Teaching communication in clinical clerkships: models from the macy initiative in health communications

Validity evidence for the clinical communication skills assessment tool (CCSAT) from 9 years of implementation in a high stakes medical student OSCE

OBJECTIVES

Communication and other clinical skills are routinely assessed in medical schools using Objective Structured Clinical Examinations (OSCEs) so routinely that it can be difficult to monitor and maintain validity. We report on the accumulation of validity evidence for the Clinical Communication Skills Assessment Tool (CCSAT) based on its use with 9 cohorts of medical students in a high stakes OSCE.

METHODS

We describe the implementation of the CCSAT including information on the underlying model, the tool's items, domains, scales and scoring, and its role in curriculum. Internal structure is explored through item, internal consistency, and confirmatory factor analyses. Evidence for CCSAT validity is synthesized within prevailing frameworks (Messick12 and Kane13) based on continuous quality improvement and use of the CCSAT for feedback, remediation, curricular design, and research.

RESULTS

Implementation of the CCSAT over time has facilitated our communication skills curriculum and training. Thoughtful case development and investment in standardized patient training has contributed to data quality. Item analysis supports our behaviorally anchored scale (not done, partly and well done) and the skills domains suggested by an a priori evidence-based clinical communication model were confirmed via analysis of actual student data. Evidence synthesized across the frameworks suggests consistent validity of the CCSAT for generalization inferences (that it captures the construct), responsiveness (sensitivity to change/difference), content validity/internal structure, relationships to other variables, and consequences/implications. More evidence is needed to strengthen validity of CCSAT scores for understanding extrapolation inferences and real-world implications.

CONCLUSIONS AND PRACTICE IMPLICATIONS

This pragmatic approach to evaluating validity within a program of assessment serves as a model for medical schools seeking to continuously monitor the quality of clinical skill assessments, a need made particularly relevant since the US NBME no longer requires the Step 2 Clinical Skills exam, leaving individual schools with the responsibility for ensuring graduates have acquired the requisite core clinical skills. We document strong evidence for CCSAT validity over time and across cohorts as well as areas for improvement and further examination.

The role of emotions in academic performance of undergraduate medical students: a narrative review

BACKGROUND

This paper is devoted to a narrative review of the literature on emotions and academic performance in medicine. The review aims to examine the role emotions play in the academic performance of undergraduate medical students.

METHODS

Eight electronic databases were used to search the literature from 2013 to 2023, including Academic Search Ultimate, British Education Index, CINAHL, Education Abstract, ERIC, Medline, APA Psych Articles and APA Psych Info. Using specific keywords and terms in the databases, 3,285,208 articles were found. After applying the predefined exclusion and inclusion criteria to include only medical students and academic performance as an outcome, 45 articles remained, and two reviewers assessed the quality of the retrieved literature; 17 articles were selected for the narrative synthesis.

RESULT

The findings indicate that depression and anxiety are the most frequently reported variables in the reviewed literature, and they have negative and positive impacts on the academic performance of medical students. The included literature also reported that a high number of medical students experienced test anxiety during their study, which affected their academic performance. Positive emotions lead to positive academic outcomes and vice versa. However, Feelings of shame did not have any effect on the academic performance of medical students.

DISCUSSION

The review suggests a significant relationship between emotions and academic performance among undergraduate medical students. While the evidence may not establish causation, it underscores the importance of considering emotional factors in understanding student performance. However, reliance on cross-sectional studies and self-reported data may introduce recall bias. Future research should concentrate on developing anxiety reduction strategies and enhancing mental well-being to improve academic performance.

Learning to Communicate: A Photovoice Study With Intensive Care Residents During Night Shifts in the Intensive Care Unit

This study explored the learning experiences of intensive care residents in an intensive care unit (ICU) during night shifts and the development of communication skills in this community of practice. This action research qualitative study used the photovoice method in four workshops. A group of nine residents shared their learning experiences and collectively analyzed, built, and presented proposals to improve residents' communication skills in the community of practice in which they become intensivists. Participatory thematic analysis was conducted. Students concluded that night shifts in the ICU offered a perfect situational learning environment for communication with one-on-one resident-teacher relationships, less administrative work, and more resident responsibility, improving intensivist identity. Role models, reflective thinking, and teamwork are essential for fostering communication skills among intensivist community members and are all trainable. The results and student suggestions were presented to teachers and decision-makers in the clinic. These photovoice strategies developed students' abilities to share their critical views and suggestions with decision-makers for subsequent implementation, enhancing their confidence in their learning process, strengthening trust-based relationships with teachers, and improving future intensivists' practice communities.

The Physician-Patient Communication Behaviors Among Medical Specialists in a Hospital Setting

Effective physician-patient communication builds robust physician-patient relationships and reduces medical disputes. However, much is unknown about the differences that exist in the communication behaviors of physicians in different departments. Using a mixed-methods research approach, the researchers used Roter Interaction Analysis System to uncover the communication behaviors of internists, surgeons, family physicians, and emergency physicians at a regional hospital in Taiwan. Semi-structured interviews were conducted to collect the communication experiences of 20 physicians from the internal medicine, surgery, family medicine, and emergency departments. The characteristics were presented through descriptive statistics, bar charts, and dendrograms. Physician-patient communications consisted of four dimensions, 10 factors, and 31 behaviors. The characteristics are as follows: (1) Internists need to improve their overall performance in terms of physician-patient communication behaviors; (2) Surgeons performed well in building relationships through non-verbal methods; (3) Family physicians excelled in facilitation and patient activation. (4) Emergency physicians performed well in patient education and counseling. The characteristics of the aforementioned communication behaviors among internists, surgeons, family physicians, and emergency physicians can be used to construct indicators of physician-patient communication in each department and to develop patient-centered healthcare services in the future.

Using Unannounced Standardized Patients to Assess Clinician Telehealth and Communication Skills at an Urban Student Health Center

PURPOSE

As the COVID-19 pandemic forced most colleges and universities to go online, student health centers rapidly shifted to telehealth platforms without frameworks for virtual care provision. An urban student health center implemented a needs assessment involving unannounced standardized patients (USPs) to evaluate the integration of a new telehealth workflow and clinicians' virtual communication skills.

METHODS

From April to May 2021, USPs conducted two video visits with 12 primary care and four women's health clinicians (N = 16 clinicians; 32 visits). Cases included (1) a 21-year-old female presenting for birth control with a positive Patient Health Questionaire-9 and (2) a 21-year-old male, who vapes regularly, with questions regarding safe sex with men. Clinicians were evaluated using a checklist completed by the USP immediately following the visit and a systematic chart review of the electronic health record.

RESULTS

USP feedback indicates most clinicians received high ratings for general communication skills but may benefit from educational intervention in several key telemedicine skills. Clinicians struggled with using nonverbal signals to enrich communication (47% well done), acknowledging emotions (34% well done), and using video for information gathering (34% well done). Low rates of standard screenings (e.g., 63% administered the PHQ-2, <50% asked about alcohol use) suggested protocols for in-person care were not easily incorporated into telehealth practices, and clinicians may benefit from enhanced care team support. Performance reports were shared with clinicians and leadership postvisit.

DISCUSSION

Results suggest project design and implementation is scalable and feasible for use at other institutions, offering a structured methodology that can improve general student health care.

Patient-physician interaction education in Korea: a systematic review

Patient-physician interaction (PPI) is an important area in medical education, but in-depth discussions on the content of the outcome of patient-doctor education are rare. Therefore, in this study, we will systematically analyze the research on PPI education in Korea. In this study, papers searched with keywords related to PPI education from Korea's academic journal service were targeted according to a systematic literature analysis method. The scope of the study was to include papers published in academic journals that are candidates for Korea Citation Index registration, excluding dissertations, research reports, posters, conference presentations, books, and internet materials. The content included papers targeting medical education and medical school students was set as the range. As a result of the analysis, although communication between PPI has many positive effects in the PPI in medical education at medical schools, obstacles do occur, and various ways to overcome them were suggested. Therefore, although medical interview training between patients and doctors in medical schools is necessary, it was analyzed as being based on overseas research or lacking in specific content. The core of PPI education appears to be medical interviews, and it seems necessary to discuss whether empathy or patient-centered medical care are appropriate as the main principles of PPI education in Korea. Therefore, education on the patient-doctor relationship is an important element in medical humanities and medical humanities education, and it is expected that research and education on this will progress more actively.

Development and Validation of the Therapeutic Communication Scale in Nursing Students

This study aimed to develop and validate a scale for measuring the therapeutic communication of nursing students. The scale development and evaluation study was conducted based on the scale development guidelines of DeVellis. A 47-item instrument was developed based on a review of the literature and interviews with 16 experts. Content validity was evaluated by ten nursing scholars, and the number of items was reduced to 35. The scale was administered to 352 nursing students from three regions in South Korea in 2022. Exploratory factor analysis and confirmatory factor analysis were performed on the scale items. Convergent validity, discriminant validity, and internal consistency reliability of the scale were evaluated. The factor analysis resulted in 15 items and two factors: relationship building and problem solving. Confirmatory factor analysis and evaluation of convergent and discriminant validity provided support for the validity of the two-factor Therapeutic Communication Scale in nursing students. The total scale demonstrated good internal consistency, with a McDonald's omega (ω) of 0.89. The Therapeutic Communication Scale is a reliable and valid measure that can be used to assess nursing students' therapeutic communication competence related to patient-centered nursing and provide foundational data to improve such skills.

Identifying the Structural and Functional Dimensions of Chronic Disease Follow-Up Interviews

The structure of medical interviews is a topic that has been extensively investigated in the scientific literature. However, some medical contexts remain unexplored, such as follow-up interviews for chronic diseases, despite being particularly rich in interactional, relational and emotional information. In this study, we set out to extract a hierarchical and functional structure from these medical consultations. The analysis method used was inspired by the methods of discourse analysis developed by the Geneva school of Roulet and colleagues. We recorded, transcribed and analyzed 13 authentic chronic disease follow-up interviews with hospital specialists. Following these analyses, we extracted a functional structure of these interviews with the phases and sequences that compose them. Findings distinguish similarities and disparities between chronic disease follow-up visits and other types of medical visits. Our discussion articulates how these types of patient-physician exchanges are similar to, but also different from, other types of medical interactions in different settings.

How Likes and Retweets Impacted Our Patients During the COVID-19 Pandemic

The growing dependence on social media for health-related information boomed during the COVID-19 pandemic, posing unprecedented challenges in navigating the vast amounts of information available right at our fingertips. Social media had a major impact on clinical decision-making affecting individuals, communities, and societies at large. In this review, we discuss the role of social media in amplifying information and misinformation as well as factors contributing to its reliance and prevalence. We review how medical providers have been impacted by this changing landscape, useful communication strategies to employ with in-office patient encounters, and how we can be active players in using social media as a tool for health promotion, correcting misinformation, and preparing for future pandemics.

Understanding medical student paths to communication skills expertise using latent profile analysis

PURPOSE

To describe patterns of clinical communication skills that inform curriculum enhancement and guide coaching of medical students.

MATERIALS AND METHODS

Performance data from 1182 consenting third year medical students in 9 cohorts (2011-2019), on a 17-item Clinical Communication Skills Assessment Tool (CCSAT) completed by trained Standardized Patients as part of an eight case high stakes Comprehensive Clinical Skills Exam (CCSE) were analyzed using latent profile analysis (LPA). Assessment domains included: information gathering (6 items), relationship development (5 items), patient education (3 items), and organization/time management (3 items). LPA clustered learners with similar strength/weakness into profiles based on item response patterns across cases. One-way analysis of variance (ANOVA) assessed for significant differences by profile for CCSAT items.

RESULTS

Student performance clustered into six profiles in three groups, high performing (HP1 and HP2-Low Patient Education, 15.7%), average performing (AP1 and AP2-Interrupters, 40.9%), and lower performing profiles (LP1-Non-interrupters and LP2, 43.4%) with adequate model fit estimations and similar distribution in each cohort. We identified 3 CCSAT items that discriminated among learner's skill profiles.

CONCLUSION

Clinical communication skill performance profiles provide nuanced, benchmarked guidance for curriculum improvement and tailoring of communication skills coaching.

Integrating Communication Skills, Awareness of Self and Others, and Reflective Feedback into One Inclusive Anatomical Representation of Relationship-Centered Health Care

The American Veterinary Medical Association Council on Education mandates in standard 11 that all accredited colleges of veterinary medicine must develop and deliver formal processes by which students are observed and assessed in nine competencies. The eighth competency combines clinical communication and sensitivity toward soliciting and understanding individual narratives across a diverse clientele to facilitate health care delivery. Several frameworks have been designed to structure health care consultations for teaching and coaching purposes. The Calgary-Cambridge guide (CCG) provides an evidence-based approach to outlining the flow of consultations, incorporating foundational communication skills and elements of relationship-centered care into a series of sequential tasks. Although the CCG was intended for use as a flexible tool kit, it lacks visible connections between concrete experiences (e.g., the consultation) and reflective observation (e.g., the feedback). This teaching tip describes the development of a novel anatomical representation of the consultation that integrates process elements of the CCG with other core curricular concepts. By combining knowledge, technical skills, critical thinking, reflection, cultural humility, and self-awareness into a skeletal consultation model, linkages are established between communication and intergroup dialogue skills, diversity and inclusion (D&I). This model has been further adapted as feline, caprine, porcine, equine, avian, and reptilian versions for in-class use as strategic visual aids that highlight key areas of focus for Professional Skills class sessions. Future developments by the authors will explore how to link species-specific consultation models to assessment rubrics to reinforce the connection between content (what) and process (how).

Design of a communication skills course in dentistry: Applying active-learning strategies to improve educational outcomes

PURPOSE/OBJECTIVE

Effective communication, between patient and dentist, is a core clinical skill that commands dedicated pedagogy similar to that of developing scientific knowledge and psychomotor skills. This study aimed to describe active-learning strategies in a dental communication skills course, which sits within a broader foundation dental course and evaluate students' educational outcomes.

METHODS

This is a two-phase retrospective, mono-centred study, completed in 2019 at an Australian dental school. Phase I, a case report, describes the Communication Skills for Oral Health (CSOH) course design and its active-learning strategies. Phase II analysed data from the course using Kirkpatrick's evaluation model to objectively measure the impact of the course and provide feedback to education designer. Students' perception (Level 1) was evaluated with an institutional, validated online survey. Descriptive and statistical analysis, included paired tests and Spearman's correlation analyses, used to investigate learning effect (Level 2) and student behaviour change (Level 3). To assess the impact of the CSOH course design (Level 4) the student grades from the course were analysed.

RESULTS

The CSOH course encompasses three major topics: Essentials of Communication Skills, Professional-Patient Relationship and Managing Difficult Situations. Each topic included didactic content complimented with a variety of active-learning strategies to teach and assess students. Positive outcomes were recorded across all Kirkpatrick levels.

CONCLUSIONS

This study suggests an efficient communication skills course design, which may assist in the development of communication skills courses in other dental education institutions.

Pediatric otolaryngology telemedicine amid a pandemic - And beyond

INTRODUCTION

The coronavirus disease of 2019 (COVID-19) pandemic catalyzed an unprecedented redesign and innovative overhaul of health care delivery thrusting from fringe to mainstream virtual care. With a return to conventional practice, we now must create a research and policy agenda using the changes wrought by COVID-19 to help create a better health care system in its aftermath. The purpose of this study was to assess satisfaction of otolaryngology outpatient visits during the pandemic.

METHODS

A prospective survey study was performed on caregivers of all patients ages 0-26 years old seen in the Division of Pediatric Otolaryngology at our large tertiary care children's hospital from February-April 2020. The three study groups were those seen in-person 6 weeks before telemedicine was implemented (IBTM), those seen in telemedicine during the first 6 weeks (TM) it was implemented at our hospital, and those seen in-person during the telemedicine period (IDTM) in the same timeframe. The survey consisted of satisfaction questions related to their visit, if their child was recommended surgery at the time of the visit, and if the caregiver agreed with the recommendation. A medical record review was also performed.

RESULTS

A total of 176 caregivers completed the survey with 113(64.2%) completing the survey for an IBTM appointment, 59(33.5%) for a TM appointment, and 4(2.3%) for an IDTM appointment. There were 100(56.8%) male patients and 167(94.9%) were white. Families gave a higher response for the statement "The ability to communicate with the physician" (p = .012) and "The overall outpatient experience" (p = .004) in the IBTM cohort compared to the TM group. There were no significant differences for the other statements regarding the ability to understand recommendations, courtesy, and knowledge of the physician. Regardless of group, 98.6% of caregivers agreed with surgical recommendation when surgery was recommended. However, when surgery was not recommended at the appointment, caregivers were 11x more likely to disagree with the surgical recommendations, OR:11.49,95%CI:1.44-91.38,p = .005.

CONCLUSION

We conclude that telemedicine was equally well received by patients as compared to traditional live assessments suggesting that virtual care is a viable post-pandemic paradigm change. Satisfaction was rated as "Good" or "Excellent", however, messaging when surgery is not recommended was less acceptable and must be improved to obtain increased caregivers' agreement in an era of shared decision making.

Introductory patient communication training for medical physics graduate students: Pilot experience

Despite medical physics becoming a more patient‐facing part of the radiation oncology team, medical physics graduate students have no training in patient communication. An introductory patient communication training for medical physics graduate students is presented here. This training exposes participants to foundational concepts and effective communication skills through a lecture and it allows them to apply these concepts through realistic simulated patient interactions. The training was conducted virtually, and eight students participated. The impact of the training was evaluated based on changes in both confidence and competence of the participants’ patient communication skills. Participants were asked to fill out a survey to assess their confidence on communicating with patients before and after the training. They also underwent a simulated patient interaction pre‐ and postlecture. Their performance during these was evaluated by both the simulated patient actors and the participants themselves using a rubric. Each data set was paired and analyzed for significance using a Wilcoxon rank‐sum test with an alpha of 0.05. Participants reported significantly higher confidence in their feeling of preparedness to interact with patients (mean = 2.38 vs. 3.88, p = 0.008), comfort interacting independently (mean = 2.00 vs. 4.00, p = 0.002), comfort showing patients they are actively listening (mean = 3.50 vs. 4.50, p = 0.005), and confidence handling challenging patient interactions (mean = 1.88 vs. 3.38, p = 0.01), after the training. Their encounter scores, as evaluated by the simulated patient actors, significantly increased (mean = 77% vs. 91%, p = 0.022). Self‐evaluation scores increased, but not significantly (mean = 62% vs. 68%, p = 0.184). The difference between the simulated patient and self‐evaluation scores for the postinstruction encounter was statistically significant (p = 0.0014). This patient communication training for medical physics graduate students is effective at increasing both the confidence and the competence of the participants in the subject. We propose that similar trainings be incorporated into medical physics graduate training programs prior to students entering into residency.

Entrustment in physician-patient communication: a modified Delphi study using the EPA approach

BACKGROUND

Competency based curricula across the globe stress on the importance of effective physician patient communication. A variety of courses have been used to train physicians for this purpose. However, few of them link competencies with practice resulting in confusions in implementation and assessment. This issue can be resolved by treating certain specific patient communication related tasks as acts of entrustment or entrustable professional activities (EPAs). In this study, we aimed to define a competency-based framework for assessing patient physician communication using the language of EPAs.

METHODS

A modified Delphi study was conducted in three stages. The first stage was an extensive literature review to identify and elaborate communication related tasks which could be treated as EPAs. The second stage was content validation by medical education experts for clarity and representativeness. The third stage was three iterative rounds of modified Delphi with predefined consensus levels. The McNemar test was used to check response stability in the Delphi Rounds.

RESULTS

Expert consensus resulted in development of 4 specific EPAs focused on physician-patient communication with their competencies and respective assessment strategies all aiming for level 5 of unsupervised practice. These include Providing information to the patient or their family about diagnosis or prognosis; Breaking Bad news to the patient or their family; Counseling a patient regarding their disease or illness; Resolving conflicts with patients or their families.

CONCLUSIONS

The EPAs for Physician-patient communication are a step toward an integrative, all-inclusive competency-based assessment framework for patient-centered care. They are meant to improve the quality of physician patient interaction by standardizing communication as a decision of entrustment. The EPAs can be linked to competency frameworks around the world and provide a useful assessment framework for effective training in patient communication. They can be integrated into any post graduate curriculum and can also serve as a self-assessment tool for postgraduate training programs across the globe to improve their patient communication curricula.

Patient autonomy in the consultation: How signalling structure can facilitate patient-centred care

OBJECTIVE

To identify types and functions of doctors' verbal signalling behaviours used to share consultation structure with patients.

METHOD

Doctors' verbal utterances signalling what would happen in the consultation were identified by two independent raters from transcripts of 78 simulated consultations from a postgraduate examination for physicians. In total, 974 behaviours were categorised as informing, inviting or instructing. Principles adopted from Speech Act Theory and Conversation Analysis were used to examine their function from their literal meaning and use in context.

RESULTS

Signalling behaviours to inform were most frequent, particularly 'signposts', with less informative signalling behaviours also found ('posts without signs' and 'signs without posts'). Behaviours to invite involvement offered limited choice. Doctors also instructed the patient in what to do (behaviour) or not to do (emotion). Behaviours signalled more 'micro-level' changes than broader consultation aims. Signalling behaviours carried roles beyond their literal meaning ('hyperfunctions') and were combined ('stacked'), often seen deflecting the conversation away from patient concerns.

CONCLUSION

Doctors use a variety of verbal signalling behaviours with multiple functions. As well as sharing information, these behaviours regulate patient agency in the consultation.

PRACTICE IMPLICATIONS

Doctors' signalling behaviours may play an important role in facilitating or inhibiting patient autonomy.

Development of the Uncertainty Communication Checklist: A Patient-Centered Approach to Patient Discharge From the Emergency Department

Clear communication with patients upon emergency department (ED) discharge is important for patient safety during the transition to outpatient care. Over one-third of patients are discharged from the ED with diagnostic uncertainty, yet there is no established approach for effective discharge communication in this scenario. From 2017 to 2019, the authors developed the Uncertainty Communication Checklist for use in simulation-based training and assessment of emergency physician communication skills when discharging patients with diagnostic uncertainty. This development process followed the established 12-step Checklist Development Checklist framework and integrated patient feedback into 6 of the 12 steps. Patient input was included as it has potential to improve patient-centeredness of checklists related to assessment of clinical performance. Focus group patient participants from 2 clinical sites were included: Thomas Jefferson University Hospital, Philadelphia, PA, and Northwestern University Hospital, Chicago, Illinois.The authors developed a preliminary instrument based on existing checklists, clinical experience, literature review, and input from an expert panel comprising health care professionals and patient advocates. They then refined the instrument based on feedback from 2 waves of patient focus groups, resulting in a final 21-item checklist. The checklist items assess if uncertainty was addressed in each step of the discharge communication, including the following major categories: introduction, test results/ED summary, no/uncertain diagnosis, next steps/follow-up, home care, reasons to return, and general communication skills. Patient input influenced both what items were included and the wording of items in the final checklist. This patient-centered, systematic approach to checklist development is built upon the rigor of the Checklist Development Checklist and provides an illustration of how to integrate patient feedback into the design of assessment tools when appropriate.

Observing and Identifying Hospitalist Best Communication Practices in Patient Interactions

This study identifies actual hospitalist best communication practices that optimize patient interactions in a busy hospital context. We observed and rated 36 hospitalists and 206 patient encounters using the Kalamazoo Essential Elements of Communication Checklist-Adapted (KEECC-A). We collected descriptive statistics of checklist scores and thematically analyzed fieldnotes to identify communication patterns. Results show hospitalists score highest and most frequently use three of seven KEECC-A dimensions: builds a relationship, shares information, and gathers information. We first identify exemplar behaviors and then provide statistical comparisons by professional and hospital tenure, gender, and day of rounding observed for these three dimensions. Male hospitalists scored higher than females for shares information and significant differences were found for gender between cross-sex patient-hospitalist interactions. Hospitalists early in their professional and hospital tenure received significantly lower ratings than mid-to-late career hospitalists in the three KEECC dimensions. Hospitalists observed on the first day of rounding received significantly higher ratings than those observed on a middle or last day. We offer interpretations to explain study findings and suggest interventions to help hospitalists with less-than-desirable communication skills.

Monitoring communication skills progress of medical students: Establishing a baseline has value, predicting the future is difficult

OBJECTIVE

To provide evidence for the validity of an Introductory Clinical Experience (ICE) that was implemented as a baseline assessment of medical students' clinical communication skills to support progression of skills over time.

METHODS

In this longitudinal study of communication skills, medical students completed the ICE, then a Practice of Medicine (POM) Objective Structured Clinical Exam 8 months later, and the Comprehensive Clinical Skills Exam (CCSE) 25 months later. At each experience, trained Standardized Patients assessed students, using the same behaviorally anchored checklist in 3 domains: Information Gathering, Relationship Development, and Patient Education and Counseling (PEC) with good internal reliability (.70-.87). Skills development patterns were described. ICE as a predictor of later performance was explored. Students' perspectives were elicited.

RESULTS

140 (80%) medical students consented to include their data in this study. Overall communication scores increased over time (eta² = .17, medium effect) mostly attributable to increase in PEC skills (eta² = .48, large effect), in 4 patterns. ICE and POM scores predicted future communication skills. Most students recognized the educational value of ICE.

CONCLUSION

Entering medical students' clinical communication skills increase over time on average and may predict future performance.

PRACTICE IMPLICATIONS

Implementing an ICE is likely a valid strategy for monitoring progress and facilitating communication skills development.

Teaching and Assessment of Dentist-Patient Communication Skills: A Systematic Review to Identify Best-Evidence Methods

Dentist-patient communication skills are important aspects of contemporary oral health care, as shared decision making with patients becomes more common. The aim of this systematic review of the literature on teaching and assessment methodologies for communication skills in dental practice was to categorize those skills most relevant to dental practice and determine the best-evidence teaching and assessment methods. The systematic review was conducted using MEDLINE, EBM-Cochrane Libraries, Embase, ERIC, BIOSIS, CAB Abstracts, and PsycINFO using the OVID search engine, together with manually searching relevant journal articles. Relevant data were extracted from all included articles, and thematic analysis, categorization, and quality review of the articles was performed. Fifty articles published between 2000 and 2016 were identified as relevant to this study. Most were comparative design studies. The largest numbers were single group studies with before and after tests and cross-sectional studies. A total of 26 communication skills were identified and grouped into four major categories: generic skills, case-specific skills, time-specific skills, and emerging skills. Review of the teaching methods described in those articles showed that educators used a combination of passive and active strategies. All the assessment measures were considered to be valid and reliable. This categorization of essential dentist-patient communication skills reported in the literature may be used to assist in curriculum design along with use of tested teaching methods and validated assessment measures. The review highlights the need for more robust study designs for research in this important aspect of dental education.

How do Swiss medical schools prepare their students to become good communicators in their future professional careers: a questionnaire and interview study involving medical graduates, teachers and curriculum coordinators

BACKGROUND

Since 2011, the Swiss Catalogue of Learning Objectives (SCLO) has provided the framework for assessing communication skills in the Swiss Medical Federal Licensing Examination (FLE). This study evaluates how far the communication curricula of five Swiss medical schools match the SCLO and international recommendations. It also explores their strengths, weaknesses, opportunities and threats (SWOT).

METHODS

A mixed method approach was used. In a first step, curriculum coordinators/key communication skills teachers and medical graduates were asked to fill out a questionnaire based on communication related objectives from the SCLO and a review of European consensus statements on communication training. Second, information was collected from all Swiss medical schools to identify which communication skills were taught in which formats and at what time points within the 6-year curricula. Finally, 3-4 curriculum coordinators/key communication skills teachers from each medical school were interviewed about their communication curriculum, using SWOT analysis.

RESULTS

Sixteen teachers/coordinators (response rate 100%) and 389 medical graduates (response rate 43%) filled out the questionnaire. Both the teachers/coordinators and the graduates considered that two thirds of the communication items listed in the questionnaire were covered in their curricula. Between sixty and two hundred structured hours were dedicated to communication, predominantly in small group and experiential formats. Assessment relied on both MCQs and OSCEs. Most of the training occurred during the first three years of medical school. Teachers felt that the need for communication skills training was now well-recognized by their institution and was taught with appropriate teaching methods. However, recruitment and training of teachers, continuity of communication skills training during clinical years, and the adoption of a common frame of reference among the five medical schools, remained a challenge.

CONCLUSION

Although the Swiss medical schools all offered a partly longitudinal communication skills training, with appropriate teaching methods, this study indicates that the communication skills actually taught do not fully match the SCLO or international recommendations. There was less training for complex communication skills training during the clinical years, and ensuring quality and coherence in the teaching remained a challenge.

Challenges in Creating a Mobile Digital Tutor for Clinical Communications Training

Doctor-patient communication is a crucial element in effective medical care, and the striking health disparities evident in patients with Type II Diabetes may in part be caused by physicians' difficulties in establishing effective communication with patients who differ from them racially, culturally, and economically. REPEAT (Realizing Enhanced Patient Encounters through Aiding and Training) is a digital tutor developed to help solve this problem. REPEAT teaches and coaches learners to improve their general and disparities-focused clinical communication skills using simulated encounters with computer-generated Synthetic Standardized Patients (SSPs) and augments experiential learning in virtual encounters by applying customized, context-sensitive, learner-focused scaffolding. REPEAT authoring tools enable rapid development of learning content, allowing economical transferability to other domains. Key human factors challenges and their design solution in REPEAT are discussed.

Effect of an Educational Intervention on Medical Student Scripting and Patient Satisfaction: A Randomized Trial

INTRODUCTION

Effective communication between clinicians and patients has been shown to improve patient outcomes, reduce malpractice liability, and is now being tied to reimbursement. Use of a communication strategy known as "scripting" has been suggested to improve patient satisfaction in multiple hospital settings, but the frequency with which medical students use this strategy and whether this affects patient perception of medical student care is unknown. Our objective was to measure the use of targeted communication skills after an educational intervention as well as to further clarify the relationship between communication element usage and patient satisfaction.

METHODS

Medical students were block randomized into the control or intervention group. Those in the intervention group received refresher training in scripted communication. Those in the control group received no instruction or other intervention related to communication. Use of six explicit communication behaviors were recorded by trained study observers: 1) acknowledging the patient by name, 2) introducing themselves as medical students, 3) explaining their role in the patient's care, 4) explaining the care plan, 5) providing an estimated duration of time to be spent in the emergency department (ED), and 6) notifying the patient that another provider would also be seeing them. Patients then completed a survey regarding their satisfaction with the medical student encounter.

RESULTS

We observed 474 medical student-patient encounters in the ED (231 in the control group and 243 in the intervention group). We were unable to detect a statistically significant difference in communication element use between the intervention and control groups. One of the communication elements, explaining steps in the care plan, was positively associated with patient perception of the medical student's overall communication skills. Otherwise, there was no statistically significant association between element use and patient satisfaction.

CONCLUSION

We were unable to demonstrate any improvement in student use of communication elements or in patient satisfaction after refresher training in scripted communication. Furthermore, there was little variation in patient satisfaction based on the use of scripted communication elements. Effective communication with patients in the ED is complicated and requires further investigation on how to provide this skill set.

Interpersonal Skills Among Fourth- and Fifth-Year Medical Students: Validation of an Assessment Tool

OBJECTIVE

The aim of this study was to validate a French version of the standardized patient satisfaction questionnaire (SPSQ), an interpersonal skills assessment form, originally published in English, destined to be completed by SPs and used as a validated tool for the evaluation of communication skills of French medical students, during ambulatory care consultations.

METHODS

During the academic year, fourth- and fifth-year medical students participated in mock ambulatory care consultations. The French SPSQ was completed by 16 SPs who performed scenarios written by professors of medicine. Validity evidence for test content, response process, internal structure, and relation to other variables was determined by calculating the Cronbach α coefficient, the Loevinger H index (response coherence), intraclass coefficients, the differences between fourth- and fifth-year students and by using item correlations as well as the correlation with an independent validated assessment form. G theory was used to identify the sources of variations in the mean of SPSQ.

RESULTS

Four hundred thirty-three students were evaluated for a period of 2 months and participated in a total of 1703 mock consultations. The Cronbach α coefficient (0.94) was superior to that of the English SPSQ. The Loevinger H index was good ranging from 0.65 to 0.70. The reproducibility among external observers (intraclass correlation coefficient = 0.67) and between external observers and the SPs (intraclass correlation coefficient = 0.79 and 0.78, respectively) was satisfactory. Results of the French SPSQ were positively and significantly correlated to the scores obtained via an independent, validated, questionnaire (R = 0.72) and showed a significant difference between fourth- and fifth-year students' scores (P < 0.0001). G coefficients were estimated at 0.64 and 0.52 for year 4 and year 5, respectively.

CONCLUSIONS

Validity evidence supports the use of French-version SPSQ scores to screen for students experiencing difficulty with communication.

Validation of the Family Meeting Behavioral Skills Checklist. An Instrument to Assess Fellows' Communication Skills

RATIONALE

Fellows in pulmonary and critical care medicine are required to show competency in facilitating family meetings for critically ill patients. There are many assessment measures available for evaluating physician-patient communication (e.g., the SEGUE Framework [Set the stage, Elicit information, Give information, Understand the patient's perspective, End the encounter]) and some designed for family meetings. However, no validated measure exists that is specifically designed to assess communication skills during family meetings with surrogate decision makers in intensive care settings.

OBJECTIVES

We developed the Family Meeting Behavioral Skills Checklist (FMBSC) to measure advanced communication skills of fellows in family meetings of critically ill patients based on a literature review and consensus of an interdisciplinary group of communications experts. We evaluated the psychometric properties of the FMBSC.

METHODS

We digitally recorded 16 pulmonary/critical care fellows performing a simulated family meeting for a critically ill patient at the end of 1 year of fellowship training. Two clinical health psychologists evaluated each recording independently using the FMBSC Rating Scale and the SEGUE Framework. Judges recorded the number of skills performed using the checklist and employed a summary rating scale to judge the level of performance for each of nine subsets of skills. Each instrument was scored and converted to percentage scores. The FMBSC and SEGUE Framework items were summed and converted to percentage scores for each category and as a total for each instrument. The rating scale items on the FMBSC were also summed and converted to a percentage score. Four primary analyses were conducted to evaluate interjudge reliability, internal consistency, and concurrent validity.

MEASUREMENTS AND MAIN RESULTS

Interrater reliability was higher for the FMBSC (intraclass correlation [ICC2,2] = 0.57) than for the SEGUE instrument (ICC2,2 = 0.32) or the FMBSC Rating Scale (ICC2,2 = 0.23). The FMBSC demonstrated evidence of concurrent validity through high positive correlations with both the FMBSC Rating Scale and the SEGUE instrument (r = +0.83, P ≤ 0.01; r = +0.65, P ≤ 0.01 respectively). All but one of the nine subscales on the FMBSC showed adequate internal consistency (reliabilities ranged from 0.18 to 0.68). Interjudge reliability was higher for the FMBSC (ICC2,2 = 0.57) than for the SEGUE instrument (ICC2,2 = 0.32) or the FMBSC Rating Scale (ICC2,2 = 0.23).

CONCLUSIONS

The FMBSC demonstrated internal consistency and structural validity in assessing advanced communication skills of fellows in facilitating family meetings of critically ill patients in the ICU. Interjudge reliability was better for the FMBS Checklist than it was for the other measures.

Dis-integration of communication in healthcare education: Workplace learning challenges and opportunities

The purpose of this paper, based on a 2016 Heidelberg International Conference on Communication in Healthcare (ICCH) plenary presentation, is to examine a key problem in communication skills training for health professional learners. Studies have pointed to a decline in medical students' communication skills and attitudes as they proceed through their education, particularly during their clinical workplace training experiences. This paper explores some of the key factors in this disintegration, drawing on selected literature and highlighting some curriculum efforts and research conducted at the University of Iowa Carver College of Medicine as a case study of these issues. Five key factors contributing to the disintegration of communication skills and attitudes are presented including: 1) lack of formal communication skills training during clinical clerkships; 2) informal workplace teaching failing to explicitly address learner clinical communication skills; 3) emphasizing content over process in relation to clinician-patient interactions; 4) the relationship between ideal communication models and the realities of clinical practice; and 5) clinical teachers' lack of knowledge and skills to effectively teach about communication in the clinical workplace. Within this discussion, potential practical responses by individual clinical teachers and broader curricular and faculty development efforts to address each of these factors are presented.

Teaching and assessment of clinical communication skills: Lessons learned from a SWOT analysis of Portuguese Angolan and Mozambican Medical Education

HIGHLIGHTS

CCS training lacks a formal structure with substantial variation of the teaching process.The interviews promoted, amongst important stakeholders, a rise in awareness of this situation and how these skills can enhance the quality of clinical practice, encouraging curricular change.A communication skills teaching model: CoSTProMed is suggested for curriculum integration.

BACKGROUND

The importance of clinical communication skills (CCS) teaching and assessment is increasingly recognized in medical education. There is a lack of outcome-based research about CCS teaching and assessment processes in Portuguese medical education. Our goal is to conduct a SWOT analysis of this process in Portugal, Angola and Mozambique in order to contribute to the establishment of an action plan for more effective CCS teaching and assessment in medical curricula.

METHODS

Between 2010 and 2012, semi-structured interviews focused on the state of the art of teaching and assessment of clinical communication skills were conducted with key stakeholders of medical courses in Portugal, Angola and Mozambique. The design corresponds to an exploratory, descriptive and cross-sectional study, with the analysis of the recorded interviews. Interview transcripts were analyzed to identify salient themes/coding template in their discussions of the CCS teaching process. The coding and analysis of the surveys is qualitative.

RESULTS

87 interviews were performed at the 8 Portuguese, 1 Angolan and 1 Mozambican medical schools. Results indicate that the teaching and assessment process of CCS is in the beginning stages with these commonalities noted: (i) Variability amongst faculty in the teaching and assessment methods, (ii) disconnection of CCS between basic and clinical cycles, (iii) content and process skills and (iv) faculty development.

CONCLUSIONS

CCS training lacks a formal structure with considerable variation of the CCS teaching process in these countries. The interviews promoted a rise in awareness of this situation and how these skills can enhance the quality of curricular change. Some important opportunities for the development and implementation of a framework of an integrated communication skills curriculum such as curricular reforms and well-established cooperation and networks were identified. The acknowledgement of the importance of integrating these skills in ME by key stake-holders and students in institutions and the identification of champions motivated to commit to the effort are strengths that should be considered to integrate and enhance CCS in the medical curricula.

Predicting medical students who will have difficulty during their clinical training

BACKGROUND

We aimed to classify the difficulties students had passing their clinical attachments, and explore factors which might predict these problems.

METHODS

We analysed data from regular student progress meetings 2008-2012. Problem categories were: medical knowledge, professional behaviour and clinical skills. For each category we then undertook a predictive risk analysis.

RESULTS

Out of 561 students, 203 were found to have one or more problem category and so were defined as having difficulties. Prevalences of the categories were: clinical skills (67%), knowledge (59%) and professional behaviour (29%). A higher risk for all categories was associated with: male gender, international entry and failure in the first half of the course, but not with any of the minority ethnic groups. Professional and clinical skills problems were associated with lower marks in the Undergraduate Medical Admissions Test paper 2. Clinical skills problems were less likely in graduate students.

CONCLUSIONS

In our students, difficulty with clinical skills was just as prevalent as medical knowledge deficit. International entry students were at highest risk for clinical skills problems probably because they were not selected by our usual criteria and had shorter time to become acculturated.

Communication training improves patient-centered provider behavior and screening for soldiers' mental health concerns

OBJECTIVE

To evaluate the effectiveness of patient-centered communication training for military providers who conduct post-deployment health screening. The half-day interactive workshop included simulated Soldier patients using video technology.

METHODS

Using a quasi-experimental design, all health care providers at four military treatment facilities were recruited for data collection during a four- to nine-day site visit (23 trained providers, 28 providers in the control group, and one provider declined to participate). All Soldiers were eligible to participate and were blinded to provider training status. Immediately after screening encounters, providers reported on their identification of mental health concerns and Soldiers reported on provider communication behaviors resulting in 1,400 matched pairs. Electronic health records were also available for 26,005 Soldiers.

RESULTS

The workshop was found to increase (1) providers' patient-centered communication behaviors as evaluated by Soldiers; (2) provider identification of Soldier mental health concerns; and (3), related health outcomes including provision of education and referral to a confidential counseling resource.

CONCLUSION

Results are promising, but with small effect sizes and study limitations, further research is warranted.

PRACTICE IMPLICATIONS

A brief intensive workshop on patient-centered communication tailored to the military screening context is feasible and may improve key outcomes.

Medical student use of communication elements and association with patient satisfaction: a prospective observational pilot study

BACKGROUND

Effective communication with patients impacts clinical outcome and patient satisfaction. We measure the rate at which medical students use six targeted communication elements with patients and association of element use with patient satisfaction.

METHODS

Participants included fourth year medical students enrolled in an emergency medicine clerkship. A trained observer measured use of six communication elements: acknowledging the patient by name, introducing themselves by name, identifying their role, explaining the care plan, explaining that multiple providers would see the patient, and providing an estimated duration of time in the emergency department. The observer then conducted a survey of patient satisfaction with the medical student encounter.

RESULTS

A total of 246 encounters were documented among forty medical student participants. For the six communication elements evaluated, in 61% of encounters medical students acknowledged the patient, in 91% they introduced themselves, in 58 % they identified their role as a student, in 64% they explained the care plan, in 80% they explained that another provider would see the patient, and in only 6% they provided an estimated duration of care. Only 1 encounter (0.4%) contained all six elements. Patients' likelihood to refer a loved one to that ED was increased when students acknowledged the patient and described that other providers would be involved in patient care (P = 0.016 and 0.015 respectively, Chi Square). Likewise, patients' likelihood to return to the ED was increased when students described their role in patient care (P = 0.035, Chi Square).

CONCLUSIONS

This pilot study demonstrates that medical students infrequently use all targeted communication elements. When they did use certain elements, patient satisfaction increased. These data imply potential benefit to additional training for students in patient communication.

Why individuals with HIV or diabetes do not disclose their medical history to the dentist: a qualitative analysis

INTRODUCTION

Evidence shows that some individuals with HIV or diabetes do not report their medical history to the dentist. Disclosure is important because these individuals can be at greater risk of oral disease.

AIMS AND OBJECTIVES

The aim of this study is to provide greater understanding of why some individuals do not disclose HIV or diabetes to the dentist.Methods In-depth interviews were conducted with 20 participants (10 HIV & 10 diabetes) based around the participant's diagnosis and disclosure history. Data were analysed using framework analysis.

RESULTS

While a lack of disclosure can be found among those with a diagnosis of HIV and diabetes, it appears that the reasons behind disclosure, or lack thereof, are different for each. The reasons are based around: differences in age, understanding of diagnosis, experience of stigma, past disclosure behaviour, trust in dentists and experience of healthcare. Few individuals had discussed the effects of their diagnosis with their dentist or were advised on the importance of seeing a dentist.

DISCUSSION

Individuals with chronic illness should be advised why it is important for the dentist to know their medical history and should be made to feel comfortable to disclose.

Veterinarian-Client Communication Skills: Current State, Relevance, and Opportunities for Improvement

Communication is increasingly recognized as a core skill for veterinary practitioners, and in recent years, attention to communication competency and skills training has increased. To gain an up-to-date assessment of the current state of veterinary communication skills and training, we conducted a survey among veterinary practitioners in the United Kingdom and United States in 2012/2013. The questionnaire was used to assess the current state, relevance, and adequacy of veterinary communication skills among veterinary practitioners, to assess interest in further training, and to understand perceived challenges in communicating with clients. There was an overall response rate of 29.6% (1,774 of 6,000 recipients), with a higher response rate for UK-based practitioners (39.7%) than practitioners in the US (19.5%). Ninety-eight percent of respondents agreed that communication skills were as important as or more important than clinical knowledge. Forty-one percent of respondents had received formal veterinary communication skills training during veterinary school, and 47% had received training post-graduation. Thirty-five percent said their veterinary communication skills training during veterinary school prepared them well or very well for communicating with clients about the health of their pets, compared to 61% of those receiving post-graduate training. Forty percent said they would be interested in further veterinary communication skills training, with the preferred methods being simulated consultations and online training. While there has been increased emphasis on communication skills training during and after veterinary school, there is a need for more relevant and accessible training.

Structured communication: teaching delivery of difficult news with simulated resuscitations in an emergency medicine clerkship

Introduction

The objective is to describe the implementation and outcomes of a structured communication module used to supplement case-based simulated resuscitation training in an emergency medicine (EM) clerkship.

Methods

We supplemented two case-based simulated resuscitation scenarios (cardiac arrest and blunt trauma) with role-play in order to teach medical students how to deliver news of death and poor prognosis to family of the critically ill or injured simulated patient. Quantitative outcomes were assessed with pre and post-clerkship surveys. Secondarily, students completed a written self-reflection (things that went well and why; things that did not go well and why) to further explore learner experiences with communication around resuscitation. Qualitative analysis identified themes from written self-reflections.

Results

A total of 120 medical students completed the pre and post-clerkship surveys. Majority of respondents reported that they had witnessed or role-played the delivery of difficult news, but only few had real-life experience of delivering news of death (20/120, 17%) and poor prognosis (34/120, 29%). This communication module led to statistically significant increased scores for comfort, confidence, and knowledge with communicating difficult news of death and poor prognosis. Pre-post scores increased for those agreeing with statements (somewhat/very much) for delivery of news of poor prognosis: comfort 69% to 81%, confidence 66% to 81% and knowledge 76% to 90% as well as for statements regarding delivery of news of death: comfort 52% to 68%, confidence 57% to 76% and knowledge 76% to 90%. Respondents report that patient resuscitations (simulated and/or real) generated a variety of strong emotional responses such as anxiety, stress, grief and feelings of loss and failure.

Conclusion

A structured communication module supplements simulated resuscitation training in an EM clerkship and leads to a self-reported increase in knowledge, comfort, and competence in communicating difficult news of death and poor prognosis to family. Educators may need to seek ways to address the strong emotions generated in learners with real and simulated patient resuscitations.

Enhancing patient-doctor-computer communication in primary care: towards measurement construction

Objective

The traditional dyadic dynamics of the medical encounter has been altered into a triadic relationship by introducing the computer into the examination room. This study defines Patient-Doctor-Computer Communication (PDCC) as a new construct and provides an initial validation process of an instrument for assessing PDCC in the computerized exam room: the e-SEGUE.

Material and methods

Based on the existing literature, a new construct, PDCC, is defined as the physician’s ability to provide patient-centered care while using the computer during the medical encounter. This study elucidates 27 PDCC-related behaviors from the relevant literature and state of the art models of PDCC. These were embedded in the SEGUE communication assessment framework to form the e-SEGUE, a communication skills assessment tool that integrates computer-related communication skills. Based on Mackenzie et al.’s methodological approach of measurement construction, we conducted a two-phased content validity analysis by a general and expert panels of the PDCC behaviors represented in the e-SEGUE. This study was carried out in an environment where EMR use is universal and fully integrated in the physicians’ workflow.

Results

The panels consisted of medical students, residents, primary care physicians, healthcare leaders and faculty of medicine members, who rated and provided input regarding the 27 behaviors. Overall, results show high level of agreement with 23 PDCC-related behaviors.

Conclusion

The PDCC instrument developed in this study, the e-SEGUE, fared well in a rigorous, albeit initial, validation process has a unique potential for training and enhancing patient-doctor communication (PDC) in the computerized examination room pending further development.

Resident physicians' attitudes and confidence in communicating with patients: a pilot study at a Japanese university hospital

OBJECTIVE

This study aimed to explore the relationships among physicians' confidence in conducting medical interviews, their attitudes toward the patient-physician relationship, and undergraduate training in communication skills among resident physicians in Japan.

METHODS

Participants were 63 first-year resident physicians at a university hospital in Tokyo. The Physician Confidence in the Medical Interview scale (PCMI) was constructed based on the framework of the Calgary-Cambridge Guide. Additionally, participants' attitudes toward the patient-physician relationship (Patient-Practitioner Orientation Scale; PPOS), undergraduate experience of communication skills training, and demographic characteristics were assessed through a self-reported questionnaire.

RESULTS

The internal consistency of the PCMI and PPOS scales were adequate. As expected from the undergraduate curriculum for medical interviews in Japan, residents had relatively higher confidence in their communication skills with respect to gathering information and building the relationship, whereas less confident about sharing information and planning treatment. The PCMI was associated with a more patient-centered attitude as measured by the PPOS.

CONCLUSION

These scales could be useful tools to measure physicians' confidence and attitudes in communicating with patients and to explore their changes through medical education.

PRACTICE IMPLICATIONS

Residency programs should consider including systematic training and assessment in communication skills related to sharing information and planning treatment.

The Group Objective Structured Clinical Experience: building communication skills in the clinical reasoning context

OBJECTIVE

Students are rarely taught communication skills in the context of clinical reasoning training. The purpose of this project was to combine the teaching of communication skills using SPs with clinical reasoning exercises in a Group Objective Structured Clinical Experience (GOSCE) to study feasibility of the approach, the effect on learners' self-efficacy and attitude toward learning communication skills, and the effect of providing multiple sources of immediate, collaborative feedback.

METHODS

GOSCE sessions were piloted in Pediatrics and Medicine clerkships with students assessing their own performance and receiving formative feedback on communication skills from peers, standardized patients (SPs), and faculty. The sessions were evaluated using a retrospective pre/post-training questionnaire rating changes in self-efficacy and attitudes, and the value of the feedback.

RESULTS

Results indicate a positive impact on attitudes toward learning communication skills and self-efficacy regarding communication in the clinical setting. Also, learners considered feedback by peers, SPs, and faculty valuable in each GOSCE.

CONCLUSION

The GOSCE is an efficient and learner-centered method to attend to multiple goals of teaching communication skills, clinical reasoning, self-assessment, and giving feedback in a formative setting.

PRACTICE IMPLICATIONS

The GOSCE is a low-resource, feasible strategy for experiential learning in communication skills and clinical reasoning.

Does improving patient-practitioner communication improve clinical outcomes in patients with cardiovascular diseases? A systematic review of the evidence

OBJECTIVE

To conduct a systematic literature review appraising the effects of interventions to improve patient-practitioner communication on cardiovascular-related clinical outcomes.

METHODS

Databases were searched up to March 27, 2013 to identify eligible studies that included interventions to improve patient and/or practitioner communication skills and assessment of a cardiovascular-related clinical outcome in adults ≥18 years of age.

RESULTS

Fifteen papers were reviewed: the primary focus in seven studies was the patient; seven included a practitioner-focused intervention and one targeted both. Two patient-focused and two practitioner-focused studies demonstrated a beneficial effect of the intervention compared to a control group. Patient-focused studies were designed to improve patients' information-seeking and question-asking skills with their practitioner. Practitioner-focused studies were designed to either improve practitioner's general patient-centered communication or risk communication skills.

CONCLUSION

Few interventions targeting patient-practitioner communication have assessed the impact on cardiovascular-related clinical outcomes, limiting the ability to determine effectiveness. Additional rigorous research supported by theoretical frameworks and validated measurement is needed to understand the potential of patient-practitioner communication to improve cardiovascular-related clinical outcomes.

PRACTICE IMPLICATIONS

Investments in communication skills trainings in medical education and practice are needed in order to attain the full potential of patient-centered care on cardiovascular-related clinical outcomes.

A qualitative assessment of provider perspectives on smoking cessation counselling

RATIONALE, AIMS AND OBJECTIVES

Few studies have examined doctors' views about counselling unmotivated smokers. This study explored doctors' perceptions of useful strategies to motivate patients to quit, how receptive they felt patients were to these strategies, and the benefits and drawbacks of discussing smoking cessation with patients.

METHODS

Fourteen semi-structured qualitative interviews were conducted with doctors and resident doctors.

RESULTS

Strategies reported by providers included: educating about the health risks of smoking, using 'scare tactics' to highlight the harmful effects and providing advice about how to quit. Providers believed that most patients were receptive to their strategies, but noted that they lacked feedback to know for sure. Providers saw the possibility of improving patients' health and decreasing overall health care costs as potential benefits, but cited the potential to damage rapport, competing priorities during already rushed visits and uncertainty about the effectiveness of their efforts as drawbacks that reduced their motivation to raise the issue with patients.

CONCLUSIONS

Doctors believe in the potential benefits of smoking cessation counselling but predominantly report focusing on enhancing patient's risk perceptions. They did not report attempting to use the wider array of recommended and empirically supported methods to counsel their patients. Providing doctors with increased training in motivational counselling and feedback about the efficacy their efforts or supplementing doctor care with behaviour change specialists would likely increase the benefits of counselling to patients.

What parents want from emails with their pediatrician: implications for teaching communication skills

OBJECTIVE

Physician-patient email communication is increasing but trainees receive no education on this communication medium. Research eliciting patient preferences about email communication could inform training. Investigators elicited parents' perspectives on physician-parent email communication and compared parent and faculty assessments of medical students' emails.

METHODS

This mixed methods study explored physician-parent email communication in 5 parent focus groups using qualitative analyses to identify themes. Differences between faculty and parent assessment scores for students' email responses were calculated using univariate general linear modeling.

RESULTS

Themes that emerged were: (1) Building the Relationship, (2) Clarity of Communication and (3) Expectations. Parents criticized student's statements as condescending. The sum of assessment scores by parents and faculty were moderately correlated (r(44)=.407, P<.01), but parents gave students lower scores on "acknowledges validity/expresses empathy" (P=.01) and higher scores on "provides next steps" (P<.01) and "identifies issues" (P<.01).

CONCLUSION

Parents place value on students' abilities to communicate clearly and convey respect and empathy in email. Parent and faculty perspectives on email communication are similar but not the same.

PRACTICE IMPLICATIONS

Differences between parental and faculty assessments of medical students' emails supports the need for the involvement of patients and families in email communication curriculum development.

Differential growth in doctor-patient communications skills

CONTEXT

Although doctor-patient communication is considered a core competency for medical doctors, the effect of training has not been unequivocally established. Moreover, knowledge about the variance in the growth of different skills and whether certain patterns in growth can be detected could help us to develop more efficient programmes. We therefore investigated the growth in general practitioner (GP) trainees' doctor-patient communication skills in their first year and whether the growth was different for distinct categories of skills.

METHODS

Seventy-one first-year GP trainees were invited to participate in a study aimed at measuring their consultation skills at the beginning (baseline) and at the end of their first year (follow-up). Consultation skills were assessed with the MAAS-Global rating list for consultation skills.

RESULTS

Data on 29 general practitioner trainees were collected. MAAS-Global scores showed a significant growth on all items but one. Patient-oriented skills showed significantly more growth than task-oriented skills. Empathy as a separate skill seems to be mastered predominantly before the start of training.

CONCLUSIONS

Three patterns in the growth in skills were distinguished: (i) low baseline, relatively high follow-up, (ii) moderate baseline, moderate growth and (iii) high baseline, hardly any growth. Patient-oriented skills follow either pattern (i) or (iii), whereas task-oriented skills follow pattern (ii). These findings may help to define where the focus should lie in the training of doctor-patient communication skills.

Curricular disconnects in learning communication skills: what and how students learn about communication during clinical clerkships

OBJECTIVE

In many medical schools, formal training in clinical communication skills (CCS) mainly occurs during pre-clinical training prior to clinical rotations. The current research examined student perceptions of both what and how they learn about CCS during clinical rotations.

METHODS

During 2008 and 2009, 4th year medical students were invited to participate in interviews focused on learning of CCS during clinical rotations. Interview transcripts were analyzed to identify salient themes in their discussions of CCS in clinical learning experiences.

RESULTS

107 senior students participated and reported learning CCS during clinical rotations mainly by: (1) observing faculty and residents; (2) conducting interviews themselves; and (3) through feedback on patient presentations. Teacher role modeling tended to not reinforce what they had learned pre-clinically about CCS and clinical teachers rarely discussed CCS. Feedback on patient presentations affected students' communication styles, at times prompting them to omit use of CCS they had learned pre-clinically.

CONCLUSIONS

Students reported that clinical learning experiences often do not reinforce the CCS they learn pre-clinically.

PRACTICAL IMPLICATIONS

Disconnects between pre-clinical and clinical CCS teaching need to be reconciled through more explicit pedagogical attention to CCS issues during clinical rotations both in the formal and informal curriculum.

Pitfalls in training simulated patients to respond appropriately to questions from medical students in family history-taking activities: the current situation surrounding the training of simulated patients for learning activities at Nippon Medical School

Our goal was to train simulated patients (SPs) to respond appropriately to questions about family history from medical students in simulated medical interviews. To this end, we carried out a survey of 91 SPs and 76 4th-year medical students to investigate their notions of what constitutes a family. All of the SPs and students surveyed deemed parents and children living together to be members of a family. In a situation where one spouse's parents live together with the basic family unit, 93% of the SPs considered them to be members of the family, whereas only 79% of the students did. Married children living apart from their parents were considered members of the family by 18% of the SPs and 39% of the students. These results indicate clear differences between the SPs and students in their notions of the family. To verify the level of understanding of the definitions of family and blood relatives in particular scenarios used in simulated medical interviews, we administered a written test to 14 SPs who were training to assist in the nationwide common achievement test in medicine, the Objective Structured Clinical Examination (OSCE). The overall score of the SPs was 93.5%; the incorrect answers were "a sibling is not a blood relative" and "a spouse is a blood relative." We analyzed the performance of these 14 SPs in medical interviews carried out after training for the OSCE, in which they were asked questions that required them to reveal their understanding of blood relatives, cohabiting relatives, and the family. All of the SPs responded appropriately to the students' questions about family history. After the OSCE, we asked the SPs to assess themselves on how well they had given their family histories and to evaluate the usefulness of the SP training they had received. Their mean self-assessment score on providing a family history was 3.6 (scale: 1-4); on the usefulness of training, it was 3.4 (scale: 1-4). In conclusion, training SPs to respond appropriately to questions about family history in medical interviews is very important. Medical students have to learn how to take family histories accurately, so SP trainers should pay attention to training SPs in giving appropriate responses to students' questions, bearing in mind the differences between family history taking and everyday conversations about the family.

Bridging the gap: How is integrating communication skills with medical content throughout the curriculum valued by students?

OBJECTIVE

To describe a program with integrated learning of communication and consultation skills developed with the intention of preventing deterioration of communication skills, and to present student evaluation data.

METHODS

Description and evaluation of the program through: (1) monthly student evaluations; (2) questionnaire on student perceptions about the integrated curriculum; (3) a questionnaire about the value of one specific integrated training preceding the pediatric clerkship.

RESULTS

Key components of training throughout years 3-6 are reinforcement throughout the clinical years, adapting communication training to the clinical context of clerkships using a sandwich model with cycles of preparation, clerkship, and reflection.

EVALUATION

response rates were 69%, 93% and 93%, respectively. Students value practicing integration of communication and medical content with SPs who represent the population of their next clerkships. They appreciate the multisource feedback during the training, feedback by clerkship specific specialists and SPs is valued most.

CONCLUSIONS

This description shows an example of an integrated curriculum that helps students to feel well prepared for their communication tasks in subsequent clerkships.

PRACTICE IMPLICATIONS

Designing and implementing communication curricula to address the issue of integration is feasible. The effects of such integrated programs should be subject to future studies.