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

Objective To describe and discuss Year 5 medical students' perceptions of their own learning about the doctor?patient relationship. Methods We carried out a qualitative study of semi‐structured interviews with 16 Year 5 medical students using 3‐way analysis at the School of Medicine, Federal University of São Paulo, São Paulo, Brazil. Results For experiences at the pre‐clinical stage, the subcategories were: positive aspects of the medical psychology course; great distance between theory and reality, and strong desire for clinical practice. For experiences at the clinical stage, the subcategories were: demand for opportunities to discuss the doctor?patient relationship; teachers as either role models or anti‐models; clinical situations favourable for developing empathic relationships, and clinical situations unfavourable for developing empathic relationships. For views about future experiences, the subcategories were: apprehension about ethical behaviour; anxiety about handling patients' psychosocial characteristics, and fear of professional ethics cases or legal action. Discussion To compensate for the lack of practical activities during the pre‐clinical stage, students search for extracurricular activities that often overload them. Because teachers function as professional role models, their attitudes towards patients have great importance. Students fear not being able to maintain their empathic capacity in the future because of work‐related issues. Knowledge of the psychological aspects of the doctor?patient relationship helps students to comprehend their experiences. Gradual contact between student and medical practice from the beginning of the course is advised. It should be followed by interdisciplinary discussions that deal with the technical aspects of cases and the doctor?patient relationship.     

Impact of a new curriculum on medical students' interpersonal and interviewing skills

OBJECTIVES: In 1998 we reported on the rise and fall of medical student communication skills during the 4 years of medical school. Since then, the University of Connecticut School of Medicine has completed a major curriculum renewal project with an emphasis on early clinical work, lifelong learning and more ambulatory training. The goals of this study were to compare students' interviewing and interpersonal skills in standardised patient (SP) assessments in the old and new curricula and to assess the success of the new curriculum in preventing a decline in student skills in this domain. METHODS: The clinical skills of 202 students were measured longitudinally during encounters with SPs in each of their 4 years of medical school. Students in this study and the earlier study were evaluated using the Arizona Clinical Interviewing Rating (ACIR) Scale. RESULTS: Compared with students from the previous curriculum, students on the new curriculum in this study showed an improvement in ACIR scores. Year 1 mean ACIR scores (1 = poor to 5 = excellent) were, respectively, 3.6 for the old curriculum cohort and 4.0 for the new curriculum group. In Year 4 the mean score for the old curriculum cohort was 3.7 and that for the new curriculum group was 3.8. Students on the new curriculum still showed a decline in ACIR scores from Years 1 to 4, but it was not as severe a decline as it had been previously. CONCLUSIONS: Pre-clinical medical students perform better on measures of interpersonal communication than their clinical counterparts. The students who participated in the new curriculum demonstrated an earlier acquisition of and a less steep decline in interviewing and interpersonal skills during the course of medical school.     

Medical students' perceptions of their educational environment: expected versus actual perceptions

Objective To compare Year 1 medical students' perceptions of their educational environment at the end of Year 1, with their expectations at the beginning of the year using the Dundee Ready Education Environment Measure (DREEM). Methods Year 1 students (n = 130) at the University of East Anglia Medical School were asked to complete the DREEM during their induction week at the beginning of Year 1, thinking about the educational environment they expected to encounter (Expected DREEM), and again as part of a compulsory evaluation at the end of Year 1, thinking about the educational environment they had actually experienced (Actual DREEM). A total of 87 students (66.92% of the starting cohort) completed the DREEM on both occasions and gave permission for their data to be published. Results The Expected DREEM score was 153 out of a maximum of 200, and the Actual DREEM score was 143. Student's expected perceptions of learning and teachers, and their expected academic self- and social self-perceptions were all more positive than their actual perceptions. There was no difference between expected and actual perceptions of atmosphere. Specific aspects of the educational environment showing dissonance were identified. In some areas students' low expectations had been matched by their actual experience. Conclusions Medical students had started Year 1 with expectations about the educational environment that had not been met. However, areas showing dissonance received low item scores on the Actual DREEM and as such would be picked up for remediation, even without information about student expectations.     

Further challenges in measuring communication skills: accounting for actor effects in standardised patient assessments

Context  Subjective rating scales for communication skills may yield more personally meaningful responses than more standardised rating schemes. It is unclear, however, whether such evaluations may be overly biased by respondents' rating styles, which may lead to unreliable measurement of examinees' communication skills.
Methods  Our study involved 212 students from the classes of 2005 and 2006 at the University of Rochester School of Medicine and Dentistry. All students were rated by actors depicting standardised patients (SPs) on the same seven cases using the 19-item Rochester Communication Rating Scale (RCRS). Different students were assigned to different actors playing the same SP. We assessed the extent to which actors' personal rating styles influenced the scores they assigned to students. Main outcome measures were: between-actor variability in responses; the degree to which actors' response styles contribute to overall scores, and improvements in reliability achieved by standardising actors' ratings.
Results  There were statistically significant differences between actors in their mean assigned scores. Scores aggregated over 18 separate SP cases have an expected generalisability coefficient of 0.79. If raw RCRS scores are used, a total of 27 replications of the RCRS are required to achieve a Cronbach's alpha of 0.8; standardisation reduces this number to 18.
Conclusions  Although actors are variable in their use of a standardised subjective scale of communication, such differences contribute to an acceptably small proportion of the total variance if scores are combined across a large number of cases. Reliability can be markedly improved by standardising scores across raters.     

Medical students' perceptions of medical malpractice

Despite increasing interest in medical malpractice in the UK, there is very little empirical research on doctors' own concerns. This paper explores first and fifth year medical students' knowledge about malpractice, their attitudes toward litigation and its perceived significance for their future practice.     

Medical students' perceptions of racial diversity and gender equality

OBJECTIVES: To assess attitudes of medical students toward issues of racial diversity and gender equality and to ascertain changes in these attitudes during the pre-clinical curriculum. METHODS: Attitudes toward multiculturalism and gender equality were assessed using a 43-item questionnaire. The survey was completed by incoming Year 1 students in 2000 and 2001, and was completed again in 2002 by the students who had entered in 2000. Mean scores were analysed at baseline by gender, ethnic group and political affiliation using analysis of variance. The paired scores of the first and follow-up surveys of the 2000 entering class were compared using paired t-tests. RESULTS: Upon entry into medical school, women, minority group students and Democrats scored significantly higher on the cultural sensitivity scale than their comparison groups. No significant changes were seen overall in the matched data. However, minority groups showed a significant increase in scores, while Republicans and white men experienced a non-significant decline. In addition, incoming students judged cultural competency education to be important. The perceived need to increase the numbers of minority group doctors varied by gender, ethnic group and political affiliation. CONCLUSIONS: Among incoming medical students, perceptions of racial diversity and gender equality vary along ethnic, gender and political lines. Additionally, pre-clinical education was associated with increased cultural sensitivity by minority group students, but not by others. These findings demonstrate the continuing need for diversity in medical school and for medical students to recognise and address their personal and group biases.     

Developing a Korean communication skills attitude scale: comparing attitudes between Korea and the West

Objectives  We aimed to develop a Korean version of the Communication Skills Attitude Scale (CSAS) created by Rees et al . in order to elucidate the positive and negative aspects of Korean pre-medical and medical students' attitudes towards communication skills (CS) learning.
Methods  We performed two surveys. In the first of these, 325 pre-medical and medical students completed a translated version of the CSAS. In the second survey, 257 medical students and doctors-in-training answered five open-ended questions to obtain more qualitative data about their attitudes.
Results  Principal component analysis with direct oblimin rotation performed with the data from the first survey produced the following five factors: facilitation of interpersonal skills; doubts about the importance of CS learning in medicine; motivation; negative attitudes towards assessment, and overconfidence. Results from the second survey indicated that facilitation and importance within a medical context were two core attitudinal factors and suggested some modification to the CSAS to improve its fit for Korean pre-medical and medical students.
Conclusions  Using a Korean version of the CSAS (CSAS-K), we determined five factors that revealed a somewhat complex attitude structure among students towards CS learning. The CSAS required some modification, possibly because CS teaching and learning in Korea are in the development stage. Finally, the educational implications of the results are discussed.     

Medical students' personality characteristics and academic performance: a five-factor model perspective

OBJECTIVES: This study investigates: (1) which personality traits are typical of medical students as compared to other students, and (2) which personality traits predict medical student performance in pre-clinical years. DESIGN: This paper reports a cross-sectional inventory study of students in nine academic majors and a prospective longitudinal study of one cohort of medical students assessed by inventory during their first preclinical year and by university examination at the end of each pre-clinical year. SUBJECTS AND METHODS: In 1997, a combined total of 785 students entered medical studies courses in five Flemish universities. Of these, 631 (80.4%) completed the NEO-PI-R (i.e. a measure of the Five-Factor Model of Personality). This was also completed by 914 Year 1 students of seven other academic majors at Ghent University. Year end scores for medical students were obtained for 607 students in Year 1, for 413 in Year 2, and for 341 in Year 3. RESULTS: Medical studies falls into the group of majors where students score highest on extraversion and agreeableness. Conscientiousness (i.e. self-achievement and self-discipline) significantly predicts final scores in each pre-clinical year. Medical students who score low on conscientiousness and high on gregariousness and excitement-seeking are significantly less likely to sit examinations successfully. CONCLUSIONS: The higher scores for extraversion and agreeableness, two dimensions defining the interpersonal dynamic, may be beneficial for doctors' collaboration and communication skills in future professional practice. Because conscientiousness affects examination results and can be reliably assessed at the start of a medical study career, personality assessment may be a useful tool in student counselling and guidance.     

Communication skills competencies: definitions and a teaching toolbox

BACKGROUND: Doctors' interpersonal and communication skills correlate with improved health care outcomes. International medical organisations require competency in communication skills. The Accreditation Council for Graduate Medical Education (ACGME) developed a toolbox for assessing this competency and 5 others, yet none initially for teaching these skills. PURPOSE AND METHODS: The original focus in the development of the ACGME competencies was evaluation. This paper represents a significant step toward defining methods for teaching communication skills competencies. A total of 16 medical education leaders from medical schools worldwide, participating in the 2003 Harvard Macy Institute Program for Physician Educators, worked together to: (1) further define the ACGME competency in interpersonal and communication skills; (2) delineate teaching strategies for each level of medical education; and (3) create a teaching toolbox to integrate communication skills competencies into medical curricula. Four subgroups defined subcompetencies, identified teaching strategies for undergraduate, graduate and postgraduate medical training and brought their work to the larger group. The expanded communication competencies and teaching strategies were determined by a consensus of the larger group, presented to 80 Harvard Macy Scholars and Faculty for further discussion, then finalised by consensus. CONCLUSION: The teaching toolbox expands the ACGME core communication competencies, adds 20 subcompetencies and connects these competencies to teaching strategies at each level of medical training. It represents the collaboration and consensus of a diverse international group of medical education leaders in a variety of medical specialities and institutions, all involved in teaching communication skills. The toolbox is applicable globally across different settings and specialities, and is sensitive to different definitions of health care.     

Children and their parents assessing the doctor-patient interaction: a rating system for doctors' communication skills

CONTEXT: Only a patient and his or her family can judge many of the most important aspects of the doctor-patient interaction. This study evaluates the feasibility and reliability of children and their families assessing the quality of paediatricians' interactions using a rating instrument developed specifically for this purpose. METHODS: A reliability analysis using generalisability theory on the ratings from 352 doctor-patient interactions across different speciality clinics. RESULTS: Ratings were normally distributed. They were highest for 'overall' performance, and lowest for giving time to discuss the families' agenda. An appropriate sample of adults' ratings provided a reliable score (G = 0.7 with 15 raters), but children's ratings were too idiosyncratic to be reproducible (G = 0.36 with 15 raters). CONCLUSIONS AND FURTHER WORK: Accompanying adults can provide reliable ratings of doctors' interactions with children. Because an adult is usually present at the consultation their ratings provide a highly feasible and authentic approach. Sampling doctors' interactions from different clinics and with patients of both genders provides a universal picture of performance. The method is ideal to measure performance for in-training assessment or revalidation. Further work is in progress to evaluate the educational impact of feeding ratings back to the doctors being assessed, and their use in a range of clinical contexts.     

Assessing resident's knowledge and communication skills using four different evaluation tools

PURPOSE: This study assesses the relationship between 4 Accreditation Council for Graduate Medical Education (ACGME) outcome project measures for interpersonal and communication skills and medical knowledge; specifically, monthly performance evaluations, objective structured clinical examinations (OSCEs), the American Board of Family Practice in-training examination (ABFP-ITE) and the Davis observation code (DOC) practice style profiles. METHODS: Based on previous work, we have DOC scoring for 29 residents from the University of California, Davis Department of Family and Community Medicine. For all these residents we also had the results of monthly performance evaluations, 2 required OSCE exercises, and the results of 3 American Board of Family Medicine (ABFM) ITEs. Data for each of these measures were abstracted for each resident. The Pearson correlation coefficient was used to assess the presence or lack of correlation between each of these evaluation methods. RESULTS: There is little correlation between various evaluation methods used to assess medical knowledge, and there is also little correlation between various evaluation methods used to assess communication skills. CONCLUSION: The outcome project remains a 'work in progress', with the need for larger studies to assess the value of different assessment measures of resident competence. It is unlikely that DOC will become a useful evaluation tool.     

Acquisition of communication skills in postgraduate training for general practice

PURPOSE: The evidence suggests that a longitudinal training of communication skills embedded in a rich clinical context is most effective. In this study we evaluated the acquisition of communication skills under such conditions. METHODS: In a longitudinal design the communication skills of a randomly selected sample of 25 trainees of a three-year postgraduate training programme for general practice were assessed at the start and at the end of training. Eight videotaped real life consultations were rated per measurement and per trainee, using the MAAS-Global scoring list. The results were compared with each other and with those of a reference group of 94 experienced GPs. RESULTS: The mean score of the MAAS-Global was slightly increased at the end of training (2.4) compared with the start (2.2). No significant difference was found between the final results of the trainees and the reference group. According to the criteria of the rating scale the performance of both trainees and GPs was unsatisfactory. CONCLUSION: The results of this study indicate that communication skills do not improve in a three-year postgraduate training comprising both a rich clinical context and a longitudinal training of communication skills, and that an unsatisfactory level still exists at the end of training. Moreover, GPs do not acquire communication skills during independent practice as they perform comparably to the trainees. Further research into the measurement of communication skills, the teaching procedures, the role of the GP-trainer as a model and the influence of rotations through hospitals and the like, is required.     

Effects of communication skills training on students'' diagnostic efficiency

This study evaluates the impact of a training programme in communications skills on subsequent diagnostic efficiency. Videotaped history-taking interviews conducted by groups of specially trained and control groups of students were rated for their diagnostic efficiency by two medical practitioners. Students in the trained group had shown greatly increased skills in interviewing and interpersonal effectiveness as a result of their training. A comparison of ratings given by the two experimentally naive, independent observers revealed that trained students were significantly better at eliciting full, relevant data from patients--they were diagnostically more efficient, but took no longer than their control group counterparts to elicit the information. Further research with the medical interview rating scale will clarify the skills required of medical students in interviewing and diagnosis and facilitate remedial training for students who show poor interview skills.     

Medical students' learning of anatomy: memorisation, understanding and visualisation

INTRODUCTION: There is much subjective discussion, but few empirical data that explore how students approach the learning of anatomy. AIMS: Students' perceptions of successful approaches to learning anatomy were correlated with their own approaches to learning, quality of learning and grades. METHODS: First-year medical students (n = 97) studying anatomy at an Australian university completed an online survey including a version of the Study Process Questionnaire (SPQ) that measures approaches to learning. The quality of students' written assessment was rated using the Structure of Observed Learning Outcomes (SOLO) taxonomy. Final examination data were used for correlation with approaches and quality of learning. RESULTS: Students perceived successful learning of anatomy as hard work, involving various combinations of memorisation, understanding and visualisation. Students' surface approach (SA) scores (mean 30 +/- 3.4) and deep approach (DA) scores (mean 31 +/- 4.2) reflected the use of both memorisation and understanding as key learning strategies in anatomy. There were significant correlations between SOLO ratings and DA scores (r = 0.24, P < 0.01), between SA scores and final grades (r = - 0.30, P < 0.01) and between SOLO ratings and final grades (r = 0.61, P < 0.01) in the subject. CONCLUSIONS: Approaches to learning correlate positively with the quality of learning. Successful learning of anatomy requires a balance between memorisation with understanding and visualisation. Interrelationships between these three strategies for learning anatomy in medicine and other disciplines require further investigation.     

Consulting skills training and medical students' interviewing efficiency

In more traditional medical education, medical students took a patient's medical history by asking a series of sequenced, routine questions, covering presenting medical problem(s); medical history; social and personal history; systems review; and physical examination. Following this process, the student then attempted to derive the patient's medical problems. This inductive problem-solving paradigm may not assist students to prepare for their future interviewing needs, given doctors use a hypothetico-deductive, problem-solving approach when interviewing patients and numerous researchers have developed specialized communication skills training programmes designed to enhance students' interviewing skills. Students given specific consulting skills training have tended to show significantly greater interpersonal effectiveness and improved interview behaviours compared with students who experience traditional patient clerking training. These improvements in interviewing tend to persist over the period of students' medical training. The aim of the present study was to determine whether specialized communication skills training helped students elicit greater quantity and quality of information from patients and if so, whether such information assisted students in improving their diagnostic skills. Videotaped history-taking interviews conducted by students trained in communication skills and untrained (control) students were rated for their interview efficiency. A comparison of ratings given by experimentally naive, independent observers revealed that trained students were more efficient, but took no longer than their control group counterparts to elicit fuller, more relevant information. However, the student groups did not differ in the accuracy or scope of their medical diagnoses. It is argued that students' lack of medical knowledge in this early phase of their clinical training militated against their being able to use their interviewing competence to derive more potentially accurate medical diagnoses.     

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

BACKGROUND: Although doctor--patient communication is important in health care, medical specialists are generally not well trained in communication skills. Conventional training programmes are generally time consuming and hard to fit into busy working schedules of medical specialists. A computer-assisted instruction (CAI) programme was developed -- 'Interact-Cancer' -- which is a time-efficient learning method and easily accessible at the workplace. OBJECTIVE: To investigate the effect of the CAI training, 'Interact-Cancer', on the communication behaviour of medical specialists, and on satisfaction of patients about their physician interaction. DESIGN: Consultations of medical specialists with cancer outpatients were videotaped at 4 specific stages, 2 before and 2 after Interact-Cancer, with intervals of 4 weeks. PATIENTS/PARTICIPANTS: Participants were 21 medical specialists, mainly internists, working in 7 hospitals, and 385 cancer outpatients. METHODS: Communication behaviour was assessed on 23 observation categories derived from the course content. Frequencies were rated as well as judgements about the quality of the performance of each target skill. Satisfaction was measured by the Medical Interview Satisfaction Scale. Data were analyzed by means of multilevel statistical methods. RESULTS: The behavioural assessment showed course effects on ratings of the physicians' quality of performance. No course effects were found on the frequencies of physicians' behaviours and on the patient satisfaction ratings. CONCLUSIONS: CAI is a promising method to supply medical specialists with postgraduate training of communication skills. The application of judgement ratings of communication behaviour proved to be valuable to evaluate course effects in real-life patient encounters.     

Assessing professionalism in the context of an objective structured clinical examination: an in-depth study of the rating process

INTRODUCTION: Professionalism is fundamental to the practice of medicine. Objective structured clinical examinations (OSCEs) have been proposed as appropriate for assessing some aspects of professionalism. This study investigated how raters assign professionalism ratings to medical students' performances in OSCE encounters. METHODS: Three standardised patients, 3 doctor preceptors, and 3 lay people viewed and rated 20 videotaped encounters between 3rd-year medical students and standardised patients. Raters recorded their thoughts while rating. Qualitative and quantitative analyses were conducted. Comments about observable behaviours were coded, and relative frequencies were computed. Correlations between counts of categorised comments and overall professionalism ratings were also computed. RESULTS: Raters varied in which behaviours they attended to, and how behaviours were evaluated. This was true within and between rater type. Raters also differed in the behaviours they consider when providing global evaluations of professionalism. CONCLUSIONS: This study highlights the complexity of the processes involved in assigning ratings to doctor-patient encounters. Greater emphasis on behavioural definitions of specific behaviours may not be a sufficient solution, as raters appear to vary in both attention to and evaluation of behaviours. Reliance on global ratings is also problematic, especially if relatively few raters are used, for similar reasons. We propose a model highlighting the multiple points where raters viewing the same encounter may diverge, resulting in different ratings of the same performance. Progress in assessment of professionalism will require further dialogue about what constitutes professional behaviour in the medical encounter, with input from multiple constituencies and multiple representatives within each constituency.     

The curriculum of communication skills teaching at Maastricht Medical School

In the Skillslab at Maastricht Medical School students are prepared for their first encounters with patients. Students can focus on individual skills, separately mastering each skill in a controlled systematic manner. With this foundation students are better equipped to face the complex intellectual and emotional demands of real patients. A large proportion of training concerns communication skills. Features of Skillslab communication skills training programme are: (1) its continuity (once every 2 weeks, from year 1 to year 6); (2) a gradual increase of complexity in skills (basic interview skills, phases of interviews, entire interviews, problem patients); (3) a gradual increase of complexity in practice situations (apparatus, role-playing, simulated patients, real patients). Evaluation shows students' and teachers' satisfaction with the programme. Comparison with conditions required for interpersonal skills training shows that these are fully met. However, there are drawbacks, which are described.