The teaching of communication skills in United Kingdom medical schools

Communication skills teaching in Brazilian medical schools: What lessons can be learned?

OBJECTIVE

To assess current practices in communication skills (CS) teaching in Brazilian medical schools (MS), looking for similarities and differences with other countries.

METHODS

This study was performed with 162 out of the 237 accredited Brazilian MS (68.35%). The quantitative data were analyzed using descriptive statistics and qualitative data using content analysis.

RESULTS

104 MS (64.2%) reported formal CS training. CS were more commonly taught in the pre-clinical years, by physicians and psychologists. Compared to other countries, Brazil was unique in offering training for "acolhimento" ("embracement"), which is a Brazilian Government strategy that requires that all those connected with healthcare delivery, from administrators to practitioners, and all allied health personnel "embrace" a dedication to caring for patients and the communities in which they live.

CONCLUSIONS

Formal CS teaching in Brazilian MS is less frequently seen in MS curriculum compared to reported data from other countries. The CS teaching of "embracement" is unique to Brazil.

PRACTICE IMPLICATIONS

This study adds to the literature by identifying the CS teaching of "embracement" in Brazilian MS, which could be considered outside Brazil.

Psychosomatics in obstetrics and gynecology - evaluation of a compulsory standardized teaching program

OBJECTIVE

This observational study was aimed at assessing the effect of case supervision in small groups over a two-year period as part of a standardized psychosomatic basic training for future obstetrician-gynecologists from the physicians' perspective.

METHODS

The supervised groups were evaluated by questionnaires distributed to all 128 candidates at the beginning (T1), at half time (T2) and at the end of the course (T3). Aside from a validated battery of questions on self-efficacy, items included self-estimated psychosomatic competence, professional satisfaction as well as a validation of the training program.

RESULTS

The training program was associated with a significant increase of self-reported psychosomatic competence (55.0/68.9, p = 0.000) and self-efficacy (2.4/2.8, p = 0.0011). While major changes occurred at the end of the first year of the supervised groups, no further enhancement could be demonstrated throughout the second year. A total of 44 (88%) study participants who answered at T3 considered the training program as helpful.

CONCLUSIONS

The presented teaching program - more precisely the supervised groups - seemed to be effective in increasing self-estimated psychosomatic competence and self-efficacy in future specialists for obstetrics and gynecology. It may serve as a model for the systematic integration of standardized psychosomatic basic training into the education of obstetrician-gynecologists.

Enhancing medical students' communication skills: development and evaluation of an undergraduate training program

BACKGROUND

There is a relative lack of current research on the effects of specific communication training offered at the beginning of the medical degree program. The newly developed communication training "Basics and Practice in Communication Skills" was pilot tested in 2008 and expanded in the following year at the University Medical Centre Hamburg-Eppendorf in Germany. The goal was to promote and improve the communicative skills of participants and show the usefulness of an early offered intervention on patient-physician communication within the medical curriculum.

METHODS

The students participating in the project and a comparison group of students from the standard degree program were surveyed at the beginning and end of the courses. The survey consisted of a self-assessment of their skills as well as a standardised expert rating and an evaluation of the modules by means of a questionnaire.

RESULTS

Students who attended the communication skills course exhibited a considerable increase of communication skills in this newly developed training. It was also observed that students in the intervention group had a greater degree of self-assessed competence following training than the medical students in the comparison group. This finding is also reflected in the results from a standardised objective measure.

CONCLUSIONS

The empirical results of the study showed that the training enabled students to acquire specialised competence in communication through the course of a newly developed training program. These findings will be used to establish new communication training at the University Medical Centre Hamburg-Eppendorf.

A proposal for overcoming problems in teaching interviewing skills to medical students

The objective of this paper is to draw attention to four features that distinguish the pedagogy of patient interviewing from the teaching of other clinical skills: (a) students are not naïve to the skill to be learned, (b) they encounter role models with a wide variability in interviewing styles, (c) clinical teachers are not usually specialists in the behavioral sciences, including patient interviewing, and (d) the validity of the methods used for assessment of interviewing skills is uncertain. We propose to adjust the teaching of patient interviewing to these features by (a) gaining an insight into the students' views and using these views as a point of departure for discussions of patient interviewing; (b) helping students to understand why different clinicians use different communication styles; (c) providing the clinical tutors with additional training that will help them function as both specialists who share their expertise with the students and facilitators of small-group learning; and (d) using assessment methods that encourage joint deliberation by the learner and the examiner, rather than a judgmental right-wrong dualism by the examiner alone. The teaching approach that we suggest is consistent with current theories of adult learning, and it occurs in an egalitarian rather than a hierarchical environment. Hopefully, students will also adopt such egalitarian attitudes toward patients, thereby reducing the tendency to a paternalistic communication style.

Teaching and assessment of explanation and planning in medical schools in the United Kingdom: cross sectional questionnaire survey

BACKGROUND

The second half of the consultation (explanation and planning) has been described as neglected in communication skills teaching in medical schools, with programmes concentrating on information gathering.

AIMS

To identify the extent and ways in which explanation and planning is taught in medical schools in the United Kingdom.

METHODS

Questionnaire mailed to consultation teaching leads.

RESULTS

Teaching in explanation and planning occurred in 32/32 medical schools. Teaching commenced in years 1 or 2 in 14/32 and year three onwards in 17/32 medical schools. Teaching took place over one year in 12/32, two years in 13/32, three years in 3/32 and 4 years in 2/32 medical schools. Different teaching methods were used, but most use discussion and rehearsal of skills with a simulated patient (21/32). 20/32 medical schools based their teaching on a published consultation model, with 18/20 using the Calgary Cambridge Guide to the Consultation. 31/32 medical schools examined their students in explanation and planning: formative assessment (3/31) or summative (16/31) or both (9/31).

CONCLUSIONS

There is now universal teaching and almost universal assessment of the second half of the consultation in medical schools in the UK. Timing of teaching, educational methods, consultation models and assessment used varies between schools.

Trends of communication skills education in medical schools

PURPOSE

To investigate the past and current status of teaching communication skills in undergraduate medical education and to review how medical education is progressing.

METHODS

A selective search was conducted of the literature that was published from 1960 to Jun 2008 in the MEDLINE, EMBASE, ERIC, Psychlnfo, and KMbase databases using "communication." All articles in 13 medical journals (including Academic Medicine, Medical Education, Teaching and Learning in Medicine, Medical Teacher, and Korean Journal of Medical Education) were reviewed. Each article was categorized according to 5 subjects (curriculum, methods, assessment, student factors, and research type).

RESULTS

A total of 306 studies met the inclusion criteria for this study. Curriculum was the most frequent subject (n=85), followed by assessment (n=71), student factors (n=48), and methods (n=23). According to this research, the current trends of teaching communication skills in medical school are characterized by curriculum development,' 'blended-methods,' 'multisource assessment,' 'student attitudes,' and 'comparative studies' of education.

CONCLUSION

It is time to figure it out optimistic ways to design a formal course. Now, 4 current trends in teaching and learning are emerging in communication skills. Curriculum development is stabilizing a variety of teaching methods are being adopted; a method of multisource assessment is being identified and the need to consider student attitudesis being recognized. In the near future, objective, comprehensive, and sophisticated evaluation is going to be the top priority in teaching communication skills with a variety of research types.

Assessment of medical communication skills by computer: assessment method and student experiences

BACKGROUND

A computer-assisted assessment (CAA) program for communication skills designated ACT was developed using the objective structured video examination (OSVE) format. This method features assessment of cognitive scripts underlying communication behaviour, a broad range of communication problems covered in 1 assessment, highly standardised assessment and rating procedures, and large group assessments without complex organisation.

SETTING

The Academic Medical Centre (AMC) at the University of Amsterdam, the Netherlands. Aims To describe the development of the AMC Communication Test (ACT); to describe our experiences with the examination and rating procedures; to present test score descriptives, and to present the students' opinions of ACT.

DESIGN

The ACT presents films on history taking, breaking bad news and shared decision making. Each film is accompanied by 3 types of short essay questions derived from our assessment model: "knows", "knows why/when" and "knows how". Evaluation questions about ACT were integrated into the assessment. Participants A total of 210 third year medical undergraduates were assessed. This study reports on the 110 (53%) students who completed all evaluation questions.

RESULTS

Marking 210 examinations took about 17 days. The test score matched a normal distribution and showed a good level of discrimination of the students. About 75% passed the examination. Some support for the validity of our assessment model was found in the students' differential performance on the 3 types of questions. The ACT was well received. Student evaluations confirmed our efforts to develop realistic films that related well to the communication training programme.

CONCLUSIONS

The ACT is a useful assessment method which complements interpersonal assessment methods for the evaluation of the medical communication skills of undergraduates.

A relação assimétrica médico-paciente: repensando o vínculo terapêutico

A relação médico-paciente é uma temática que hoje encontra um renovado interesse na produção cientifica, na formação e prática clínica com a aplicação de técnicas comunicacionais que podem proporcionar uma melhor qualidade na relação. O presente artigo, por meio de uma revisão da literatura e da apresentação dos resultados de uma pesquisa que realizamos sobre a relação entre médicos e pacientes no Programa de Saúde da Família no Estado do Ceará, se propõe a refletir sobre quais os fatores que estão na raiz desta problemática. Uma melhor relação médico-paciente não tem somente efeitos positivos na satisfação dos usuários e na qualidade dos serviços de saúde, mas exerce também uma influência direta sobre o estado de saúde dos pacientes. Esta demanda exige a implementação de mudanças visando à aquisição de competências na formação dos médicos.

'Loss of self': a psychosocial study of the quality of life of adults with diabetic foot ulceration

At present, recognition of the importance of psychosocial factors in the care of individuals with diabetes is still in its infancy. Understanding of the specific psychosocial factors relating to diabetic foot ulceration is embryonic. The study reported in this paper begins to raise awareness of psychosocial quality of life issues for patients living with diabetic foot ulceration, as narrated by the patients themselves. Findings revealed a range of restrictions on daily life that profoundly affected the individual's sense of self. These findings have implications for patients' adherence to treatment. Implications of these findings for health promotion are also reported.

An innovative model for teaching and learning clinical procedures

CONTEXT

Performing a clinical procedure requires the integration of technical clinical skills with effective communication skills. However, these skills are often taught separately.

OBJECTIVES

To explore the feasibility and benefits of a new conceptual model for integrated skills teaching. : Design A qualitative observation and interview-based study of undergraduate medical students.

METHODOLOGY

Medical students performed technical and communication skills in realistic clinical scenarios (urinary catherization and wound closure), using latex models connected to simulated patients (SPs). Procedures were observed, videorecorded and assessed by tutors from an adjoining room. Students received immediate feedback from tutors and SPs, before engaging in a process of individual feedback through private review of their videotapes. Group interviews explored the response of students, SPs and tutors. Data were analysed using standard qualitative techniques.

SUBJECTS

Fifty-one undergraduate students were recruited from the Faculty of Medicine, Imperial College, London.

RESULTS

The scenarios provided a realistic simulation of two common clinical situations and proved feasible in terms of time, facilities and resources within this institution. Students found the opportunity to integrate communication and technical skills valuable, challenging and an appropriate learning experience. Immediate feedback was especially highly valued. Some students found difficulty integrating technical and communications skills, but benefited from conducting two procedures in the same session.

CONCLUSION

The integrated model was feasible and was perceived to be valuable. Benefits include the opportunity to integrate, within a safe environment, skills which are often taught separately. Promoting reflective practice may enable the successful transfer of these integrated skills to other procedures.

Context-bound communication skills training: development of a new method

OBJECTIVES

To examine how communication skills training might be integrated into everyday clinical practice in a manner that is acceptable to clinicians.

DESIGN

General practitioners from 3 group practices agreed to take part, in turn, in a study of how to manage difficult consultations about antibiotic prescribing for acute respiratory infections. This provided the opportunity to conduct communication skills training in which lessons learned from one practice were taken into the next.

SETTING

United Kingdom general practices.

SUBJECTS

Three groups of general practitioners.

FINDINGS

Difficulties with the acceptability of a traditional off-site workshop approach, using role play as the main teaching method, led to the development of a new training method (context-bound training), which proved to be practical and acceptable to experienced clinicians. The main features of the method were the delivery of training in the clinicians' place of work, and the transformation of their reported difficult cases into scenarios which they then encountered with a standardized simulated patient before and after brief seminars. Everyday clinical experience was kept in the foreground and 'communication skills' in the background.

CONCLUSIONS

The method is acceptable to clinicians and adaptable to a range of clinical situations. It offers potential for improving the communication skills of clinicians both in hospital and primary care settings.

The effectiveness of a computer-assisted instruction programme on communication skills of medical specialists in oncology

BACKGROUND

Although doctor--patient communication is important in health care, medical specialists are generally not well trained in communication skills. Conventional training programmes are generally time consuming and hard to fit into busy working schedules of medical specialists. A computer-assisted instruction (CAI) programme was developed -- 'Interact-Cancer' -- which is a time-efficient learning method and easily accessible at the workplace.

OBJECTIVE

To investigate the effect of the CAI training, 'Interact-Cancer', on the communication behaviour of medical specialists, and on satisfaction of patients about their physician interaction.

DESIGN

Consultations of medical specialists with cancer outpatients were videotaped at 4 specific stages, 2 before and 2 after Interact-Cancer, with intervals of 4 weeks.

PATIENTS/PARTICIPANTS

Participants were 21 medical specialists, mainly internists, working in 7 hospitals, and 385 cancer outpatients.

METHODS

Communication behaviour was assessed on 23 observation categories derived from the course content. Frequencies were rated as well as judgements about the quality of the performance of each target skill. Satisfaction was measured by the Medical Interview Satisfaction Scale. Data were analyzed by means of multilevel statistical methods.

RESULTS

The behavioural assessment showed course effects on ratings of the physicians' quality of performance. No course effects were found on the frequencies of physicians' behaviours and on the patient satisfaction ratings.

CONCLUSIONS

CAI is a promising method to supply medical specialists with postgraduate training of communication skills. The application of judgement ratings of communication behaviour proved to be valuable to evaluate course effects in real-life patient encounters.

Physician Communication Skills: Results of a Survey of General/Family Practitioners in Newfoundland

PURPOSE

To describe the attitudes related to communication skills, confidence in using communication skills, and use of communication skills during the physician-patient encounter among a population-based sample of family physicians.

PROCEDURES

A mailed survey, distributed to all family physicians and general practitioners currently practicing in Newfoundland. The questionnaire was designed to collect data in five general areas-participant demographics, physician confidence in using specific communication strategies, perceived adequacy of time spent by physicians with their patients, physician use of specific communication strategies with the adult patients they saw in the prior week, and physician use of specific communication strategies during the closing minutes of the encounters they had with adult patients in the prior week.

MAIN FINDINGS

A total of 160 completed surveys was received from practicing family physicians/ general practitioners in Newfoundland, yielding an adjusted response rate of 43.1%. Most of the respondents (83.8%) indicated their communication skills are as important as technical skills in terms of achieving positive patient outcomes. Between one-third and one-half of the respondents, depending on the educational level queried, rated their communications skills training as being inadequate. Fewer than 20% of the respondents rated the communications skills training they received as being excellent. Physicians indicated a need to improve their use of 8 of 13 specific communication strategies during patient encounters, and reported using few communication strategies during the closing minutes of the encounter. Interactions that occurred during a typical encounter tended to focus on biomedical versus psychosocial issues.

CONCLUSIONS

Family physicians/general practitioners recognize a need to improve their communications skills. Well-designed communications skills training programs should be implemented at multi-levels of physician training in order to improve patient satisfaction with their encounters with family/general practitioners, and to increase the likelihood of positive patient outcomes.

Examiner fatigue in communication skills objective structured clinical examinations

CONTEXT

The assessment of undergraduates' communication skills by means of objective structured clinical examinations (OSCEs) is a demanding task for examiners. Tiredness over the course of an examining session may introduce systematic error. In addition, unsystematic error may also be present which changes over the duration of the OSCE session.

AIM

To determine the strength of some sources of systematic and unsystematic error in the assessment of communication skills over the duration of an examination schedule.

METHODS

Undergraduate first-year medical students completing their initial summative assessment of communication skills (a four-station OSCE) comprised the study population. Students from three cohorts were included (1996-98 intake). In all 3 years the OSCE was carried out identically. All stations lasted 5 minutes with a simulated patient. Students were assessed using an examiner (content expert) and a simulated-patient evaluation tool, the Liverpool Communication Skills Assessment Scale (LCSAS) and the Global Simulated-patient Rating Scale (GSPRS), respectively. Each student was assigned a time slot ranging from 1 to 24, where 1, for example, would denote that the student entered the exam first and 24 indicates the final slot for entry into the examination. The number of students who failed this exam was noted for each of the 24 time slots. A control set of marks from a communication skills written exam was also adopted for exploring a possible link with the time slot. Analysis was conducted using graphical display, covariate analysis and logistic regression.

RESULTS

No significant relationship was found between the schedule point that the student entered the OSCE exam and their performance. The reliability of the content expert and simulated-patient assessments was stable throughout the session.

CONCLUSION

No evidence could be found that duration of examining in a communication OSCE influenced examiners and the marks they awarded. Checks of this nature are recommended for routine inspection to confirm a lack of bias.

Barriers to breaking bad news among medical and surgical residents

Communicating "bad news" to patients and their families can be difficult for physicians.

OBJECTIVE

This qualitative study aimed to examine residents' perceptions of barriers to delivering bad news to patients and their family members.

DESIGN

Two focus groups consisting of first- and second-year medical and surgical residents were conducted to explore residents' perceptions of the bad news delivery process. The grounded theory approach was used to identify common themes and concepts, which included: (1) guidelines to delivering bad news, (2) obstacles to delivering bad news and (3) residents' needs.

SETTING

McMaster University, Hamilton, Ontario, Canada.

SUBJECTS

First- and second-year residents.

RESULTS

Residents were able to identify several guidelines important to communicating the bad news to patients and their family members. However, residents also discussed the barriers that prevented these guidelines from being implemented in day-to-day practice. Specifically, lack of emotional support from health professionals, available time as well as their own personal fears about the delivery process prevented them from being effective in their roles. Residents relayed the need for increased focus on communication skills and frequent feedback with specific emphasis on the delivery of bad news. The residents in our study also stressed the importance of processing their own feelings regarding the delivery process with staff.

CONCLUSIONS

Although most residents realize important guidelines in the delivery of bad news, their own fears, a general lack of supervisory support and time constraints form barriers to their effective interaction with patients.

Measurement of communication skills in cancer care: myth or reality?

Despite wide agreement about the importance of effective communication in cancer care there is continuing evidence of the need for nurses, doctors and colleagues to be helped to improve their communication skills. Consequently, there has been a growing demand for effective methods for evaluation of communication training programmes. This paper discusses theoretical perspectives in this field and describes the rationale underpinning the development of a detailed objective method of assessing interviews between health professionals and cancer patients. The method enables an utterance by utterance rating of transcribed interviews to be made which can be used to construct profiles of interviewer and patient behaviours and interactions. All categories were developed from interviews drawn from a large sample of participants (n=206) at counselling skills workshops. Six domains have been identified and these are: grammatical style; the purpose of each technique; what is being discussed, the degree of feeling expressed; explicit avoidance; and the use made of patients' cues. Each domain contains a mutually exclusive set of categories. In addition the method enables the sequence of events to be plotted. Using these methods, examples from published studies will be given to show how the processes of interaction within a health care interview can be better understood, thus enabling the most effective techniques to be taught, the effectiveness of different teaching methods to be assessed and how changes brought about by training have the potential to make a significant clinical difference to patients.

Teaching clinically experienced physicians communication skills. A review of evaluation studies

CONTEXT

Interest in the teaching of communication skills in medical schools has increased since the early seventies but, despite this growing interest, relatively limited curricular time is spent on the teaching of communication skills. The limited attention to the teaching of these skills applies even more to the physicians' clinical years, when attention becomes highly focused on biomedical and technical competence. Continuing training after medical school is necessary to refresh knowledge and skills, to prohibit decline of performance and to establish further improvements.

OBJECTIVE

This review provides an overview of evaluation studies of communication skills training programmes for clinically experienced physicians who have finished their undergraduate medical education. The review focuses on the training objectives, the applied educational methods, the evaluation methodology and instruments, and training results.

METHODS

CD-ROM searches were performed on MedLine and Psychlit, with a focus on effect-studies dating from 1985.

RESULTS

Fifteen papers on 14 evaluation studies were located. There appears to be some consistency in the aims and methods of the training programmes. Course effect measurements include physician self-ratings, independent behavioural observations and patient outcomes. Most of the studies used inadequate research designs. Overall, positive training effects on the physicians' communication behaviour are found on half or less of the observed behaviours. Studies with the most adequate designs report the fewest positive training effects.

CONCLUSION

Several reasons are discussed to explain the limited findings. Future research may benefit from research methods which focus on factors that inhibit and facilitate the physicians' implementation of skills into actual behaviours in daily practice.

A survey of communication skills training in UK schools of medicine: present practices and prospective proposals

It is now widely accepted that effective interpersonal communication is at the heart of quality health care delivery but that current standards in medicine must be improved (Numann 1988; Cowan et al. 1992). One approach acknowledged by the General Medical Council (1991) devotes more attention during training to the theme of communication, and quite significant modifications of the undergraduate medical curriculum are presently taking place. This article documents the results of a postal survey of the 26 UK Schools of Medicine, designed to illuminate current practices and future plans in respect of communication skills training (CST). As such, it takes advantage of the present period of ongoing curricular innovation and change to extend and update earlier reviews (Whitehouse 1991; Frederikson & Bull 1992). A total of 19 responses was received. Following preliminary analysis, the four schools who had already implemented their new curriculum were selected for further in-depth investigation by means of telephone interviews. In addition to reporting frequencies and percentages for responses to questions, cross-tabulations were carried out to explore relationships between certain of the findings. Apart from some consistency in CST teaching methods adopted, the overall picture to emerge is one of considerable variability in such areas as course content, timing, duration and assessment. Foremost among the difficulties encountered in implementing CST appeared to be lack of adequate physical resources and suitably trained staff. Future plans were often sketchy and inchoate. Results are discussed and tentative recommendations for the further development of CST in the medical curriculum proffered.

Evaluation of two videotape instruction programmes on how to break bad news--for Cantonese-speaking medical students in Hong Kong

OBJECTIVES

To evaluate a culture-specific videotape on how to 'break bad news' and another videotape produced by a western university, and to determine if the language of presentation influenced the students' perceived abilities to execute basic skills.

SUBJECTS

Third year medical students at the Faculty of Medicine, the University of Hong Kong.

DESIGN

Longitudinal study with experimental design.

INTERVENTION

Two instructional tapes on breaking bad news; one using Chinese speaking role models and one using English.

RESULTS

In both groups, self-efficacy summed scores increased from 26.8 (95% CI = 25.9-27.7) at the pre-test to 29.0 (95% CI = 28.4-29.6). The biggest changes occurred in perceived self-efficacy regarding specific skills. However, students using the Chinese tape rated skills as more useful than those using the English tape.

CONCLUSION

The videotapes were useful in teaching communication skills. Culturally relevant audiovisual materials were more effective.

Videotaped interviewing of non-English speakers: training for medical students with volunteer clients

In a multicultural society such as Australia, with over 20% of its population born overseas, interpreters are often required to facilitate medical interviews. However, where a patient has some proficiency in English, medical interviews are sometimes conducted across the boundaries of culture and language. This is a report of an educational innovation to teach interviewing skills to pre-clinical medical students with the assistance of volunteers of non-English-speaking backgrounds. Pre-clinical students interviewed community volunteers on topics of general life history in a sequence of 16 tutorials. Each student conducted two interviews. Teaching methods included feedback from the volunteers, tutorial discussion facilitated by playback of videotapes, and modelling of skills by the teachers. Evaluations by volunteers and students indicated high satisfaction with the teaching methods and outcomes. Students gained confidence in interviewing people from different cultures. Evaluation of students' pairs of videotapes by an independent rater achieved satisfactory reliabilities and indicated significant gains in inquiry skills and the communication of positive attitudes. Skills in communicating empathy and in using simple language did not improve measurably.

INTERACT-CANCER. The development and evaluation of a computer-assisted course on communication skills for medical specialists in oncology

One of the main problems in training medical specialists in communication skills is the fact that very few specialists participate in such courses. Most courses on communication skills are hard to combine with a busy medical practice because of the course attendance requirement on working days. Interact-Cancer has been developed to facilitate training in communication skills for medical specialists. It is an interactive, computer-assisted course, which fits relatively easily into the busy schedule of medical specialists in oncology because of its flexible character. The course can be followed individually by the participant in his/her own department at suitable periods of time. Interact-Cancer has introduced a new training method. In this study, the appeal of the method to the target group has been tested. Thirty-three medical specialists participated in Interact-Cancer. They evaluated the course as worthwhile, relevant to daily oncological practice, attractive and pleasant. They stated that the course brought inadequacies in their own behaviour to their attention and encouraged them to change their communicative behaviour.

Doctor-patient communication: a study of junior house officers

This study evaluates junior house officers' perceptions of their communication skills with cancer patients; the usefulness of their undergraduate communication skills training; and their sources of emotional support. All 42 junior house officers employed at Guy's and Lewisham Hospitals in August 1994 were interviewed using a study-specific, semi-structured interview. Sixty-seven per cent of junior house officers felt they had adequate communication skills in relation to medical issues, but only 36% felt they had adequate skills in relation to psychological issues. Thirty-one per cent of doctors reported that they never, or nearly never, enquired about the emotional adjustment of dying patients. Lack of time was the most commonly reported reason for avoiding asking about psychological problems (62% of junior house officers), followed by wishing to avoid awkward questions (51%) and inadequacy of skills to deal with such issues (44%). Ninety-eight per cent of junior house officers had attended the 1-week undergraduate communication skills course at Guy's and St Thomas's Hospital Medical School (UMDS). Sixty-seven per cent of those who had attended found the course helpful and 62% felt they would benefit from further training as junior house officers. Seventy-four per cent felt they could discuss their work-related concerns with colleagues and 95% felt they could talk to friends. In contrast only about 9% felt they could, if needed, talk to a counsellor. Although the majority of the junior house officers reported benefit from their communication skills training, the course does not appear to be meeting all their communication training needs. Junior house officers require further training opportunities at the undergraduate and postgraduate levels. Traditional counselling services for junior house officers may not be meeting their support needs.

The Calgary-Cambridge Referenced Observation Guides: an aid to defining the curriculum and organizing the teaching in communication training programmes

Effective communication between doctor and patient is a core clinical skill. It is increasingly recognized that it should and can be taught with the same rigour as other basic medical sciences. To validate this teaching, it is important to define the content of communication training programmes by stating clearly what is to be learnt. We therefore describe a practical teaching tool, the Calgary-Cambridge Referenced Observation Guides, that delineates and structures the skills which aid doctor-patient communication. We provide detailed references to substantiate the research and theoretical basis of these individual skills. The guides form the foundation of a sound communication curriculum and are offered as a starting point for programme directors, facilitators and learners at all levels. We describe how these guides can also be used on an everyday basis to help facilitators teach and students learn within the experiential methodology that has been shown to be central to communication training. The learner-centred and opportunistic approach used in communication teaching makes it difficult for learners to piece together their evolving understanding of communication. The guides give practical help in countering this problem by providing: an easily accessible aide-mémoire; a recording instrument that makes feedback more systematic; and an overall conceptual framework within which to organize the numerous skills that are discovered one by one as the communication curriculum unfolds.

Clinical communication skills teaching: the role of cognitive schemata

Although the inclusion of the teaching of clinical communication skills is common in the training of health professionals, few published papers exist which either describe the theoretical basis of such teaching or provide comprehensive assessment procedures. This paper highlights the contributions of behavioural analysis and, centrally, the development of cognitive scripts or schemata to the understanding of the teaching of clinical communication skills. A model for a course designed explicitly to develop such scripts is described and the implications of such an understanding are discussed.

Evaluation of a breaking bad news course for medical students

This paper presents the evaluation of a Breaking Bad News course run for three groups of medical students (fourth and fifth year from the London Hospital Medical College and fourth year from St Bartholomew's Hospital Medical College). The course, which is student centred, uses group discussion, videotape presentations and role-play including actors. All teachers, clinicians and human science tutors, had been through a staff training programme on teaching methods. At the end of the course, students' knowledge of important principles in giving bad news had increased, particularly in relation to interpersonal communication; they were more confident in their ability to break bad news well; and the course learning methods were highly rated. The course was just as well received by fourth year as by fifth year students and several said they would like more of this training. The evaluation shows that if reservations about role-play can be overcome then this experiential learning is highly valued by students.

Asking relatives for permission for a post mortem examination

This article discusses the possible aims, benefits, and also the content, format and timing of training in one specific aspect of clinical practice; how to request permission for post mortems.

How do clinicians learn to request permission for autopsies?

A postal survey of 434 clinicians at four local hospitals was undertaken in order to identify the methods by which clinicians learn how to request permission for hospital autopsies and to assess the preferred techniques and timing of relevant communication skills training. The majority of 128 responding clinicians had learnt through personal experience with some assistance from senior colleagues and peers. Few clinicians appeared to have learnt through formal training. The preferred methods for the provision of communication skills training were training in small groups (such as seminars or tutorials) and observation of clinicians at work. The most desirable time for the provision of this training was considered to be between the beginning of the final undergraduate year and the end of the pre-registration house officer year. The communication skills training provided within medical education is in need of improvement. More emphasis should be given to clinical-task- or situation-specific applications such as requesting permission for autopsies.

Community-based medical education: feasibility and cost

The General Medical Council has issued a call for an increase in community-based medical education, and many medical schools are enhancing the community component of their curricula. This paper uses the experience of a community-based junior medical firm to explore the potential costs, and highlight some of the unresolved problems, which a major transfer of education to the community might engender. Community-based medical education is not a cheap option. The cost of this programme for the academic year 1992-93 was 266,494 pounds, or 60 pounds per student session. This compares with the Service Increment for Teaching and Research (SIFTR) provision of 41,140 pounds per student per annum, or (excluding the 25% of SIFTR which is supposed to cover research costs), 64 pounds per student session. There are a number of possible ways of funding community-based education, including a diversion of SIFTR toward departments of primary health care. As this would have serious implications for the financial viability of some medical schools, an urgent discussion about the future funding of medical education is required.

Teaching communication skills to clinical students

Seven years' experience in teaching communication skills to first year clinical students at St Mary's Hospital School of Medicine is described. The first component consists of a day during the introductory clinical course; this is divided into a lecture and small seminar groups and involves behavioural scientists and clinicians from many departments. The second component uses simulated patients and video feedback and takes place in small groups later in the year. Participation of the students through active critical discussion, role play, and interactive video feedback are important aspects in the success of the course. The methods have been refined through evaluation by students and tutors. This article aims to allow others, already running or considering such a course, to develop effective courses within the practical constraints of their own institutions.

Behavioural sciences and the real world: report of a community interview scheme for medical students

A community interview scheme was designed to provide preclinical medical students with an opportunity to investigate the role of social and psychological variables in patient care and gain insight into interpersonal aspects of the interview process. Evaluation of the scheme showed that students and community interviewees found their participation valuable. Eighty per cent of interviewees were willing to take part in the scheme in the following year. The strongest predictor of willingness to participate was interviewees' rating of the extent to which they had enjoyed the experience. Students valued the opportunity to meet 'real people', to explore social and psychological determinants of health and illness and to develop communication skills. A significant positive change in perceived interviewing competence was observed. It is suggested that the scheme might be further developed by using feedback from interviewees to provide students with evidence of both their own skill development and the benefits of self-disclosure to the patients involved.

A communication skills course for preclinical students: evaluation of general practice based teaching using group methods

Teaching preclinical medical students about doctor-patient communication gives them an opportunity to develop their interviewing skills prior to their having to elicit lists of symptoms in their clinical years. General practitioners should be among the more efficient interviewers in clinical medicine and therefore able to make important contributions to the teaching of interviewing skills. This paper describes the aims, objectives and methods of the preclinical communications skills course at St George's Hospital Medical School. The contribution of the Division of General Practice and Primary Care to the teaching of interviewing skills in the preclinical course has been evaluated using rapid group methods. Students were asked to identify examples of specific interviewing behaviours in videotaped general practice consultations, and to judge whether the behaviours were helpful or unhelpful in eliciting relevant information from the patient. Students who had been given experience in interviewing patients in small groups led by general practitioners identified significantly more helpful and unhelpful interviewing behaviours in the taped consultations than students who had not received the small-group teaching. Students rated the teaching as relevant and effective in terms of giving insights into the interviewing skills they needed to develop. Group methods of evaluation such as these might prove useful to other medical schools with class sizes of 150 students or more.

Subjective and behavioural evaluation of the teaching of patient interview skills

One aim of the course in general practice and public health medicine during the final year at the University of Sheffield is to help students to develop further their interpersonal communication skills with particular reference to their skills in interviewing patients. During the course students meet twice in small groups with a tutor in order to review audiotape recordings of interviews with patients seen during their general practice attachments. The main activity during these tutorials is group discussion of the interviewer's behavioural options at significant points during the interview. Students also listen individually with a tutor to an interview that they have recorded, discuss this interview and assess it against a set of explicit criteria as part of their summative course assessment. In response to an anonymous end-of-course questionnaire, 85% of students felt that their interview skills had been improved by the teaching and 68% that listening to their own recordings had been the most helpful aspect. During interviews with simulated patients recorded at the end of the course, students asked more open questions, fewer questions referring to physical symptoms, more questions referring to feelings, beliefs or behaviour and fewer questions of a check-list type than during interviews recorded at the start. A number of students also requested examples of specific events during the end-of-course interviews although none had done so at the beginning of the course. All of these changes were statistically significant and were in directions that were consistent with the teaching in the small-group tutorials.