the interviewer,
interviewing children, the family, and discussing and
planning treatment. There was discussion on both patient
and professional roles and on some sociological aspects of
illness.

Froelich and Bishop (1972) in their book Medical
Interviewing, a Programmed Manual described a design "to
actively teach the student alternative ways of responding
to a patient and to develop a feeling for the appropriate
lead." They listed the fourfold purpose of the medical

interview: (1) to gather information about the patient

30

and his illness that is not available from other sources,
(2) to establish a relationship with the patient that will
facilitate his diagnosis and treatment, (3) to give the
patient an understanding of his illness, and (4) to support
and direct the patient in his treatment. The manual
directs the student to read a brief section and then

answer a question or set of questions.

Hopkins (1972) as editor of Patient-Centered
Medicine put together a number of papers from the first
international conference of the Balint Society in Great
Britain on "The Doctor, His Patient, and the Illness." It
was an account of many physicians and their associations
with patients, focusing on the doctor-patient relationship.
There was also a demonstation of a Balint-type group of
physicians discussing their patients, and a chapter on
illness and its management.

Dobbs and Carek (1972) discussed a conceptual
model of the medical interviewing process which was
designed to clarify the functions of the interview and
demonstrate the problems created. They defined four
levels in such an interview process: (1) data gathering,
(2) information storage, (3) evaluation and synthesis of
data, and hypotheses formation and testing, and (4) edu-
cation and therapy. The authors illustrated that blocks
in any of those areas can lead to inadequate interview

sessions. The implication of the model was that instruction

31

has often concentrated on isolated aspects of the interview
rather than the overall process. The authors added that
without the aid of videotape it was unlikely that the
instructor would have a realistic picture of the students'
skills and deficiencies, because a student's report,

though well organized, might not be the result of a good
interview.

Elstein, Kagan, Shulman, Jason, and Loupe (1972)
identified these four goals in their study of medical
inquiry:

1. Identify the intellectual strategies and tactics
of expert clinicians

2. Generate a psychological theory to explain these

features
3. Relate the theory to current theories
4. Develop instructional methods and materials to

assist medical students in acquiring their
problemrsolving skills
They described a systematic program of testing, evaluation,
and teaching.

Burra (1972) described a course taught at Queen's
University designed to train undergraduate medical students
in the psychiatric skills relevant to general practice-
Role playing in groups of six to eight students with
specific protocol was the teaching mode. They had a total

of four one-to-two-hour sessions. After a twenty-to-thirty

32

minute interview the participants would return for dis-
cussion with the rest of the group. Students were asked
to compare the role-playing format with a multiple-
choice questionnaire format and expressed an "almost
unanimous" preference for the role-playing. Researchers
also found that the use of a rating scale interfered with
and inhibited discussion.

Messner and Schmidt (1974) described a course in
family medicine at Harvard Medical School employing a pre-
ceptor and including patient conferences recorded on
videotape. The use of videotape allowed exposure to many
problems not observed during a clerkship. They found that
the videotape medium.did not lessen the emotional impact
of the interviews. The authors also found brief replay of
the videotaped sessions meaningful. "The principles
involved in the management of these (emotional) problems
are often difficult to teach by such traditional methods

as lectures and readings.‘ The videotaped segment of the
course consisted of a forty-five-to-seventy-five minute
session between a patient and a psychiatrist. This was
preceded by a case history and discussion by the health-
care team. Following the interview, the student, patient,
and psychiatrist discussed the situation further. The
authors advocated a videotaped library for reference use.

Goroll, Stoeckle, and Lazare (1974) described

clinical interviewing as taught to first-year medical

33

students. In the tendweek course, each student videotaped
interviews of six or seven patients and met in weekly
conferences to discuss the interviews. The content of the
course focused on the four areas of the patient's request
to seek help, medical data, psychological data, and social
data. Student interviews were rated by two nurse practi-
tioners on an arbitrary one-to-seven scale for each cate—
gory. Other elements of evaluation were patient opinion
of their care, student opinion of their experience, and
the effect of the course on clinic operations. Only six
students participated in this course and their overall
interview performance significantly improved. Conclusions
were that preclinical students could learn to interview
patients without compromising patient care. However, the
training did slow clinic operations.

Bowden and Barton (1975) concentrated on the
content of medical student psychiatric education. Goals
were organized into six areas: (1) recognition of psycho-
social aspects of medical events; (2) developmental
adaptation during the life cycle; (3) interactional
adaptation; (4) attitudinal, observational, and diagnostic
skills; (5) recognition and management of psychopathologi-
cal disorders; and (6) the physician's role adaptation.
Bowden and Barton described non-directiveness, attentive-
ness to nonverbal behavior, and grasp of the importance of

the doctor-patient interaction as necessary interview

34

skills. They also stated that "because of the critical
importance of role modeling in clinical situations, it is
important that education of the student in humanistic
attitudes involve faculty other than psychiatrists."

Ward and Stein (1975) reviewed the literature on
the teaching of interviewing to medical students and
psychiatry residents and concluded that the emphasis on
teaching must shift from.content to process. Their method
of teaching students included a seminar focused on reducing
the emotional distance between doctor and patient. They
emphasized that the teaching of such skills needed to be
highly individualized and that "a live patient was neces-
sary because the literature indicates that simulation,
reading, or anything less than an authentic interchange
between two people would be highly inadequate to learn the
subtle process skills required." Considerable description
and examples were given of self-confrontation and patient
confrontation. Specific objective criteria were not used
for determining emotional distance; however, many of the
interviewers' comments did relate to Klein's Experiencing

Scale.

Summary and Discussion
This review of the methods of teaching interview-
ing to medical personnel was an overview of the advances
in the field since its beginning after World War II. Most

of the literature was descriptive in nature. Included in

35

the various methods of teaching interviewing were lectures,
seminars, small group discussions, case conferences, video
feedback, role playing, programmed texts, observation of
others, interviewing live and 'simulated' patients, writing
a history, and using manuals of interviewing. The studies
that did evaluate used a number of novel and creative
instruments which deserve attention and more extensive
study and validation.

The literature showed medical educators' acceptance
of interviewing as a valuable and necessary part of a
physician's training. However, the need for followeup was
especially clear concerning the effects of skilled inter-
viewers on their patients and the retention of interview-
ing skill over time.

Much of the literature was either quite general in
its approach to interviewing or very specific in its goals
and processes. In contrast to the approaches to inter-
viewing in the past, IPR offers both the specific skills
of interviewing technique and a broad—based theoretical
perspective. It also offers the student opportunities to
study him/herself in action, to practice specific skills,
and to generalize the use of these skills to diverse
settings. The teaching of interview skills to medical
personnel was one aspect of this study. The following
section on family medicine discusses whether such a train-

ing program can be of particular interest to the family

36

physician. Following that is a look at the specific IPR

literature, its outcome, and its impact.

Family Medicine: Roles, Needs, and Training

The behavioral science literature in the field of
family medicine is limited in quantity and mostly descrip-
tive. The focus for this section is on recent writings in
family medicine with relevance to theoretical and training

issues in behavioral science.

Establishing Family Medicine as a Specialty

Before the founding of the Board of Family Medi-
cine, Alpert (1968) discussed the resistance of some
medical schools toward accepting Family Medicine as a
discipline. Some medical educators, who felt that one
physician could not do everything, did not consider family
medicine seriously as a specialty. Alpert discussed the
need for family physicians: "If medical schools continue
to train physicians in the future as at present, the
community role of the family physician will be performed
by someone else, since the need will not disappear."
Alpert contended that the family physician should be
available in the office, the hospital, and patient's home,
whether the patient was in crisis or not. Alpert suggested
research be done to determine who best fulfilled the
function of the family physician--perhaps it would be a

group practice where physician's assistants deliver the

37.

bulk of patient health care. Alpert stated that the family
physician could not practice medicine alone, but that a
health-care team of professionals covering a wide range of
community resources would be the most efficient method of
delivering health care. He called for upgrading the status
of family medicine as a specialty. In conclusion, he
stated, "There should be no doubt that the function of
family medicine exists, but whether it will be provided by
the medical education remains to be seen."

Lienke (1970) observed that since the American
Board of Family Practice was established in 1969, family
practice has found a place as the nation's twentieth
specialty and has become formally recognized. One objec-
tive of the Board was to bring general practice up to date,
standardizing training and certification. Lienke quoted
Dr. Lynn Carmichael's concept of Family Medicine as "the
organized body of knowledge or the scientific discipline
concerned with comprehensive and continuing health main-
tenance of patients and their families." In his article
Lienke defined and discussed the family physician and
family practice. The unit in his model on family practice
training focused primarily on ambulatory patient care and
closely resembled a kind of practice that physicians might
experience upon completion of their residency training.
Lienke stated that

Comprehensive care given by the family doctor requires
his skill in using and coordinating the services of

38

all the various health specialists and health-related
agencies . . . As a full member of a model family
practice group, the resident learns the psychological
principles and the technical mechanisms for main-
taining a durable partnership with its associated
advantages for a rich personal and professional life.
(p.2099)

Leinke also described the clinic and hospital experience

at the University of Oklahoma where the behavioral science

area included the following seven goals:

'01.

Extend the trainee's understanding of psycho-
physiological mechanisms in health and disease

Increase skills in interviewing and other
aspects of interpersonal transactions, and
promote understanding of psychodynamic factors
at work in the doctor-patient relationship

Show how concepts of health and disease are
related to an individual's culture

Impart some comprehension of group dynamics
and processes, especially as they relate to
family life in our culture

Develop an understanding of the ways in which
each trainee's own attitudes and emotions
influence work with patients, and the ways in
which the trainee's own family life may affect
the understanding and therapeutic capability in
dealing with families

Assist the trainee in understanding the dynamics
involved in doctor-patient relationship and the
other interpersonal transactions of family
practice

Provide analysis and evaluation of the learning
process in family medicine as it involves both
the individual trainee and the structure of the
program as a whole; and analyze the effective-
ness of the program in terms of the relative
merits of this approach to health education and
patient care as compared with other strategies"
(D. 2100)

39

Lienke concluded that family practice residency formalized
the teaching of total assessment and management of patient
care.

Darley (1970) emphasized the patient-care-team
concept for the future education of those in family prac-
tice. He stressed that patient care teams be organized
around goals of continuing, comprehensive patient- and
family-centered medicine.

Kieley (1971) stressed the role of family physician
as psychotherapist in maintaining a patient's equilibrium.
The doctor-patient relationship was the fundamental basis
of therapy; and though therapeutic goals might be limited,
he believed it was important that the family physician
practice suppressive and supportive psychotherapy. He
described several misconceptions surrounding time commit-
ments, physician discomfort, deep psychoanalysis, and
extensive specialty training, and he referred to the
logistics of scheduling psychotherapy for patients, inter—
viewing techniques, the relationship between doctor-patient,
the aims of psychotherapy, and its limits. Finally, the
principles of psychotherapy were discussed in terms of the
focus on conscious material from.the patient, avoiding the
provocation of anxiety, avoiding moralistic lectures, not
forcing patients to learn, and avoiding arguments. The
physician's understanding of himself was stressed as the

most essential qualification for management of patients

40

with emotional problems.

Definition of Family Medicine

 

Geyman (1971) reviewed the definitions of family
medicine as an academic discipline, outlined a definition
of family medicine in terms of its function, and discussed
the implications of such a definition. Geyman defined
"family physician" as a physician who:

"1. Serves as the physician of first contact and
provides an accessible means of entry into the
health care system

2. Evaluates his patients' total health needs,
provides personal health care within his range
of competency, and refers patients when indicated
to other specialists or community resources

3. Accepts responsibility for his patients' total
health care, including the use of consultants,
within the context of the family and community

4. Acts as a coordinator of his patients' health
services" (p. 815-16)

He also pointed out the difference between family practice
and family medicine. "Family practice denotes the process
of application of the knowledge and skills of the family
physician as he delivers health care to families. Family
medicine is the academic discipline which is acquired and
applied by the family physician."

Geyman reviewed other definitions of family medi-
cine by Lienke, Carmichael, Stephens, and McWhinney.
Carmichael saw family medicine as a behavioral discipline,
not a medical or surgical one. Stephens described a cur-

riculum in family practice with elements of forensics,

41

history, human growth and development, family structure and
function, social dimensions of behavior, philosophic and
moral dimensions of behavior, and the science of medical
practice all combined. McWhinney labeled five elements of
family medicine--evaluation of symptoms, natural history of
disease, physical and mental development, human behavior,
and social influences.

Geyman stressed the difficulty of defining family
medicine concisely. Other specialties were defined on the
basis of anatomy, age, and sex--for example, dermatology,
pediatrics, and obstetrics. Family medicine cut across
these boundries. Another difficulty was that family
medicine involved each step in health care--prevention,
detection, treatment, and rehabilitation. Finally, family
medicine resisted definition because its skills and know-
ledge must vary with the geographical location and the
particular type of practice. In light of these difficul-
ties, Geyman developed a functional definition of family
medicine as:

That body of knowledge and skills applied by the
family doctor as he provides primary, continuing,
and comprehensive health care to patients and their
families regardless of their age, sex, or presenting
complaint. It is a horizontal discipline, sharing
portions of all other clinical disciplines from which
it is derived but applying its derivative portions in
a unique and holistic way to families. In addition,
family medicine includes new, incompletely developed
components, such as family dynamics in health and
disease and its own areas of research.

The discipline of Family Medicine can be

further described as: (1) including an area of
competency to deal with approximately 90 percent of

42

all health problems of the family, (b) involving

the responsibility to arrange and coordinate re erral
to other specialists and community resources when
indicated, (c) including responsibility for patient
care both in and out of the hospital, with emphasis
on more effective ambulatory care, and (d) requiring
teamwork with an expanding health team. (p.818)

The Family Doctor's Role

Bock and Egger (1971) described a training model

for family practice residents in behavioral science at

Ball State University which emphasized "the relationships

among family physicians, educators, researchers, and

administrators." They described a multi-level model

summarized as follows:

Level 1

Level 2

Level 3

Level 4

Health was viewed from the perspectives of
the individual, family, and community.
Health had three aspects--physical, social,
and intellectual-emotional, and three
resultants--knowledge, attitude, and
practice.

The key issues were growing and developing,
interacting, and decision-making.

Eight concepts described this level. These
concepts were that: (1) growth was recip-
rocally determined by heredity and environ-
ment; (2) the family was the basic societal
unit; (3) the use of health information and
products was dependent on cultural percep-
tions; (4) human behavior was determined by
a complexity of forces; (5) health care
should be comprehensive; (6) education and
research should be done on social and
cultural dimensions of nutrutional patterns;
(7) disease existed in a reciprocal relation-
ship with the individual and his environment;
and (8) interpersonal relationships deter;
mined the competency of the family physician.

This was the level of "the operational or
functional aspect of behavioral science."

43

At this level, "the primary skill which must
be mastered by family physicians is the
skill of people management."

Level 5 This level was described as the most
important one. The major concept was
training of residents to improve their use
of behavioral science.

Stanford (1972) discussed the family doctor's role
as a counselor. She related a survey by the American
Academy of Family Physicians of its (then) 2,300 members
which revealed that United States family doctors spend one-
fifth of their working time counseling patients for emo-
tional problems. The areas of counseling most frequently
cited were, in order of decreasing frequency, marital
counseling, individual adjustment problems, and problems of
single, divorced, or widowed persons. She discussed the
family doctor's professional relationships with psychia-
trists and/or psychologists, and also noted that most of
the doctors responding believed their training in the area
of counseling was inadequate. Stanford also called for
continuing education courses for doctors already in
practice.

Baker (1974) at Rochester, described the unique
areas of expertise essential to the provision of compre-
hensive, continuous medical care and the fit of family
medicine into that realm. He pointed out that general
practice residencies in the fifties failed because they
did not "demonstrate decisively what it is that the family

physician can do better than the specialist." Baker

44

discussed six skills unique to family practice: (1) Ambu-
latory care. White's study showed that over 90 percent of
all illness is treated on an ambulatory basis, although
medical education for over fifty years has been almost
entirely hospital-based. The program at the University of
Rochester focused on the "fifty most commonly seen condi-
tions." (2) Continuity of care. (3) Use of ancillary
personnel. Residents worked with a health team in a
private practice. (4) Counseling. "The family doctor
acts as health counselor to his patients in a very broad
area, and he has had to develop an intimate knowledge of
existing systems and sources of health care. . . . Skill
in psychological counseling is also essential to all
physicians, yet training in the handling of emotional
problems of patients and their families is often neglect-
ed." The Rochester faculty taught interview techniques,
self-awareness and sensitivity, and counseling skills to
its residents. (5) Preventive medicine. The treatment
was patient-centered rather than illness-centered.

(6) Economics. Residents were made aware of the high cost
of medicine and were considerate of their patients in this
regard. These six areas which Baker described were the
unique ways in which family medicine filled a legitimate

place as a specialty in the health care system.

45

Summary and Discussion

This review of the family medicine literature
emphasized family medicine as an academic discipline with a
relevant place among the medical specialties, its special
training needs of non-hospitalized patient contact, and the
team approach in a model group practice. The problems of
defining the new specialty were discussed. The need for
family physicians to be trained in the behavioral sciences,
in interviewing and psychotherapeutic skills, and in team
management was shown. This literature review also described
many of the innovative programs which were formulated to
cope with the complex problems of training the specialist

in family medicine.

The IPR.Method, Theory, and Research

The prolific literature on IPR was divided naturally
into categories according to the group trained. This study
addressed the following five categories: IPR and psycho-
therapy, IPR and training para-professionals, IPR and
counselor education, IPR and general education, and IPR in
the medical realm.
IPR and Psychotherapy

Kagan, Krathwohl, and Miller (1963) described the
use of video recall with therapist and client. The inter-
action was video-recorded and later viewed in the presence

of another trained counselor. The therapist and the client

46

were in separate rooms equipped with playback monitors.
The replay was stopped for both therapist and client any
time either of them.indicated. Though the number of
participants in this study was small, the authors were
optimistic for the potential usefulness of IPR as an
accelerator of psychotherapy.

Woody, Krathwohl, Kagan, and Farquhar (1965)
combined hypnosis with IPR. Videotapes of some of the
psychotherapy sessions were studied by eight clinicians.
Results confirmed that hypnotic and IPR techniques aided
the client's involvement in the counseling process.

Kagan and Schauble (1969) studied simulated recall
using the IPR.method to test client growth in therapy.

The client was videotaped while watching stimulus films.
The tape was played back to the client who responded to it
with the aid of an inquirer. Client physiology was recorded
on a polygraph recorder and could be played back on a

split screen. Client growth was measured along the four
dimensions of (l) admission of own discomfort, (2) commit-
ment to change, (3) client differentiation of stimuli, and
(4) client behavior. Results suggested that affective
stimulation within the IPR process accelerated the client's
ability to perceive, differentiate, and gain insight into
his/her reactions to others. '

Resnikoff, Kagan, and Schauble (1970) studied an

eighteen-year-old male who had reached a therapeutic

47

impasse after eleven counseling sessions. The twelfth
session was done with videotaped recall. Then two groups
of judges rated tapes of sessions nine through fifteen
using a rating instrument with five dimensions and a five-
point scale consisting of (1) ability to gain insight, (2)
level of defensiveness, (3) ability to experience feelings,
(4) ability to relate to the therapist, and (5) overall
therapeutic relationship. Four categories of client
behavior were also identified--client owning of discomfort,
client commitment to change, client differentiation of
stimuli, and client behavioral changes. It was noted that
following the IPR sessions the rating by both groups of
judges increased over the five variables. At the fifteenth
session, the appearance of a solidified positive plateau
was effected by the ceiling effect of the instrument. This
case served to illustrate that even when a good therapeutic
relationship exists, progress may be accelerated by means
of videotape recall.

Schauble (1970) studied client response to therapy
using a part of the complete IPR course, the video recall
of a client's response to affect simulation. Interviews
one and six were recorded and rated by judges. The mea-
surement used was a variation of the instrument developed
by Resnikoff, Kagan, and Schauble (1970) above which ruled
on acceptance of feeling, desire to change, differentiation

of stimuli, and level of self-exploration. The IPR group

48

when compared with a traditional group showed significant
improvements on all four measures. It was concluded that

the IPR technique had accelerated client growth in therapy.

IPR and the Training of Para-professionals

Scharf (1971) compared an intensified IPR course
with an intensified community skills program for training
undergraduates as para-professional counselors. Each
training program lasted five days and totaled forty hours.
The intensified IPR model consisted of five progressive
steps: (1) a lecture on facilitative conditions, (2)
tape-rating, (3) affective skills training, (4) role-
playing, and (5) the IPR process. The community skills
program.was based on Carkhuff's work with discrimination
training, empathy training, role—playing, group discus-
sion, and client interviewing. Scharf use six different
criterion measures immediately post-treatment and again
eight weeks later. They were the Affective Sensitivity
Scale (Form C), audiotapes of client interviews rated on
the Carkhuff Empathic Understanding in Interpersonal
Processes-Revised (CE-II), and four subscales of the
Counselor Verbal Response Scale (CVRS). The results were
inconclusive, but suggested that an intensive course
(forty hours in one week) was not an effective way to
teach using either IPR or Carkhuff's model.

Dendy (1971) involved undergraduates as para-

professional counselors in their positions as Resident

ll

49

Assistants (R.A.'s). He used twenty-two R.A.'s from one
residence hall as the treatment group and compared them
with another group of R.A.'s from.a different dorm, who
received similar training, but without affect simulation
films. Another comparison group from.the same dormitory
was randomly assigned to empathy training groups which used
role-playing and tape-rating. (These subjects were the
same ones that Scharf tested above.) A third criterion
group consisted of eight professional counselors from the
Michigan State University Counseling Center.

Dendy's treatment design involved rating pre-
recorded tapes on the element of empathic understanding and
effective communication, response to affect simulation, and
use of IPR techniques. The training was in two four-week
phases, one in the spring and one in the fall of 1970, for
a total of thirty-eight hours. Dendy used the same crite-
rion measures as Scharf and administered them.before and
after each of the phases of the training program. Results
showed a significant difference in both phases of treat-
ment, pre to post. He also found that the skills learned
in the first phase of training did not deteriorate over the
three-month summer recess. Another finding was that the
R.A.'s were taught to function on certain dimensions of
helping relationships at levels no different from that of
experienced professional counselors at or near the Ph.D.

level.

50

Archer (1971) studied the undergraduates trained in
Dendy's (1971) study as para-professional counselors to see
if they could be used to train fellow students in inter-
personal communication skills. Also, he compared an IPR
training model with an encounter-developmental model. The
criterion measures used included the ASS-C, the Personal
Orientation Inventory (POI), the Wisconsin Relationship
Orientation Survey (WROS), and the Barrett-Lennard Relation-
ship Inventory. The sample consisted of volunteers for a
student-led interpersonal communication skills training
program. Results of the study showed that a structured IPR
training model could be used successfully by undergraduates
to teach interpersonal skills to other undergraduates, that
an integrated IPR.model was more effective than a less
structured Encounter-Developmental group training model,
and that undergraduates could function as para-professional
group leader/trainers. The study also showed that the
therapy training method could be adapted for use in non-
therapy, growth-oriented settings, and that interpersonal
communication skills training could have an effect (based
on non-systematic observations) on the operation of the

social system (the dorm) from.which the trainees came.

IPR and Counselor Education
Goldberg (1967) compared the IPR method to a
traditional approach to counselor education. The tradi-

tional approach (one hour of individual supervision after

51

each of six client interviews) was intended to help the
counselor understand the relationship with the client.
Both IPR and the traditional approach included listening
skills and recall, but the IPR method did not include
affective sensitivity training. Criterion measures (CVRS
and WROS) were administered pre and post-training. Both
groups improved significantly on both measures but the IPR
trainees had higher ratings than the traditional trainees.
Spivack (1970) studied the IPR approach in compari-
son with a traditional classroom approach to counselor
education. All trainees received five weeks of each
treatment in the ten-week course. Criterion measures were
taken before training, midway through, and at the end.
After the first five weeks, results favored the IPR model
on the Understanding, Specific, and Exploratory subscales
of the CVRS in an interview with a coach client. When
role-playing clients were used, the IPR group scored
significantly higher than the traditional group on all of
the CVRS scales. Spivack's conclusion was that IPR could
be used successfully in a formal counselor training program.
Grezgorek (1971) studied all of the forty-four
counselors employed in the Michigan Department of Correc-
tions. Most of the trainees had been guards in the system
before they were counselors. The training was done by an
advanced doctoral student in counseling and by a Ph.D.

counselor. Criterion measures consisted of the Affective

52

Sensitivity Scale (Form B), the CVRS, and the Empathic
Understanding in Interpersonal Process (EUIPS). A pre-post
design was used. The focus in the experimental treatment
groups differed in that in one group, trainees were en-
couraged to deve10p more effective ways of dealing with
clients, and in the other, treatment focused on the train-
ee's ability to develop self-awareness and an understanding
of self-dynamics in interpersonal interactions. The ten-
day training program was divided into a series of four
basic tasks: (1) a lecture and discussion of facilitative
counseling, (2) simulated confrontation using affective
sensitivity films, (3) the recall process, and (4) group
review and discussion of videotaped client contacts. The
training sessions lasted two weeks for a total of eighty
hours. The results showed that the affective treatment
focused on trainee self-awareness had a significant overall
effect on counselor performance in training. The two
treatments were not different in the ability to perceive
client feelings and reactions as measured by the A.S.S.;
they were different when counselor performance was measured.
Trainees in the affective treatment group made significant
gains pre-to-post on the combined results of the criteria.
Grezgorek concluded that the evidence supported the notion
that prison counselors must learn to "own up to their own
feelings" if they are to make gain in their dealings with

clients (inmates).

53

Heiserman (1971) compared the IPR program (reduced
to sixteen hours) to a cognitive teaching approach of the
same length. All subjects received both treatments in
different order. The design was the standard pre-mid-post-
treatment one, and the CE-II, the WROS, and the four sub-
scales of the CVRS were used as criterion measures. The
WROS showed the only significant change, which was that
clients reacted more positively to the counseling relation-
ship if they had IPR-trained counselors. It was concluded,
however, that there was no significant difference between
the methods since no other measures supported the WROS
data. A possible explanation wsa that the students'
abbreviated exposure to IPR was insufficient to produce
greater change.

Rowe (1972) used an expanded fifty-hour IPR train-
ing program for twenty-one student counselors in a graduate-
level course. No control group was used. Pre and post
measures were taken using the ASS-C, the CVRS, and the CE-
II. Significant differences on the ASS-C, the Affective
and Specific subscales of the CVRS, and the CE-II were
found. The Understanding and Exploratory dimensions of the
CVRS showed no significant differences. Rowe also addressed
the question of the trainees' post-training effectiveness
as counselors. Criterion levels for the measures were
compared with those of the Ph.D.-level professional coun-
selors studied by Scharf. The IPR group functioned signif-

icantly lower on the Understanding and Specific levels of

54

the CVRS. The other four variables showed no significant
difference between the IPR trained group and the Ph.D.-
level counselors. It was concluded that the fifty-hour
intensified IPR program enabled trainees to substantially
increase their ability to function effectively in counsel-
ing relationships.

Ward, Kagan, and Krathwohl (1972) studied the IPR
method under two conditions--with video and with audio--
and compared that to regular supervision using an audio-
tape. Three judges rated videotapes of fifty-four prac-
ticum students using a scale consisting of (1) thirty-
three behavioral and feeling items, (2) a single global
evaluation representing the normal curve with the base
divided into eight equal segments, and (3) the judges'
adjectives or descriptive phrases. Supervisors of those
students in the IPR settings recognized positive changes
in their students, but this did not correlate with the
judges' findings. Results were not significant, possibly
due to the nature of the coached client as the interviewee
or of the criterion measures themselves.

Kingdon (1975) studied IPR and traditional super-
vision as counselor training techniques. Supervisors were
doctoral students in counseling, counselors were master's
level trainees, and clients were graduate psychology
students. The IPR phase consisted of three videotaped

interviews with recall sessions, and was compared to a

55

phase consisting of three audiotaped interviews and tradi-
tional supervision. This minimal exposure to IPR showed no
significant results on counselors' empathy level, client
satisfaction, supervisor ratings, or clients' self-reported
inhibitions. However, the IPR supervision did effect a
significant change in the clients' level of self-exploration
over time. The inhibitory factor of the video equipment

and the recall sessions diminished from.session one to

session three.

IPR and General Education

Danish and Brodsky (1970) used part of the IPR
experience, the Affect Simulation Films, to train thirty
policemen attending a Basic Police Training School. They
posited that self-awareness of aggression thresholds and of
possible loss of emotional control were important goals in
police training and education. The films provided strong
emotional stimuli to which the policemen were asked to
respond. Although evaluation was not reported, the authors
noted that the preliminary test was promising.

Archer et. al. (1972) described their use of physi-
ological feedback as part of videotaped feedback. Recall
was conducted with a split-screen replay showing both the
subject's face watching stimulus films and the ongoing.
physiological process as recorded by a Grass recorder.
Archer et. a1. explored the possible uses of this tool for

research in emotional involvement and found that adding the

56

physiological feedback to the recall session increased the
effectiveness of recall.

Hartson and Kunce (1973) used videotaped replay
and recall in group work. They selected thirty-seven
students from a large state university and studied them in
groups, comparing the IPR method with a T-group method.
The IPR groups showed significantly greater change in
individual and group interaction factors. Socially active
subjects with high self-esteem.showed no difference between
methods. However, the self-confrontation of IPR was
beneficial to socially inactive subjects with low self-
esteem, while the T-group method seemed to have an adverse
effect. Criterion measures used were pre and post measures
of individual subjects on the Jourard Self-Disclosure
Scale, self-acceptance from an adaptation of Bills' Index
of Adjustment and Values, and readiness for group inter-
action from.Hill's Interactional Matrix-Form B. Hartson
and Kunce designed a twenty-five item Likert-type scale
and a "satisfaction with therapy" measure. Information
was gathered on the nature of the group interaction. A
trained judge rated audiotapes of the groups from.the
fifth and sixth sessions using the Hill Interactional
‘Matrix. Subjects in the IPR group had significantly
higher change scores on the individual measures of self-
disclosure and of readiness. The T-group showed signifi-
cantly higher mean satisfaction scores. None of the other

measures were statistically significant.

57

IPR and the Training of Medical Interviewers

Despite the numerous studies of IPR in various
settings, only a few evaluative studies have been done on
the medical interview. Resnikoff (1968) used the IPR
technique to study therapeutic interviewing skills.
Twenty-three medical students interviewed four different
simulated patients over a four-week period. The pre and
post administration of the ASS-B, peer and staff ratings,
and the MCAT Science examination were the criterion mea-
sures used both to evaluate the students and to check the
validity of the CVRS. The understanding dimension of the
CVRS was the only measure to discriminate between the level
of skill before and after the IPR training. A low or
negative correlation was present with the MCAT, ASS-B, and
the CVRS. The explanation offered was that medical students
were resistant to rating one another and there was little
agreement among the staff. The experimenter subjectively
found improvement in interviewing skills, but it was only
minimally verified by empirical findings.

Jason and Kagan (1971) offered a course at Michigan
State University called Doctor-Patient Relationship. Its
purpose was to teach basic therapeutic interviewing skills
to medical students using IPR. Measurement was subjective
self-report or instructor rating, without common criteria.
The course goals included learning and applying the IPR

technique.

58

Werner and Schneider (1974) taught first-year
medical students to communicate and interact with patients
using the IPR method. A pre-post experimental design
measured behavior changes in student performance. The
course met two hours a week for ten weeks with a total of
four interview experiences. The authors listed the follow-
ing five behavioral objectives for the course:

1. To identify the degree to which interactions
were exploratory-nonexploratory, affective-
cognitive, listening-ignoring, and confronting-
avoiding

2. To help the student be able to describe feelings
and overt reactions to the patient

3. To identify places in the interview where the
student was not maximally effective

4. To identify aspects of the interaction that
caused personal concern

5. To practice interviewing and explore new ways of
responding in the interview situation

Eighty-seven first-year medical students were in the
course. Due to the individualized nature of instruction,
a faculty member worked three hours per week with each
group of four or five students. Faculty were trained in
the IPR method. Criterion measures were the Affective
Sensitivity Scale and CVRS. There were significant pre-
to-post gains on the A.S.S. and on the exploratory and

affective dimensions of the CVRS.

59

Huber (1975) studied IPR as a training method for
teaching family medicine residents and Clinical Pastoral
students at Lancaster General Hospital, Lancaster, Pennsyl-
vania. The IPR course was reduced to a twenty-six hour
version and given to ten family medicine residents and
twenty pastors-in-training. The course was presented
three times during the one-year period. A no-treatment
comparison group consisted of fourteen subjects, both
pastors and residents. The criterion measures were audio
tapes of simulated client interviews using the Accurate
Empathy Scale (TE), the ASS (Form C), and the WROS.
Results indicated that trainees had an increased level of
empathy; however, the increase for the family medicine
residents was not statistically significant. The twenty
pastoral trainees had a significant increase in empathy.
The level of communicated empathy to the client did not
change, nor were there significant increases in the com-

fort level of the clients in the simulated interviews.

Summary and Discussion
The literature review demonstrated the wealth of
diverse populations and settings in which IPR.was taught
and evaluated. Overall, the literature showed validation
of the method as a means of teaching interviewing skills
and affect sensitivity. Only two studies failed to report
significant findings. To summarize, IPR.was found effec-

tive in training counselors, in accelerating client growth

60

in psychotherapy, as a method of training undergraduate
para-professional counselors, and as a means of training
medical students and residents in the interviewing pro-
cess. Parts of it were also found influential in the
training of police and theologians. Furthermore, the
effectiveness of IPR.was shown in relation to traditional
methods of counselor supervision, direct encounter T-
groups, audio versions of IPR, and no-treatment control

groups.

CHAPTER 3
METHODOLOGY

This study included both aspects of basic behav-
ioral science research--process and outcome measures.
This chapter contains a description of specific design
features and analysis procedures used in the study.
First, an overview of the design plan is given. A dis—
cussion of the plan in detail follows, covering the setting,
the subjects, and the delimitations of the design. Finally,
the focus of the study and the research hypotheses are
presented. The second part of the chapter contains a
discussion of the evaluation instruments and how they were
applied, the kind of data obtained and how it could be
interpreted, and the statistical procedures used to analyse

the data.

The Design
The design, as described by Campbell and Stanley
(1963), was a quasi-experimental pretest, posttest design,
with subjects serving as their own controls. The subjects
(family medicine residents--discussed below) were given'
the Affective Sensitivity Scale during the first week of
the IPR experience and required to audio tape-record two

patient interviews. Residents were then involved with the

61

62

thirty-two hour version of IPR as presented in the course
outline (Appendix). A posttest of the Affective Sensitiv-
ity Scale was administered after the last week of the
course and a second series of audio tapes was made of
patient interviews. Patient charts were audited for the
three-month period prior to training for the pretest and
for the three-month period after IPR training for the
posttest. Thirty patient charts were audited at each time
for each resident. Data was collected on affect words and
other indicators of personal-social data in the interview
and on prescription practices. An additional measurement
was obtained from the residents' yearly in-training
examination in which they interviewed a simulated patient.
All interviews were rated using the Counselor Verbal
Response Scale (CVRS). The section on instrumentation
later in this chapter describes the rating in further
detail.

The design of this study was partly determined by
the unique demands of its setting. These demands are

discussed below.

The Setting

The setting for this study was the Duke-Watts
Family Medicine Center, an ambulatory primary care center
located in Durham, North Carolina. The setting presented
some particular experimental problems. One problem was

the space available for teaching and the scheduling of

63

residents into the IPR sequence. The classroom.available
within the Family Medicine Center could seat no more than
six. Another problem was that the blocks of time during
which residents were available for IPR training varied
between one and two months, which resulted in the thirty-
two hour IPR course being divided either into four hours-
per-week for eight weeks, or into eight hours-per-week for
four weeks. A.more detailed description of the scheduling

of IPR training for the residents follows below.

The Subjects

The subjects in this study were the family medicine
residents in the Family Medicine Program between February
1976 and March 1977. Residents who left midway were not
included in this study because posttesting was not possible.
First-year residents were those entering the program.in
July, 1976. Second-year residents entered in July, 1975,
and third-year residents entered in July 1974.

Since each class was scheduled differently in the
rotation system and their available time and commitments
varied, the three groups of residents participated in
different ways in the study. All of the first-year residents
were available for IPR only during their orientation month
(July, 1976) because their first year was taken up with'
fulfilling their basic medical commitments. The first-
year residents did not have chart audit data available

since they had no patient contact prior to their IPR

64

experience. The data on the twelve first-year residents
consisted of the Affective Sensitivity Scale scores pre
and post, and the CVRS on real and simulated patients.

The second-year residents were able to attend IPR
only during their specific family medicine rotation of two
months. At that time they had limited outside commitments.
Either two or four of them were assigned to that rotation
at one time. A total of ten second-year residents partici-
pated in the study.

The third-year class was divided. Half of the
residents were involved in the pilot study (February,

1976) and were trained before some of the experimental
procedures were finalized. As a result, some data was not
available from them. The other half of the third-year
class (six residents) took the IPR sequence on their family
medicine rotation. Also, from the total of thirty-six
residents, one resident left the program prematurely, one
graduated early, and one was over-stressed by family
matters and requested to take IPR at a later date. This
left a total of thirty-three residents who participated

fully in the study.

Delimitations of the Design

The unique structure of the setting and the every
day educational demands made on the residents meant that
this study, unlike a laboratory experiment, could not be

rigidly controlled in all details. Other limits on the

65

amount of control possible in the study resulted from the

following:
1. Protection of patients' rights had to be observed
2. The delivery of health care could not be inter-
rupted
3. True control groups were impractical and unavail-
able
4. One trainer, a doctoral candidate in counseling,

was responsible for the teaching of interview
skills. This meant that IPR had to be taught
six times in the year to reach all of the
residents, and that the outcomes could be the
results of a single instructor's skills, rather
than of the IPR model
Since the residents' schedules were not under the
researcher's control, random selection of residents for treat-
ment and non-treatment groups was not possible. Instead,
residents were placed in the IPR sequence from an already
existing, complex rotation-assignment system. The residents
could be called away for a medical emergency, and often
classes were interrupted. Another consideration for research
was the sample size, limited to thirty-three, the total
number of residents currently enrolled in the program.
Due to the nature of IPR itself, the teaching Of
small groups of residents was not as confounding a factor

as it might seem. The materials and the instructor remained

66

the same-~i.e., the same IPR films were used in all groups.
In preparing for the study, the hypothetical design of one
pretest period followed by training all the residents
simultaneously, and then by giving them a posttest, was
considered. However, large groups of IPR trainees do much
of their classroom activities in subgroups of three to
five. These subgroups provide different experiences for
their participants, even in the simultaneous training
setting. Therefore differences in results based on the
nature of the small groups available at Family Medicine
and the time of their IPR training were not expected.
Other factors, however, must be considered. The
residents were in a training program, exposed to many
sources of stimulation and information. Certainly they
must have learned interactional skills in other spheres
which might influence their performance for better or
worse. Also, third-year residents had more clinical
experience to back their explorations of new behavioral
skills, and the age and experience of residents could not
be controlled. Because the specific questions asked in
this study were of the immediate effect and outcome of
training, neither the long-term effects of training nor
comparisons between IPR and other training models were‘

dealt with here.

67

Hypgtheses

 

Sufficient laboratory studies with IPR were per-
formed over the past fourteen years to permit certain
hypotheses about its application in this field setting.
Since IPR was demonstrated through laboratory studies to
be more than a chance experience, it was hypothesized that
pre-post differences in this setting would be significant.
Although the usual impact of IPR in terms of Affective
Sensitivity and interviewing skills was evaluated, the
crucial question of this research centered on the impact
of IPR training as evaluated through statements of affect
or personal—social indicators on the charts and through
changes in residents' drug treatment of their patients.
Five hypotheses were tested in order to evaluate this
impact. The research hypotheses were:

H1: There will be a positive change pre-to—post
IPR training on the Affective Sensitivity Scale
Scores for family medicine residents (alpha
at .05)

H2: There will be a pre-to-post IPR training
increase for residents on the exploratory,
active listening, affective, and honest
labeling subscales of CVRS (alpha at .05)

H3: Residents with IPR training will use a greater
number of exploratory, active listening, affec-

tive and honest labeling responses (on the

68

CVRS) than residents without IPR training on
the in-training exam

There will be an increase in the number of
affect words and statements indicative of
resident discussion with the patient of
personal-social concerns pre-to-post IPR train-
ing (alpha at .05)

There will be a decrease in the prescription
frequency of benzodiazepins (Valium and Librium)
for patients of residents pre-to-post training
in IPR (alpha at .05)

The evaluation instruments and the analytical pro-

cedures used to test these hypotheses are discussed below.

Instrumentation

The evaluation instruments were selected to insure

their appropriateness to the study and their relevance to

the clinical setting. The following guidelines were used:

1.

Instruments must reflect the skills taught in
IPR

Instruments should be reliable and valid

The instruments must be acceptable to the resi-
dents (Residents could reject a tool or an
experiment if it became cumbersome or if they
saw it as irrelevant to their learning needs)
Feedback must be given to the residents to max-

imize the educational function of the IPR

69

experience and to minimize the "guinea pig"
feeling among residents
5. Respect for patient privacy and confidentiality
must be shown
6. Economic use must be made of time, space, and
money
After considering the guidelines and the setting,
the following instruments were chosen: the Affective
Sensitivity Scale (A.S.S.), the Counselor Verbal Response
Scale (CVRS), and a chart audit. These instruments are

described in detail in the following sections.

Affective Sensitivity Scale

The Affective Sensitivity Scale developed by Kagan
et. al. (1970) was an instrument designed to measure one
individual's ability to detect and describe the immediate
affective state of another. The scale consisted of
multiple-choice items which the respondent selected after
watching filmed vignettes of actual interviews in numerous
settings (school, counseling, group, family, medical, and
informal). Studies on the first scale showed that it was
unaffected by the pretest-posttest practice effect. The
Kuder-Richardson reliability was judged to be from .70 to
.80. Validity was partially supported. 7

Revision of the scale into Form B resulted in a
scale of eighty-nine items. These items discriminated

between high scorers who were attracted to correct answers

70

describing strong feelings, and low scorers who were drawn.
to distractors describing weak or neutral feelings. Low
scorers were also drawn toward the distractors which
contained negative feelings directed towards the counselor
in the film. On Form B the test-retest reliability was
between .58 and .75. The concurrent validity studies
showed that a low positive relationship existed between
scores and judgements of counseling effectiveness. A more
substantial correlation existed between scores and judge-
ments of affective sensitivity. Predictive validity of
the scale was not established.

Danish and Kagan (1971) found that the Affective
Sensitivity Scale reflected personal growth in interper-
sonal sensitivity. Scores did not change significantly
from.retesting or from.a placebo treatment. Other studies
(Resnikoff, 1972; Campbell, Kagan, and Krathwohl, 1971)
supported these findings.

In this study, an updated version of the A.S.S.,
Form D, was used for evaluation. The vignettes were quite
diverse in character and the clothing more modern. The
scale of sixty-three items took seventy-five minutes to
administer and could be objectively scored by the research-
er. Form D of the Affective Sensitivity Scale was adminis-
tered to all of the residents pre and post training.
Feedback was offered to those residents who wanted it

after the posttest administration. The A.S.S. provided

71

data for the hypothesis dealing specifically with the
notion that A.S.S. scores would increase after training
(H1). The scores were analyzed using an SPSS program for
multiple t-tests. All eleven subscales were compared to
check for differences on any level of the total score.
Comparisons were made between weighted and unweighted
scores. (The specific scale format and scores are found

in the appendix.)

Counselor Verbal Response Scale

 

The CVRS was a measure of specific listening
skills. It measured the four skills taught in the first
part of the IPR series: exploratory, active listening,
affective, and honest labeling responses. Audiotape
interviews were collected of actual patients, selected at
random. Permission was obtained from the patient for all
interviews, and the experimenter worked to insure that the
residents' patient care was not interrupted. Two patient
interviews were rated for each resident both pre and post
training in IPR. The tapes were rated in a double blind
fashion to assure a non-biased score. Neither the raters
nor the experimenter knOW’WhiCh tapes were pretraining and
which were post-training. Residents were responsible for
handing in the interviews before their first IPR sessions
and were required to hand in two more interviews after
finishing the IPR sequence. None of the tapes were rated

until all of the residents had completed the IPR course.

72

Twenty responses from the tapes were judged, the
first five being omitted as introductory. The scores were
totaled in each of the four listening categories and the
data was used to evaluate the hypothesis that residents
would show an increase on their listening skill scores
pre-to-post-training in IPR (H2). The statistical proce-
dures used to evaluate the results of the CVRS for live
interviews with actual patients were the Wilcoxon matched
pairs signed-rank test and the more conventional t-test.
Non-parametric statistics were used to accommodate the
relatively small n of nineteen. The CVRS was also used to
assess the hypothesis dealing with the differing responses
of residents who had IPR and those who did not at a point
in time when half of the residents were trained and half
were not (H3). The in-training exam served as a convenient
"excuse" to administer the CVRS again. Residents were
audio recorded in their interview with a simulated patient.
They were aware of the testing situation, but not of the
specific use of the audio tape. This application of the
measure served to cross-validate the findings on the
actual patient interviews. It also presented a "standard"
stimulus to which all the residents responded. This added
the dimension of standardization not available on the
actual patient interviews, where there were differences

among patients. The data for the simulated patient

73

application of the CVRS was analyzed using the Mann-
Whitney U-test to determine if the sample arose from the
same or differing populations-~i.e., different if IPR had
had an effect.

The CVRS was relatively easy to administer and
took a minimum of time from.the residents. The CVRS as a
measure of listening skill was a direct product of the IPR
course and was a significant evaluative tool. The question
of whether or not the resident learned the basic IPR
skills was assessed using the CVRS.

Beyond the assessment of basic skills, however,
was this question: Did the IPR course make any difference
in patient care? This question was addressed using the

chart audit.

The Chart Audit

 

The chart audit was developed as a way of monitor-
ing the prescribing practices of the residents and their
use of affect words and other statements which might
indicate that personal-social issues had been discussed in
the interview. It provided a pre and post index of the
affective words or phrases used by residents, and in
addition, a pre and post index of the frequency and kinds
of drugs prescribed for patients by the residents. Since
affective sensitivity was one of the parameters measured
in the study, the data from actual patients' charts was

added to validate the actual resident behavior that might

74

show affective sensitivity. It was suspected that if a
resident was sensitive to affect, he/she would use more
words of an affective nature in describing his/her clinical
impressions of the patient. Also, sensitive residents
ought to reflect their sensitivity in the diagnosis made
as well as in their prescription of anti-anxiety drugs
(benzodiazepins). As stated in the hypotheses, after IPR
training residents were expected to use themselves as
therapeutic agents rather than to use drugs.

The chart audit was derived through the following
steps. First, members of the faculty of the Family Medi-
cine Program were polled for their views on who the most
sensitive and least sensitive residents were. Second,
using their compiled list of the most and least sensitive
residents, a series of patient charts were drawn at random.
These charts were examined by the researcher for apparent
differences with the following questions in mind:

1. Did residents use affect-laden words at all
(were the words appropriate for the medical
record)?

2. Were benzodiazepins (minor tranquilizers such as
Valium.and Librium) prescribed by the residents?

3. Could a single patient encounter be selected
from.the patient's chart and codified (was there
enough information to warrant the search)?

It was found in this preliminary survey that:

75

l. Affect words and other personal-social indi—
cators were noted on charts, and more of these
words clustered in the charts of those residents
identified by the faculty as sensitive

2. Enough benzodiazepins were prescribed to warrant
a closer look

3. One patient encounter per chart did give a
measurable quantity of affect words and other
personal-social indicators (hereafter, referred
to as affect words) and of the drugs prescribed
by the residents

Drawing from these preliminary findings, the third
step was to devise the chart audit with guidelines for
auditors (see Appendix for guidelines). Fourth, guide-
lines were approved by the faculty and raters were employed
to pilot test the audit form. Raters were not family
medicine-related in order to facilitate the non-biased
rating of patient encounters. With minor changes suggested
by the raters, the chart audit was adopted. Inter-rater
reliability was not measured since all target words were
discussed and decided upon by concensus. However, checks
were made on coding accuracy and care was taken to prevent
the raters from being fatigued by limiting their work
periods to two hours or less at one time. i

This chart audit information was gathered on

thirty patient charts both pre and post IPR training. Pre

76

and post total scores were obtained for the resident's
affect words noted and for the frequency of use of benzo-
diazepins. The charts were randomly selected from a three
month period both pre and post training. The hypotheses
which this procedure tested stated that residents would
note more affect words after IPR training than they did
before (H4) and also that they would prescribe less benzo-
diazepins after training than before (H5).

Statistical analysis was done using the Wilcoxon
signed-rank matched pairs test and the t-test for matched
pairs since residents served as their own controls. The
non-paramentric Wilcoxon was used to accommodate the small
n of sixteen and the traditional t was used for comparison.
The actual rating of the chart and the CVRS was done by
the same team of raters. These raters were carefully

selected, as indicated below.

Selection of Raters

The three raters for the CVRS were selected from a
population of people already trained in IPR. In addition
to these three raters, two additional raters, with the
same background in IPR, were added for the chart audit.
After their IPR training, they served as inquirers for
other students to keep their skills in IPR fresh and
accessible.

The three raters for the CVRS were para-professional

counselors in the community, and they worked in a health

77

organization and at the local crisis intervention center.
Their college degrees were in health education, psychology,
and the humanities, and two were working toward graduate
degrees in social work and in public health, respectively.
They were paid for the CVRS work and as chart auditors.

A non-family medicine physician was on hand at all times
to translate medical terminology during the rating ses-
sions. Inter-rater reliability was determined by the
Pearson r and the Wilcoxon T-Tests. Assessment was made
according to the direction and magnitude of difference
between the raters. The interjudge correlations are
reported in Chapter 4.

The combination of chart audit, CVRS, and A.S.S.
provided for a multiple evaluation of the residents'
interpersonal process and outcome, gave a cross-validation
of results without overtesting the residents, and supplied
information on a number of different dimensions. The
combination helped to maintain resident interest and
proved relevant to their educational process. A correla-

tion analysis is provided in Chapter 4.

Summary
The assessment of the impact of IPR on the family

medicine residents was a task divided between direct and
indirect (unobtrusive) measurement techniques. The study
of the affectve components of the doctor-patient relation—

ship focused on the impact on the doctor of affective

78

training and interviewing skills. The impact was deter-
mined through the affect words and other personal-social
indicators noted in the patient charts and through pre-
scribing practices. Data was collected unobtrusively and
residents were unaware of this dimension of the study.
The in-training exam was tape recorded with their know-
ledge; however, they did not know that it was part of this
project, but considered it rather as a routine part of
their in-training exam. Thus the ratings on these tapes
were also unobtrusive measures. However, the residents
were aware of other measures of their IPR training, i.e.,
audio tape ratings pre and post and the Affective Sensi-
tivity Scale pretest and posttest.

Figure 1 below shows how each of the hypotheses
was analyzed with regard to the criteria tested in the
hypothesis, the evaluation instrument applied to the data,
the sample size, and the statistical procedure used.

This chapter described the pretest posttest quasi-
experimental design used in this study, along with the
setting and its complications, design delimitations, and a
description of the subjects. The research hypotheses were
stated, and the instrumentation and procedures used for
measurement were discussed. The results of the analysis

of the data are presented in the next chapter.

79

 

 

 

 

 

 

 

 

 

 

 

 

Evaluation A.S.S. C.V.R.S. Chart Audit
Instrument
I r
Actual :Simu- BehaviorallDrugs
atient . lated Observa- '
Criterion :Patient tions :
t-test {Mann- f
Basic Skills nWilcoxon:Whitney ,
n = 19 | U'TeSt I
In = 33 l
I L
t-teSt : :
Affective Wilcoxj I I
Sensitivity on : l
n = 23 l '
l I
l : t-test
Drug Use : ,Wilcoxon
: :n = 16
i 'T
I t‘téSt l
Behavioral : Wilcoxon :
Observations : n = 16 .
+ L
Hypothesis H1 H2 E H3 H4 { H5
FIGURE 1

SUMMARY OF DATA ANALYSIS

CHAPTER 4
ANALYSIS

This chapter contains the results of direct
‘measurement by the Affective Sensitivity Scale and the
C.V.R.S. and indirect measurement by the chart audit of
affect words noted and of prescribing practices. After a
brief explanation of why the number of subjects did not
remain constant for each test, the results of this study
are described in the order of their appearance as hypoth-
eses. For clarity, each hypothesis is restated. Then the
statistical procedures used to evaluate that hypothesis
are described, and the data is presented in table format.

A discussion of the results follows the tables.

Number of Subjects
Throughout this study, as can be seen from the
results, the total number of subjects (n) per hypothesis
varied. The factors which caused this variation are
summarized below.
1. First-year residents could not be pretested
on the chart audit since IPR training was given
during their orientation to the residency and
therefore they had no prior patient charts.

2. Six of the third-year residents were involved

80

81

in pre-study IPR training and could not be used
in the experiement for CVRS and A.S.S. measure-
ments.

3. Due to tape malfunction or poor sound quality,
some CVRS tapes were not useable and those tapes
had to be dropped.

4. Six residents rotated through IPR very late in
the year, and their chart data was not included
in the study due to time constraints involving
shutting down the computerized chart retrival
system in preparation for major expansion of
facilities at the Family Medicine Center.

5. Four residents missed the A.S.S. pretest. Their
scores could not be used for the study.

6. Two second-year residents were receiving IPR
training during the in-training exam and were
not counted in the total for the in-training
CVRS.

The above circumstances account for the variations
of n within the total population (n=33). The following

sections describe the hypotheses and findings.

Hypothesis One (H1)

 

The first hypothesis was: There will be a posi-
tive change pre-to-post IPR training in the Affective
Sensitivity Scale scores for family medicine residents.

This hypothesis was evaluated using the Affective

82

Sensitivity Scale designed by Kagan and Schneider (1970).
The multiple-choice scale was administered on or before
the first IPR session and again after the last session.
The scale was rated on eleven dimensions with regard to
the number of correctly identified statements about the
vignettes. (A copy of the Affective Sensitivity Scale
dimensions are in the Appendix.) In addition, a total
score was obtained from the combination of the categories.
There was some category overlap so the sum of responses
per category equaled more than the total number of re-
sponses. A random score represented the number of re-
sponses incorrectly identified. Statistical significance
was tested using the SPSS t-test on each of the thirteen
dimensions with alpha at .05 (one tailed test). Tables
4.1-4.6 (See Appendix, p.126-131) show pre-post mean
Affective Sensitivity Scale scores on all eleven internal
dimensions, the total score mean, and the random.mean.
Mean scores, degrees of freedom, t-value, and p-value are
indicated. The tables are arranged first to describe the
total group (all three classes of residents) followed by
the first-year residents alone, and the second-year resi-
dents alone. There were only three third-year residents
and their subgroup scores were not listed separately. For
each group, separate tables show the difference between
mean scores done with two different rating schemes. The

weighted scheme counted two points for preferred

83

responses, one point for an acceptable response and zero
points for a random response. The unweighted mean scores
were rated counting one point for each preferred response,
one point for each acceptable response, and no points for
random responses. For reference, Table 4.7 below lists
the individual means on the Affective Sensitivity Scale

pre and post-training in IPR.

Table 4.7

Individual Pre-Post Means (Total Score)
on the Affective Sensitivity Scale

 

 

 

Resident Resident

Number Year Pre Post Number Year Pre Post

First Year Second Year
7901 83 81 7801 67 -
7902 70 80 7802 81 66
7903 88 89 7803 89 86
7904 82 79 7804 - 98
7905 75 57 7805 81 68
7906 59 52 7806 90 94
7908 73 68 7807 84 88
7909 82 81 7809 80 79
7910 75 84 7810 86 90
7911 78 85 7811 73 72
7912 69 70 7813 - 64

7814 85 -

Third Year
7702 89 -
7704 75 79
7712 77 76

 

 

84

Table 4.8 ’

Individual Means Pre and Post IPR Training
on the CVRS

 

 

Exploratory Active Affective Honest
Listening Labeling

Pre Post Pre Post Pre Post Pre Post

 

 

 

 

 

 

 

First Year
7902 1 2.25 3 2.75 .25 .75 .25 o
7904 .5 1 2.5 4.5 .25 1.5 o 1.5
7907 .25 2.5 2.5 1 o 1 .25 o
7908 .25 1 1 1.5 o o o .25
7909 .75 1.5 1 1 .5 o o o
7910 .5 .75 1.25 5.25 o 1.25 o 1
7911 o 1 3.5 .5 o 2 o 1

 

Group Means .46 1.42 2.1 2.35 .14 .92 .07 .53

 

Second Year

 

 

 

 

 

 

 

 

 

 

 

 

 

7801 1.75 1.5 1 2.5 0 0 0 0
7802 .5 3 1.5 2.5 0 3.5 0 2.5
7804 1 2 5 2.25 .5 2.25 0 .5
7805 .75 - 1.75 - 0 - 0 -
7806 2.25 5.5 5 3.5 1.5 4 .75 3
7807 1.5 l 5 2 5 3.5 3 5 5
7809 4.5 0 3 .75 3 .75 0 0
7810 .75 .75 1.75 2.25 .5 1 .25 .25
7811 .5 3 1 2 5 .5 1.5 0 5
7813 l 3 2.5 .25 .5 3.5 0 25
7814 1 2 4 2.5 0 2.5 0 .5
GroupiMeans 1.47 2.22 2.72 2.25 .95 2.1 15 .80
Third Year
7702 2 3 .5 1.5 .15 1.25 0 0
7704 .25 1 5.25 5 0 1 0 .5

 

 

 

 

 

 

 

 

 

 

 

 

 

Group Means 1.125 2 2.875 1 .75 1.12 0 .25

 

85

Results

Hypothesis one was not supported by the data for
the resident group as a whole, or for any year taken
separately. Overall there were no significant gains on
the Affective Sensitivity Scale total scores or on any
subscale within. A discussion of the possible meanings of
the A.S.S. scores pre-to-post-training is found in Chapter
5.

Hypothesis Two (H2)

 

The second hypothesis was: There will be a pre-
to-post-training increase on the exploratory, active
listening, affective, and honest labeling scales of the
CVRS. This hypothesis was evaluated by the CVRS, a rating
scale based on the four basic communication skills taught
in the IPR series. Audio tapes were used to collect
actual patient interviews of the residents. These tapes
were coded and distributed in a double blind fashion to
the raters to assure a non-biased rating procedure. The
responses were counted by the trained raters and total
scores for each of the four categories were compared pre-
to-post-training. The number of basic communication skill
responses out of the twenty rated responses were compared.
Statistical significance was tested using a TI SR-52
programmable calculator with t-tests for paired samples.
In addition, the Wilcoxon matched pairs signed-rank test

was used as the non-parametric statistic to work

86

with the small n's and non-random selection of residents.
Table 4.8 (above, p. 84) lists the individual means for
each resident, on each dimension, pre and post IPR training.
Table 4.9 below juxtaposes the t-test data analysis
and the Wilcoxon test to compare the two. As is evident,
they do not differ in p-values for the dimension listed.
Both statistical procedures show a p-value of less than
.05 for the dimensions of affective, exploratory, and
honest labeling. The t-test factors are pretest and
posttest means, degrees of freedom, t-values, and p-
values. The Wilcoxon factors given are n (number of mean
responses with a difference), T-values, and z-values. All

p-values are for a one-tailed test with alpha at .05.

Table 4.9

Pre-Post CVRS Scores

 

 

Wilcoxon
t-test Paired (n=l9) Comparison of
Comparison of Correlated Means Matched Scores
Pre- Post- D.F. t p n T Z p
DIMENSION test test l-tai l-tail

 

Explora- .
tory 1.06 1.90 18 -2.28 <.05 17 18.5 -2.74 <.05(.003)

Active 2.513 2.394 18 .279 >.05 18 95 .414 >.05(.342)
Listening

Affective .632 1.566 18 -2.69 <.05 17 27 -2.34 <.05(.0096)

Honest .105 .644 18 -2.97 <.05 13 5 2.83 <.05(.002)
Labeling

 

 

 

 

 

 

 

 

 

87

Results

This hypothesis was supported by the data on the
subscales of affective, exploratory, and honest labeling
(p less than .05). The p levels on the active listening
subscale were greater than .05 on both t-test and Wilcoxon,
and therefore did not support the hypothesis. Although
the active listening subscale did not show significant
pre-to-post gains, conclusions could not be made about

that subscale due to the low inter-rater reliability.

Inter-rater Reliability

 

Inter-rater reliability was judged by the Pearson
r correlation coefficient and the Wilcoxon mathced pairs
signed-rank test. The r statistic is a measure of associ-
ation; therefore, one must look for a value showing
significantly greater association than expected by chance,
as expressed in a value of tr more extreme than the critical
value for o<= .05, one-tailed test. One problem with the
correlation coefficient is that it tends to be reduced if
either or both raters exhibit little variance within the
ratings they assign. In this light, it is reasonable to
consider the difference between their ratings using
statistical methods that are not dependent upon distribu-
tion variance.

The T statistic is such a measure of difference;
therefore, one must look for a value showing that any

observed difference could be considered a function solely

88

of chance (i.e., that the raters are not significantly
different), as expressed in a value of zT less extreme
than the critical value for 0(= .05, two-tailed test. If
raters show either significant association or lack of
significant difference, their ratings may be considered
reliable assessments of the variable being measured.

Table 4.10 below shows the correlation coefficient
r and p-values for association as well as the Wilcoxon z
and p-values for difference for all three rating pairs on
all four CVRS dimensions. As can be seen from Table 4.10,
inter-rater reliability was acceptable on all dimensions
except the active listening dimension. Since significant
reliability was not achieved on this dimension, inference

about the subscale could not be made.

Hypothesis Three (H3)

 

The third hypothesis was: Residents with IPR
training will give a greater number of exploratory, active
listening, affective, and honest labeling responses than
residents without IPR training on the in-training exam.
This hypothesis was evaluated using the CVRS as in hypoth-
esis two. Twenty responses were rated, giving scores on
each subscale, and comparisons were made between the two
groups of residents. Residents were in the IPR group if
they had had the IPR course before their in-training exams.

Residents were in the non-IPR group if they had not yet

89

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90

been scheduled for their IPR course by the time of the in-
training exam. Two residents were in the middle of the
IPR course at the time of the exam and their scores were
not included in the study. Statistical analysis was done
using the Mann-Whitney U-Test for statistical significance.
The research question of whether or not these residents
were from.the same or differing populations was answered
by this test.

Table 4.11 contains the results of the statistical
analysis of the third hypothesis using the Mann-Whitney U-
test. It shows the means (i1) and the number of residents
trained in IPR at the time of testing (n1), the means
(i2) and the number of residents untrained in IPR at the
time of testing (n2), U-values, and p-values (one tailed
alpha at .05). Values listed are for each dimension of
the CVRS (the four listening skills).

Results

The data only partially supported the hypothesis.
There was a significant difference shown on the affective
dimension of the CVRS between residents trained in IPR and
those not trained. There were no significant differences
on the exploratory, active listening, or honest labeling
subscales, but the highest inter-rater reliability was on
the affective dimension, the only dimension found signifi-
cant across groups. Thus, there is a possible interaction

between reliability and findings.

91

Table 4.11

Total Group Scores on the In—Training Exam
Using the CVRS

 

 

 

 

 

 

 

IPR Non-IPR MANN-WHITNEY U TEST
DIMENSION i1 111* 522 n2** U p (1 tail)
Exploratory 5.2 15 4.47 18 129 >.05
Active
Listening 3.2 15 2.2 18 92.5 >.05
Affective 1.93 15 0.83 18 83 <.05A,
Honest
Labeling 0.7 15 0.38 18 114 >.05
NOTE: For this table, n = 33
i = means number of responses per category
*nl = number of residents trained in IPR at time
of testing

**n2 = nunber of residents untrained in IPR at
time of testing

A. = significant increase

Inter-Rater Reliability
Table 4.12 shows the inter-rater reliability for
hypothesis three. Inter-rater reliability was judged in
exactly the same manner as for hypothesis two. Inter-rater

reliability was low but significant.

92

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Hypothesis Four (H4)

 

The fourth hypothesis was: There will be an
increase, pre-to-post IPR training, in the number of
affect words and statements indicative of resident dis-
cussion with the patient of personal-social concerns pre-
to-post IPR training. This hypothesis was evaluated using
the chart audit form found in the appendix. Thirty patient
charts were audited both pre and post IPR training for a
total of 60 patient charts per resident. First-year
residents were not included in this part of the evaluation
since they had no patient charts available before their
IPR training. The number of affect words and phrases
indicative of patient personal or social concerns noted on
the charts were counted and tabulated by the same group of
raters who judged the CVRS data. Since judgements were
made by consensus of the raters, inter-rater reliability
could not be determined.

Statistical analysis for the chart audit was
performed using the Wilcoxon matched pairs signed-rank
test due to the small n available for this portion of the
study. The t-test for matched pairs was also used for
comparison purposes.

Table 4.13 (below, p. 94) shows the individual and
group means for affect words noted and for benzodiazepins
prescribed. From the data below it can be seen that

for both second and third-year residents the percent of

Table 4.13

Chart Audit Means Pre and Post
IPR Training

 

 

Percentage of Charts Percentage of Charts

 

 

 

 

 

 

 

with Affect Words with Benzodiazepins
Noted* Prescribed*
% Pre % Post % Pre % Post
Third Year
Residents
7702 30% 13% 3% 0%
7704 53% 43% 16% 3%
7705 20% 20% 3% 0%
7706 20% 43% 10% 6%
7708 20% 56% 0% 0%
7709 13% 23% 10% 6%
7713 36% 30% 6% 3%
GROUP MEAN 27.4% 32.5% 6% 2%
Second Year
Residents
7803 23% 38% 0% 3%
7804 26% 20% 0% 0%
7805 50% 40% 6% 0%
7806 23% 38% 3% 3%
7807 23% 30% 0% 6%
7809 50% 76% 6% 0%
7810 46% 46% 0% 26%
7811 50% 40% 3% 3%
7813 43% 23% 3% 6%
GROUP MEAN 37.1% 39% 2% 5%

 

 

 

*From 30 encounters pre and 30 encounters post IPR
training per resident

95

affect words did increase although not significantly
overall. The third-year residents decreased their pre-
scription rate of benzodiazepins while the second-year

group increased their rate. (Note particularly the increase
of resident 7810.)

Table 4.14 shows the statistic used, n, degrees of
freedom, T-values for the Wilcoxon, and t-values for the
t-test. The p-values are listed with alpha at .05 for a
one-tailed test. The table shows that there was no dis-
crepancy between the p-values for the Wilcoxon and the t-
test. There were no significant pre-to-post differences

of affect words noted on the chart audit.

Table 4.14

Affect Words Noted Pre and Post IPR Training on the Chart
Audit for Second and Third Year Residents Combined

 

 

 

n df T t p (1 tail)
Wilcoxon l6 . . . 45.5 . . . >.05
t test 16 15 . . . -.67 >.05

 

Results

The data did not support this hypothesis. There
appears to have been an increase in affect words in the
hypothesized direction but this was not a significant

increase.

96
Hypothesis Five (H5)

The fifth hypothesis was: There will be a de-
crease in the prescription frequency of benzodiazepins
(Valium and Librium) for patients of residents pre-to-post
training in IPR. This hypothesis was evaluated using the
chart audit form on the same patient charts that were used
for hypothesis four. The same set of thirty charts pre-
training and thirty charts post-training were judged by
the raters. Tabulations were made of any drugs prescribed,
but only prescriptions of benzodiazepins were used for the
study. If the drug was prescribed or refilled during the
visit of the patient, the incident was listed.

Statistical methods used to test this hypothesis
were the t—test and the Wilcoxon matched pairs signed-rank
test. The non-parametric Wilcoxon was used here because
of the small n and the non-randomization of the population
of residents. Table 4.15 shows the degrees of freedom,
the Wilcoxon T, the parametric t-test value, and p-values
for both tests. The n of sixteen represents the total
group, while the n of seven represents the third year
only. Again, first-year residents were not included in
this measure since they had no patient charts before their

IPR training.

97

Table 4.15

Frequency of Benzodiazepin Prescriptions
of Residents Pre-Post IPR Training

 

 

 

n df T t p(1 tail)
Wilcoxon
Total 16** . . . 29 >.05
Third Year 7 . . . 0 <.05
t-test
Total 16 15 . . . .097 >.05
Third Year 7 6 . . . 2.710 <.05*

 

* .05 2-tailed Pearson Correlation Coefficient
** 16 represents the total group
7 represents third year only

Results

The data partially supported the hypothesis. There
was a significant decrease in prescription frequency of
benzodiazepins for the third year residents pre-to-post
training in IPR. There was no overall group decrease
since the second-year residents as a group did not signifi-
cantly decrease or increase their benzodiazepin prescription
frequency. The Wilcoxon p-value and t-test value of p did
not differ in their significance. The findings were thus

similar by both parametric and non-parametric standards.

98

Correlation Analysis

In addition to the statistical analysis done for
each hypotheses and instrument, a correlation analysis was
done using the SPSS program for correlation with missing
values. This was selected due to the number of variables
with different n's in this study, a result of the setting.

The results of the correlation analysis showed
some statistically significant relationships; however, the
6 x 6 matrix of variables produces some significant corre-
lations by chance alone. Considered along with the small
n's in the significant correlations, these findings were
not judged generalizable. However, they were presented in
this pilot study for the purpose of raising questions for
further study. Figure 2 below shows the significant
correlations between instruments, p-values, and the number
of cases in each correlation. Implications of the corre-
lation analysis are found in Chapter 5. Correlations are
listed for instruments corresponding to the same time
period. That is, the pretest of one instrument was
measured with the pretest of another instrument, and not
with the posttest trial.

The CVRS pretest showed a significant positive
correlation with the pretest of the Affective Sensitivity
Scale on two subscales, affective and honest labeling.
There was a significant negative correlation between CVRS
pretest and the pretest chart audit for affect words

noted, but there was no significant correlation with the

99

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100

benzodiazepins. The posttest trial of the CVRS showed a
significant negative correlation (on the exploratory
subscale) with the posttest chart audit of affect words
noted. The posttest CVRS did not correlate significantly
with any other posttest.

The pretest chart audit of affect words noted
showed a significant negative correlation with the pretest
of the Affective Sensitivity Scale; however, the posttest
chart audit of affect words showed no significant corre-
lations.

The pretest chart audit for benzodiazepins pre-
scribed showed a significant negative correlation with the
pretest trial of the Affective Sensitivity Scale, but no
significant correlations were found for the posttest

trial.

Summary
This chapter described the hypotheses and the

evaluation procedures used for each hypothesis, as well as
the statistical analysis, the data presented in the tables,
and the results. The results are summarized below:
1. There were no significant gains on the Affec-
tive Sensitivity Scale pre-to-post training
in IPR. In fact, pre-to-post trials remained
essentially unchanged.
2. There were pre-to-post training increases in

the CVRS, a measure of basic communication

101

skills. Three of the four skill dimensions sig-
nificantly increased after training in IPR. The
active listening dimension was the only one that
showed no significant increase post-training.

Low inter-rater reliability on the active listening
dimension appears to have confounded the findings.

3. The affective dimension of the CVRS showed sig-
nificant differences between residents who had
IPR training and those who did not at the time
of their in-training exam. Residents who had
the IPR training showed significantly more
affective responses to a simulated patient than
did those residents without IPR training. The
three other dimensions of the CVRS did not show
significant changes.

4. There was not a significant increase in affect
words or other statements indicative of a
personal-social interview on patient charts pre-
to-post training in IPR.

5. Third-year residents did show a significant
decrease in benzodiazepin prescription frequency
pre-to-post training in IPR. Second-year resi-
dents did not show a significant decrease.

These results arose from the evaluation of the
hypotheses both by direct measurement by CVRS and the

Affective Sensitivity Scale, and through indirect

102

measurement by chart audit of affect words noted and of
prescription frequencies. In this way, both the process
and the outcome of the training were evaluated. Although
the process measures were not consistent with each other
in their results, there was no decrease in skill level
measured at any time. The lack of significance in the
Affective Sensitivity Scale scores is discussed in Chapter
5 in some detail. Support was found for increased basic
communication skills through the CVRS. The indirect
measures of the chart audit were favorable. Although
there were no significant gains in the number of affect
words noted, there was a clear trend in that direction.
The decrease in prescription frequency for benzodiazepins
was a significant finding for the third-year residents.

Most promising from.these results was the connec-
tion between the direct measure of interpersonal relation-
ship skills and the outcome measures of prescribing
practices. Chapter 5 contains a discussion of the impli-
cations of such findings and suggestions for further work
on the relationship between physician sensitivity and

patient management.

CHAPTER 5
SUMMARY, RESULTS, AND IMPLICATIONS

The purpose of this study was to train family
medicine residents in interviewing skills and affective
sensitivity using the Interpersonal Process Recall method
and to measure the impact of that training on the resi-
dents' skills and performance. A search of the medical
and educational literature was made to discover any research

related to the topic of this study.

Background of the Problem

The family medicine literature consistently empha-
sized the therapeutic role of the family doctor. Stanford's
(1972) survey of American Academy of Family Physicians
members found that they spent one-fifth of their working
time counseling patients for emotional problems. Stanford
thought training in counseling skills for physicians was
inadequate. Baker (1974) believed that the skills essen-
tial to psychological counseling of patients and their
families were often neglected as a training issue. Balint
(1954) emphasized the doctor-patient relationship and .
through his Balint groups fostered an atmosphere of support
and safety in which to generate such skills.

The teaching of interviewing skills was described

103

104

in the literature, and the need for such teaching was often
cited. Froelich (1969) stated that consumers (patients)
demanded more sensitive interviewers and that social pres-
sure was responsible for the current trend of teaching
interviewing skills. Enelow and Swisher (1972) emphasized
gathering data to formulate a total understanding of the
patient's situation. Their emphasis on the process of data
collection, rather than on the data itself, was based on
their philosophy of communication as a tool for physicians.
Froelich and Bishop (1972) discussed the four purposes of
the medical interview: to gather information, to establish
a relationship that will facilitate diagnosis and treat-
ment, to give the patient an understanding of the illness,
and to support and direct the patient in treatment.
Froelich and Bishop also helped establish the use
of the doctor—patient relationship as a diagnostic and
therapeutic tool. This interpersonal tool, when used
appropriately, results in more complete gathering of per-
tinent information since the patient is less likely to be
defensive and withholding, and since the more complete the
history is, the more accurate the diagnosis may be. Thus,
physicians more in tune with their patients are more likely
to hear, and hence to deal with, a patient's affective re-
sponse to an illness. Therefore, it was hypothesized that
physicians would be more likely to note affect words and

other statements indicative of personal-social concerns on

105

their patients' charts after IPR training than before
training. Because these physicians would respond as thera-
peutic agents themselves, it was also hypothesized that
they would prescribe less benzodiazepins after training in
IPR than before training.

The use of IPR as a training tool was studied by
Werner and Schneider (1971) with medical students, by Dendy
(1971) with resident assistants, by Archer (1971) with
undergraduates, and by Spivack (1970) for counselor educa-
tion. Kingdon (1975) in her study of counselors who were
given either IPR or traditional supervision found that
there was no significant difference between the methods
when the counselors were measured. However, the clients of
the IPR-supervised counselors showed significantly higher
levels of self-exploration over time.

The IPR process has been learned by many people,
professionals in mental health as well as students, work-
ers, and school children. Family medicine residents should
prove no exception. It was hypothesized that residents
trained in IPR would increase their affective sensitivity
skills and that they would have better basic communication
skills after training. The final hypothesis was that the
CVRS would discriminate between those residents who had IPR
training and those who did not at a point in time when half

of the residents were trained and half were not.

106

Methodology and Analysis of Data

 

Thirty-three family medicine residents from the
Duke-Watts Family Medicine program were given the thirty-
two hour version of IPR. They had eight three-hour lecture
discussion sessions and four to eight hours of video
recall in small groups. The residents were pretested and
posttested with both process and outcome measures. The
subjects served as their own controls. Process measures
were the Affective Sensitivity Scale, a measure of affec-
tive sensitivity using filmed vignettes as stimuli, and
the CVRS, a measure, judged by trained raters, of quality
and quantity of listening skills used in an interaction.
These measures were administered pre and post IPR training
as a way of giving feedback to residents as well as eval-
uating their IPR.skills. The CVRS was also administered
with simulated patient interviews when half of the resi-
dents had received IPR training and half had not, in order
to determine if the CVRS could discriminate between those
residents who were trained and those who were not. The
outcome measure used were pre and post audits of the
residents' patient charts to determine the number of
affect words and other statements indicative of a personal-
social interview, and to determine the quantity of benzo-
diazepins the residents were prescribing. I

Analysis of the data was performed using both

parametric and non-parametric statistics. In similar past

107

studies, parametric statistics were used. Non-parametrics
were also used here because the assumptions of normality
could not be made in this highly select population with its
relatively small n's. No difference in the results was
found between the two types of statistics. The non-
parametrics supported the findings of the parametric sta-
tistics in all cases. A correlation analysis on the instru-

ments was also performed.

Results

The process data was partially supportive of the
hypotheses. From.the literature on IPR, it was expected
that family medicine residents, like others, would increase
their affective sensitivity. This was not demonstrated by
the results of the Affective Sensitivity Scale scores, pre
to post IPR training. Since this study was completed the
A.S.S. has been revised by its authors, who found that Form
D did not correlate well with other measures of affective
sensitivity. The other direct measure of sensitivity and
basic communication skills, the CVRS, did register signifi-
cant increases in the affective, exploratory, and honest
labeling dimensions, thereby supporting the expectation of
increased basic communication skills and sensitivity.

There were no studies in the literature suggesting a
relationship between physician sensitivity and pre- '

scribing practices. However, the use of the self as a

108

therapeutic tool was discussed by Balint (1954), Baker
(1975), and others. It was predicted that as the residents
gained more confidence in serving as therapeutic tools,
they would give fewer prescriptions for minor tranquil-
izers. Instead, the residents would use their own abili-
ties to sooth, comfort, and deal with their patients'
anxiety. The outcome data for this hypothesis, the chart
audit, partially supported this prediction. The third-
year residents did decrease their prescriptions of the
benzodiazepins. The second-year residents, however, did
not. There were no significant increases in the noting of

affect words on the chart audit pre-to-post—training.

Conclusions

 

These results leads to several conclusions about
the study. These conclusions are:

1. Affective Sensitivity Scale scores, pre-to-
post-training, showed no statistically
significant increase. Although individual
scores remained largely unchanged, there was a
wide variance among the residents, with more
high scores than low ones.

2. Measurement by the CVRS showed a significant
pre-to-post-training increase in basic commun-
ication skills.

3a. The affective subscale on the CVRS discriminated

109

between those residents trained in IPR and those
not trained.

3b. The exploratory, active listening, and honest
labeling subscales of the CVRS did not discrimi-
nate between residents trained in IPR and those
untrained. These findings were confounded by
low inter-rater reliability except in those
areas which were statistically significant.

4. The chart audit did not show any statistically
significant increase in affect words noted.

5a. Third-year residents did prescribe significantly
less benzodiazepins after IPR training.

5b. Second-year residents showed no significant
decrease in frequency of benzodiazepin pre-
scriptions.

The significance of these conclusions and their relevance

to medical education are discussed below.

Discussion
The results of the study are discussed in this
section in terms of the findings on each of the three

instruments used.

The Affective Sensitivity Scale
The expected increases in Affective Sensitivity
Scale scores did not occur. There are several factors

which could account for this. A ceiling effect of the

110

instrument may have been reached, since residents started
out scoring in the upper range of the scale. The already
sensitive residents may not have scored significantly
higher on the posttest because the instrument was not as
sensitive a discriminator on the upper ranges. Also, the
Affective Sensitivity Scale Form D, which was used in the
study, was relatively new and may not have been as well
validated as the earlier form. It was assumed that Form D
was similar enough to the earlier form that data would
apply; however, at about the same time this study was
completed evidence was found by Kagan and Schneider (per-
sonal communication, Dec. 1977) that the new scale did not
correlate well with the old one and that revisions were
needed in the new scale. The new scale may well measure
some other cognitive function, but to determine that was
not within the scope of this study. Another possible
explanation of the findings was that the Affective Sensi-
tivity Scale measured residents' responses to filmed
vignettes, but that these stimuli were mild by comparison
to the real life trauma of a resident's life. The lack of
significant increase, however, does not invalidate the
gains on the other measure of sensitivity and listening
skills, the CVRS. The residents' involvement was perhaps
higher on the CVRS where their own patients were used in
the evaluation. There was some difficulty in taking the

posttest portion of the Affective Sensitivity Scale. It

111

was done with time taken from.other services, which could
have created some resentment of the posttest itself.
Another factor was that the residents had seen the post-
test Form D before. The residents possibly expected that
it would be easier the second time around and that they
would know the right answers, and so found it frustrating
to have difficulties with it. The residents' discourage-
ment may have been a factor in the lack of significance of
the findings. Also, there were some scores with a marked
decrease in performance. These decreases may have been
due to such factors as a resident "trying too hard," being
up for the past night on call, or having personal diffi-
culties. Most residents were pleased with the feedback
derived from the Affective Sensitivity Scale after their
posttest. However, there were several who did not want to
know their scores.

The consistency of the scores and of the patterns
of the Affective Sensitivity Scale grid was remarkably
high with few exceptions. Possibly residents' medical
training made it difficult for them to forget their first
trial. The findings on the Affective Sensitivity Scale
suggest the need for further validation studies of the
scale and the need for greater reliability of the extreme
scores. The profile pattern of pretesting to posttesting
suggests a lack of change, yet judging by the CVRS there

were positive changes in affective sensitivity.

112

The CVRS

It was not surprising that the CVRS scores were
supportive of the hypotheses. The CVRS directly measured
the basic communication taught in the first phase of the
IPR series. Although the residents did not know hOW the
audio tapes they made would be judged, they were on good
performance just knowing that the recorder was in the room
with them. They tried to do their best on interviews both
pre and post. It was very evident that their tries on the
posttest trials were more successful since they had more
practice with the skills. The flexibility of the CVRS and
its use both with simulated and real patients proved
valuable to the study. The use of real patients as well
as simulated ones gave the researcher a measure of cross-
validation not often available in research studies. It
was suspected from.the data that residents were more at
ease with their own real patients and so responded with
more energy available for basic communication skills.
Aggressive follow-up was necessary following initial
requests for post tapes, since residents were often quite
busy. However, with the cooperation of the nursing staff
and with readily available recording materials, all resi-
dents did comply. The method proved reliable, valid, and
worthwhile, and it indicated changes relevant to the 4
study.

The simulated patient trial of the CVRS was

113

attempted under conditions more stressful than those with
the real patients. On the in-training exam, residents
were being evaluated by a team of judges on their inter-
viewing skills (though not on the same dimensions as the
CVRS--residents did not know they were being judged on the
CVRS dimensions). This stress may have accounted for a
significant difference occuring on only one of the basic
communication skills scores, the affective scale. Another
factor which may have influenced the other scales was that
the residents who had already been trained in IPR at the
time of the in-training exam were for the most part, first-
year students with less experience generally and no prior
experience with the exam. They were perhaps more anxious
about taking this exam than were their more experienced
peers. Inter-rater reliability scores for the Counselor
Verbal Response Scale (CVRS) were somewhat low even though
great care was take to train the raters. The raters
expressed difficulty in rating the medical interviews,
particularly because what seemed like an appropriate
response often did not fit into any of the CVRS categories.
Much of the medical history was appropriate cognitive,
demographic, or symptom.description material. Given that
the CVRS was difficult to apply to the medical interview
and that for the in-training exam the affective dimenSion
was the one of best inter-rater reliability scores, it is

interesting that the affective dimension was also the only

114

significant discriminator between those residents with
training in IPR and those without IPR training. Perhaps
other subscales were not significant due to the low

reliabilities of the raters.

The Chart Audit

 

The chart audit data of affect words and other
personal-social indicators and of prescription frequencies
did not lend itself to traditional analysis and more work
is needed on the chart audit system used. The chart audit
data indicated that there were significant decreases in
prescribing of benzodiazepins for the third-year residents.
However, there were some very extreme increases in pre-
scriptions among a small number of residents. These
extreme scores could have thrown off the general trend for
most of the residents and might account for the performance
of the second-year group. All of the extreme users of the
benzodiazepins were from the second-year class. Residents
were not aware that their charts were being audited for
either the drug information or for the behavioral observa-
tions. While this study found that only a small portion
of residents significantly changed their prescribing
practices, that change could affect the course of a
patient's treatment.

A weakness in the chart audit was that the sensi-
tive resident, defined by personal contact or the CVRS,

did not always write onto the chart the perceptions made

115

about the patient. Another weakness in the measure was
that its newness had not yet given it the additional
validity or reliability indices necessary to be a useful
research tool. Since no similar instrument was found in
the literature, one was specially designed for this study.
It is not yet known how this instrument can best be used.
For example, are thirty patient encounters pre and post
training a representative sample? Do further definitions
of affect words need to be made? HOW’WOUId residents have
changed had they known that their charts would be audited
for drug frequencies and behavioral observations? It is
not known if this instrument accurately reflected the
changes that the residents were making. There are sensi-
tive residents who do not write down everything they think
a patient may be feeling or experiencing. This kind of
measure may be too indirect in its measurement. The
random selection of charts frmm each of the residents'
patient population proved no easy task as there were often
misplaced records, medical student notes, or computer
misinformation which was misleading. But there were
definite affect words noted in the chart and this instrument

attempted to identify them.

Discussion of the Correlation Analysis
The correlation analysis summarized in chapter 4
gave rise to several interesting speculations. Before

training in IPR, the honest labeling subscale of the CVRS

116

pretest showed a significant negative correlation with the
pre affect words noted. This could suggest that these
residents were actually labeling their patients' affect
appropriately in the real patient interviews but not using
that same language on their charts. On the post honest
labeling dimension with the post affect words noted, the
negative correlation changed to a random one, which
suggested that residents at the time of the posttest were
no longer exhibiting such a marked discrepancy. However,
the converse is also possible--residents not labeling
affect in the presence of their patients, but doing so on
the charts. On the posttest, that discrepancy was not
evident.

After training in IPR, the exploratory subscale of
the post CVRS was negatively correlated with the affect
words noted. This finding suggested that those residents
who used exploratory statements with their patients did
not note affect words on the chart audit. This movement
from a random effect at pretest time on the exploratory
dimension to a negative one at posttest time was sugges-
tive of interviewers who relied on more exploratory
responses to stay safe. Possibly, those who wrote affect
words on charts were doing more labeling of affect and
less exploring.

Similar findings were associated with the CVRS

pretest and the Affective Sensitivity Scale pretest. Both

.117

the affect and honest labeling subscales of the CVRS
correlated positively with the A.S.S.--those who scored
higher on the A.S.S. also scored higher on the CVRS dimen-
sions and those who scored lower on the A.S.S. also scored
lower on the CVRS. However, the posttest trials of those
instruments were not significantly correlated, suggesting
a change in skill level on the CVRS. Since the CVRS
scores did increase pre-to-post but the A.S.S. scores did
not increase significantly, it follows that there may be
some distinction between those who have a native ability,
i.e., high scores on the A.S.S., and those who acquire the
basic skills over time. Possibly those with native ability
exhibited CVRS skills on the pretest, but on the posttest
their peers applied the skills they had learned.

The trend of the significant correlations was to
move toward a random effect at posttest. This trend was
found for the A.S.S. with both affect words noted and
benzodiazepins. First, a negative correlation was noted,
then during the posttest it was random. Those who scored
higher in the A.S.S. pretest did not write affect words in
the charts, but they prescribed more benzodiazepins.

Those who scored lower on the A.S.S. pretest wrote affect
words but prescribed less benzodiazepins. That was not
the case on the posttest, however. Those who scored
higher on A.S.S. changed by writing more affect words in

the charts and prescribing less benzodiazepins, and those

118

who scored lower on the A.S.S. wrote affect words less and
prescribed more.

The number of significant correlations in the
study was quite small, with little reliable generalization
possible. However, the issues above are useful to point
out and indicate the need for replication in further
research. In addition to the above considerations, the
pre-post quasi-experimental design of this study raised
additional issues. There are some experimental problems
when a true control group is not possible. Although
setting up a control group in a field setting may be
extremely difficult, the added ability to generalize
findings may make it a worthwhile effort. Without a true
control group, results are difficult to generalize. A
control group of residents might have stayed unchanged, or
they might have prescribed many more drugs and noted far
fewer affect words. On the other hand, the opposite could
have occurred. IPR in the first case would then have made
a significant impact because the residents with IPR train-
ing (the treatment group) did not drastically increase
prescription frequencies and noted less affect words. In
the second case, IPR could have been judged detrimental to

the treatment group.

119

Implications

Two questions emerge from the findings. These
questions are (1) How does the affect sensitivity of the
physician influence prescribing practices? and (2) What
other affective factors may be involved in the practice of
family medicine, including diagnosis and treatment plans?
Those two questions cannot yet be answered empirically.
Further studies need to be done on the assessment of
physicians' sensitivity to affect and on the relationship
of that sensitivity to medical practice. With the rising
cost of medical education it is important to be able to
justify the kind of training that will be needed to teach
affective sensitivity and basic communication skills.
Outcome studies of patient populations will be needed to
document the belief that such affective sensitivity train-
ing is indeed cost-effective. New studies will require
new evaluative instruments. One such new instrument is
the chart audit developed for this study.

The chart protocol for behavioral observations, if
validated, could be used for both research and feedback to
residents. Such an instrument could provide an educational
evaluation of the residents' progress, and the feedback it
could provide would make residents more likely to consider
their patients in both a medical and behavioral framework.

A chart audit may not be the format to assess

change in outcome. Perhaps patient perceptions or

120

compliance would be better measures. Another possible
approach to evaluation of interpersonal training is to
look at diagnoses from both treatment and control groups
and have a panel of experts evaluate the diagnoses after a
reexaminaion of each patient.

The IPR model was readily accepted in the residency
program. It probably answered needs of both the faculty
and residents. One such need was that of specific and
acquirable skills which fostered the resident's confidence
in communicating with patients. Another need was the
resident's desire to have time for reflection and self-
study. So often in the residency period time for reflec-
tion is sacrificed for work, sleep, time with loved ones,
or recreation. IPR created a legitimate time and place to
be with oneself, to "center," to feel, and to express
feelings directly. This need for reflection and processing
is important in the learning process. Learning theory
principles support the notion of incorporation time and
this time was provided by the IPR course. Because resi-
dents were encouraged not to role-play, but instead to
share their own real concerns, they used one another for
support and for feedback. The fostering of peer support
and cooperation rather than competition is an asset well
worth the time it takes to develop, whether for a new

resident or an established physician in practice.

121

Recommendations

 

A review of the implications and the results of
the study suggests several specific recommendations.
Future research could aim.to control for the confounding
variables of history and maturation which could be accom-
plished by training all the residents at one time. In
addition, the group could be split offering one-third of
each class to one IPR instructor, one-third to another IPR
instructor, and one-third as a control group with no
intervention. The use of more than one instructor would
control for the instructors' impact on the training, and a
control group would further strengthen the research.

Other modifications include comparisons of IPR
with other teaching models, and introducing IPR at different
times in the medical education--for instance, first-year
medical school versus fourth-year versus internship or
residency. A longitudinal study of the impact of such
training could help identify the most appropriate time for
such a course to be offered, if indeed differences were
found. Other measurement tactics could be taken such as
attitudinal surveys about patient management, self-concept,
or patient compliance. These would be valuable sources of
outcome data.

An important recommendation is that the IPR train-
ing itself be given adequate followeup (and studies need
to be done to determine what is adequate). This follow-up

might be in the form of a monthly recall session, a basic

122

communication skill review, or serving as an inquirer for
a peer. In any case, residents commented (via personal
communication) that they needed a refresher in IPR and
some type of reinforcement, and that they sometimes forgot
to use their skills. Follow-up is an important adjunct to
the original IPR experience. Another research possiblity
is to teach first-year residents and measure longitudinally
over the second and third years to determine the long
range impact of IPR training. Another important change is
that the Affective Sensitivity Scale, Form E, which does
correlate with the original scale, should be applied as an
indicator of student learning. In medical or other field
settings, the attitude subjects have about their training
can influence the outcome of a study. It is suggested
that overt testing of subjects be kept to a minimum to
reduce the possibility of their developing resentment over
time spent with testing procedures (especially if immedi-
ate feedback is not available) and also to minimize the
feeling of being a "guinea pig." In a project where
personal affect is explored, it is important not to be
intrusive or rigid. People can be invited to look at
themselves, but little is gained when participation is not
voluntary. It is advised that those requesting not to
participate be allowed to drop out. 4
Teaching of IPR in the medical setting calls for

the instructor to be well versed about the numerous every-

123

day examples the medical system offers. This means
listening and observing closely for a time in order to
learn from.the residents the relevant areas to approach.
It is also recommended that IPR should be offered to
spouses interested in keeping up with their partners.
This generates an instant practice set for residents and
also reinforces the learning situation.

The use of the audio tapes with the CVRS is strong-
ly recommended as a teaching tool as well as an evaluative
one. In the study, residents made such tapes and often
wanted to talk about the interview afterwards. The residents
were introduced to a learning technique of processing

their encounters which many still use on their own.

Non-hypothesized Observations: The Impgct of IPR
The full impact of IPR training on the Family

Medicine Program cannot be appreciated without some addi-
tional information on its importance to the medical system
and to the community. This study took two years to
complete. In that time IPR went from a foreign—sounding
word to a well-accepted, mandatory part of the residents'
curriculum. Very positive, unsolicited feedback was
reported to the instructor from a standard evaluation form
eliciting the non-specific evaluation of the Family Medi-
cine Center experience by residents. For example, resi-

dents made statements like the following about IPR:

124

1. Best teaching done by the Family Medicine Pro-
gram, possibly the best teaching in three years
of residency

2. A super experience! Belinda is helping me
develop my feelings, understand them, and use
them effectively.

3. IPR is absolutely indispensable.

4. IPR is very useful.

In addition, though attendance of non-residents was not
allowed (for experimental purposes), requests for more IPR
courses began to arrive. Word of mouth spread from.resi-
dent to resident. Their spouses and others asked for IPR
to enable them to keep up with the ability to "listen and
understand" their own communications more fully. The
Family Medicine nurses repeatedly requested IPR and arranged
their time to get the IPR experience. A neighboring
university (UNC) is currently planning to use IPR with
their medical students. Duke nursing students came in
groups to try to enroll in the course, and the Physician's
Associates arranged for all of their students to take IPR.
Because the demand for IPR courses exceeded the
supply of available instructors, two additional psycholo-
gists, trained similarly to the researcher, were given
positions in the university. In addition, this instructor
was invited to present the IPR model to a group of faculty

representing every family medicine program in the state.

125

A nationwide faculty development program sponsored by STFM
(Society for Teachers of Family Medicine) featured an IPR
presentation which received outstanding ratings from.the
participants. An invitation to train the family doctors
at Andrews Air Force Base in early 1978 resulted from this
presentation. It became quite clear that IPR did indeed
have an impact on the residency training program, the
university, and the community.

As a result of the focus on the behavioral science
aspects of training, residents also began asking for more
consults with their patients and became interested in
Balint groups and family interactions as well as in their
own personal growth. Their appreciation, enthusiasm. and
cooperation made teaching them a joy. Another important
aspect of the IPR experience was that it provided a legiti-
mate forum for direct honest communication between instruc-
tor and resident which for many residents opened the door
to personal exploration, trust, and growth. This feeling
of trust seemed to generalize to other faculty as well--
residents began to train the faculty, nurses, and pre-
ceptors by giving clearer, more sensitive feedback, and by
being more capable of confronting themselves and others.
Thus, IPR promises to have a continuing effect on these

residents, and through them.to many others.

APPENDIX

Table 4.1

Weighted Scores on the Affective Sensitivity Scale
for the Total Group (Years 1, 2, 3)

126

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Weighted
Pre X Post t df p
Client 32.956 32.869 .13 22 .05
Interviewer 33.913 32.869 1.02 22 .05
Child 11.739 11.782 -.08 22 .05
Male 46.391 45.782 .44 22 .05
Female 31.478 31.521 -.05 22 .05
Educational 21.695 21.260 .60 22 .05
Health 13.391 12.695 1.36 22 .05
Informal 8.190 8.285 -.33 20 .05
Group 16.695 17.130 -.79 22 .05
Counseling 11.571 11.333 .46 20 .05
Psychotherapy 23.391 24.260 -1.09 22 .05
TOTAL 78.826 77.521 .89 22 .05
Random 9.000 9.217 -.35 .05

df - 20 t - > 1.725 1 tail
df = 22 t = > 1.717

 

Table 4.2

Unweighted Scores on the Affective Sensitivity Scale
for the Total Group (Years 1, 2, 3)

127

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Unweighted
X
Pre Post t df p
Client 22.826 22.739 .21 22 .05
Interviewer 23.043 22.782 .60 22 .05
Child 7.869 8.087 -.76 22 .05
Male 30.782 30.913 -.15 22 .05
Female 22.260 22.739 -1.08 22 .05
Educational 14.956 15.304 -l.09 22 .05
Health 9.304 :8.695 1.99 22 .05
Informal 5.476 5.714 -1.75 22 .05
Group 11.956 12.434 -1.59 22 .05
Counseling 7.761 7.666 .34 20 .05
Psychotherapy 16.260 16.521 -.67 22 .05
TOTAL 54.000 53.782 .35 22 .05
df = 20 t = > 1.725 1 tail
df - 22 t - > 1.717

 

Weighted Scores on the Affective Sensitivity Scale
for lst Year Residents

Table 4.3

128

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Weighted
X
Pre Post t df p
Client 30.909 31.636 .69 10 .05
Interviewer 32.636 31.818 .57 10 .05
Child 11.454 11.454 .0 10 .05
Male 45.454 44.818 .28 10 .05
Female 29.727 29.818 .46 10 .05
Educational 20.636 20.090 .46 10 .05
Health 13.000 12.636 .46 10 .05
Informal 8.300 7.900 .80 9 .05
Group 16.545 16.818 .39 10 .05
Counseling 11.300 11.400 .12 10 .05
Psychotherapy 22.090 22.909 .60 10 .05
TOTAL 75.818 75.090 .30 10 .05
df = 9 t = > 1.833 1 tail
df = 10 t = > 1.812

 

Table 4.4

Unweighted Scores on the Affective Sensitivity Scale

for lst Year Residents

129

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Unweighted
X
Pre Post t df p
Client 21.727 22.090 —.63 10 .05
Interviewer 22.363 22.454 -.23 10 .05
Child 7.545 7.727 -.45 10 .05
Male 30.090 30.636 -.43 10 .05
Female 20.909 21.909 -1.51 10 .05
Educational 14.363 14.636 -.63 10 .05
Health 9.000 8.818 .39 10 .05
Informal 5.500 5.600 -.43 9 .05
Group 11.723 12.272 -1.49 10 .05
Counseling 7.600 7.700 -.22 9 .05
Psychotherapy 15.545 16.090 -.92 10 .05
TOTAL 52.090 52.818 -l.02 10 .05
df = 9 t = > 1.833 1 tail
df = 10 t = > 1.812

 

Weighted Scores on the Affective Sensitivity Scale
for 2nd Year Residents

Table 4.5

130

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Weighted
X
Pre Post t df p
Client 35.400 33.800 2.28 9 .05
Interviewer 35.0 33.8 .66 9 .05
Child 12.000 11.900 .12 9 .05
Male 47.60 47.20 .19 9 .05
Female 34.10 33.00 .86 9 .05
Educational 22.50 22.20 .29 9 .05
Health 13.80 12.80 1.20 9 .05
Informal 8.55 9.11 -1.64 8 .05
Group 17.00 17.80 -.78 9 .05
Counseling 11.77 11.00 1.02 8 .05
Psychotherapy 25.30 26.00 -1.00 9 .05
TOTAL 82.70 80.20 1.20 9 .05
df = 9 t = > 1.833 1 tail
df = 10 t = > 1.860

 

Table 4.6

Unweighted Scores on the Affective Sensitivity Scale

for 2nd Year Residents

131

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Unweighted
X
Pre Post t df p
Client 24.00 23.300 1.00 9 .05
Interviewer 23.500 22.900 .68 9 .05
Child 8.100 8.300 -.39 9 .05
Male 31.300 31.100 .14 9 .05
Female 23.700 23.500 .29 9 .05
Educational 15.400 15.700 -.50 9 .05
Health 9.500 8.600 1.96 9 .05
Informal 5.666 5.888 -1.51 8 .05
Group 12.200 12.700 -.89 9 .05
Counseling 7.777 7.555 .51 8 .05
Psychotherapy 17.200 12.100 .20 9 .05
TOTAL 56.000 54.600 1.24 9 .05
df = 8 t = > 1.860 1 tail
df = 9 t = < 1.833

 

132

Course Outline

 

 

Week Class—-2 hours/session Lab--l-2 hours/session
1 Introduction to course Operation of equipment
Active listening and lab
Exploratory response modes
2 Review of above Individual video recall
Affective and Honest Label- of interviews
ing modes. Affective films.
3 Affective Sensitivity films Individual recall
4 Film of recall session Individual recall
5 Inquirer role discussion Inquirer training
and practice. Film
6 Inquirer role discussion Inquirer training
and practice
7 Mutual recall film and Mutual recall
discussion
8 Mutual recall film and Mutual recall with sig-
theory discussion nificant other

Definition of terms:

AEEive listening, Exploratory, Affective, and Honest
Labeling. These listening skills provide the backbone of
the vocabulary of IPR training and give the participants a
common base from which to work.

Affective Sensitivity films are a series of short
(approximately one minute77vignettes of actors and
actresses portraying emotions that the students respond to.
Initially in the training, the participants are asked to
confront only films, they progress to video tapes of an
interaction that has just happened (there is still safety
in distance), and eventually to confrontation in the "here
and now" with their co-workers and patients.

Recall is that process whereby students are given the
opportunity in labs to "debrief" after a short ten-minute
interaction that is replayed for them on video tape. This
process is facilitated by an inquirer.

An In uirer is one who is specially trained in the
techniques of IPR and is a non-judgemental, non-critical,
yet active listener who encourages the student to use the
time to understand him/herself more fully. (The video
tape provides feedback enough, hence the non-critical role
of the inquirer. The instructor will act as inquirer for
the group until week five, when the participants will be
trained to take on that role themselves).

Individual or Mutual recall depends upon whether the
student views the tape private y with the inquirer or to-
gether with the interviewee and the inquirer.

133

AFFECTIVE SENSITIVITY SCALE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FORM D
Feedback

NAME: Date of Testing:
The following scores represent your performance on
the Affective Sensitivity Scale, Form D. Scores have
been determined from multiple areas of content and
context, and are not mutually exclusive. Next to
your actual score for each category is the standard
score, based on the norms for the 'expert judges"
or criterion group.
You will note that partial credit has been given on
some items. If you selected the preferred alterna-
tive, you received two points for that item. If you
selected any other acceptable response, you received
one point. If you selected an alternative that was
considered random, or unrelated, you received no
points for that item, a score of zero.

Acceptable Responses
Pfeferred Other Random TOTAL STANDARD
Item.# +2 +1 0 SCORE

Client 28

Interviewer 26

Child 10

Male 36

Female 27

Educational 18

Health 11

Informal 6

Group 14

Counseling 9

Psychotherapy 19

TOTAL 63

 

 

 

 

 

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BIBLIOGRAPHY

135

Guidelines for Chart Audit
Specific Guidelines and Examples-

1. Family History (look for facts plus interpretation)
no - patient lives with mother
yes - mother of patient is overprotective

Is there an indication of dynamic family interaction?
no - Married with 3 children
yes - Marital Conflict

2. Diagnosis (must contain reference to cause or
precipitating event)
no - depression
yes - depression secondary to loss of spouse

3. Treatment Plan (is there evidence of treatment
beyond the organic or chemical?)
no - valium
yes - valium then if no improvement refer for
psychotherapy

Non-Specific Guidelines-

Look for words which indicate interpretation of facts,
explanations, or cause and effect:
secondary to, due to, because of, as a result of, etc.

Look for any mention of 'troubles', 'dischord',
'stress', 'difficulty', 'concern', emotional problems, etc.

Look for any mention of sexual problems.

Look for any mention of alcohol or drug use.

Examples:
no - Patient eneuretic times 1 month
yes - Patient eneuretic. May be secondary to move
to new school.
no - Patient wants birth control

yes - Patient beginning sexual relations and wants
birth control.

no Lump in breast. Possible cancer.
yes - Patient concerned about lump in breast. Afraid
of cancer.

no - Alcohol, one pint per day.
yes Patient drinks heavily, one pint per day,
for his 'nerves'.

To make a yes decision, there must be present any one of
the above examples of physician sensitivity. '

To make a no decision, there must not be any indication
of sensitiVity.

l = Valium 3 = Anit-Depressant 5 = Other 7 = Other
2 = Librium 4 = Valium/Librium. 6 = No Drug Tranquilizer
+ Anti-Depressant

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