Use of Trained
Mothers
to Teach
Interviewing
Skills
to
First#{149}Year
Medical
Students:
A Follow-up
Study
Paula L Stiliman, M.D., Darrell L. Sabers, Ph.D., and Doris L. Redfield, B.M.
From the Departments of Pediatrics and Medical Education, Unicersity of Arizona College of Medicine, Tucson
ABSTRACT. This report describes an attempt to evaluate the effectiveness of “trained mother” interviews early in the medical school curriculum. As an adjunct to a first-year course that teaches interviewing techniques, half of the
students were exposed to an interview with one of three
trained mothers early in the course. This treatment interview was immediately followed by a feedback session which concentrated on the content and process of interviewing. At
the end of the course, all students had an evaluative
interview. Those students who had an initial interview and feedback session with a trained mother scored significantly
higher on both the content and process of their interviews than the control group. This technique is an effective and
efficient way to teach interviewing skills to medical students
prior to entering any of their clinical clerkships. A follow-up
assessment conducted one year later indicated that one interview with a trained mother is sufficient for optimal learning and that the skills learned are retained over at least
that period of time. Pediatrics 60:165-169, 1977,
IrsrraRVIEW-INC, PATIENT SIMULATORS, TRAINED MOTHER5.
Nonphysicians have been used successfully to
teach and evaluate interviewing skills in medical
school curricula. Heifer and his colleagues’5 led
the pioneering effort, and recently, we have
demonstrated the effectiveness of using a
modi-fled method.6
The use of “trained mothers” and the Arizona
Clinical Interview Rating (ACIR) scale was first
shown to be effective in teaching interviewing
skills to students in a pediatric clerkship.6 The
success of that study provided the impetus for
using the same technique earlier in the medical
school curriculum. In the first of two studies
reported here, trained mothers were used to teach
interviewing skills as part of a course in
prepara-lion for clinical medicine. This course occurs
during the first year of medical school before the
student has entered any clinical clerkships. In the
second study, a follow-up of these students was
conducted during their second year of medical
school as they rotated through a pediatric clinical
clerkship.
METHODS
The methods used for the study of first-year
medical students were the same as those
previously used.6 Three nonphysician mothers
were taught to give a consistent and authentic
history of a child’s common medical problem. A
checklist containing all of the pertinent
informa-tion was devised for each mother’s history. This
checklist was used as a scoresheet for determining
the amount of content data gathered by the
student. These content scores compared the
amount of information the student actually
obtained to the total amount of information listed
on the mother’s checklist and were represented as
percents.
The ACIR scale was used to rate each student’s
interviewing technique. This scale lists 16
inter-viewing skills. Levels of excellent, average, and
poor performance are described for each skill.
The highest score a student may obtain on each
item is 5 and the lowest is 1. The sum of the scores
of the 16 items, the process score, is reported as a
raw score. The highest possible score a student
Received May 26; revision accepted for publication December 20, 1976.
Presented in part before the Ambulatory Pediatric
Associa-lion, St. Louis, April 27, 1976.
ADDRESS FOR REPRINTS: (P.L.S.) Curriculum
TABLE I
Cor.rrr AND PROCESS SCORES#{176} IN PREPARATION FOR CLINICu. MEDICINE STUDY
Group No. Treatment
Interview
Evaluative
Interview
Content scores, %
Experimental 28 31.2 (15.4) 61.7 (19.6)
Control 32 42.8 (19.4)
P < .01
Process scores, points
Experimental 28 48.2 (8.5) 57.9 (7.0)
Control 32 47.0 (9.0)
P < .001
#{176}Seoresare means with standard deviations in parentheses.
can obtain is a rating of 5 on each of the 16 items
for a total score of 80 points. The entire scale has
been published.6
Student interviews with trained mothers were
videotaped. Parts of the videotape were then
replayed and the mother critiqued the interview.
This feedback session was intended to provide the
student with objective information with which to
improve his interviewing technique. By the end of
the feedback session the content checklist and
process rating scale were completed by the
mother. The average length of time required for
completion of the interview and feedback session
was less than 90 minutes, with the interview
lasting from 20 to 45 minutes and the feedback
session lasting approximately 45 minutes. These
times varied among students.
EXPERIMENTAL DESIGN
The 64 students in the course were randomly
assigned to either an experimental or a control
group. The students had the same basic
instruc-tion in interviewing, which consisted of lectures,
assigned reading, and small group session with
clinical preceptors. Students in the experimental
group had two interviews with a trained mother.
The first interview and feedback session for each
student was considered the treatment, the second
served as a comparison with the control group
and was an evaluative interview. The treatment
and evaluative interviews for the experimental
group were separated by approximately six
weeks. Each student in the control group had only
one interview, an evaluative interview, which
was held at the same time as the evaluative
interview for the experimental group. The
mothers were not told to which group a student
belonged at the time of the evaluative interview.
No student in the experimental group had two
interviews with the same mother. Four members
of the experimental grpup were eliminated from
the study because of scheduling difficulties in
arranging interviews. The final comparison
included 28 students in the experimental group
and 32 students in the control group.
RESULTS
The means and standard deviations of student
scores on the interviews are presented in Table I.
The treatment interview for the experimental
group served two purposes. (1) Scores on the
treatment interview were assumed to represent
the level of interviewing skills attained ‘by all
students at the beginning of the preparation for
clinical medicine course. This assumption was
considered valid because of the random
assign-ment of students to experimental and control
groups. (2) The feedback and evaluation session
experienced by the experimental group after this
interview was considered to be the treatment and
was the variable distinguishing the experimental
group from the control group.
Content Scores
The difference in the content scores between
31.2% for the experimental group’s treatment
interview and the score of 42.8% on the
evalua-tive interview for the control group is an estimate
of the improvement in content-gathering skills
attributed solely to the instruction in the
prepa-ration for clinical medicine course. This
differ-ence was found to be significant by a t test of
means using independent samples (t = 2.28, P < .05).
The mean content score for the experimental
group’s evaluative interview was 61.7%. This
mean was found to be significantly higher than
the mean of 42.8% obtained by the control group
on the evaluative interview by the same statistical
test (t = 3.71, P <
.01).
This difference indicatesthat the content learned from the experience with
the trained mother is additive to what is taught in
the preparation
for clinical
medicine
course.
Process Scores
There was essentially no difference in the mean
process scores between the treatment interview
for the experimental group (48.2 points) and the
evaluative interview for the control group (47.0
points). Thus, there was no evidence that students
learn the process of interviewing by participation
in the preparation for clinical medicine course;
however, the mean score on the evaluative
inter-view for the experimental group (57.9 points) was
significantly higher (it = 5.19, P <
.001)
than theTABLE II
MEAN CONTENT AND PROCESS Scoius IN FOLLOW-UP STUDY
Group No. Content (%) Process (Points)
Experimental (group having two previous 28 70.4 64.5
interviews)
Control (group having one previous interview) 32 65.7 61.5
No significant difference
No significant difference
group (47.0 points). This significant difference
was attributed to the treatment interview and
teaching session with a trained mother. Thus,
while content-gathering skills were learned both
in the course work and from the trained mother,
only the interview with the trained mother
improved the process (technique) of
interview-ing.
At the conclusion of the preparation for clinical
medicine course, the students were asked which
method of instruction they had found most useful
for helping them learn interviewing skills.
Sixty-eight percent of the students selected the
combi-nation of trained mothers and small group sessions
with clinical preceptors. Twenty-two percent
selected the trained mother only. In view of the
relatively small amount of time devoted to an
interview with a trained mother this response
suggests that the use of trained mothers is an
economical instructional technique.
Students were also encouraged to make free
response comments. The interview with the
trained mother received positive comments from
24 students (e.g., “Best single source of training”
and “Should have more in other areas besides
pediatrics”). The interview experience received
negative comments from three students.
Corn-rnents from the students in the experimental
group indicated that the second interview was
especially helpful. Other comments indicated
that students
did
not wish to substitute theexperience with a trained mother for
interview-ing “real” patients. Rather, they believed that the
two experiences complemented each other. Because three mothers with unique histories
were included in the study, an additional analysis
compared the amount students learned from
interviewing the different mothers. For this
comparison
the
students
in the experimentalgroup were separated according to which mother
they had interviewed on the treatment interview.
The mean scores on the evaluative interview were
then
compared
for the
three
groups.
The
differ-ences among these means were not significant.
Therefore, it
was concluded
that
students learnedapproximately the same amount regardless of
which mother was interviewed.
FOLLOW-UP STUDY
The
following
year,
as
the
students
rotated
through their pediatric clerkship, each was given
another interview with a trained mother. No
student ever interviewed the same mother twice.
Tables II through IV present data relevant to the
follow-up
study.
The
resultsof the
follow-up
study
revealed
no
significant difference between students who had
two interviews during the preparation for clinical
medicine course and those who had only one
(Table
II). The data indicate that maximumlearning occurred with the initial interview and
feedback
session,
and that any increment inlearning due to more than one interview is not
sufficient
to
justifythe expense
and
time
involved
in additional interviews.
To see
if one
interview
early
in the
medical
school curriculum
was
of
long-term
value
in
improving
interviewing
skills,
the
32 second-yearmedical
students
in the
pediatric
clinical
clerk-ship who previously had one evaluative interview
with a trained mother during their first year of
medical school were compared to a comparable
TABLE HI
M CONTENT AND PROCESS SCoius IN SECOND-YEAR hrrERvlEw
No. Content (%) Pmcess (Points)
Group having 1 first-year interview 32 65.7 61.5
Group having no first-year interview 18 53.1 P<.01
i...#{149}x
x’i
H{Th”
-L--
L
xJx)
TABLE IV
MFs. Cowitrrr .r’w PROCESS SCORES IN LoNc-rEiui Vsus SHORT-TERM RETENTION STUDY
No. Content (‘%) Process (Points)
Treatment and evaluation separated by one year 32 65.7 61.5
Treatment and evaluation separated by 6 weeks 18 62.7 64.7
No significant difference
No significant difference
group
of second-year
students
in the
pediatric
clerkship who had had no prior exposure to a
trained
mother
(Table
III).
The
group
having
a
first-year interview scored significantly higher
(P <
.01)
than the group having no previousinterview in both the content and the process of
interviewing.
These
results
have
been
interpreted
to show
that
one interview
with
a trained
mother
duringthe
firstyear
of medical
school
provides
for optimal
learning
of interviewing
skills
by this
technique and that these skills are maintained forat least one year.
To see if the short-term
improvement
in
inter-viewing
skills
resulting
from
an interview
with
a
trained
mother
was
equivalent
to the
long-term
improvement,
two
additional
groups
of students
were
compared.
The
first
group
of students
had
their treatment interview with a trained mother
during their first-year preparation for clinical
medicine
course
and
had
their
evaluative
inter-view during their second-year pediatric clinical
clerkship. These interviews were separated by
approximately one year. The second group had
both their treatment and evaluative interviews
during
a second-year
pediatric
clinical
clerkship.
These
interviews
were
separated
by
approxi-Group
1 N = 28Group 2 N = 32
Group
3 N =18First Year Students Second Year Students
6 wks. 1 Yr. 6 wks.
V V
Interview & l Interview & Interview & Interview &
Feedback Feedback iiii:iiii:i:jFeedback Feedback
Study I ---- Study Ill
-Study II“ Study IV
mately
sixweeks.
As shown
in Table
IV, there
was
no
significant
difference
between
these
groups’
scores on the evaluative interview. These data
indicate
that
long-term
and
short-term
improve-ment
in
interviewing
skills
are
approximately
equivalent.
The
results
indicate
that
once
a student
has
interacted
with
a trained
mother
and
has
been
exposed to the criteria in the ACIR scale, he isable
to
assimilate
the
interviewing
skills
and
reproduce them at a later time whether it be sixweeks
or a year
later.
The
Figure
represents
the
summary
of
the
designs
of the
studies
presented
in this
section.
DISCUSSION
These
studies
have
demonstrated
that
(1)
it ispossible to teach interviewing skills to medical
students and objectively evaluate skill attainment
before
the
students
enter
clinical
clerkships;
(2)
the
interviewing
skills
learned
by
medical
students through exposure to trained mothers are
retained;
and
(3)
the
long-term
retention
of
attained skills is approximately equivalent to the
short-term retention.
The
approach
to
teaching
and
evaluation
of
interviewing skills includes three basic steps. Thefirst
step
is to clearly
state
the objectives
that
the
student must accomplish.The
16 objectives
used
in
these studies areclearly
stated
and defined inthe
ACIR
scale.The
second
step
is to provide
a
standard learning experience
by
which
these
objectives
can betaught.
The
learning
experience
in these
studies
consisted
of exposure
to the ACIR
Summary of study designs. Study I demonstrates that an
interview and feedback session with a trained mother early in the first year of medical school improves the content and process of interviewing. Study II demonstrates that one
interview and feedback session with a trained mother
provides maximal benefit for improvement of interviewing
skills. Study ifi demonstrates that interviewing skills acquired from a single interview and feedback session with a trained mother are retained for at least one year. Study IV demonstrates that the improvement in interviewing skills is maintained at a constant level six weeks as well as one year
scale and individualized instruction in its use by a
trained mother. It has been demonstrated that
students exposed to the scale and instructed in its
use
by
a trained mother can significantly improvetheir interviewing skills. The third step is to
provide an objective means of evaluation to ensure that the stated objectives are actually
attained. This was done by training mothers in the
use of the ACIR scale for which intrarater
relia-bility coefficients of .85 to .90 and an interrater reliability coefficient of .87 have been established.
By using this scale, the mothers were able to
verify that interviewing skills were acquired to a
set level of competence and to evaluate the
students in a constructive and instructive way.
The use of trained mothers as teachers and
evaluators is both efficient and economical,
leaving physicians with more time for other kinds
of teaching. Student response to this program has
been enthusiastic.
A possible criticism of these studies is that
students in the experimental groups were exposed
to the evaluation criteria during the treatment
interview, whereas students in the control group
were not exposed to these criteria prior to their
evaluative interview. We feel that using the same
instrument (ACIR scale) for teaching as well as for
evaluation is not a serious flaw. Rather, we
believe that once students are told the criteria by
which they are to be judged, it is appropriate to
use those criteria for evaluation. The data
mdi-cate that one exposure to these criteria with an
active learning experience is sufficient and that
the length of time between exposure and
evalua-lion is inconsequential up to one year. A future
study is planned to determine if exposure to the
ACIR scale alone is as effective as active
partici-pation in an interview and individual instruction
in the use of the ACIR scale by a trained
mother.
SUMMARY
Students in a first-year preparation for clinical
medicine course showed a significant
improve-ment in interviewing skills as a result of a
treatment interview and feedback session with a
trained mother. A follow-up of the students over a
two-year period indicates that maximum learning
occurred after the first interview and feedback
session with the trained mother. Skills learned
during an interview early in the medical school
curriculum are retained for up to one year. One
early interview provides for optimal learning of
interviewing skills and long-term and short-term
improvements in interviewing skills are
equiva-lent.
REFERENCES
1. Helfer RE: An objective comparison of the pediatric interviewing skills of freshman and senior medical students. Pediatrics 54:623, 1970.
2. HeIfer RE, Hess J: An experimental model for making objective. measurements of interviewing skills. J Clin Psychol 26:327, 1970.
3. Heifer RE, Ealy KF: Observations of pediatric inter-viewing skills. Am J Dis Child 123:556, 1972.
4. Heifer RE, Black MA, Teitelbaum H: A comparison of pediatric interviewing skills using real and simu-lated mothers. Pediatrics 55:397, 1975.
5. Heifer RE, Black MA, Heifer ME: Pediatric interview-ing skills taught by nonphysicians. Am J Dis Child
129:1053, 1975.
6. Stillman PL, Sabers DL, Redfield DL: Use of parapro-fessionais to teach and evaluate interviewing skills in medical students. Pediatrics 57:769, 1976.
ACKNOWLEDGMENT
We wish to thank Dr. Robert I. Cutts, coordinator of the preparation for clinical medicine course, for allowing us to