What do medical trainees think is so difficult about communicating with patients?

"I Surrendered": Metaphors in Residents' Stories about Communication Challenges

It is well-known that communication with patients can be challenging for residents. Although some studies have focused on residents' experiences of communication challenges, few, if any, have investigated the language residents use when describing such challenges. In this study, we explore the metaphors residents use when asked to share stories about challenging communication situations. Metaphor has been the focus of research in a variety of health-related disciplines; here, we use it to gain an understanding of why these situations are seen as challenging. Methodologically, we draw on metaphor-led discourse analysis, which facilitates a systematic approach to the identification and analysis of metaphors. The empirical material consists of 138 Danish residents' 259 narratives about communication challenges. We identified more than 700 metaphors used in connection with accounting for communication challenges with patients. The metaphors are primarily driven by vehicles belonging to four groups, namely: "Location," "Movement," "Games and play," and "Battle and warfare." We discuss the implications of these metaphors in relation to residents' conceptualizations of communication and challenges.

A paediatric logbook: Millstone or milestone?

Logbooks are ubiquitous in undergraduate and postgraduate medical education. Here, two alumni who are in the early phase of their career, reflect on their experience in their undergraduate paediatric term and how this was shaped by their mandatory paediatric logbook.

Simulated patient's feedback to improve communication skills of clerkship students

BACKGROUND

The changing trends of the society and revisions to medical education have changed the way medical students are trained to adroitly care for patients hence, patient centered care has become need of today's society and communication skills are imperative in developing patient physician relationship. Increasingly, simulations are being used to aid medical students to incorporate theoretical knowledge into practice. There are innumerable studies regarding communication skills in terms of reliability, validity and feasibility but no such study has been documented using simulated patient's feedback in improving communication skills in Pakistan. The aim of this study is to explore whether simulated patients' feedback improves the communication skills of undergraduate medical students.

METHODS

During a randomized control trail a group of eighty students in the final year clerkship at Al-Nafees Medical College have participated in pre-post Objective Structured Clinical Exam (OSCE) on communication skills. The students were selected through convenience sampling technique. Four Objective Structured Clinical Exam (OSCE) stations based on different scenarios of communication skills were developed. Each station of fifteen minutes duration was assessed by both simulated patients and faculty using a validated tool LCSAS (Liverpool Communication Skills Assessment Scale). The difference between the pre and post-tests of two groups was explored by applying independent t-test. Cronbach's alpha was used to check the reliability of scores and effect size was calculated.

RESULTS

Results of this study have showed that there is significant improvement in communication skills after receiving feedback from simulated patients (p value ≤0.05) was observed. An overall Cronbach α = 0.83 on LCSAS reveal a high internal consistency and there was adequate demonstration of effect size(r = 0.8).

CONCLUSION

The results on the scores of the students on the Liverpool Communication Skills Assessment Scale confirm that simulated patient's feedback is essential to enhance the communication skills of the medical students. This study offers significant evidence towards successful conduction of a formal communication skills development initiative at Al-Nafees Medical College using simulated patient feedback during teaching and assessments.

How do residents perceive and narrate stories about communication challenges in patient encounters? A narrative study

OBJECTIVE

This article investigated residents' narratives to gain their understandings of which patterns are challenging in doctor-patient conversations.

DESIGN

Qualitative narratological framework.

PARTICIPANTS

We analysed 259 narratives from 138 residents' oral recounts of communication with patients in which they had felt challenged.

RESULTS

The analysis identified an ideal narrative for the doctor-patient encounter with the resident as protagonist pursuing the object of helping the patient with his health problem. Disruptions of this ideal narrative were at play when challenges occurred. Regardless of medical setting, challenges were often related to the establishment of a common object, and the communication actants had to go through negotiations, disagreements or even battles when trying to reach a common object. Challenges also occurred when actants which in the ideal narrative should act as helpers become opponents. We find narratives where patients, relatives and colleagues become opponents.

CONCLUSIONS

Our study showed that communication challenges were the result of disruptions of the perceived ideal narrative. Residents found it especially challenging to establish a common object, and dealing with helpers turned opponents. Patient communication is thus a challenge in the transition phase from student to doctor, and doctor-patient communication is complex in nature and continuously perceived to be so by residents, despite pregraduate training.

Beyond words: What can help first year medical students practice effective empathic communication?

OBJECTIVE

To gain insight into first year medical students' experiences of practicing empathic communication and how patients that train students perceive such communication, in order to inform early communication skills training.

METHODS

Our study consisted of four focus groups, two of year one students who completed a first semester clinical skills course, one of standardized patients, and one of volunteer outpatients. Focus group transcripts were independently coded and iteratively reviewed to identify major themes. Course evaluation data was collected and analyzed.

RESULTS

Themes from student focus groups described significant challenges in striving to convey empathy: coping with anxiety due to multitasking, "buying-in" to learning empathy, and managing vulnerability when engaging emotionally. Patients appreciated students' expression of vulnerability and nonverbal communication.

CONCLUSION

First year medical students encounter challenges in learning empathic communication, and patients may perceive empathy from students in ways other than verbal responses. Early communications curricula should focus on assisting students with anxiety of multi-tasking, sense of vulnerability, buy-in to communications training, and the importance of non-verbal communication.

PRACTICE IMPLICATIONS

A deliberate focus on empathetic responsiveness, especially non-verbal, might lessen anxiety, improve attentional switching, and build confidence in managing vulnerability for early medical students learning communication skills.

The learning effects of different presentations of worked examples on medical students' breaking-bad-news skills: A randomized and blinded field trial

OBJECTIVES

Effective instructional approaches are needed to enable undergraduates to optimally prepare for the limited training time they receive with simulated patients (SPs). This study examines the learning effects of different presentation formats of a worked example on student SP communication.

METHODS

Sixty-seven fourth-year medical students attending a mandatory communication course participated in this randomized field trial. Prior to the course, they worked through an e-learning module that introduced the SPIKES protocol for delivering bad news to patients. In this module, a single worked example was presented to one group of students in a text version, to a second group in a video version, and to a third group in a video version enriched with text hints denoting the SPIKES steps.

RESULTS

The video-with-hints group broke bad news to SPs significantly more appropriately than either of the other groups. Although no further condition-related effects were revealed, students who learned from the text version most frequently (although non-significantly) ignored unpleasant emotions (standardised emotional cues and concerns) expressed by the SPs.

CONCLUSIONS

The learning effect was strongest when the video-based worked example was accompanied by hints.

PRACTICE IMPLICATIONS

Video-related learning approaches that embed attention-guiding hints can effectively prepare undergraduates for SP encounters.

A Preliminary Qualitative Evaluation of an In-home Geriatric Care Elective Experience for Third-year Medical Students

Introduction: The aging population is growing quickly and has a higher prevalence of comorbid and chronic diseases. A majority of this group resides in the home setting. The purpose of this study was to examine the attitudes of third-year medical students following a pilot component of an internal medicine clerkship, consisting of four in-home visits with geriatric patients.

Methods: A qualitative study design, utilizing focus groups, was used to assess general themes in students’ responses regarding their attitudes to geriatrics, the field of geriatrics and the in-home care pilot program.

Results: Twelve students participated in three focus group sessions. Six themes were identified across all focus group sessions. These included 1) distinct advantages to the home setting, 2) more time for relationship building, 3) increased insight to the aging process, 4) increased compassion, 5) suggestions for program improvement, and 6) future quality of care.

Conclusion: The results demonstrate that students found the program to be of value to their medical education. Students developed positive attitudes and compassion for the elderly community. The insight they gained during this program may allow them to understand their role in caring for increasing numbers of aging patients in future populations. Suggestions made by the students showed their perceived value of the program and desire for it to continue for future students. Future studies should utilize validated tools and more longitudinal study designs to assess temporal changes in attitudes.

Take the HEAT: A pilot study on improving communication with angry families

OBJECTIVE

Our objective was to evaluate the utility of an educational program consisting of a workshop based on the Take the HEAT communication strategy, designed specifically for addressing patients who are angry, using a novel tool to evaluate residents' skills in employing this method.

METHODS

33 first-year pediatric and internal medicine-pediatrics residents participated in the study. The workshop presented the Take the HEAT (Hear, Empathize, Apologize, Take action) strategy of communication. Communication skills were assessed through standardized patient encounters at baseline and post-workshop. Encounters were scored using a novel assessment tool.

RESULTS

After the workshop, residents' Take the HEAT communication improved from baseline total average score 23.15 to total average score 25.36 (Z=-3.428, p<0.001). At baseline, empathy skills were the lowest. Intraclass Correlation Coefficient demonstrated substantial agreement (0.60 and 0.61) among raters using the tool.

CONCLUSION

First-year pediatric trainees' communication with angry families improved with education focused on the Take the HEAT strategy. Poor performance by residents in demonstrating empathy should be explored further.

PRACTICE IMPLICATIONS

This study demonstrates the utility of a brief communications curriculum aimed at improving pediatric residents' ability to communicate with angry families.

Learning communication from erroneous video-based examples: A double-blind randomised controlled trial

OBJECTIVE

Appropriate training strategies are required to equip undergraduate healthcare students to benefit from communication training with simulated patients. This study examines the learning effects of different formats of video-based worked examples on initial communication skills.

METHODS

First-year nursing students (N=36) were randomly assigned to one of two experimental groups (correct v. erroneous examples) or to the control group (no examples). All the groups were provided an identical introduction to learning materials on breaking bad news; the experimental groups also received a set of video-based worked examples. Each example was accompanied by a self-explanation prompt (considering the example's correctness) and elaborated feedback (the true explanation).

RESULTS

Participants presented with erroneous examples broke bad news to a simulated patient significantly more appropriately than students in the control group. Additionally, they tended to outperform participants who had correct examples, while participants presented with correct examples tended to outperform the control group.

CONCLUSION

The worked example effect was successfully adapted for learning in the provider-patient communication domain.

PRACTICE IMPLICATIONS

Implementing video-based worked examples with self-explanation prompts and feedback can be an effective strategy to prepare students for their training with simulated patients, especially when examples are erroneous.

Attachment styles and clinical communication performance in trainee doctors

OBJECTIVE

To investigate the relationship between trainee doctors' attachment style and their performance in qualifying clinical and communication skills assessments.

METHODS

Participants were 190 undergraduate medical students whose performance was assessed by examiners across two areas (communication and clinical skills) during their qualifying Objective Structured Clinical Examination (OSCE). Simulated patients also rated communication skills. Participants' attachment style was rated across two dimensions, avoidance and anxiety, using the Relationship Questionnaire (RQ).

RESULTS

Lower levels of attachment avoidance and anxiety significantly predicted higher performance in both communication and clinical skills.

CONCLUSION

Trainee doctors' attachment styles are associated with patient communication and clinical performance. Further research is needed to investigate the impact of attachment on consultations between doctors and patients within clinical settings.

PRACTICE IMPLICATION

Attachment theory can inform our understanding why, for some student doctors, interacting with patients may be particularly challenging and require additional support by medical educators.

The stories they tell: How third year medical students portray patients, family members, physicians, and themselves in difficult encounters

BACKGROUND

Physicians have long had patients whom they have labeled "difficult", but little is known about how medical students perceive difficult encounters with patients.

METHODS

In this study, we analyzed 134 third year medical students' reflective essays written over an 18-month period about difficult student-patient encounters. We used a qualitative computerized software program, Atlas.ti to analyze students' observations and reflections.

RESULTS

Main findings include that students described patients who were angry and upset; noncompliant with treatment plans; discussed "nonmedical" problems; fearful, worried, withdrawn, or "disinterested" in their health. Students often described themselves as anxious, uncertain, confused, and frustrated. Nevertheless, they saw themselves behaving in empathic and patient-centered ways while also taking refuge in "standard" behaviors not necessarily appropriate to the circumstances. Students rarely mentioned receiving guidance from attendings regarding how to manage these challenging interactions.

CONCLUSIONS

These third-year medical students recognized the importance of behaving empathically in difficult situations and often did so. However, they often felt overwhelmed and frustrated, resorting to more reductive behaviors that did not match the needs of the patient. Students need more guidance from attending physicians in order to approach difficult interactions with specific problem-solving skills while maintaining an empathic, patient-centered context.

Medical students' creative projects on a third year pediatrics clerkship: a qualitative analysis of patient-centeredness and emotional connection

BACKGROUND

Increasingly, medical educators are incorporating reflective writing and original creative work into educational practices with the goals of stimulating student self-awareness, appreciation of multiple perspectives, and comfort with ambiguity and uncertainty. This study investigated students' creative projects to assess the extent to which they adopted a patient/relationship-centered, emotionally connected position toward patients and families.

METHODS

Over a 10 year period, students on a required third year pediatrics clerkship individually or in groups completed either a reflection or an education project using a creative medium. 520 projects (representing 595 students, 74.7 % of total eligible students) were qualitatively analyzed according to various thematic and emotion-based dimensions.

RESULTS

The majority of projects were personal narrative essays and poetry. The largest number of project themes related to the importance of patient/relationship-centered medicine with patients. The next largest number of projects focused on health education of parents, patients, or classmates. In telling their stories, students were more likely to use a personal voice representing either their or the patient's perspective than an objective, impersonal one. In terms of emotional tone, projects were more likely to be serious than humorous. The largest number of students' emotions expressed an empathic tone. Students identified a large number and wide range of both negative and positive feelings in themselves and their patients. The majority of student emotions were positive, while the majority of patient and family emotions were negative.

CONCLUSIONS

Students' preference for patient-centered, relational themes, as well as their tendency to favor the first voice, empathic tone, and willingness to express a range of positive and negative emotions in presenting their projects, suggests that they valued emotional connection with patients and families during the pediatrics clerkship experience.

Strengthening student communication through pediatric simulated patient encounters

As medical students enter the role of physician, clinical outcomes not only rely on their mastery of clinical knowledge, but also on the effectiveness in which they can communicate with patients and family members. While students typically have numerous opportunities to practice clinical communication with adult patients, such practice in pediatric settings is limited. This study examines if simulated patient (SP) encounters strengthen third-year medical students' communication skills during the pediatrics clerkship. During 2011-2013, three SP encounters (comprising 3 pediatric scenarios) were incorporated into a pediatrics clerkship at one United States medical school to give students a safe venue to practice advanced communication with observation and direct feedback. Third-year medical students engaged in the scenarios and received both written and oral feedback from an evaluator observing the encounter. With IRB approval, students' self-perceived confidence and abilities at performing the advanced communication skills were measured using an eightitem, Likert scale questionnaire administered pre and post the SP encounter. Pre- and post-questionnaires (n=215; response rate, 96%) analyzed using a Wilcoxon-matched pairs signed-rank test demonstrated statistically significant increases in students' perception of their confidence and abilities regarding their performance (P<0.05; Bonferroni correction, P<0.006). There was an increases in student confidence and self-perceived ability in: first, communicating with children and family members of young patients; second, managing confrontational situations involving parents; third, performing a thorough psychosocial history with an adolescent; and fourth, using Evidence Based Medicine to motivate parents.

(Re)Introducing communication competence to the health professions

Despite the central role that communication skills play in contemporary accounts of effective health care delivery in general, and the communication of medical error specifically, there is no common or consensual core in the health professions regarding the nature of such skills. This lack of consensus reflects, in part, the tendency for disciplines to reinvent concepts and measures without first situating such development in disciplines with more cognate specialization in such concepts. In this essay, an integrative model of communication competence is introduced, along with its theoretical background and rationale. Communication competence is defined as an impression of appropriateness and effectiveness, which is functionally related to individual motivation, knowledge, skills, and contextual facilitators and constraints. Within this conceptualization, error disclosure contexts are utilized to illustrate the heuristic value of the theory, and implications for assessment are suggested. Significance for public healthModels matter, as do the presuppositions that underlie their architecture. Research indicates that judgments of competence moderate outcomes such as satisfaction, trust, understanding, and power-sharing in relationships and in individual encounters. If the outcomes of health care encounters depend on the impression of competence that patients or their family members have of health care professionals, then knowing which specific communicative behaviors contribute to such impressions is not merely important - it is essential. To pursue such a research agenda requires that competence assessment and operationalization becomes better aligned with conceptual assumptions that separate behavioral performance from the judgments of the competence of that performance.

The influence of medical students' and doctors' attachment style and emotional intelligence on their patient-provider communication

OBJECTIVE

Attachment style and emotional intelligence (EI) have been highlighted as potential factors influencing the variation in medical students' and doctors' patient-provider communication (PPC), particularly in relation to emotive issues. The objective of this review is to systematically review and synthesise the published literature relating to the influence of medical students' and/or doctors' attachment style and EI on their PPC.

METHODS

Electronic and hand searches were conducted to identify all published literature relating to the aim of the review. Data were narratively synthesised.

RESULTS

1597 studies were identified. 14 were included in the review, of which 5 assessed the influence of attachment style and 9 assessed the influence of EI on PPC. No studies assessed the impact of both attachment style and EI on PPC.

CONCLUSION

Whilst tentative links were found between both PPC and both attachment style and EI, heterogeneity in study design, predictor variables and outcome measures made drawing conclusions difficult.

PRACTICE IMPLICATIONS

More research is needed to assess the influence of both attachment style and EI on PPC.