Help, I'm losing patient-centredness! Experiences of medical students and their teachers

Insights into the meaning of medical students' studies. An online survey at two medical faculties

Objective

The aim of the study was to investigate how medical students' deal with their own questions of meaning during their studies, how they cope with patients' questions of meaning or crises of meaning, to what extent their experience of meaning changes during their studies, and what role medical studies play in this.

Methods

In 2022, we conducted an exploratory cross-sectional study in the form of an online survey at two German universities with students in the clinical part of their studies. Quantitative data were analyzed descriptively, and group differences were analyzed using Mann-Whitney U tests. Free-text comments were analyzed using thematic analysis.

Results

Of the 111 participants (response rate 12%), 92% had addressed questions of meaning. 64% of the students felt that their studies were meaningful, and 45% felt that their clinical internships were meaningful. 59% reported that they had been confronted with questions of meaning in their contact with patients, although many of them felt that they had been inadequately prepared for this (56%). This impression was stronger among respondents at the beginning of the clinical phase compared to respondents at the end (U(56,34)=660, p=0.012). According to the students, strategies for dealing with questions of meaning were active engagement with topics of meaning, tolerance of uncertainties, or avoidance. In addition to the basic requirement of openness to all topics of meaning, students expressed the wish to be better prepared for professional questions of meaning and for follow-up work on stressful events. A wide range of critical experiences with training and the healthcare system had an inhibiting effect on the experience of meaning.

Conclusion

Since a higher sense of purpose can be associated with improved health and motivation, university programs might have the potential to support students' sense of purpose and, in the long term, improve their capacities to support patients who grapple with questions of meaning.

Do educational interventions reduce the gender gap in communication skills?- a systematic review

BACKGROUND

Efficient doctor-patient communication is essential for improving patient care. The impact of educational interventions on the communication skills of male and female students has not been systematically reviewed. The aim of this review is to identify interventions used to improve communication skills in medical curricula and investigate their effectiveness in improving the communication skills of male and female medical students.

METHODS

A systematic review of the literature was conducted using the PRISMA guidelines. Inclusion criteria were as follows: used intervention strategies aiming to improve communication skills, participants were medical students, and studies were primary research studies, systematic reviews, or meta-analyses.

RESULTS

2913 articles were identified based on search terms. After title, abstract, and full-text review, 58 studies were included with interventions consisting of Training or Drama Courses, Curriculum-Integrated, Patient Learning Courses, and Community-Based Learning Courses. 69% of articles reported improved communication skills for both genders equally, 28% for women more than men, and 3% for men more than women. 16 of the 58 articles reported numerical data regarding communication skills pre-and post-intervention. Analysis revealed that post-intervention scores are significantly greater than pre-intervention scores for both male (p < 0.001) and female students (p < 0.001). While the post-test scores of male students were significantly lower than that of female students (p = 0.01), there is no significant difference between genders for the benefits, or difference between post-intervention and pre-intervention scores (p = 0.15), suggesting that both genders benefited equally.

CONCLUSION

Implementation of communication training into medical education leads to improvement in communication skills of medical students, irrespective of gender. No specific interventions benefitting male students have been identified from published literature, suggesting need of further studies to explore the phenomenon of gender gap in communication skills and how to minimize the differences between male and female students.

Medical students' attitude toward patient-centeredness: A longitudinal study

OBJECTIVES

This study explored the trajectories of patient-centered orientation in a sample of Italian medical students throughout medical school.

METHODS

Four consecutive student cohorts were longitudinally assessed at the second (T0) and fifth year (T1) of medical school. Students completed a questionnaire including demographics and the Italian validated version of the Patient-Practitioner Orientation Scale.

RESULTS

352 students completed both administrations. Students became more patient-centered in terms of Sharing along the course of their clinical curriculum, whereas there were no significant changes in Caring. Groups with distinct developmental trajectory patterns of both Caring and Sharing were identified. Students high in patient-centeredness at T0 reported significantly lower scores at T1 while students with lower scores at T0 significantly increased from the first to the last measurement. Female students significantly outscored their male colleagues on Caring and Sharing in both administrations.

CONCLUSIONS

Findings call for innovative education strategies to sustain patient-centeredness attitudes in medical students entering hospital-based clinical medicine. Further research is needed to identify characteristics of the medical curriculum that are primarily involved in fostering students' patient-centeredness.

PRACTICE IMPLICATIONS

Including the assessment and monitoring of patient-centeredness throughout the medical school can inform tailored education aiming to foster this dimension.

"The Water in Which We Swim:" A Unique, Post-Clerkship Multidisciplinary Course

OBJECTIVE

To improve patient outcomes and promote health equity, medical students must be taught not only biomedicine, but also the social sciences to understand the larger contexts in which patients live and health care operates. Yet, most undergraduate medical education does not explicitly cover these topics in a required, longitudinal curriculum.

METHODS

In January 2015 at Harvard Medical School, we created a two-part sequence (pre- and post-clerkship) of required, 4-week multidisciplinary courses-"Essentials of the Profession I and II"-to fill this gap. "Essentials of the Profession II (EOP2)" is an advanced social sciences course anchored in patient narratives and the lived experiences of students and includes clinical epidemiology and population health, healthcare delivery and leadership, health policy, medical ethics and professionalism, and social medicine that engages students to conduct structural analyses to be effective healers, advocates, and leaders.

RESULTS

Per student course evaluations, the overall course rating was 1.7 (SD 0.9, 1 = excellent and 5 = poor); its overall rating has improved over time; and it has scored well even when run virtually. It was rated highly in application of critical thinking, integration of the disciplines, and relevance for clinical work. Qualitative analyses of student responses revealed the following key course strengths: breadth of topics, teaching faculty and guest speakers, and small group discussions. The weaknesses included workload, lack of diversity of opinions, repetition, and time spent in lectures.

CONCLUSIONS

We argue that EOP2 is "essential" for post-clerkship medical education. It offers an opportunity to re-ignite and enhance humanism and activism; remind students why they chose the medical profession; equip them with frameworks and toolkits to help them to overcome challenges; and devise solutions to improve health care and patient outcomes that are applicable to their future training and ongoing practice of medicine.

Development of an instrument for medical students' self-assessment of facets of competence for patient-centred care

OBJECTIVE

To develop a facets of competence self-assessment instrument (FOCSI) with operationalised items for ten competence facets required for patient-centred care at the beginning of residency.

METHODS

We conducted focus groups and cognitive interviews with final-year medical students to develop items that match students' clinical experience. We tested 50 items in two samples and analysed model fit and internal consistency of all possible combinations to identify the optimal ten-item-solution. Item analysis was performed as well as correlation with six personality traits.

RESULTS

An optimal ten-item solution for the self-assessment instrument emerged for sample 1 (n = 101, 27.2 ± 3.5 years, 75.2 % female). We validated the model fit with sample 2 (n = 135, 27.7 ± 3.9 years, 66.7 % female): χ2(35) = 49.3, p = .055, CFI = .94, RMSEA = .055, SRMR = .058, Cronbach's alpha = .78. The personality factors 'Conscientiousness' and 'Extraversion' correlate positively with most FOCSI items.

CONCLUSION

The operationalised FOCSI items support undergraduate medical students close to graduation in realistic self-assessment of facets of competences for patient-centred care in their transition to residency.

PRACTICE IMPLICATIONS

Realistic self-assessment of facets of competence will provide medical students with the opportunity to monitor their competence development as part of self-directed learning for gaining adaptive expertise in professional, patient-centred care.

Interaction with Patients as a Budding Doctor: An Experience

Every medical student amidst COVID-19 missed out on an integral part of medical education which is interaction with patients as all the physical classes were postponed for months. Effective interaction with patients is the heart of medicine and it provides a synergistic effect on the delivery of high-quality care to the patient. However many medical students underestimate the art of communication. This article highlights the importance of basic communication skills; also encourages reflecting upon the whole experience and extracting the learning to apply to any further interactions.

Keywords

communication; empathy; medical students; healthcare quality.

Perceptions on the current content and pedagogical approaches used in end-of-life care education among undergraduate nursing students: a qualitative, descriptive study

BACKGROUND

With the aging of the population, high rates of cancer and comorbidity complexity, the end-of-life care for patients will be ever more important. Nurses have always played an essential role in end-of-life care. Insufficient education and training in end-of-life care has been regarded as a major reason of inadequate symptom recognition, symptom management, and communication which results in mental trauma for both the patient's family and attending health care providers. Undergraduate nurses do end-of-life care as part of their clinical learning. However, undergraduate nurses' perceptions of the education they received about end-of-life care are not documented.

OBJECTIVE

This study aimed to critically explore the current state of education regarding end-of-life care from the perspectives of undergraduate nurses.

METHODS

We used a descriptive qualitative design. Face-to-face semi-structured interviews were conducted from May to August 2020, with a purposive sample of 15 fourth-year undergraduate nurses who finished the internship. Data were transcribed verbatim and analyzed using content analysis.

FINDINGS

Three main themes relating to undergraduate nurses' experiences of end-of-life care education emerged from the thematic analysis: 1) Universities provide foundational knowledge about end-of-life care, but it still needs improvement; 2) Clinical practice consolidates and drives undergraduate nurses' knowledge, skills and confidence about end-of-life care; and 3) cultural attitudes of patients' family toward disease and death sometimes impedes learning and knowledge translation about end-of-life care.

CONCLUSION

Undergraduate nursing students benefit from not only theoretical content delivered in the university setting but also practice happened on clinical placement. The current undergraduate curriculum, related to end-of-life care, is disjointed. Meanwhile, undergraduate nurses' learning and knowledge translation of end-of-life care are impeded by cultural attitudes toward disease and death.

Optimising planned medical education strategies to develop learners' person-centredness: A realist review

CONTEXT

Person-centeredness is a stated aim for medical education; however, studies suggest this is not being achieved. There is a gap in our understanding of how, why and in what circumstances medical education interventions that aim to develop person-centredness are successful.

METHODS

A realist review was conducted with a search of Medline, Embase, HMIC and ERIC databases and the grey literature using the terms 'medical education' and 'person-centred' and related synonyms. Studies that involved a planned educational intervention in medical education with data on outcomes related to person-centredness were included. The analysis focused on how and why different educational strategies interact with biomedical learner perspectives to trigger mechanisms that may or may not lead to a change in perspective towards person-centredness.

RESULTS

Sixty-one papers representing fifty-three interventions were included in the final synthesis. Nine context-intervention-mechanism-outcome configuration (CIMOc) statements generated from the data synthesis make up our refined programme theory. Where educational interventions focused on communication skills learning or experiences without person-centred theory, learners experienced dissonance with their biomedical perspective which they resolved by minimising the importance of the learning, resulting in perspective endurance. Where educational interventions applied person-centred theory to meaningful experiences and included support for sense making, learners understood the relevance of person-centeredness and felt able to process their responses to learning, resulting in perspective transformation towards person-centredness.

CONCLUSION

Our findings offer explanations as to why communication skills-based interventions may be insufficient to develop learners' person-centredness. Integrating experiential person-centred learning with theory on why person-centredness matters to clinical practice and enabling learners to make sense of their responses to learning, may support perspective transformation towards person-centredness. Our findings offer programme and policymakers testable theory to inform the development of medical education strategies that aim to support person-centredness.

Knowing-in-action that centres humanising relationships on stroke units: an appreciative action research study

Background:

Equal, collaborative and therapeutic relationships centred on the person affected by stroke are important for supporting recovery and adjustment. However, realising these relationships in hospital practice is challenging when there is increasing focus on biomedical needs and organisational pressures. Despite a body of evidence advocating for quality relationships, there remains limited research describing how to achieve this in clinical practice. This appreciative action research (AAR) study aimed to describe the processes involved in co-creating meaningful relationships on stroke units.

Design and methods:

An AAR approach was used to develop humanising relationship-centred care (RCC) within two hospital stroke units. Participants were staff (n = 65), patients (n = 17) and relatives (n = 7). Data generation comprised of interviews, observations and discussion groups. Data were analysed collaboratively with participants using sense-making as part of the AAR cyclical process. Further in-depth analysis using immersion crystallisation confirmed and broadened the original themes.

Findings:

All participants valued similar relational experiences around human connections to support existential well-being. The AAR process supported changes in self, and the culture on the stroke units, towards increased value being placed on human relationships. The processes supporting human connections in practice were: (i) sensitising to humanising relational knowing; (ii) valuing, reflecting and sharing relational experiences with others that co-created a relational discourse; and (iii) having the freedom to act, enabling human connections. The outcomes from this study build on existing lifeworld-led care theories through developing orientations for practice that support relational knowing and propose the development of RCC to include humanising values.

Medical students' experiences when empathizing with patients' emotional issues during a medical interview - a qualitative study

BACKGROUND

There is evidence that empathy decreases as medical students go through clinical training. However, there are few in-depth studies investigating the students' own experiences when trying to empathize in concrete clinical encounters. We therefore wanted to explore medical students' perceptions, experiences, and reflections when empathizing with patients expressing emotional issues.

METHODS

A qualitative content analysis of semi-structured interviews with third year medical students (N = 11) was conducted using video-stimulated recall from their own medical interview with a simulated chronically ill patient. Students were led to believe that the patient was real.

RESULTS

Five themes which may influence student empathy during history-taking were identified through analysis of interview data: (1) Giving priority to medical history taking, (2) Interpreting the patient's worry as lack of medical information, (3) Conflict between perspectives, (4) Technical communication skill rather than authentic and heart-felt and (5) The distant professional role.

CONCLUSIONS

The participating students described conflicts between a medical agenda, rules and norms for professional conduct and the students' own judgments when trying to empathize with the patient. To our knowledge, this is the first study ever to document the students' own perspective in concrete situations as well as how these reported experiences and reflections affect their empathy towards patients. Since we now know more about what is likely to hinder medical students' empathy, educators should actively encourage group reflection and discussion in order to avoid these negative effects of history taking both inside and outside of the clinical setting.

Doctors' experiences of earlier mandatory postgraduate communication skills training: a qualitative study

OBJECTIVES

This study explored the question: what are doctors' perspectives on and experiences with their earlier mandatory postgraduate communication skills training?

METHODS

The study used a qualitative, exploratory design. We used purposeful sampling based on the principle of maximal variation to ensure different clinical perspectives. Thus, three focus groups were formed with 12 doctors who had attended mandatory postgraduate communication skills training within 1-9 years prior to the study. The doctors were from three specialties: internal medicine, oncology, and general practice. We used a semi-structured interview guide, and the focus groups were video-recorded. Thematic analysis was used to analyze the data material. Through an iterative process, we identified main and sub-themes.

RESULTS

The first-year residency mandatory postgraduate communication skills training provided all participants with skills that had helped them in their ongoing clinical work. In addition, five dominant themes were observed: modes of use, the timing of course, experience with experiential methods, sharing challenges with peers, and need for continuous feedback and follow-up.

CONCLUSIONS

Doctors value early mandatory postgraduate communication skills training even years after attending the course and request similar ongoing initiatives. Their experiences are positive, they found the timing relevant, and they used the learned skills in their ongoing clinical work, even years after the initial course. Our study indicates that more attention should be given to 'early career' postgraduate communication skills training that is tailored to specific clinical contexts, including hospital settings.

Clinical empathy in GP-training: Experiences and needs among Dutch GP-trainees. "Empathy as an element of personal growth"

OBJECTIVE

Clinical empathy has been described as a key component of effective person-centeredness in patient-physician communication. Yet little is known about general practitioner (GP) trainees' experiences and opinions regarding clinical empathy, empathy-education and the development of empathic skills. This study aimed to explore trainees' experiences with clinical empathy during GP training.

METHODS

This study used focus group interviews. GP trainees at two Dutch universities were approached by e-mail. Focus groups were conducted between April and November 2018. Six focus groups were conducted: two with starting trainees, two with trainees at the end of their first year and two with trainees at the end of their 3 years' training. Two experienced qualitative researchers analyzed the focus groups. During the thematic analysis the differences and similarities between the various stages of education were taken into account and a framework for the identified themes and subthemes was developed.

RESULTS

Thirty-five GP trainees took part. Four main themes could be identified. Starting trainees experienced frictions regarding the influence of personal affective reactions on their medical competencies. Trainees at the end of their first year indicated that they reached a balance between empathic involvement and their responsibility to carry out relevant medical tasks, such as following GP guidelines. Trainees at the end of their three years' training recognized the mutual relationship between the development of the behavioral part of clinical empathy and personal growth. All trainees stated that their needs concerning education changed during their GP training and proposed changes to the curriculum.

CONCLUSIONS

GP trainees face various obstacles in developing empathic skills and behavior. Particularly they mention handling personal affective reactions. Trainees express a clear wish for clinical empathy, in its theoretical as well as its skill and emotional aspects, to play a central role in the curriculum.

PRACTICE IMPLICATIONS

More explicit attention to be paid to empathy by embedding theoretical education, explicit attention to skill training and assessment of empathic behavior by patients and supervisors.

Medical students' expressions of empathy: A qualitative study of verbal interactions with patients expressing emotional issues in a medical interview

OBJECTIVE

Explore medical students' verbal responses to patients expressing emotional issues in a medical interview.

METHODS

Eleven third-year students were instructed to conduct a medical interview with a simulated chronically ill patient while being videotaped (but were led to believe that the patient was real). An interaction analysis system (VR-CoDES) was used to identify patient utterances containing emotional expressions as well as student utterances responding to these emotional expressions. A qualitative content analysis of student utterances was then conducted.

RESULTS

Four categories that depicted student responses were identified: (1) questions focusing on a medico-professional agenda, (2) allowing disclosure of emotions without explicit acknowledgment of emotions, (3) attempts at reassurance, and (4) explicit recognition of emotions, but most often on a factual and descriptive level.

CONCLUSIONS

Our analysis indicate that these students gave priority to medico-professional tasks and responsibilities in their responses. They demonstrated some interest in the patient's emotional experiences whilst most often leaving out their own personal perspectives.

PRACTICE IMPLICATIONS

Communication skills curricula should address how the medical interview affects empathy and interaction with patients and encourage discussion and reflection on how to retrieve medical information while paying adequate attention to the patient's and own emotions, experiences, and perspectives.

Does nonviolent communication education improve empathy in French medical students?

OBJECTIVES

To evaluate the impact of nonviolent communication (NVC) training on five aspects of medical students' empathy skills using implicit and explicit measures.

METHODS

312 third-year French medical students were randomly allocated to an intervention group (n = 123) or a control group (n = 189). The intervention group received 2.5 days of NVC training. For each group, empathy-related skills were measured implicitly using three cognitive tests (Visuo-Spatial Perspective Taking, Privileged Knowledge, Empathy for Pain evaluation) and explicitly using two self-rating questionnaires (Jefferson Scale of Physician Empathy, Empathy Quotient). Both groups completed tests and questionnaires before (pre-test) and three months after training (post-test). Responses were collected via online software, and data were analyzed using paired linear mixed models and Bayes Factors.

RESULTS

We found a significant increase in the Jefferson  Scale of Physician Empathy (JSPE) score between pre- and post-tests in the intervention group compared to the control group (linear mixed models: 0.95 points [0.17, 1.73], t₍₁₅₈₎ = 2.39, p < 0.05), and an expected gender effect whereby females had higher JSPE scores (1.57 points [0.72, 2.42], t₍₂₆₂₎ = -3.62, p < 0.001). There was no interaction between these two factors.

CONCLUSIONS

Our results show that brief training in nonviolent communication improves subjective empathy three months after training. These results are promising for the long-term effectiveness of NVC training on medical students' empathy and call for the introduction of NVC training in medical school. Further studies should investigate whether longer training will produce larger and longer-lasting benefits.

Making the invisible more visible: Reflections on practice-based humanising lifeworld-led research - existential opportunities for supporting dignity, compassion and wellbeing

BACKGROUND

The need for dignity and compassion in healthcare is enshrined in policy, but is often difficult to enact in practice and what is precisely meant by these concepts is unclear. In this paper, we have explored theoretical underpinnings which form the basis of a lifeworld-led approach which was used in a research study to support the humanity of service providers and users alike.

AIM

In this article, we share our analysis of what we have learnt after undertaking an innovative appreciative action research project with patients and staff in a stroke ward with the aim of exploring if a novel phenomenologically driven and philosophically derived humanising framework could be applied in health care. Following the research, we wanted to develop a theoretical understanding of the processes occurring during the research in order to provide a framework and language which could be used to support practical lifeworld developments in the future. We analysed the approach through Participatory and Appreciative Action Reflection.

FINDINGS

As researchers, we found that the approach was underpinned by four key existential principles. The first principle was recognising a mutually arising reality rather than a reality 'out there'. The second was recognising a reality which was constantly changing rather than 'fixed'. The third was recognising that we needed to work from within, as part of a human living system rather than trying to control reality from the 'outside'. Finally, we recognised that this reality could only be accessed through human knowing, including embodied knowing rather than intellectual knowing alone. These principles challenged many of the usual ways of thinking and working within research and healthcare contexts.

CONCLUSION

Understanding the processes and reality in this way gave new perspectives; enhancing our understandings and views of ourselves, what is important and most importantly what is possible in caring systems.

Empathy and attitude toward communication skill learning as a predictor of patient-centered attitude: a cross-sectional study of dental students in Korea

BACKGROUND

Enhancing medical students' practice of patient-centered care is a goal of medical schools. In addition to exploring the demographic and academic factors of the students, it is necessary to identify other attitudes and perceptions that may influence the student's patient-centered attitude and inclination toward communication skill learning. This study aimed to assess patient-centered attitudes among dental students in Korea and identify the association between the students' characteristics and empathy, communication skill learning attitude, and patient-centered attitude.

METHODS

Data were collected via a cross-sectional online survey, and 312 dental students were included in the analyses. The study participants completed the Patient-Practitioner Orientation Scale (PPOS), the Interpersonal Reactivity Index (IRI), and the Communication Skills Attitude Scale (CSAS). Analyses were performed using independent samples' t-tests, hierarchical multi-variable regression, and ANOVA with a post-hoc Tukey test.

RESULTS

The students tend to be moderately patient-oriented toward the sharing subscale of PPOS score (M = 3.78, standard deviation [SD] = 0.54) and slightly more patient-centered toward the caring subscale of PPOS score (M = 4.41, SD = 0.52) of patient-centered attitudes. Being a female and a shorter academic period in dentistry were associated with attitudes toward patient-centered care. Empathy and positive attitude toward learning communication skills were also related to a patient-centered attitude, and among aspects of empathy, "empathic concern" had the greatest significant impact on patient-centered attitude.

CONCLUSIONS

Gender, academic period, empathy, and attitudes on learning communication skills were important influencing factors of patient-centered attitudes. Patient-centered attitude can and must be taught. Education programs should focus on enhancing empathy, emphasizing positive attitudes on learning communication skills, and conducting follow-up educational sessions to prevent students from becoming less patient-centered with an increase in duration of their academic period.

Congruence between nursing students' and patients' views of student-patient relationships

The growing emphasis on learning with and from patients has shifted the focus from education and healthcare professionals to the student-patient relationship. The relationship between student and patient, with a supportive preceptor as a resource, can influence the progression and development of an authentic person-centred approach to care among students. The purpose of this study was to analyse the congruence between nursing students' and patients' views of their relationship during students' clinical placement. The study compared data from cross-sectional matched cohort pairs of nursing students (n = 187) and patients (n = 187) in Finland. The data were collected between March 2015 and May 2016 using corresponding questionnaires and procedures in both cases. Both students' and patients' views were moderately or weakly congruent in terms of facilitative relationship, characterised as a mutually enriching relationship for both students and patients through dialogue. Patients, however, tended to see the relationship significantly more often as mechanistic, focusing on students learning practical skills, compared to students who saw the relationship more often as facilitative. Patients' age and the reasons for care were the only background variables that predicted the congruence between students' and patients' views of their relationships. These findings suggest ways in which student-patient relationships can be made more meaningful in supporting learning in clinical education.

Empathy, well-being and stressful experiences in the clinical learning environment

OBJECTIVE

This study examines whether students in the clinical phase show reduced well-being and lower empathy scores compared to preclinical students. Furthermore, it explores students' most stressful experiences.

METHODS

A cross-sectional mixed-methods study was conducted among medical students of the revised patient- and student-centred curriculum at Witten/Herdecke University (Germany). An online survey included questions regarding empathy (JSPE-S), well-being (WHO-5), distressing factors in the learning and clinical environments, mistreatment and thoughts of dropping out.

RESULTS

176 (34 %) of 517 medical students completed the questionnaire, 73 being preclinical and 103 clinical students. Despite lower well-being, clinical student did not demonstrate lower empathy levels. Main stressors during the clinical phase were negative physician role models and financially focussed care rather than challenging patient encounters. Compared to preclinical students, clinical students showed more mistreatment experiences and higher ratings towards thoughts of dropping out.

CONCLUSION

Our results illustrate contemporary challenges to establishing a learner-centred clinical environment that nurtures well-being and empathy of medical students. The sustainment of empathy despite more stressful experiences and lower well-being may be due to protective factors.

PRACTICE IMPLICATIONS

The paper suggests activities to support clinical students to find ways to adapt the clinical learning environment to students' needs.

Attitudes of medical students towards interprofessional education: A mixed-methods study

BACKGROUND

Interprofessional Education (IPE) aims to improve students' attitudes towards collaboration, teamwork, and leads to improved patient care upon graduation. However, the best time to introduce IPE into the undergraduate curriculum is still under debate.

METHODS

We used a mixed-methods design based on a sequential explanatory model. Medical students from all six years at the University of Bern, Switzerland (n = 683) completed an online survey about attitudes towards interprofessional learning using a scale validated for German speakers (G-IPAS). Thirty-one medical students participated in nine semi-structured interviews focusing on their experience in interprofessional learning and on the possible impact it might have on their professional development.

RESULTS

Women showed better attitudes in the G-IPAS across all years (p = 0,007). Pre-clinical students showed more positive attitudes towards IPE [Year 1 to Year 3 (p = 0.011)]. Students correctly defined IPE and its core dimensions. They appealed for more organized IPE interventions throughout the curriculum. Students also acknowledged the relevance of IPE for their future professional performance.

CONCLUSIONS

These findings support an early introduction of IPE into the medical curriculum. Although students realise that interprofessional learning is fundamental to high-quality patient care, there are still obstacles and stereotypes to overcome.

TRIAL REGISTRATION

ISRCTN 41715934.

Determinants of mental health professionals' attitudes towards recovery: A review

OBJECTIVE

The attitudes of mental health professionals towards consumers' recovery are far more pessimistic than what is needed for the recovery-orientation to truly permeate systems of care. It has become pressing to depict determinants for these attitudes and how they evolve during professionalization. This, in the hopes to adjust not only medical education, but also ongoing training of professionals.

METHODS

A systematic search of PubMed and PsycINFO databases was conducted, yielding a net 15 303 records. Twenty-two publications from specific educational journals and reference lists were added. Finally, thirty-four full texts were read, from which twenty-two articles were included.

RESULTS

From the reviewed studies emerged five main determinants: profession, education, age, clinical experience, and nature of the contact with consumers. Traditional clinical placements during residency, negative experiences with acute patients, younger age and the professional attitudes of psychiatrists seem to all be determining factors for professionals' pessimistic attitudes towards recovery.

CONCLUSIONS

This review found specific determinants for attitudes in recovery and four out of five can be acted upon. For a recovery-orientation to be implemented across our mental health system, we formulate recommendations within the Canadian context for revision of curriculum, recovery-specific training, and operationalisation through state/provincial technical assistance centers.

Learning from patients about patient-centredness: A realist review: BEME Guide No. 60

Background: Patient-centred work is an essential part of contemporary medicine. Literature shows that educational interventions contribute to developing patient-centredness, but there is a lack of insight into the associated learning processes.Objective: Through reviewing articles about educational interventions involving patients, we aspire to develop a program theory that describes the processes through which the educational interventions are expected to result in change. The processes will clarify contextual elements (called contexts) and mechanisms connected to learning patient-centredness.Methods: In our realist review, an initial, rough program theory was generated during the scoping phase, we searched for relevant articles in PubMed, PsycINFO, ERIC, CINAHL and Embase for all years before and through 2016. We included observational studies, case reports, interviews, and experimental studies in which the participants were students, residents, doctors, nurses or dentists. The relevance and rigour of the studies were taken into account during analysis. With deductive as well as inductive coding, we extended the rough program theory.Results: In our review, we classified five different contexts which affect how upcoming professionals learn patient-centredness. These aspects are influenced through components in the intervention(s) related to the learner, the teacher, and the patient. We placed the mechanisms together in four clusters - comparing and combining as well as broadening perspectives, developing narratives and engagement with patients, self-actualisation, and socialisation - to show how the development of (dimensions of) patient-centredness occurs. Three partial-program-theories (that together constituting a whole program theory) were developed, which show how different components of interventions within certain contexts will evoke mechanisms that contribute to patient-centredness.Translation into daily practice: These theories may help us better understand how the roles of patients, learners and teachers interact with contexts such as the kind of knowledge that is considered legitimate or insight in the whole illness trajectory. Our partial program theories open up potential areas for future research and interventions that may benefit learners, teachers, and patients.

Assessing the training needs of medical students in patient information gathering

BACKGROUND

Effective communication is at the heart of good medical practice but rates of error, patient complaints, and poor clinician job satisfaction are suggestive of room for improvement in this component of medical practice and education.

METHODS

We conducted semi-structured interviews with experienced clinicians (n = 19) and medical students (n = 20) to explore their experiences associated with teaching and learning clinical communication skills and identify targets for improvements to addressing these skills in medical curricula.

RESULTS

Interviews were thematically analysed and four key themes emerged; the importance of experience, the value of role-models, the structure of a consultation, and confidence.

CONCLUSIONS

The findings reinforce the need for improvement in teaching and learning communication skills in medicine, with particular opportunity to target approaches to teaching foundational skills which can establish a strong grounding before moving into more complex situations, thus preparing students for the flexibility required in medical interviewing. A second area of opportunity and need is in the engagement and training of clinicians as mentors and teachers, with the findings from both groups indicating that preparation for teaching and feedback is lacking. Medical programs can improve their teaching of communication skills and could learn from other fields s to identify applicable innovative approaches.

Student's Inventory of Professionalism (SIP): A Tool to Assess Attitudes towards Professional Development Based on Palliative Care Undergraduate Education

Introduction: Quality medical education, centered on a patient's needs, is crucial to develop the health professionals that our society requires. Research suggests a strong contribution of palliative care education to professionalism. The aim of this study was to design and validate a self-report inventory to measure student's professional development. Method: Sequential exploratory strategy mixed method. The inventory is built based on the themes that emerged from the analysis of four qualitative studies about nursing and medical students' perceptions related to palliative care teaching interventions (see Ballesteros et al. 2014, Centeno et al. 2014 and 2017, Rojí et al. 2017). The structure and psychometrics of the inventory obtained is tested in two different surveys with two different groups of medical students. Inventory reliability and construct validity are tested in the first survey group. To verify the inventory structure, a confirmatory factor analysis is performed in a second survey group. Results: The inventory has 33 items and seven dimensions: a holistic approach, caring for and understanding the patient, personal growth, teamwork, decision-making, patient evaluation, and being a health care professional. Cronbach's-alpha was 0.73-0.84 in all seven domains, ICC: 0.95. The confirmatory factor analysis comparative fit index (CFI) was 1 with a standardized root mean square Index 0.088 (SRMR) and obtained a 0.99 goodness-of-fit R-square coefficient. Conclusions: this new inventory is grounded on student's palliative care teaching experiences and seems to be valid to assess student's professional development.

Students' patient-centered-care attitudes: The contribution of self-efficacy, communication, and empathy

OBJECTIVES

Patient-centered-care (PCC) attitudes are important to enhance PCC behavior, but research on perceptions and attitudes that contribute to PCC attitudes is limited. We tested a new model, assessing whether the association between self-efficacy and PCC attitudes is mediated by communication and empathy attitudes. Furthermore, we assessed medical-school-stage and gender differences in these variables.

METHODS

Medical/dentistry students (N = 653) completed self-reported questionnaires. Analyses were performed using Pearson's-correlations, PROCESS macro, and independent samples t-tests.

RESULTS

The association between communication self-efficacy and PCC attitudes was completely mediated by communication and empathy attitudes. Students in clinical years had more positive attitudes toward PCC and empathy, and higher communication self-efficacy. Females had more positive attitudes toward PCC, communication, and empathy.

CONCLUSIONS

The results emphasize the importance of communication self-efficacy and the mediating role of communication and empathy attitudes in enhancing PCC attitudes. This highlights the need to focus on learners' affective matter (what they feel/think) about their competencies and attitudes.

PRACTICE IMPLICATIONS

Educational interventions should improve understanding of the benefits of applying good communication skills, of learning the importance of empathy and its relevance to patient care, and strengthening students' confidence in applying these skills. Attention to these is important for enhancing students' PCC attitudes.

Assessing attitudes of patient-centred care among students in international chiropractic educational programs: a cross-sectional survey

Background

Patient-centred care is internationally recognized as a foundation of quality patient care. Attitudes of students towards patient-centred care have been assessed in various health professions. However, little is known how chiropractic students' attitudes towards patient-centred care compare to those of other health professions or whether they vary internationally, and between academic programs.

Objective

To assess the association of select variables on student attitude towards patient-centred care among select chiropractic programs worldwide.

Methods

We conducted a cross-sectional study using the Patient-Practitioner Orientation Scale (PPOS) to assess students' patient-centred attitudes towards the doctor-patient relationship. Eighteen items were scored on a 1 to 6 Likert scale; higher scores indicating more patient-centredness. All students from seven chiropractic educational programs worldwide were invited to complete an online survey. Results were analyzed descriptively and inferentially for overall, sharing and caring subscales. General linear regression models were used to assess the association of various factors with PPOS scores.

Results

There were 1858 respondents (48.9% response rate). Student average age was 24.7 (range = 17-58) years and 56.2% were female. The average overall PPOS score was 4.18 (SD = 0.48) and average sharing and caring subscale scores were 3.89 (SD = 0.64) and 4.48 (SD = 0.52), respectively. There were small but significant differences in all PPOS scores by gender, age, and program. Year/semester of study within a program typically was not associated with scores, neither was history of previous chiropractic care nor having family members who are health professionals.

Conclusion

This is the first international study assessing students' attitudes of patient-centred care in chiropractic educational programs. We found small but significantly different PPOS scores between chiropractic programs worldwide that did not change across year/semester of study. Scores tended to be lower than those reported among medical students. Observed differences may be related to curricular content, extent of patient exposure and/or regional cultural realities.

Navigating Tensions of Efficiency and Caring in Clerkship: A Qualitative Study

Phenomenon: Clerkship is a challenging transition during which medical students must learn to navigate the responsibilities of medical school and clinical medicine. We explored how clerks understand their roles as both medical learners and developing professionals and some of the tensionss that arise therein. Understanding how the clinical learning environment shapes the clerkship role can help educators foster compassionate care. Approach: We conducted 5 focus groups and 1 interview with 3rd-year medical students (n = 14) at University of Toronto between January and June 2016 regarding the perceived role of the clerk, compassionate care, assessment and feedback. Data were analyzed thematically. Findings: In addition to transitioning to a new learning environment, clerkship students assume different roles in response to complex and often competing expectations from preceptors. We identified three main themes: learning to impress preceptors with varying expectations, providing compassionate care-sometimes supported by preceptors, other times being secondary to efficiency-and passing assessments that required a different skill set than simply being a "good clerk." Insights: Clerks perceive their role as providing compassionate care to patients and balance this with fulfilling the (sometimes) competing roles of being a student and developing medical professional. In a system where efficiency is often prioritized, medical students are afforded an opportunity to help satisfy the demand for greater compassion in patient-centered care.

Healthcare professionals' perceptions of learning communication in the healthcare workplace: an Australian interview study

OBJECTIVES

The literature focuses on teaching communication skills in the 'classroom', with less focus on how such skills are informally learnt in the healthcare workplace. We grouped healthcare work based on the cure:care continuum to explore communication approaches based on work activities. This study asks: 1) How do healthcare professionals believe they learn communication in the workplace? 2) What are the differences (if any) across the 'type of work' as represented by the cure:care continuum?

DESIGN

This qualitative study used semi-structured individual interviews.

SETTING

Community care and acute hospitals in Australia (Victoria and New South Wales).

PARTICIPANTS

Twenty qualified healthcare professionals (medicine n=4, nursing n=3, allied health n=13) from various clinical specialties (eg, acute, rehabilitation, surgery, palliative care) participated.

METHODS

Data were analysed using framework analysis, which involved the development of a thematic coding framework. Findings were mapped to participants' descriptions of work using the cure:care continuum.

RESULTS

Three themes were identified that varied across the cure:care continuum: professional discourse-tying communication approaches to work activities; personal identities-the influence of personal identities on healthcare communication and role modelling-the influence of others in the socially bound context of healthcare work.

CONCLUSIONS

This study highlights the influence of professional, personal and social factors on the learning of healthcare communication in the workplace. Our study illuminates differences in communication practice related to work activities, as conceptualised by the cure:care continuum. The results call for further examination of the 'nature' of work activities and the concomitant influence on developing healthcare communication.

Perceptions of Patient-Centered Care among First-Year Medical Students

Phenomenon: Teaching patient-centered care (PCC) is a key component of undergraduate medical curricula. Prior frameworks of PCC describe multiple domains of patient-centeredness, ranging from interpersonal encounters to systems-level issues. Medical students' perceptions of PCC are thought to erode as they progress through school, but little is known about how students view PCC toward the beginning of training. This study explores the perceptions of PCC among 1st-year medical students to inform curricular development and evaluation. Approach: Medical students participated in semistructured, in-person interviews within 4 months of starting medical school as part of a longitudinal study. Transcripts were analyzed using a grounded theory approach and the constant comparative method to describe responses and characterize emergent themes. Transcripts were reviewed to compare codes and compile a final codebook. Findings: Thirty-eight students completed interviews. Students provided heterogeneous definitions of PCC, including perceptions that PCC is implicit and obvious. Many students were unable to provide a concrete definition of PCC, juxtaposing PCC with other priorities such as profit- or physician-centered care, whereas others thought the term was jargon. Some participants defined PCC as upholding patient values using hypothetical examples centered around physician behavior. Insights: Although students appeared to enter medical school with a range of perceptions about PCC, many of their descriptions were limited and only scratch the surface of existing frameworks. Rather than their perceptions of PCC eroding during medical school, students may never fully develop a foundational understanding of PCC. Our findings reinforce the need for authentic, clinically experiential learning opportunities that promote PCC from the earliest stages of medical education.

Listen to the outpatient: qualitative explanatory study on medical students' recognition of outpatients' narratives in combined ambulatory clerkship and peer role-play

BACKGROUND

Understanding patients' narratives has been associated with methods of improving care that go beyond what may be regarded as a "narrow" view of scientific medicine. Medical interview training in which medical students develop understanding of the importance of patients' narratives is receiving increased attention. However, students generally receive education on patients' narratives that does not distinguish inpatients and outpatients. No studies exploring the characteristics of outpatients' narratives have been reported. We developed an educational program combining ambulatory clerkship and peer role-play using actual narratives from outpatients that students had encountered during their clerkship. These narratives were used as peer role-play scenarios in which the students acted as outpatients. This study explored what and how medical students learned about the characteristics of outpatients' narratives through this original educational program.

METHODS

Participants were 70 fifth-year medical students from Nagoya University, Japan. We conducted 13 focus groups, based on a convenience sample of 11 groups in 2012, one group in 2013, and one group in 2017 (from 17 clinical groups in each year). Focus group transcripts were analyzed using the "Steps for Coding and Theorization" qualitative data analysis method. We assessed medical anthropological findings regarding narratives in a conceptual framework.

RESULTS

Patients' narratives as perceived by medical students were divided into four quadrants by two axes: medical versus lived content, and objective versus subjective structure. Students recognized that outpatients' narratives mainly used a subjective structure, but were mixed and crossed each quadrant. This was described as "irreproducibility." Students also recognized that narratives of simulated patients and inpatients were mainly limited to a medical-lived content with an objective structure. These differences in narrative characteristics were recognized through students' previous interactions with simulated patients and inpatients.

CONCLUSIONS

Despite some limitations, medical students learn about patients' narratives in our original educational program in a way that would be difficult to achieve through training using simulated patients or inpatients.

Students with an autonomous role in hospital care - patients perceptions

BACKGROUND

There have been calls to enhance clinical education by strengthening supported active participation (SAP) of medical students in patient care. This study examines perceived quality of care when final-year medical students are integrated in hospital ward teams with an autonomous relationship toward their patients.

METHODS

We established three clinical education wards (CEWs) where final-year medical students were acting as "physician under supervision". A questionnaire-based mixed-method study of discharged patients was completed in 2009-15 using the Picker Inpatient Questionnaire complemented by specific questions on the impact of SAP. Results were compared with matched pairs of the same clinical specialty from the same hospital (CG1) and from nationwide hospitals (CG2). Patients free-text feedback about their hospital stay was qualitatively evaluated.

RESULTS

Of 1136 patients surveyed, 528 (46.2%) returned the questionnaire. The CEWs were highly recommended, with good overall quality of care and patient-physician/student-interaction, all being significantly (p < 0.001) higher for the CEW group while experienced medical treatment success was similar. Patient-centeredness of students was appreciated by patients as a support to a deeper understanding of their condition and treatment.

CONCLUSION

Our study indicates that SAP of final-year medical students is appreciated by patients with high overall quality of care and patient-centeredness.

Audiology Students' Perspectives of Enacting and Learning Clinical Communication: A Qualitative Interview and Video Reflexivity Study

PURPOSE

Effective clinical communication is pivotal to the provision of quality hearing health care. To date, audiology students reportedly felt ill-prepared when counseling patients about their hearing impairment, yet there is a paucity of studies exploring how clinical communication is taught and learned in audiology programs. Thus, the aims of the study were (a) to explore final year audiology students' perspectives of their own clinical communication skills during an in-house university clinical placement and (b) to explore students' perceptions of their clinical communication education.

METHOD

Using a qualitative description approach, students were asked to coview their filmed clinical encounter using video reflexivity during a semistructured interview on clinical communication education. Fifteen final year graduate audiology students from The University of Melbourne, Australia, participated in the study. The interviews were audio-recorded and analyzed thematically.

RESULTS

The overarching themes of striving to be patient-centered, assessment shapes behavior, and power relations emerged from students' reflection of their own clinical encounter. In addition, the theme what students want described the perceived teaching methods that assisted students' clinical communication practices.

CONCLUSIONS

The findings of this study highlight the challenges that students perceived during their clinical placement as they strive to enact a patient-centered interaction. An assessment rubric that incorporates communication skills can provide greater opportunities for feedback and self-reflection. Additionally, clinical communication education that adopts experiential learning and is longitudinally integrated into the curriculum can further reinforce students' communication learning needs.

Medical Trainees' Experiences of Treating People With Chronic Pain: A Lost Opportunity for Medical Education

PURPOSE

Evidence suggests that physicians' opinions about patients with chronic pain become progressively negative over the course of medical training, leading to decline in empathy for these patients. Few qualitative studies have focused on this issue, and thus the experiences shaping this process remain unexplored. This study addressed how medical trainees learn about chronic pain management through informal and formal curricula.

METHOD

This study adopted a constructive qualitative approach informed by the theoretical lens of the hidden curriculum. Thirteen open-ended interviews were conducted with medical students and residents at various training stages; interviewees had experience treating patients with chronic pain, shadowing the care of these patients, or both. Interviews elicited information about stage of medical training, general descriptions of work, and concrete experiences of managing patients with chronic pain. All interviews were collected in Toronto between June and August 2015.

RESULTS

Most interviewees described the management of chronic pain as challenging and unrewarding and attributed this at least in part to their perception that pain was subjective. Trainees also recounted that their inability to cure chronic pain left them confused about how to provide care, and voiced a perception that preceptors seemed to view these patients as having little educational value.

CONCLUSIONS

Specifically because chronic pain is subjective and incurable, listening and communication become crucial for patient care. Instead of sheltering trainees, medical educators should be offered the opportunity to reflect on the skills that are required to provide patient-centered care for this population. This approach has the potential to greatly benefit both trainees and patients.

Changes in patient-centered attitude and confidence in communicating with patients: a longitudinal study of resident physicians

BACKGROUND

Patient-centered care has been one of the most frequently discussed principles in medical practice. However, there is a serious concern that the patient-centered attitudes of physicians diminish over the course of their medical education. This longitudinal study examined changes in resident physicians' patient-centered attitudes and their confidence in communicating with patients, and explored the relationship between the two traits.

METHODS

The study participants were resident physicians at a university hospital in Tokyo. Participants' patient-centered attitudes (as measured by the Patient-Practitioner Orientation Scale [PPOS]), and their confidence in communicating with patients (as per the Physician Confidence in the Medical Interview scale: [PCMI]) were assessed through self-reported questionnaires completed at the beginning of residency (n = 204) and again at the end of the first year (n = 95).

RESULTS

PPOS scores declined significantly during the year, both in terms of attitude toward sharing information and decision-making with patients, and attitude of caring for patients' expectations and emotions. The shift in caring attitude differed significantly by gender. The increase in PCMI score was greater for those with a smaller decrease in PPOS score.

CONCLUSIONS

As seen in previous studies of medical students, resident physicians' patient-centered attitudes declined during their first year of residency, while there may be a gender-based difference within the shift. The increase in physicians' confidence in communicating with patients was greater for those who showed a smaller decline in patient-centered attitude. Additional studies are needed to detail the changes in physicians' attitudes, confidence, and communication skills over the course of their medical training, and to develop systematic assessment and training programs.

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.

Dental students' self-perceived communication skills for patient motivation

AIMS

The aim of this study was to evaluate dental students' self-perceived communication skills for patient motivation over the course of their training.

MATERIALS AND METHODS

Pre-clinical and clinical dental students at the University of Bern School of Dental Medicine were surveyed annually from 2008 to 2011 utilising a written questionnaire. Self-reported data were pooled from all classes per time-point in the curriculum.

RESULTS

A total of 157 students were surveyed from five classes with an overall response rate of 94.8%. A total of 393 questionnaires were available for analysis. The self-perceived skill-sets for general patient care and patient communication were rated at the end of the first clinical year with mean Visual Analog Scale values of 75.0 ± 1.6 and 75.1 ± 1.5, respectively. During the second clinical year, the self-perceived skills increased in both patient care (82.5 ± 1.2, P = 0.0004) and patient communication (81.4 ± 1.4, P = 0.0034). The students rated their competence higher when providing oral hygiene instructions as opposed to motivating patients to quit tobacco use, modify their diet or employ stress-reduction strategies (P < 0.005). At the end of the pre-clinical year, 74.5% of the students expressed interest in receiving more extensive communication training (P < 0.004).

CONCLUSIONS

Though dental students in this study demonstrated a steady increase in their level of comfort motivating patients to utilise oral hygiene instructions, they also expressed the desire for more motivational training early in their curriculum. Therefore, these results may indicate the need to enhance communications training in patient motivation on all behavioural aspects early in the dental curriculum.

Preparedness for practice: the perceptions of graduates of a regional clinical school

OBJECTIVE

To assess graduates' self-reported preparedness with reference to a range of clinical practice capabilities, including those related to patient-centred care.

DESIGN

A retrospective survey of self-reported preparedness for practice, based on a survey developed by the Peninsula Medical School (United Kingdom) and adapted to account for Australian circumstances and to provide more information about patient-centred care-related capabilities.

SETTING AND PARTICIPANTS

Launceston Clinical School, a regional clinical school for undergraduate medical students. Medical students who had graduated during 2005-2014 and were contactable by email were invited to participate in the study.

MAIN OUTCOME MEASURES

Graduates' self-reported preparedness for practice in 44 practice areas, measured on a 5-point Likert scale.

RESULTS

Responses from 135 graduates (50% of invited graduates, 38% of the eligible graduate population) were received. Most graduates felt prepared in 41 of the 44 practice areas; 80% felt at least well prepared in 17 areas. After clustering the 44 areas into six thematic groups, no differences were found between men and women who had graduated in the past 4 years. As male graduates become more experienced (5-10 years after graduation), retrospective perceptions of preparedness in some areas differed from those of more recent graduates; this was not found for female graduates.

CONCLUSION

The survey identified strengths and weaknesses in the preparation of doctors for practice. It could be more broadly applied in Australia to obtain longitudinal data for assessing the quality of learning for curriculum planning purposes, and for aligning graduates' needs and expectations with those of the medical training and health care employment sectors.

Medical students' perceptions of the patient-centredness of the learning environment

BACKGROUND

Patient-centred care is an important aspect of quality health care. The learning environment may impact medical students' adoption of patient-centred behaviours.

METHODS

All medical students at a single institution received an anonymous, modified version of the Communication, Curriculum, and Culture instrument that measures patient-centredness in the training environment along three domains: role modelling, students' experience, and support for patient-centred behaviours. We compared domain scores and individual items by class year and gender, and qualitatively analyzed responses to two additional items that asked students to describe experiences that demonstrated varying degrees of patient-centredness.

RESULTS

Year 1 and 2 students reported greater patient-centredness than year 3 and 4 students in each domain: role modelling (p = 0.03), students' experience (p = <0.001), and support for patient-centred behaviours (p < 0.001). Female students reported less support for patient-centred behaviours compared with male students (p = 0.03). Qualitative analysis revealed that explicit patient-centred curricula and positive role modelling fostered patient-centredness. Themes relating to low degrees of patient-centredness included negative role modelling and students being discouraged from being patient-centred.

CONCLUSIONS

Students' perceptions of the patient-centredness of the learning environment decreased as students progressed through medical school, despite increasing exposure to patients. Qualitative analysis found that explicit patient-centred curricula cultivated patient-centred attitudes. Role modelling impacted student perceptions of patient-centredness within the learning environment.

Dissemination and Implementation of Shared Decision Making Into Clinical Practice: A Research Agenda

Shared decision making (SDM) is essential to advancing patient-centered care in emergency medicine. Despite many documented benefits of SDM, prior research has demonstrated persistently low levels of patient engagement by clinicians across many disciplines, including emergency medicine. An effective dissemination and implementation (D&I) framework could be used to alter the process of delivering care and to facilitate SDM in routine clinical emergency medicine practice. Here we outline a research and policy agenda to support the D&I strategy needed to integrate SDM into emergency care.

The Role of Education in the Implementation of Shared Decision Making in Emergency Medicine: A Research Agenda

Shared decision making (SDM) is a patient-centered communication skill that is essential for all physicians to provide quality care. Like any competency or procedural skill, it can and should be introduced to medical students during their clerkships (undergraduate medical education), taught and assessed during residency training (graduate medical education), and have documentation of maintenance throughout an emergency physician's career (denoted as continuing medical education). A subgroup representing academic emergency medicine (EM) faculty, residents, content experts, and patients convened at the 2016 Academic Emergency Medicine Consensus Conference on SDM to develop a research agenda toward improving implementation of SDM through sustainable education efforts. After developing a list of potential priorities, the subgroup presented the priorities in turn to the consensus group, to the EM program directors (CORD-EM), and finally at the conference itself. The two highest-priority questions were related to determining or developing EM-applicable available tools and on-shift interventions for SDM and working to determine the proportion of the broader SDM curriculum that should be taught and assessed at each level of training. Educating patients and the community about SDM was also raised as an important concept for consideration. The remaining research priorities were divided into high-, moderate-, and lower-priority groups. Moreover, there was consensus that the overall approach to SDM should be consistent with the high-quality educational design utilized for other pertinent topics in EM.

Reflective practice and its role in facilitating creative responses to dilemmas within clinical communication - a qualitative analysis

BACKGROUND

Good communication is a major factor in delivering high quality in care. Research indicates that current communication skills training alone might not sufficiently enable students to find context-specific creative solutions to individual complex personal and interpersonal challenges in the clinical context. This study explores medical students' experiences with real communication dilemmas in a facilitated group setting. The aims were to gain a better understanding of whether and, if so, how reflective practice can enhance students' ability to find creative individual solutions in difficult communication situations and to identify factors within the reflective setting that foster their creative competency.

METHODS

Thematic content analysis was used to perform a secondary analysis of semi-structured interview data from a qualitative evaluation of a group reflective practice training for final-year medical students. The categories that arose from the iterative deductive-inductive approach were analyzed in light of current scientific understandings of creativity.

RESULTS

Reflection on real difficult clinical communication situations appears to increase medical students' ability to handle such situations creatively. Although group reflection on clinical dilemmas involving personal aspects can stir up emotions, participating students stated they had learned a cognitive process tool that enhanced their communicative competence in clinical practice. They also described changes in personal attitudes: they felt more able to persevere and to tolerate ambiguity, described themselves more open and self-efficient in such complex clinical communication situations and thus more motivated. Furthermore, they reported on factors that were essential in this process, such as reflection on current and real challenges, a group format with a trainer.

CONCLUSIONS

Reflective practice providing a cognitive process tool and using real clinical challenges and trainer support in communication education may provide learners with the skills and attitudes to develop creativity in practice. Implementing reflection training in clinical communication education may increase students' overall communicative competency.

Longitudinal assessment of medical student attitudes toward older people

Delivering adequate care to older people requires an increasing number of physicians competent in the treatment of this expanding subpopulation. Attitudes toward older adults are important as predictors of the quality of care of older people and of medical trainee likelihood to enter the geriatrics field. This study assessed the attitudes of 404 US medical students (MS) from the start of medical school to graduation using the University of California, Los Angeles (UCLA) Geriatrics Attitude Scale. It is the first study to utilize a longitudinal design to assess attitudes among students in a medical school with a longitudinal geriatrics clinical experience in the first two years and a required geriatrics clerkship in the third year. Participants' attitude scores toward older people were found to significantly decrease from 3.9 during the first two years to 3.7 during the final two. Significant differences existed between MS1 and MS3, MS1 and MS4, MS2 and MS3, and MS2 and MS4. Women and older students held significantly more positive attitudes than men and younger students. These results show that planned clinical exposures to older adults may not be sufficient to halt the decline in attitudes in medical school. A comprehensive empathy-building intervention embedded in the curriculum may better prevent this decline.

Dealing with emotions: medical undergraduates' preferences in sharing their experiences

CONTEXT

Patient care evokes emotional responses such as uncertainty, grief and pride in medical students. There is a need for opportunities to share and express such emotions because they influence students' professional development and well-being. There is a trend towards introducing mentor programmes into medical curricula. It remains unknown whether students are willing and able to share their emotional experiences within this formal setting. We set out to explore how medical students share their emotional experiences and why.

METHODS

We used thematic analysis, including purposeful sampling, parallel processes of data collection and constant comparative analysis, maintaining an audit trail for validation purposes. The study had a constructivist, interactional design and used Goffman's dramaturgical theory as an interpretive framework. Nineteen students participated in individual, semi-structured interviews.

RESULTS

Participants' narratives revealed a preference for sharing emotional experiences away from people who might expect them to uphold formal behaviour. They deliberately decided with whom to share their emotional experiences. Participants had a preference to talk to fellow students working in the same department, or family and friends outside medical school.

CONCLUSIONS

Participants found it difficult to uphold behaviours that they thought patients, preceptors or the organisation expected of them as future doctors. In adjusting their behaviour to meet those expectations, they became attuned to how to best present themselves based on the people present. This influenced how they chose which emotional experiences to share with whom.

Medical students developing confidence and patient centredness in diverse clinical settings: a longitudinal survey study

BACKGROUND

Medical student clinical confidence and positive attitudes to patient centredness are important outcomes of medical education. The clinical placement setting is regarded as a critical support to these outcomes, so understanding how the setting is influential is important. The aim of this study was to compare students' attitudes towards patient-centredness and clinical confidence as they progressed through their medical course, and understand the influence of diverse clinical placement zones.

METHODS

Students at one Australian medical school completed a questionnaire at the beginning of second year and at the end of their third year of medical training. The questionnaire measured attitudes to patient centred care, clinical confidence, role modelling experiences and clinical learning experiences. Descriptive analyses investigated change in these attitudes over time. Repeated measures analysis of variance was used to assess the influence of placement location on each variable of interest. Responses to two open-ended questions were also coded by two researchers and themes were identified.

RESULTS

Student confidence increased over the course of two years of clinical training (p < 0.001), but attitudes to patient centredness (p = 0.933) did not change. The location of clinical placements (urban, outer urban and rural) was unrelated to levels of confidence or patient centredness. Students had positive attitudes towards patient-centredness throughout, and noted its importance in contributing to quality care. Patient-centred care was encouraged within the clinical placements, and was influenced by positive and negative role modelling, direct teaching, and opportunities to practise patient-centred care.

CONCLUSIONS

A new generation of doctors with a strong patient-centred focus is emerging. Medical schools have a responsibility to facilitate clinical placements that will support the acquisition and maintenance of skills in patient centred care through positive role modelling.

Decline in medical students' attitudes to interprofessional learning and patient-centredness

CONTEXT

Interprofessional learning (IPL) is valuable in preparing health care students to work collaboratively in teams, with patients' needs at the core. Patient-centredness is the impetus for communication and collaboration in health care. Debate continues on when it is best to develop positive student attitudes towards these aspects of care. Should IPL commence early before attitudes to patients, professional stereotypes and identity are formed, or later for advanced learners with greater experience of their roles and responsibility in health care? This study explores graduate-entry medical students' attitudes to IPL and patient-centred care, on programme entry and after an early interdisciplinary clinical experience (ICE).

METHODS

An extended version of the Readiness for Interprofessional Learning Scale (RIPLS) was administered to four cohorts of medical students (n = 279) on entry and after the 3-week placement. This 26-item RIPLS comprised four subscales: team work and collaboration; professional identity; roles and responsibilities; and patient-centredness. The impact of the placement on students' attitudes was assessed by using repeated measures analysis of variance to compare pre- and post-ICE subscale scores.

RESULTS

There were significant main effects of time (pre- versus post-ICE) for the subscales of teamwork and collaboration, professional identity and patient-centredness, but not for roles and responsibilities. Scores for teamwork and collaboration, professional identity and patient-centredness were all lower post-ICE.

CONCLUSIONS

The students' less positive attitudes to teamwork and collaboration and professional identity may be due to the experience itself, or because it reinforced negative beliefs about the value of learning from non-medical health professionals. Perhaps the students' idealised view of their future role as a doctor was challenged by the experience, or they had an underdeveloped professional identity. Limited student experience of patients having an active role in their own health care may explain the decrease in attitudes to patient-centredness. A longitudinal qualitative study will explore these results.