Training medical practitioners in information transfer skills: the new challenge

Interactional skills training in undergraduate medical education: ten principles for guiding future research

BACKGROUND

High-quality healthcare requires practitioners who have technical competence and communication skills. Medical practitioners need interpersonal skills for gathering and transferring information to their patients, in addition to general consultation skills. Appropriate information gathering increases the likelihood of an accurate diagnosis. Transferring information should be performed in a way that promotes patient understanding and increases the probability of adherence to physician recommendations. This applies to: (i) primary prevention such as smoking cessation; (ii) secondary prevention including preparation for potentially threatening interventions; and (iii) tertiary care, including breaking bad news regarding treatment and prognosis.

DISCUSSION

This debate paper delineates factors associated with undergraduate medical communication skills training where robust research is needed. Ten key principles are presented and discussed, which are intended to guide future research in this field and ensure high quality studies with methodological rigour are conducted. The literature on communication skills training for medical school undergraduates continues to grow. A considerable portion of this output is represented by commentaries, descriptive studies or poorly designed interventions. As with any field of healthcare, quality research interventions are required to ensure practice is grounded in high-level evidence.

Training Medical Students in Behavioural and Cognitive Strategies

It is argued that psychologists have an important role in ensuring appropriate training of medical students in behavioural and cognitive strategies. This paper outlines the innovative medical curriculum at the University of Newcastle and describes the contribution of cognitive psychology to the problem-solving method which underlies the curriculum. It also describes the medical school's approach to training students in interactional skills. One focus of the interactional skills training is to provide practical skills which incorporate behavioural and cognitive strategies to address common, preventable health problems, such as excessive alcohol consumption.

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.

A validated questionnaire to assess the knowledge of psychiatric aspects of alcohol use disorder

BACKGROUND

To the best of our knowledge, there is no validated instrument for measuring knowledge of psychiatric aspects of alcohol use disorder (AUD) amongst medical students. Our aim was to develop an instrument for this purpose and to describe the instrument's psychometric properties. We also investigated whether the instrument could demonstrate a significant change in scores following an educational intervention consisting of a 60-minute PowerPoint lecture on AUD, associated handouts, and role-plays.

METHODS

The Knowledge of Psychiatric Aspects of Alcohol Questionnaire (KPAAQ) was developed from the Kaplan and Saddock textbook synopsis chapter on alcohol related disorders. The questionnaire included 6 categories of clinically relevant material: metabolism of alcohol, short-term effects of alcohol, long-term effects of alcohol, AUD, alcohol withdrawal, and alcohol use in pregnancy. The KPAAQ was administered to 75 medical students in Years 4 and 5 from the Hebrew University in Jerusalem, Israel, during a relevant clinical rotation. Following the initial administration of the KPAAQ, the students attended a 60-minute lecture (in Hebrew) based on material from the University of Sydney's learning module on alcohol. The KPAAQ was readministered to the students immediately following the lecture.

RESULTS

The KPAAQ demonstrated good reliability (Cronbach α =.92 for all questions) and validity r(209) =.674, P <.001. Knowledge of alcohol and alcoholism significantly increased after the educational intervention (F(2, 154) = 151.60, P <.001). Post hoc comparisons using the Scheffe test revealed a significant positive change in knowledge after students received the intervention (mean difference = 33, P <.001).

CONCLUSIONS

These initial findings suggest that the KPAAQ is a reliable and valid instrument for assessing medical student knowledge of psychiatric aspects of AUD over 6 clinical categories.

Undergraduate medical education in substance use in Ireland: a review of the literature and discussion paper

BACKGROUND

Medical complications of substance use are a considerable cause of morbidity and the role of the physician in the care of such problems has consistently been demonstrated. Appropriate knowledge and skills are necessary to carry out this role.

AIMS

To review the literature on training undergraduate medical students in identifying and managing substance misuse and to discuss the implications of this literature for Irish medical education.

METHODS

A search of the literature was performed using keywords; "substance-related disorders", "undergraduate" and "curriculum". All abstracts were reviewed and the full text of relevant abstracts was studied and references reviewed for further articles.

RESULTS

Despite an increase in prevalence of the problem of drug and alcohol use in Ireland and the UK, this has not been reflected in undergraduate medical curricula. In the UK, minimal time is devoted to formal teaching of medical undergraduates in the area of substance misuse and many doctors do not have the appropriate knowledge, skills, attitudes and confidence to treat patients with such problems. In Ireland, no data has reported formal undergraduate teaching hours in the area of drug and alcohol misuse. Internationally, substance abuse curricula have been developed and implemented in medical schools in the United States and Australia.

CONCLUSION

While substance misuse is increasing in prevalence, this is not reflected in the composition of medical curricula, especially in Ireland. International best practice whereby undergraduate curricula that adequately address substance misuse and related issues are systematically developed and implemented, is recommended for adoption by Irish medical schools.

Breaking the news in amyotrophic lateral sclerosis

Diagnosis communication is a mainstay of the patient-physician relationship and in ALS represents the beginning of the treatment. In Europe, the diagnosis is now communicated to most patients, but with some differences from north to south. Communication is the basis of the patient's autonomy. When adequately informed, patients are able to consider their preferences about life-extending interventions. However, this discussion is sometimes entertained too late. Both the style and the context of this discussion have profound impact on patient satisfaction. The content of the communication should include all relevant information about the disease and should be performed honestly while preserving hope. Collusion with relatives can create difficulties in the relationship with a patient and isolate them from their family. Diagnostic communication is an ongoing process and should form part of every follow-up visit. Communication with the dying patient is often reinforced by non-verbal messages, acknowledgements of patients' emotions, and by listening. Written material may increase satisfaction of patients and their relatives, but should never substitute for face-to-face discussion.

The influence of structured education and clinical experience on the attitudes of medical students towards substance misusers

Negative attitudes to patients with substance misuse disorders form a well-recognised barrier to the implementation of best practice. The influence of structured education and clinical experience on the attitudes of medical students towards substance misusers was investigated at an Australian university. First-year students were surveyed before and after 3 weeks of drug and alcohol education and in the same year, fourth-year students were surveyed before and after a 9-week block. Males, older students and those with prior clinical experience tended to have more negative attitudes. Attitudes improved significantly after exposure to interactive learning modules which included contact with patients with substance dependence, including individuals in remission. The level of dislike of problem drinkers significantly decreased after teaching. After fourth-year education, students reported a greater sense of responsibility towards providing intervention and less anticipation of discomfort working with these patients. In particular, confidence and attitudes towards heroin users improved near the end of training after contact with illicit drug users in the small group or individual interview setting. By the end of drug and alcohol education, less than half (42%) of students reported they could not imagine working with substance misusers as a career. Findings support the provision of structured drug and alcohol education and supported clinical experience for every medical student if appropriate evidence-based treatment is to be provided.

The general practitioner's role in AOD issues: overcoming individual, professional and systemic barriers

General practitioners (GPs) and increasingly other medical practitioners are well placed to address alcohol and other drug (AOD) problems. Their involvement in this area of care, however, is assessed to be less than optimal. There is, however, a growing body of evidence for the potential efficacy of medical practitioner intervention at the primary care, emergency department and in-patient level. There is also considerably expanded scope to operate from an evidence-based perspective. However, key questions arise regarding what constitutes best practice in the translation of the growing AOD knowledge base into clinical practice behaviours. This paper explores possible contributory factors to the low level of engagement with AOD issues by GPs and examines a wide range of individual, structural and systemic issues that may be amenable to change. Strategies for the dissemination of research findings, changing professional practice behaviour and introducing sustainable structural reforms are also addressed.

Preventive and other interactional skills of general practitioners, surgeons, and physicians: perceived competence and endorsement of postgraduate training

BACKGROUND

Perceived competencies and support for formal postgraduate training across a range of preventive and other interactional skills were examined in three medical groups.

METHODS

All eligible final year students and recent graduates of the three major Australian medical colleges (n = 767) were mailed a questionnaire examining communication skills in four domains: preventive, educational, therapeutic, and general.

RESULTS

Overall consent rate was 45%. For most items, at least one-third of each group reported low competence. On preventive items, low competence ratings ranged from 5 to 39% in general practice, 38 to 67% in surgery, and 33 to 51% in the speciality physician group. Significant intergroup differences occurred on eight competence items. Agreement with training on preventive topics ranged from 80 to 91% in general practice, 48 to 69% in surgery, and 72 to 82% in the specialty physician group. On all 11 training items where significant differences occurred, the general practice group reported the highest level and the surgeon group the lowest level of endorsement for formal training and assessment.

CONCLUSIONS

Substantial proportions in the general practice, surgery, and the physician specialty report lack of competence in common interactional skills. There were high levels of support for formal training in preventive and other interactional skills. The strong endorsement supports the development of effective, tailored interactional skills training programs.

Teaching medical students alcohol intervention skills: results of a controlled trial

OBJECTIVE

To assess the relative effectiveness of videotape feedback and lecture methods for teaching alcohol brief intervention skills.

DESIGN

In a controlled trial, two student blocks received a manual, lecture and demonstration about the principles and practice of brief alcohol intervention. In addition, experimental students made a 20-min videotape and participated in a 1.5-h small group feedback session. Prior to and after training, all students completed questionnaires and videotaped interviews with simulated patients.

SETTING

Faculty of Medicine and Health Sciences of the University of Newcastle, Australia.

SUBJECTS

Final-year medical students.

RESULTS

Levels of alcohol-related knowledge, attitudes and interactional skills as well as general interactional skills were significantly improved after teaching. Alcohol-related interactional skills that were unsatisfactory at pretest reached satisfactory standards at post-test. An intergroup comparison of the improvement between pre- and post-teaching scores indicated that there was no significant difference in the effectiveness of the two methods.

CONCLUSIONS

Training can improve medical student performance in alcohol intervention. Further research is required to examine the relative effectiveness of different teaching methods.

Informed consent in clinical training--patient experiences and motives for participating

The purpose of this study was to assess patients' attitudes to and experiences of participating in the clinical training of medical students. Samples of patients (n = 582) selected at random from six different departments (gynaecology, psychiatry, internal medicine, paediatrics, urology and a health care centre with general practitioners) were interviewed by means of a questionnaire. The patients were selected from those who had consulted the actual departments in the last six months of 1995. Four hundred and forty-one patients (76%) answered the questionnaire. Seventy-one per cent of all patients had experience of participating; of these 41% had estimated that they had once or several times participated without being informed. Eighty per cent felt aggrieved if they were not informed. On average 88% were, in principle, positive to participating. Of those who were, in principle, negative a majority had negative experiences of participating. Elderly patients tended to accept participating more often without being informed. Almost all patients seemed to be positive to participating in the education of medical students, although a silent precondition might be that patients should be informed and given the opportunity to abstain.

The role of the clinical psychologist in gynecological cancer

Gynecological cancers, which account for a substantial proportion of cancer cases in women, can precipitate a wide range of psychological difficulties including affective disturbances, sexual problems, certain somatic symptoms, and family issues. The clinical psychologist has a unique contribution to make in the assessment and treatment of the psychological needs of gynecological cancer patients, while also conducting research and providing training for health professionals regarding the psychological issues associated with gynecological cancer. Although the gynecological cancer setting affords the clinical psychologist multiple personal benefits, strategies must usually be implemented to minimize any negative impact arising from working in an area of considerable psychological stress.

A preliminary exploration of the interactional skills of trainee surgeons

BACKGROUND

The interactional skills of 21 surgical trainees were studied in the areas of breaking bad news to patients and preparing patients for potentially threatening medical procedures. When compared to the established guidelines for dealing with these issues, the trainees performed poorly.

METHODS

Trainees were videotaped using clinical histories delivered by simulated patients in simulated consulting rooms. All videos were scored on standard rating scales where the criteria for rating the specific interactional skills were adopted from existing guidelines.

RESULTS

The proportion of trainees who could meet the guidelines when breaking bad news was low. The proportion of trainees who met the guidelines were: closing the the consultation (0%), provided patient information about prognosis (43%) and treatment (38%) and when they gave support (10%). There were also low numbers of trainees who could meet the guidelines when they prepared patients for potentially threatening procedures. Ten per cent of trainees followed the guidelines when providing information, 25% could establish treatment goals, 35% could give a prognosis and 0% could deal appropriately with psychosocial issues or close the consultation appropriately.

CONCLUSIONS

It is concluded that there is a need for further formal training in interactional skills as part of surgical training.

Breaking bad news. 3: Encouraging the adoption of best practices

Steps to encourage clinicians to adopt the best practices for communicating bad news to patients are outlined. First, official, credible guidelines endorsed by key organizations or professional bodies, giving a clear message about the components and importance of the best practices, must be produced. Second, the guidelines should be disseminated; publication in journals or mailing to clinicians is unlikely to be sufficient. Third, clinicians should be provided with feedback on whether their performance meets established standards. This requires acceptable systems to collect valid and reliable performance data. Fourth, clinicians need contingencies for providing best practice care. Fifth, barriers to improvement should be explored and strategies to address them, including interactional skills training, implemented. Continuous quality assurance, commitment, and evaluations will help clinicians use the best practices for breaking bad news to patients.

Communicating with patients: surgeons' perceptions of their skills and need for training

BACKGROUND

This study assessed surgeons' current perceived level of competence in a number of interactional skills, their perceptions of the need for training and assessment in interactional skills, and their perceptions of the appropriateness of the format and content of two existing communication skills training packages.

METHODS

Of 267 surgeons who were sent the survey, 63% (n = 143) of eligible respondents completed and returned it.

RESULTS

More than three-quarters of the sample identified the following skills as being important or very important in being a good surgeon: breaking bad news; preparing patients for surgical procedures; educating patients about their diagnosis and treatment, and increasing the likelihood that they will remember what they have been told; detecting anxiety and depression in patients, encouraging patients to express these and listening to their anxieties. More than half the sample felt at least competent at seven of the 10 interactional skills, but almost one-third of the sample reported being 'not or not at all competent' at increasing patients' ability to remember what they have been told and at encouraging patients to express anxieties about their condition, and a further 13.3% reported a lack of competence at breaking bad news to patients about their diagnosis/prognosis. A higher proportion reported a lack of competence in providing bereavement counselling (59.6%), and gaining consent for organ donation (56.6%) and for autopsy (48.9%). The majority rated different aspects of the two communication skills training packages as either 'good' or 'excellent'.

CONCLUSIONS

The survey identified a number of communication skills which are perceived by surgeons to be important and to require formal training and assessment.

Training experiences immediately after medical school

Trainees in all teaching hospitals in New South Wales were surveyed using a self-completion, postal questionnaire to assess perceptions of the quality and extent of training received for interactional and technical skills. The response rate was 67.1%. Mean age was 25.4 years and 38.8% were female. Overall, training was found to be generally poor in terms of time and educational strategies used. Interactional skills were found to receive lower levels of training than technical skills both prior to and during the intern year with significantly fewer (P < 0.000) educational strategies reported for training received in interactional skills than for technical skills. Trainees' perceptions of the adequacy of training was significantly more negative for interactional than technical skills (P < 0.001). Assessment of competence was also significantly lower for interactional than technical skills (P < 0.001). On average, fewer than one in three trainees considered themselves to be competent in interactional skills compared to two-thirds who reported themselves as competent for technical skills. The findings of this study highlight the need for improved efforts with regard to both the quality and quantity of training provided during the intern year. Considerable scope exists for improved educational experiences for both interactional and technical skill areas, but particularly for interactional skills. Overall, greater use of a range of basic educational strategies such as the provision of 'observation' and 'critical feedback' is indicated. Efforts also need to be directed toward the training of clinical educators to optimize the potential of the preregistration period.

Effective teaching of communication skills for medical practice: selecting an appropriate clinical context

Increasingly, courses in communication skills are being incorporated into medical training. In order for communication skills to be effectively maintained in post-training medical practice, they must be taught within an appropriate clinical context. The present paper describes and provides rationale for seven criteria by which to select clinical issues which are appropriate foci for communication skills courses. The criteria are: (1) the issue must be one which is encountered frequently in clinical practice; (2) the issue must be associated with a high burden of illness; (3) there must be evidence that practitioners need to improve skills for dealing with the issue; (4) there must be an intervention, of which communication skills are an integral component, that is demonstrably effective for dealing with the clinical issue; (5) the intervention must represent a cost-effective means of dealing with the issue; (6) the intervention must be acceptable to doctors and be able to be incorporated into routine medical practice; (7) the intervention must be acceptable to patients. Examples of clinical issues which fit these criteria are given in the paper and include smoking, hazardous alcohol consumption, non-adherence to treatment instructions, overdue cervical screening, inappropriate diet, recovery from medical interventions, and breaking bad news to patients.

A controlled trial of educational strategies to teach medical students brief intervention skills for alcohol problems

OBJECTIVES

Comparatively little is known about the most effective educational strategies to train medical students to successfully intervene in their patients' alcohol problems. The relative effectiveness of two educational programs to teach medical students brief intervention skills for managing alcohol problems was examined.

METHODS

Teaching took place over 3 hr and was either the traditional didactic teaching program on the principles and practice of brief and early intervention or an interactive program involving a shortened lecture, clinical practice, and small group feedback on clinical performance. Students were assessed on a 10-min videotaped encounter with a simulated patient before and after teaching according to how they addressed alcohol-related issues and on their general interactional skills.

RESULTS

Performance on alcohol-related issues and interactional skills were significantly improved after teaching, although still poor in terms of clinical performance. A between-groups comparison on pre/ postteaching difference scores indicated interactive training was no more effective than traditional didactic lectures in developing the knowledge and skills needed for a brief alcohol intervention.

CONCLUSION

The need for more detailed teaching sessions on sensitive areas such as alcohol use in indicated.

Attitude of physicians toward patient package inserts for medication information in Belgium

In Belgium, the distribution of medications to outpatients in community pharmacies is almost exclusively by branded unit-of-use packages, with a package insert inside every package. At the time of the study (spring 1990), the implementation of legislation that mandated a shift from highly technical documents to patient package inserts (PPIs), understandable by the lay person, had begun. This study explores the attitude of practising physicians toward written medication information for patients. A mail questionnaire was sent to 1500 (8% random sample) Belgian general practitioners and to 500 (22% random sample) internal medicine specialists. A total of 543 usable questionnaires were returned (27.5% return rate). Ninety-two percent of the physicians stated that their patients seldom or never requested additional information on drug efficacy or side effects, during routine consultation; 30% estimated that more than half of their patients read the PPI; 75% expect that a patient would experience side effects after reading about them in the PPI; 59% agreed that the PPI could help the patient react more adequately in unforeseen situations. It was possible to cluster the respondents in a stable segmentation of three clusters: moderately positive physicians (20%), ambiguous to neutral physicians (44%), physicians overtly negative to written drug information (36%). The low response rate to this extensive postal questionnaire limits the conclusions to a qualitative description of relevant clusters of respondents. In contrast with the opinion of physicians about patient readership, results from other studies indicate that the vast majority of patients read the package inserts.

Training medical students in HIV/AIDS test counselling: results of a randomized trial

The study assessed the effectiveness of a programme aimed at increasing medical students' skills in counselling patients presenting for HIV testing/AIDS information. Senior medical students were randomly assigned to receive a short course in pre- and post-test counselling, or to a control group which received the usual curriculum. The students' performance in counselling simulated patients was videotaped at baseline and after 3 months. A subsample was also assessed at 12 months. Students receiving the programme showed significantly greater improvement in pre- and post-test counselling skills over 3 months than did the controls. For the sub-sample continuing to 12 months, a significant effect over time was found; however, there was no significant difference between the groups. This may have been influenced by the small sample sizes used for the 12-month assessment. General interactional skills improved for the over-all sample over 3 and 12 months, but again there were no significant differences between groups. Those exposed to the programme did not show significantly greater changes in either knowledge or attitude scores over either time frame, compared with controls. When taught in addition to the usual undergraduate curriculum at Newcastle University, this short interactional skills course significantly enhanced students' ability to provide pre- or post-test counselling for HIV/AIDS.

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.

Increased focus on the teaching of interactional skills to medical practitioners

The interaction which occurs between the doctor and patient has been described as the cornerstone of medial care. Research has shown that interactional skills can have a substantial impact on patient outcomes in a number of areas. However, as practitioners do not necessarily acquire such skills through clinical practice, the introduction of formal training programmes for both under and postgraduate medical practitioners should be more closely examined. This paper outlines a number of issues which need to be considered in the formal instruction of medical practitioners in interactional skills. These issues include the teaching of skills within a clinical context that will reflect actual medical practice, the use of all medical disciplines to teach the skills and the inclusion of formal assessment strategies based on the same rigorous criteria as other components of the medical curriculum.