Medical students' perceptions of their learning about the doctor-patient relationship: a qualitative study

Exploring challenges and perceptions in the learning environment: an online qualitative study of medical students

BACKGROUND

The teaching and learning environment (TLE) in medical schools is critical for shaping the outcomes and competencies of graduates. Research on TLE has highlighted its influence on student learning approaches and outcomes, yet gaps remain, particularly in qualitative insights, especially in Saudi Arabian contexts. This study aims to explore the students' experiences and perceptions of the TLE in a new medical college.

METHODS

This qualitative study consisted of a total of five focus group discussions (3consequtive sessions for male group and two for female group) conducted virtually using the Zoom videoconferencing application. All the discussion sessions took place during a lockdown because of the COVID-19 pandemic between December 2020 and February 2021. Each session lasted for 45-60 min. Each group was formed of 4-5 students from different academic levels in the Majmaah medical school, which was established 10 years ago and is located in a small city. After "verbatim transcription" of the sessions was made, a framework thematic analysis of the data was performed using the NVivo software.

RESULTS

The study results revealed that various elements, such as educational content, faculty roles, and personal factors, collectively influenced the students' educational experiences. The students valued educational relevance and autonomous decision-making. The multifunctional role of faculty as mentors, evaluators, and resource providers was considered essential in enhancing academic experiences. Additionally, there was an evident need to improve the physical learning environment and facilities to adapt to emerging educational needs. These results align with existing literature, emphasizing the integration of theory and practice and the significant impact of faculty roles in academic experiences.

CONCLUSION

The findings suggest that medical colleges should involve students more in decision-making related to their education and ensure the practical relevance of the educational content. Establishing open communication channels between students and faculty who act as mentors and evaluators is also essential. Furthermore, enhancing supportive infrastructures, such as mental health and financial services, and promoting extracurricular activities are crucial for fostering a more effective and nurturing learning environment.

Narrative medicine in clinical internship teaching practice

Objective: To explore the effect on empathy skills of integrating narrative medicine instruction into clinical internship undergraduate medical education.Methods: One hundred clinical undergraduate students who were transferred to gynecology and obstetrics in 2016 were selected as subjects and divided into two groups. The control group adopted the traditional practice teaching mode, while the experimental group adopted a narrative medicine integrated with traditional teaching mode. The impact of the narrative medicine course was evaluated using the Davis Empathy Scale, and the students' acceptance of the course was investigated using a self-developed questionnaire.Results: After completion of the rotation, the empathy scores of the experimental group were higher than those of the control group (p < 0.05). Students in the experimental group rated the integration of narrative medicine into the internship class highly, and most students thought that the narrative medicine course was of great benefit with respect to the humanistic quality of medical teaching.Conclusion: The application of narrative medicine teaching in the clinical practice teaching of obstetrics and gynecology promoted students to improve their empathy ability.

Beyond empathy decline: Do the barriers to compassion change across medical training?

BACKGROUND

Despite being a mandated, foundational value in healthcare, research on compassion remains limited. Studying the individual, patient, clinical, and contextual factors that interfere with compassion-the "barriers"-may clarify our understanding of the origins of compassion and identify potential targets for improving patient-centred care. Studies of the related construct of empathy have suggested that medical students report declines with increasing clinical experience. In contrast, when comparing physicians with medical students, increased clinical experience predicts lower barriers to compassion. Whether-and how-a similar experience-related decline in the factors that interfere with compassion occurs across medical training remains unknown.

AIMS

To describe how the barriers to compassion vary across clinical training in medical students.

METHOD

New Zealand medical students (N = 351) in their clinical years (Years 4-6) completed measures of the Barriers to Physician Compassion (BPCQ) and potential covariates such as demographics, work burden factors, and dispositional factors. The BPCQ indexes the extent to which barriers in four domains (individual, patient, clinical, and contextual) interfere with a physician/student's compassion towards patients. Analyses of variance and regression analyses were used to explore the effect of year level on the four types of barriers.

RESULTS

Year 4 students reported slightly lower student-related, environmental and patient/family-related (but not clinical) barriers than Year 6 students (effect size: ɷ2 < 0.05); all barriers increased comparably across training. Controlling for relevant confounds, regression analyses confirmed that lower year level predicted lower barriers to compassion. Higher self-compassion, but not gender, predicted lower barriers.

CONCLUSIONS

In extending studies of empathy decline, this report suggests that students experience higher barriers to compassion as clinical training progresses. This is in contrast to existing studies contrasting physicians with medical students, where greater experience was associated with lower perceived barriers to compassion. Self-compassion may offset increases in barriers to care.

Medical Students' Perspectives on the Factors Affecting Empathy Development During Their Undergraduate Training

INTRODUCTION

This study investigated the perspectives of medical students on the factors influencing empathy development during their undergraduate training.

METHODOLOGY

A descriptive phenomenological approach was used to generate illustrations of empathy development and decline that had educational significance and applicability. Individual online semi-structured interviews were conducted to elicit experiential details from twelve final-year medical students. The interview recordings were transcribed verbatim, and data were analysed employing Braun and Clarke's thematic analysis method.

RESULTS

The self-reported empathic behavior of medical students seemed to have improved with time in medical school. Students attributed their empathy development to real patient encounters, positive role-modelling by teachers, and attainment of confidence and personal maturity. They identified exams, academic overload, time constraints, personal stresses, negative role models, unconducive learning environments, and lack of formal empathy training as barriers to empathy development.

CONCLUSION

Medical institutes should identify and address the barriers to empathy development and encourage the holistic development of medical students. Furthermore, medical educators should model their behavior accurately for their increasing roles and responsibilities and support the students in their empathic expressions with patients.

One-month long foundation course for newly joined Indian medical undergraduates: Faculty and students' perspective

Background

A one-month long foundation course has been introduced at the entry-level for first-year MBBS (Bachelor of Medicine and Bachelor of Surgery) students in the medical institutions across India from 2019. Therefore, the present study is aimed at describing the experience of implementing a one-month long foundation course conducted for the Competency-based Undergraduate Medical Curriculum (CBUC) of Indian Medical Graduate as per the guidelines from the National Medical Commission (NMC) (erstwhile Medical Council of India, MCI). We have evaluated the student and faculty perceptions towards the effectiveness of the program.

Methods

The foundation course had six modules Orientation, Skills, Field visit to Community Health Centre, Professional Development including Ethics, Sports and Extracurricular activities, Computer Skills, and Language enhancement program. Regular feedback wascollected from students (N = 250) and teachers (N = 26) involved in the Foundation course using a semi-structured questionnaire. The program's overall feedback was also obtained at the end of the course, using a validated questionnaire. The quantitative findings were expressed in frequency and percentage. The qualitative observations (reflections of students and faculty) were subjected to thematic.

Results

The students and faculty appreciated the one-month long foundation course. The course's defined objectives were met as indicated by most students (98.4%) and faculty (75%). The course seemed to be useful for students to embark on a formal MBBS curriculum. It also exposed them to new knowledge and practices, as indicated by the feedback. Thematic analysis of the students' and faculty's reflections was carried out and two themes were identified, i.e., 'strengths' and 'challenges.' The Foundation Course Committee will work out appropriate remedial measures to overcome the challenges in the future sessions for subsequent batches.

Conclusions

The one-month-long foundation course was found to be beneficial for newly joined students to get introduced and adjusted to higher education systems' demands. Also, the challenges faced during the program needs to be addressed with suitable remedial measures while implementing for subsequent batches. This effort will ensure a smooth conduct of the foundation course for the future batches of medical undergraduates and make the program more effective.

Medical Students' Perspectives on Empathy: A Systematic Review and Metasynthesis

PURPOSE

Some evidence indicates that physician empathy declines during medical training, which has made it the subject of much research. Qualitative studies are relevant in this context, focusing as they do on how students themselves conceive and understand empathy during medical school. The aim of this study was to explore medical students' perspectives on empathy by conducting a metasynthesis, including a systematic review of the literature and analysis of included studies.

METHOD

The authors systematically searched 4 databases through June 17, 2019, for qualitative studies reporting medical students' perspectives on empathy in medical school. They assessed article quality using the Critical Appraisal Skills Program, and they applied thematic analysis to identify key themes and synthesize them.

RESULTS

The authors included 35 articles from 18 countries in their analysis. Four main themes emerged: (1) Defining empathy, with a lack of understanding of the concept; (2) Teaching empathy, with a focus on the hidden curriculum and clinical supervisors; (3) Willingness to be an empathetic doctor, with ambivalence expressed by some study participants; and (4) Evolution of empathy during medical school, specifically its decline.

CONCLUSIONS

Medical students are beset by theoretical confusion regarding the concept of empathy, and they express doubts about its utility and relevance. Instruction should focus on simpler concepts such as listening, and schools should leverage clinical supervisors' strong influence on students' empathy. Prioritizing certain types of knowledge (clinical facts) during medical education has a globally negative effect on medical students' empathy.

A Tomada de decisão em prevenção quaternária

Introdução: O processo de tomada de decisões na prática clínica pode ser analisado sobre diversos aspectos, que confluem em um caminho que tramita entre o conhecimento teórico e a sua aplicação na prática. Nas situações que envolvem bioética, as questões que envolvem as tomadas de decisão são ainda mais complexas, considerando que são momentos que tangenciam a subjetividade dos atores envolvidos. Objetivo: Verificar as tendências de justificativa bioética durante as tomadas de decisão que envolvem situações clínicas de prevenção quaternária entre residentes e preceptores de medicina de família e comunidade. Métodos: Qualitativo, utilizando como instrumento entrevistas projetivas individuais, com vinhetas clínicas fictícias como gatilho das perguntas norteadoras da entrevista. Após a transcrição das mesmas, foi realizado a técnica de análise temática do material. Resultados: Os participantes tiveram uma tendência em justificar suas escolhas de tomada de decisão através de três grandes blocos temáticos, que se relacionam entre si. O primeiro bloco foi a justificativa das tomadas de decisão pelos conhecimentos científicos, o segundo bloco foi baseado nos princípios biomédicos principialistas e o terceiro bloco foi um conteúdo relacionado a relação médico paciente. Conclusões: Pela discussão destes resultados foi possível verificar que existe uma trama entre objetividade clínica e subjetividade pessoal, que não demonstram ser concorrentes, mas sim simbióticas, para alcançar o fim único que é a beneficência do usuário.

Relationships and boundaries: Learning needs and preferences in clerkship medical environments

PURPOSE

Relationship boundaries recognition is an essential element of medical practice. The aim of the study was to assess final year medical students' perceived need for education regarding professional boundaries.

MATERIALS AND METHODS

This was a cross-sectional study. An anonymous paper questionnaire was distributed to 128 final year medical students. Standard descriptive statistics, unpaired t-test to evaluate differences between male and female groups and Pearson correlation to determine relationships between variables were used.

RESULTS

The survey was completed by 84.4% of students who identified the need for more emphasis in the curriculum for all of topics during training and practice pertaining to boundaries and relationships (mean 6.61±1.32 on a scale of 0 to 9; and 6.66±1.27 respectively). Topics with a high interest ranking requiring additional attention were mistreatment of medical students (mean 7.22±1.96), coping with mistakes in clinical care (mean 7.25±1.63), reporting of medical mistakes (mean 7.58±1.36), and gender bias in clinical care (mean 7.10±1.82). Women perceived a greater need for attention to all topics in the curriculum. Significant differences between the perceptions of female and male students were observed regarding topics such as responding to an impaired colleague (p<0.001), and a physician's social responsibilities (p = 0.001).

CONCLUSION

Medical students recognized the need for more education and training in the undergraduate medical ethics curriculum regarding patient-physician relationship boundaries.

Depression and Abuse During Medical Internships in Peruvian Hospitals

OBJECTIVE

To estimate the prevalence of depression and abuse and identify the associated factors in medical interns in Peruvian hospitals.

METHODS

We conducted a multicentre, cross-sectional and analytical study during the months of March to May 2016. We included medical interns from 18 Peruvian hospitals, in Lima and provinces. We used a survey that included sociodemographic data and a scale to measure the perception of abuse (psychological, physical and sexual). In addition, we used the Spanish version of the PHQ-9 to evaluate depression. We used Poisson regression with robust variances to calculate prevalence ratios (PRs).

RESULTS

A total of 402 medical interns participated in the study, the median age was 25 [IQR: 21-33], and 52.7% were male. Moreover, 25.4% of them suffered from depression. In the adjusted model, the variables associated with depression were age (PRa=1.15), the number of hours they sleep per day (PRa=1.23), being a woman (PRa=3.33), performing the internship in a province (PRa=0.25), studying at a public university (PRa=0.64), living with parents (PRa=0.65) or alone (PRa=0.33), and having perceived some type of abuse (PRa=1.07).

CONCLUSIONS

A quarter of surveyed medical interns had depression. Early screening is necessary to identify perceived abuse and other triggering depression factors that may adversely affect work performance and overall mental health during medical internships.

Barriers to teaching communication skills in Spanish medical schools: a qualitative study with academic leaders

BACKGROUND

In recent years, Spanish medical schools (MSs) have incorporated training in communication skills (CS), but how this training is being carried out has not yet been evaluated.

OBJECTIVE

To identify the barriers to the introduction and development of CS teaching in Spanish MSs.

METHODS

In a previous study, 34 MSs (83% of all MSs in Spain) were invited to participate in a study that explored the factual aspects of teaching CS in these schools. The person responsible for teaching CS at each school was contacted again for this study and asked to respond to a single open-ended question. Two researchers independently conducted a thematic analysis of the responses.

RESULTS

We received responses from 30 MSs (85.7% of those contacted and 73% of all MSs in Spain). Five main thematic areas were identified, each with different sub-areas: negative attitudes of teachers and academic leaders; organisation, structure and presence of CS training in the curriculum; negative attitudes of students; a lack of trained teachers; and problems linked to teaching methods and necessary educational logistics.

CONCLUSIONS

The identified barriers and problems indicate that there are areas for improvement in teaching CS in most Spanish MSs. There seems to be a vicious circle based on the dynamic relationship and interdependence of all these problems that should be faced with different strategies and that requires a significant cultural shift as well as decisive institutional support at the local and national levels. The incorporation of CS training into MS curricula represents a major challenge that must be addressed for students to learn CS more effectively and avoid negative attitudes towards learning CS.

Influence of DISC behavioral profile on the short- and long-term outcomes of home-based pulmonary rehabilitation in patients with chronic obstructive pulmonary disease

INTRODUCTION

Pulmonary rehabilitation (PR) programs are commonly prescribed for patients with severe respiratory disorders, but little is known about how the patient's personality traits influence PR outcomes. We analyzed the response of patients with chronic obstructive pulmonary disease (COPD) to a home-based PR program according to their predominant behavioral profiles using the Dominance - Influence - Steadiness - Conscientiousness (DISC) tool.

METHODS

This was a retrospective observational study of 335 COPD patients referred by their pulmonologists between January 2010 and December 2015. The DISC behavioral profile was determined at the beginning of the program. Patients received individual supervised sessions at home once a week for 8 weeks, which consisted of exercise training and psychosocial, motivational, and educational support, all tailored to the participant's DISC profile. Exercise tolerance (6-minute stepper test, 6MST), anxiety and depression (Hospital anxiety and depression scale, HADS), and quality of life (Visual simplified respiratory questionnaire, VSRQ) were evaluated immediately before and after the PR program (T0 and T2, respectively) and then 6 and 12 months later (T8 and T14, respectively). Responders were defined as patients who exhibited at least minimal clinically important differences (improvements) from baseline.

RESULTS

Of the 335 COPD patients, 102 (30.4%), 98 (29.3%), 82 (24.5%), and 53 (15.8%) were classified as having predominant D, I, S, and C behavioral traits, respectively. All four patient groups showed significantly (P<0.01) improved performance in the 6MST, HADS, and VSRQ evaluations at T2 (n=300), T8 (n=262), and T14 (n=231) compared with T0, and the proportion of responders in all groups at T8 and T14 was high (∼60%). The percentage of responders differed significantly between groups only at T2, when the S group contained fewer responders on the HADS anxiety subscale. Most patients who did not complete the study were classified as D type (42/102, 41.2%), followed by I (28/98, 28.6%), S (22/82, 26.8%), and C (12/53, 22.6%) types.

CONCLUSION

The personality profile of COPD patients influenced their adherence to, but not their benefit from, a home-based PR program. The high proportion of patients in all personality groups showing significant improvements in outcomes supports a personalized approach to the design of PR programs.

Perception Versus Reality: The Use of Teach Back by Medical Residents

Background:

Health care providers (HCPs) may ask patients if they understand their diagnosis or instructions during clinic visits; patients often simply say yes. However, many patients leave with little idea of their medication and discharge instructions. Teach Back (TB) is a patient-centered health-literate technique that allows HCPs to confirm patient understanding during clinic visits.

Objective:

The purpose of this pilot study was to determine a relationship between perception and actual use of TB by medical residents in primary care outpatient clinics (providers, N = 16; clinic visits, N = 80) and, if the observed rate of TB was discordant with perception, did a TB skills training intervention have any impact on use of TB (clinic visit, N = 78). We were also interested in language used during TB and if use of TB was related to patient demographics or health literacy level.

Methods:

Medical residents' perception was measured using the “Always Use Teach-Back Confidence and Conviction Scale” (N = 16). Clinic visits were audiotaped and scored for use of TB (pre-intervention, N = 80; post-intervention, N =78). The intervention was a 1-hour TB skills training course. Content analysis was performed to understand the use of TB language.

Key Results:

Despite the high level of confidence/conviction about TB (r[16] = .669, p <. 05) TB was only used twice out of 80 visits during pre-intervention clinic visits. During post-intervention, use of TB increased to 41 times by 10 residents (c2[1, N = 16] = 6.533, p <. 05). TB language after the intervention was more collaborative; there was a relationship between gender and use of TB.

Conclusion:

Results from our pilot study identified three important observations that may be critical to improving health-literate physician communication: residents believe they are using TB in the clinic for many patients; use of TB was discordantly low at 2.5%; and a single 1-hour skills training intervention dramatically increased TB use to 53%. Residents used patient-centered TB language after the training intervention. [HLRP: Health Literacy Research and Practice. 2019;3(2):e117–e126.]

Plain Language Summary:

Medical residents believe they are using Teach Back to confirm patient understanding in the clinic 60% of the time when they actually used Teach Back only 2.5% of the time. After an educational intervention, they used Teach Back 53% of the time; Teach-Back language was collaborative and patient-centered, and all but two patients confirmed their medication and discharge plan.

Medical students' perceptions towards learning communication skills: a qualitative study following the 2-year training programme

OBJECTIVES

This study aimed to gain an understanding of the perceptions of 4th-year medical students about a training course in communication skills with 'experiential learning' characteristics, completed over the past two years.

METHODS

Twenty 4th-year medical students were invited to participate in a qualitative study with focus groups. These students were selected randomly, stratifying by gender, from all 4th-year medical students (106) at the Francisco de Vitoria University (Madrid). The students had just completed their communication skills training taught in small groups, with simulated patient interviews and feedback. The focus-group facilitator used an open-ended discussion guide to explore the students' perceptions. Thematic analysis was used to identify salient themes from these discussions.

RESULTS

Sixteen students participated in two focus groups. The discussions revealed two contrasting perceptions: while this learning is considered useful, it nevertheless brings about a great deal of stress, especially regarding student exposure to peers in small-group sessions when interviewing standardised patients, and summative assessment. This generates a range of negative feelings in students that could affect perspective and attitude towards the importance of doctor-patient relationships.

CONCLUSIONS

Experiential learning is effective in improving students' communication skills. However, these results suggest that use of such strategies requires a strong focus on "student-centred" teaching approaches, in order to minimise some sensitive topics that may arise during the learning. Further research is needed to refine these strategies depending on the teaching situation and to identify different ways of implementing these experiential methods.

[The DISC tool improves communication and results in pulmonary rehabilitation]

INTRODUCTION

Competence in personal relationships is essential for a caregiver, especially in pulmonary rehabilitation (PR). Considering the behavioral profile of patients might help to optimize their management and the results of PR.

METHODS

We evaluated eight hundred and thirty-two consecutive patients with chronic respiratory disease who received eight weeks of home-based PR. Their exercise tolerance (six-minute stepper test, 6MST), mood (HAD), and quality of life (VSRQ, MRF28) were evaluated at the beginning and end of PR. For six hundred and ninety patients, a behavioral approach was implemented at the beginning of PR by using the DISC tool to identify four behavioral profiles: dominance, influence, steadiness, conscientiousness. The remaining 142 patients served as the control group.

RESULTS

Subjectively, the therapeutic alliance was more easily established with the behavioral approach. Compared with the control group, patients with the "steadiness" profile were younger (60.7±12 years) and mostly female (52.8%), whereas patients with the "conscientiousness" profile were older (67.5±10.6 years) and mostly male (85.5%). The four behaviorally profiled groups showed no differences in exercise tolerance, mood, or quality of life scores at baseline. Globally, all patients improved their exercise tolerance, mood and quality of life. The percentage of responders to 6MST and VSRQ (>MCID) was 7.5% and 5.3% higher with the behavioral approach. For non-responders to 6MST and VSRQ (<MCID), only patients benefiting from the behavioral approach improved the other parameters studied, patients from control group having exhibited no improvement at all.

CONCLUSIONS

The DISC-guided behavioral approach improves the patient-caregiver relationship and achieves better results at the end of PR.

Psychodynamic approaches to teaching medical students about the doctor–patient relationship: randomised controlled trial

Aims and method

To evaluate the effectiveness of two psychodynamic psychotherapy teaching methods, a student psychotherapy scheme (SPS) and participation in a Balint group, in teaching first-year clinical medical students about doctor–patient communication and the doctor–patient relationship. The 28 students, who were randomly allocated to three groups (SPS group, Balint group starting at baseline and Balint group starting at 3 months and acting as partial controls), were rated on a questionnaire testing their knowledge of emotional and psychodynamic aspects of the doctor–patient relationship administered at baseline, at 3 months and at 1 year.

Results

At 3 months, students in the SPS and Balint groups scored higher than the partial control group, the difference approaching significance at the 5% level. At 1 year, participation in either teaching method led to significantly higher scores compared with baseline.

Clinical implications

Psychodynamic psychotherapy teaching methods are effective in increasing students' knowledge of the doctor-patient relationship and potentially also improving their communication skills.

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.

A meta-ethnography of interview-based qualitative research studies on medical students' views and experiences of empathy

BACKGROUND

Quantitative research suggests that medical students' empathy declines during their training. This meta-ethnography asks: What new understanding may be gained by a synthesis of interview-based qualitative research on medical students' views and experiences of empathy? How can such a synthesis be undertaken?

METHODOLOGY

A meta-ethnography synthesizes individual qualitative studies to generate knowledge increasing understanding and informing debate. A literature search yielded eight qualitative studies which met the inclusion criteria. These were analyzed from a phenomenological and interpretative perspective.

RESULTS

The meta-ethnography revealed a conceptual confusion around empathy and a tension in medical education between distancing and connecting with patients. Barriers to empathy included a lack of patient contact and a strong emphasis on the biomedical over the psycho-social aspects of the curriculum. A number of influences discussed in the paper lead students to adopt less overt ways of showing their empathy.

CONCLUSION

These insights deepen our understanding of the apparent decline in empathy in medical students. The lessons from these studies suggest that future curriculum development should include earlier patient contact, more emphasis on psycho-social aspects of care and address the barriers to empathy to ensure that tomorrow's doctors are empathetic as well as competent.

Anatomy adventure: a board game for enhancing understanding of anatomy

Certain negative factors such as fear, loss of concentration and interest in the course, lack of confidence, and undue stress have been associated with the study of anatomy. These are factors most often provoked by the unusually large curriculum, nature of the course, and the psychosocial impact of dissection. As a palliative measure, Anatomy Adventure, a board game on anatomy was designed to reduce some of these pressures, emphasize student centered and collaborative learning styles, and add fun to the process of learning while promoting understanding and retention of the subject. To assess these objectives, 95 out of over 150 medical and dental students who expressed willingness to be part of the study were recruited and divided into a Game group and a Non-game group. A pretest written examination was given to both groups, participants in the Game group were allowed to play the game for ten days, after which a post-test examination was also given. A 20-item questionnaire rated on a three-point scale to access student's perception of the game was given to the game group. The post-test scores of the game group were significantly higher (P < 0.05) than those of the non-game counterparts. Also the post-test score of the game based group was significantly better (P < 0.05) than their pretest. The students in their feedback noted in very high proportions that the game was interesting, highly informative, encouraged team work, improved their attitude, and perception to gross anatomy.

Depression in medical students: cluster symptoms and management

BACKGROUND

Rates of depression among medical students have been shown to be high and related to year of study and other factors. We report on cluster of symptoms related to depression and their association with other difficulties in specific domains.

METHODS

481 (Response rate=79.8%) medical students completed a questionnaire about areas of difficulty in the medical school (studies, leisure, colleagues, professors, and patients), and Beck Depression Inventory (BDI). We studied correlation among areas of difficulty and clusters of BDI along with year in the course.

RESULTS

Two areas which contributed most difficulty were studies and leisure. The significant associations for studies were seen between somatic cluster of depressive symptoms and the level of the course. Difficulties associated with leisure activities and with colleagues were correlated with the affective cluster of symptoms of depression. Activities related to clinical matters especially working with patients in the internship year were associated with somatic clusters. The different associations confirmed that rather than relying on scores emphasis should be placed on clusters of symptoms.

LIMITATIONS

Sample from a single medical school.

CONCLUSIONS

Although the clusters are associated with specific difficulties, it is important that educators and health professionals are aware of streesors the medical students face. The correlations if confirmed in future studies with qualitative factors could guide the development of more specific therapeutic or curriculum interventions.

Teaching professionalism in medical education: a Best Evidence Medical Education (BEME) systematic review. BEME Guide No. 25

INTRODUCTION

We undertook a systematic review to identify the best evidence for how professionalism in medicine should be taught.

METHODS

Eligible studies included any articles published between 1999 and 2009 inclusive. We reviewed papers presenting viewpoints and opinions as well as empirical research. We performed a comparative and thematic synthesis on all papers meeting inclusion criteria in order to capture the best available evidence on how to teach professionalism.

RESULTS

We identified 217 papers on how to teach professionalism. Of these, we determined 43 to be best evidence. Few studies provided comprehensive evaluation or assessment data demonstrating success. As yet, there has not emerged a unifying theoretical or practical model to integrate the teaching of professionalism into the medical curriculum.

DISCUSSION

Evident themes in the literature are that role modelling and personal reflections, ideally guided by faculty, are the important elements in current teaching programmes, and are widely held to be the most effective techniques for developing professionalism. While it is generally held that professionalism should be part of the whole of a medical curriculum, the specifics of sequence, depth, detail, and the nature of how to integrate professionalism with other curriculum elements remain matters of evolving theory.

Medicinal relationships: caring conversation

CONTEXT

Good social relationships are crucial to well-being and to health in particular. The perception of having supportive social relationships has effects on reducing morbidity and mortality comparable with those of a good diet, regular exercise and cessation of moderate smoking. This suggests that supportive, trusting relationships with doctors could have a substantial direct biomedical effect on patients' health.

METHODS

A critical review of the patient-doctor relationship (PDR) literature is presented, along with a review of relevant interactional studies that examine doctor-patient interactions from the perspective of conversation analysis (CA). This literature shows how patients respond to doctors' verbal and non-verbal behaviours in systematic ways that affect how they disclose and how they relate to doctors.

RESULTS

Findings from the CA literature suggest that clinicians might consider several important interactional features to improve the PDR and perhaps also patient health outcomes: (i) the use of open-ended questions (e.g. 'What brought you in today?') and positive polarity items (e.g. 'Is there something else you wanted to talk about today?') elicits patient concerns and addresses unmet concerns more effectively than the use of closed questions and negative polarity items, respectively; (ii) eye gaze suggests availability and an attending recipient, and patients indicate that doctor attentiveness at crucial parts of their problem presentation is important, and (iii) verbal dysfluencies are one practice speakers employ to gain the attention of a non-attending recipient. Doctors may want to pay attention to patients' dysfluencies to better understand when their attention is valued.

CONCLUSIONS

Constructing supportive relationships with patients often does not require a great investment of time, but it does require commitment to 'being there for patients'. This review suggests that when doctors attune to language and social practices during medical consultations, the relationships they develop with patients may substantially improve patients' health and be intrinsically rewarding for both doctors and patients.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

PRACTICAL IMPLICATIONS

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

Mixed messages in learning communication skills? Students comparing role model behaviour in clerkships with formal training

BACKGROUND

Medical students learn professional communication through formal training and in clinical practice. Physicians working in clinical practice have a powerful influence on student learning. However, they may demonstrate communication behaviours not aligning with recommendations in training programs.

AIMS

This study aims to identify more precisely what differences students perceive between role model communication behaviour during clerkships and formal training.

METHOD

In a cross-sectional study, data were collected about physicians' communication performance as perceived by students. Students filled out a questionnaire in four different clerkships in their fourth and fifth year.

RESULTS

Just over half of the students reported communication similar to formal training. This was especially true for students in the later clerkships (paediatrics and primary care). Good examples were seen in providing information corresponding to patients' needs and in shared decision making, although students often noted that in fact the doctor made the decision. Bad examples were observed in exploring cognitions and emotions, and in providing information meeting patient's pace.

CONCLUSIONS

Further study is needed on actual physician behaviour in clinical practice. From our results, we conclude that students need help in reflecting on and learning from the gap in communication patterns they observe in training versus clinical practice.

Third year medical students perceptions towards learning communication skills: implications for medical education

OBJECTIVE

To analyze students' perceptions towards learning communication skills pre-and-post training in a Communication and Clinical Skills Course (CCSC) at a Portuguese Medical School.

METHODS

Content analysis was used to describe and systematically analyze the content written by students (n=215 from a total of 229) in an open-ended survey. In addition, content analysis association rules were used to identify meaning units.

RESULTS

Students' pre-training definitions of communication skills were not specific; their post-training definitions were more precise and elaborated. Students perceived communications skills in Medicine as important (61%), but recommended that teaching methodologies (52%) be restructured. There appeared to be no connection between criticism of teaching skills performance and perceptions of the other aspects of the course.

CONCLUSION

Students' experiences at CCSC are associated with their perceptions of communications skills learning. Content analysis associations indicated that these perceptions are influenced by context.

PRACTICE IMPLICATIONS

Improvement of curricula, teaching and assessment methods, and investment in faculty development are likely to foster positive perceptions towards learning communication skills in these students.

Health-related quality of life predictors during medical residency in a random, stratified sample of residents

OBJECTIVE

To evaluate the quality of life during the first three years of training and identify its association with sociodemographicoccupational characteristics, leisure time and health habits.

METHOD

A cross-sectional study with a random sample of 128 residents stratified by year of training was conducted. The Medical Outcome Study -short form 36 was administered. Mann-Whitney tests were carried out to compare percentile distributions of the eight quality of life domains, according to sociodemographic variables, and a multiple linear regression analysis was performed, followed by a validity checking for the resulting models.

RESULTS

The physical component presented higher quality of life medians than the mental component. Comparisons between the three years showed that in almost all domains the quality of life scores of the second year residents were higher than the first year residents (p < 0.01). The mental component scores remained high for third year residents (p < 0.01). Predictors of higher quality of life were: second or third year of residency, satisfaction with the training program, sufficient time for leisure, and care of critical patients for less than 30 hours per week.

CONCLUSION

The mental component of quality of life was the most impaired component, indicating the importance of caring for residents' mental health, especially during their first year and when they are overloaded with critical patients.

Faculty and medical students' perceptions of teaching and learning about the doctor-patient relationship

OBJECTIVE

To explore student and faculty perceptions of how students are learning doctor-patient relationship skills in their clinical medical education.

METHODS

Exploratory qualitative study involving data from interviews and focus groups with students and interviews with teaching faculty.

RESULTS

Respondents reported that pre-clinical relationship skills curricula were not well-coordinated with clinical curricula. Within the clinical curriculum, respondents perceived a disparity between general practice and hospital-based attachments. Teaching of relationship skills on the wards was highly variable, rarely explicit, and primarily dependent on role-modelling. In contrast, general practice runs included explicit teaching with feedback that reinforced skills taught in the pre-clinical curriculum. Respondents recommended increased focus on and assessment of students' interpersonal skills within clinical settings.

CONCLUSION

Pre-clinical and clinical relationship skills curricula were not coordinated. The tension between service commitments and student teaching in hospital-based attachments contributed to an insufficient focus on communication and relationship skills acquisition and did not reinforce teaching in pre-clinical and ambulatory clinical settings.

PRACTICE IMPLICATIONS

The teaching of doctor-patient relationship skills can be augmented by coordinating pre-clinical and clinical curricula and by requiring observation and structured feedback related to explicit criteria of student skills acquisition across all clinical learning experiences.

Empirical research on empathy in medicine-A critical review

OBJECTIVE

There is a growing amount of empirical research on empathy in medicine. This critical review assesses methodological limitations in this body of research that have not received adequate attention.

METHODS

Scientific publications presenting empirical research on medical students' or physicians' empathy were systematically searched for.

RESULTS

206 publications were identified and critically reviewed. Multiple empirical approaches have been used. However, there are some remarkable tendencies given the complexity of the study object: empathy is often not defined. Qualitative approaches are rarely used and the predominant quantitative instruments have a relatively narrow or peripheral scope. For example, the concrete experiences, feelings, and interpretations of the physician and the patient, and empathy in clinical practice, are often neglected. Furthermore, possible influences of medical training and working conditions on empathy have not been adequately explored.

CONCLUSION

The empirical studies of empathy in medicine tend to separate empathy from main parts of clinical perception, judgment, and communication. Thus, important aspects and influences of empathy have been relatively neglected.

PRACTICE IMPLICATIONS

Future studies should include transparent concepts, more than one method and perspective, qualitative approaches, the physician's and the patient's concrete experiences and interpretations, and the context in which empathy is developed and practiced.

Talking with patients and peers: medical students' difficulties with learning communication skills

BACKGROUND

Patient-centered communication skills, such as an empathic attitude towards patients and a holistic perspective on health, are difficult to acquire. Designing effective courses requires better understanding of the difficulties that students perceive with learning to talk with patients

AIMS

The study aimed at exploring students' common difficulties with learning patient-centered communication skills.

METHODS

Group discussions about student-patient interviews were videotaped and analyzed with regard to issues that students perceived as difficult and to their reflections about these difficulties.

RESULTS

The students reported feeling intrusive as they explored the patient's psychosocial situation. They avoided being empathic and felt insecure about coping adequately with emotionally loaded topics. Their difficulties were mainly due to insufficient understanding of the functional relations between psychosocial issues and health conditions. Moreover, students were insecure concerning the function of affective feedback in the diagnostic process. However, the group discussions generated a language for analyzing and structuring interviews that helped develop the students' professional identities.

CONCLUSIONS

Students experienced moral qualms about applying major aspects of patient-centered interviewing. Instruction in communication skills should aim at filling the students' knowledge gaps and fostering their awareness and expression of emotional perceptions. Long-term relationships with patients could help develop patient-centered communication.

Learning to connect: students' reflections on doctor-patient interactions

OBJECTIVE

Reflective writing is an established method for teaching medical students empathetic interactions, though little is known about students' reflections on connecting with patients during the clinical clerkship. The purpose of this study was to describe factors that medical students perceive contribute to or detract from making connections with patients and families, as identified in a writing assignment during the pediatric clinical clerkship.

METHODS

Reflective essays submitted by third-year medical students about interacting with patients/families during their pediatric clerkship were qualitatively analyzed for thematic content.

RESULTS

Major themes emerging in 44 essays analyzed included time, knowledge, language and culture, and actions. Barriers to connecting for some students were considered resources by others. Critical reflection was present in 31.8%.

CONCLUSIONS

Students' perceptions of factors that influence their interactions with patients and families will enhance or detract their ability to make connections. Through reflection, medical students - amidst clinical responsibilities - can identify how, why, and whether or not connections with patients/families have occurred.

PRACTICE IMPLICATIONS

Recognizing what factors medical students perceive as enhancing and detracting from connecting with patients/families will help preceptors foster those connections and mitigate barriers. Future study could assess how to best provide specific individualized feedback to best enhance critical reflection. We recommend the inclusion of brief reflective writing exercises during clinical clerkships in medical school, as it may augment students' ability to connect.

The characteristics of depressive symptoms in medical students during medical education and training: a cross-sectional study

BACKGROUND

Medical education and training can contribute to the development of depressive symptoms that might lead to possible academic and professional consequences. We aimed to investigate the characteristics of depressive symptoms among 481 medical students (79.8% of the total who matriculated).

METHODS

The Beck Depression Inventory (BDI) and cluster analyses were used in order to better describe the characteristics of depressive symptoms. Medical education and training in Brazil is divided into basic (1st and 2nd years), intermediate (3rd and 4th years), and internship (5th and 6th years) periods. The study organized each item from the BDI into the following three clusters: affective, cognitive, and somatic. Statistical analyses were performed using analysis of variance (ANOVA) with post-hoc Tukey corrected for multiple comparisons.

RESULTS

There were 184 (38.2%) students with depressive symptoms (BDI > 9). The internship period resulted in the highest BDI scores in comparison to both the basic (p < .001) and intermediate (p < .001) periods. Affective, cognitive, and somatic clusters were significantly higher in the internship period. An exploratory analysis of possible risk factors showed that females (p = .020) not having a parent who practiced medicine (p = .016), and the internship period (p = .001) were factors for the development of depressive symptoms.

CONCLUSION

There is a high prevalence towards depressive symptoms among medical students, particularly females, in the internship level, mainly involving the somatic and affective clusters, and not having a parent who practiced medicine. The active assessment of these students in evaluating their depressive symptoms is important in order to prevent the development of co-morbidities and suicide risk.