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.     

Impact of supervision and self-assessment on doctor-patient communication in rural Mexico.

OBJECTIVE: To determine whether supervision and self-assessment activities can improve doctor-patient communication. SETTING AND PARTICIPANTS: Six supervisors, 60 doctors in their last year of training, and 232 primary health care patients at rural health clinics in Michoacan, Mexico. DESIGN: The main evaluation compared post-intervention measures in control and intervention groups. A small panel study also examined changes from baseline to post-intervention rounds in both groups. INTERVENTION: Over a 4-month period, specially trained supervisors added 1 hour of supervision on interpersonal communication and counseling (IPC/C) to regular site visits. Doctors, who had received prior IPC/C training, periodically audiotaped and assessed their own consultations. MAIN OUTCOME MEASURES: These comprised frequency of doctors' facilitative communication, doctors' biomedical information-giving, and patients' active communication. RESULTS: The performance of all doctors improved markedly over the study period, but gains in facilitative communication and information-giving were significantly greater in the intervention than the control group. No single component of the intervention was responsible for the improvement; it resulted from the combination of activities. The doctors appreciated the more supportive relationship with supervisors that resulted from the intervention and found listening to themselves on audiotape a powerful, although initially stressful, experience. CONCLUSION: Supportive supervision and self-assessment activities can reinforce IPC/C training, prompt reflection and learning, and help novice doctors improve their interpersonal communication skills.     

A self-learning approach to history-taking

The present study examines the effectiveness of self-learning in interviewing skills training. Self-learning was carried out by self-evaluation of one's interviews by the use of an audiotape. Fifteen doctors specializing in internal medicine listened to their interviews and evaluated themselves against the suggested performance included in a rating scale. This procedure was repeated twice and composed the educational programme. Three main aspects of history-taking were involved: (1) eliciting patient information; (2) interviewing technique and (3) attitudes toward the patient. Comparison of performance at the first and third interview revealed significant improvement in all three aspects. Doctor-patient communication and written history performance were involved indirectly in the study but no significant improvement was revealed. The educational approach appeared simple and effective to the doctors. It is suggested that a brief programme of self-learning with feedback from audiotapes is both convenient and effective, improving essential aspects of history-taking performance.     

The relationship between medical students' attitudes towards communication skills learning and their demographic and education-related characteristics

INTRODUCTION: The General Medical Council (GMC) has stressed the importance of medical students' attitudes towards learning. However, few studies have explored medical students' attitudes towards communication skills learning. This study explores the relationship between the attitudes of medical students at two different schools and their demographic and education-related characteristics. METHODS: A total of 490 medical students from the Universities of Nottingham (Years 1 and 2) and Leicester (Year 1) completed the 26-item Communication Skills Attitude Scale (CSAS) and a personal details questionnaire satisfactorily. The relationships between students' attitudes and their demographic and education-related characteristics were analysed separately for Nottingham and Leicester students using both univariate and multivariate statistics. RESULTS: The attitudes of Nottingham and Leicester medical students towards communication skills learning were significantly associated with a number of demographic and education-related characteristics. Both Nottingham and Leicester students with more positive attitudes towards communication skills learning tended to be female, tended to think their communication skills needed improving and tended not to have parents who were doctors. Both Nottingham and Leicester students with more negative attitudes towards communication skills learning tended to think their communication skills did not need improving. DISCUSSION: The results indicate that medical students' attitudes towards communication skills learning are associated with their demographic and education-related characteristics. These findings have a number of implications for educational practice and further research and these are discussed in this paper.     

A pre-employment programme for overseas-trained doctors entering the Australian workforce, 1997-99

OBJECTIVES: Overseas-trained doctors (OTDs) have limited access and formal interaction with the Australian health care system prior to joining the Australian medical workforce. A pre-employment programme was designed to familiarize OTDs with the Australian health care system. METHOD: All OTDs who had passed their Australian Medical Council (AMC) exams and were applying for a pre-registration year in New South Wales were invited to participate in the voluntary, free programme. A 4-week full-time programme was developed consisting of core group teaching and a hospital attachment. The curriculum included communication, health and workplace skills; and sessions on culture shock and the role of junior doctors. A pilot programme was run in 1997. The programme was repeated in 1998 and 1999. The OTDs' confidence regarding the general duties of internship, and attitudes towards hospital workplace skills were examined. RESULTS: The 66 OTDs reported greater understanding of staff and communication issues and familiarization with the hospital environment. They reported a more realistic understanding of the role of a junior doctor, the need for separation of workplace and personal responsibilities and knowledge of pathways for future professional development. The course structure, with a focus on hospital attachments, establishment of a peer network, and workplace familiarization facilitated entry into the hospital workforce. CONCLUSION: The pre-employment programme enabled the OTDs to have a more equitable entry into the public hospital system, resulting in a more integrated, confident and functional workforce.     

Improved communication between doctors and with managers would benefit professional integrity and reduce the occupational medicine workload

BACKGROUND: Professional expectations for communication skills are explicit. These skills are needed for professional integrity and personal morale. Nevertheless, occupational physicians see doctors as patients for whom communication among between doctors and with their managers are the principal cause of their presenting health problems. AIM: To describe the frameworks of professionalism in medicine and the duty to care for good communication; present issues surrounding competency in communication skills; identify health problems among doctors associated with poor communication; and consider roles of economic appraisal and preventive strategies. METHOD: A literature review identified key publications of professional expectations and requirements of doctors for their communication skills. Health problems among doctors associated with poor communication and presenting at least twice in a National Health Service (NHS) occupational health (OH) department during January-December 2002, were sought by manual retrieval of all doctor-patient records. The categories of communication difficulty were agreed in the focus group discussion of the presenting problems with occupational physicians. RESULTS: Nine categories of communication difficulties among doctors resulting in their presentation in OH departments with health problems were identified. CONCLUSIONS: Personal health problems caused by poor communication involve considerable time and potential litigation costs. Doctors need to be reminded of their responsibilities. Opportunity cost studies would help to strengthen an evidence base for the need of doctors to adhere to the professional requirements of good communication skills.     

An evaluation of the impact of training Honduran health care providers in interpersonal communication.

OBJECTIVE: To evaluate the impact of interpersonal communication (IPC) training on practice and patient satisfaction and to determine the acceptability of this training to providers in a developing country. DESIGN: The study used a pre-post design with treatment and control groups. Data collection methods included interaction analysis of audio-taped clinical encounters, patient exit interviews, and a self-administered questionnaire for health providers. STUDY PARTICIPANTS: Interaction analysis was based on an experimental group of 24 doctors and a control group of eight with multiple observations for each provider). Exit interviews were carried out with 220 pre-test patients and 218 post-test patients. All 87 health providers who received training responded to the self-administered questionnaire. INTERVENTION: A brief in-service training programme on interpersonal communications was presented in three half-day sessions; these focused on overall socio-emotional communication, problem solving skills and counselling. MAIN OUTCOME MEASURES AND RESULTS: The IPC intervention was associated with more communication by trained providers (mean scores of 136.6 versus 94.4; P = 0.001), more positive talk (15.93 versus 7.99; P = 0.001), less negative talk (0.11 versus 0.59; P = 0.018), more emotional talk (15.7 versus 5.5; P = 0.021), and more medical counselling (17.3 versus 11.3; P = 0.026). Patients responded by communicating more (mean scores of 113.8 versus 79.6; P = 0.011) and disclosing more medical information (54.7 versus 41.7; P = 0.002). Patient satisfaction ratings were higher for providers who had received the training and providers reported training to be relevant and useful. CONCLUSIONS: Further validation of IPC skills and simplification of assessment methods are needed if IPC is to be an area for routine monitoring and quality improvement.     

The effects of patient communication skills training on compliance

OBJECTIVE: To examine the relationship between communication skills training for patients and their compliance with recommended treatment. DESIGN: A randomized control design was used, with patients nested within physicians. Each physician was audiotaped with 6 patients, 2 patients in each of the 3 intervention conditions: (1) a trained group (n = 50) received a training booklet in the mail 2 to 3 days prior to the scheduled appointment, (2) an informed group (n = 49) received a brief written summary of the major points contained in the training booklet while in the waiting room prior to the scheduled appointment, and (3) an untrained group (n = 51) did not receive any form of communication skills intervention. SETTING: Participants included physicians and patients from 9 different primary care, family practice locations. Two locations were clinics associated with a large, university-based medical school and hospital, while 7 were private practice offices in the community. PARTICIPANTS: The sample included 25 family physicians (averaging 11 years postresidency) and 150 patients. Patients were randomly selected from appointment records and randomly assigned to 1 of 3 intervention conditions. INTERVENTION: A training booklet designed to instruct patients in information seeking, provision, and verification. MAIN OUTCOME MEASURE: Patients' compliance with medications, behavioral treatment (e.g., diet, exercise, smoking cessation), and/or follow-up appointments and referrals. RESULTS: Trained patients were more compliant overall than untrained or informed patients. Training positively influenced compliance with behavioral treatments and follow-up appointments and referrals. CONCLUSION: Training patients in communication skills may be a cost-effective way of increasing compliance and improving the overall health of patients.     

Skills and attributes of directors of educational programmes

OBJECTIVES: The purpose of this study was to obtain a list of desirable skills and attributes of prospective educational programme directors as judged by potential employers of future directors. DESIGN: An international mail survey was conducted worldwide, using a one-page, open-ended questionnaire. SETTING: University of Illinois at Chicago, USA. SUBJECTS: Deans, department heads and chief executive officers from the various health professions. RESULTS: A total of 139 respondents completed the questionnaire (22. 3% response rate). Responses were remarkably similar across health professions. The nine leading skills were: oral communication skills, interpersonal skills, competent practitioner, educational goal-definition skills, educational design skills, problem-solving and decision-making skills, team worker and building skills, written communication skills and fiscal manager and budgeting skills. The three leading personal attributes were: visionary, flexible and open-minded and trustworthy and value-driven individual. CONCLUSIONS: The complete list of skills and attributes can be used by employers or administrators to build checklist items when hiring or reviewing programme directors or to plan and evaluate training programmes. The importance of leadership compared to managerial responsibilities is discussed as well as the need to train future educational programme directors.     

Improving the quality of service delivery in Nigeria.

This study evaluates the effect of a nurse training program in family planning counseling skills on the quality of service delivery at the clinic level, as well as its impact on client compliance with prearranged appointments. The study used a quasi-experimental design to compare certified nurses who received six weeks of family planning technical training with certified nurses who, in addition to the technical training course, received a three-day course in counseling skills. Data were collected through client exit interviews, expert observation, and inspection of medical record abstracts. Trained nurses performed better than their untrained counterparts in the quality-of-care areas investigated--interpersonal relations, information giving, counseling, and mechanisms for encouraging continuity. The likelihood that clients will attend follow-up visits was also found to improve when they were attended by trained professionals. Short-term counseling training can significantly improve the quality of care provided by family planning workers, as well as client compliance with follow-up appointments.     

Can first-year medical students contribute to better care for patients with a chronic disease?

First-year medical students at the University of Western Australia are attached to a patient with a chronic illness in order to begin to understand the world of the chronically ill and their families. The patients are recruited by general practitioner preceptors who have been reticent in accepting first-year students because of their perceived immaturity and lack of medical knowledge. Not only have the preceptors' reservations proven groundless, but the teaching exercise has produced an unintended and positive side in that 35% of students discovered new information which was judged by the patients' general practitioners to be of significant help in the total management of patients' illness. Since these were only first-year medical students, the effect should be much greater with more mature students. Doctors often have incomplete records and act on incomplete information. Medical students are a means of correcting some of these deficits. In return they develop better psychosocial and communication skills and achieve considerable personal development by demonstrating to patients, their preceptors and themselves that they can be useful in contributing to more effective patient care.     

Testing an empirically derived mental health training model featuring small groups, distributed practice and patient discussion

Objectives  Internationally, family doctors seeking to enhance their skills in evidence-based mental health treatment are attending brief training workshops, despite clear evidence in the literature that short-term, massed formats are not likely to improve skills in this complex area. Reviews of the educational literature suggest that an optimal model of training would incorporate distributed practice techniques; repeated practice over a lengthy time period, small-group interactive learning, mentoring relationships, skills-based training and an ongoing discussion of actual patients. This study investigates the potential role of group-based training incorporating multiple aspects of good pedagogy for training doctors in basic competencies in brief cognitive behaviour therapy (BCBT).
Methods  Six groups of family doctors ( n  = 32) completed eight 2-hour sessions of BCBT group training over a 6-month period. A baseline control design was utilised with pre- and post-training measures of doctors' BCBT skills, knowledge and engagement in BCBT treatment.
Results  Family doctors' knowledge, skills in and actual use of BCBT with patients improved significantly over the course of training compared with the control period.
Conclusions  This research demonstrates preliminary support for the efficacy of an empirically derived group training model for family doctors. Brief CBT group-based training could prove to be an effective and viable model for future doctor training.     

Teaching and assessing clinical skills: a competency-based programme in China

The objective of this study was to develop a compentency-based clinical skills teaching and assessment programme in China utilizing modern teaching techniques. Medical teachers from three schools agreed on items for inclusion in the complete physical examination of an asymptomatic adult, an outline for an adult and paediatric history, and important interviewing skills. Lesson plans, performance checklists, and written and videotape training materials were developed. Standardized patients were trained at one school to assist with the teaching at that school and with the assessment at all three schools. A national, a provincial, and a local medical school in China were used. Before beginning the new curriculum for students in their first year of clinical training, baseline data were collected on skills of students at various levels of training in the previous curriculum at all three schools. Although in the previous curriculum there was some improvement in clinical skills among advanced compared to more junior students, performance was lower than expected by staff. One year after implementation of the new curriculum, students were evaluated. These students significantly outperformed their counterparts as well as the more senior level students tested the previous year. This project has established a competency-based teaching and assessment programme in China that allows for rapid improvement in the clinical skills of students. Within a short time, a sophisticated group of medical educators has been formed, who now function as consultants to other educators in their own country. Many aspects of this programme are being adapted throughout China and are applicable to medical schools throughout the world.     

The lessons of deafness: deafness awareness and communication skills training with medical students

This paper describes a 1-day course on deafness awareness and communication skills with fourth-year medical undergraduates and summarizes their evaluation of the course. Deaf people commonly experience major communication difficulties with doctors. This course gives students an awareness of deafness (and of the insights deaf people can give to an understanding of communication)--the lessons of deafness--and challenges some critical assumptions in medical practice. Students are given personal experience of deafness and of the consequent powerlessness and loss of self-confidence, while also learning new communication skills which they then apply in a role-play consultation with a deaf patient. Systematic evaluation has been built into the programme and student opinion has been unanimously enthusiastic.     

Doctors who did not participate in a continuing education programme

One hundred doctors were interviewed regarding their use of a series of educational programmes which had been mailed to them unsolicited. Doctors who used the materials did not differ from those who did not with respect to geographical location, sex and higher qualifications.
The forty-five doctors who had used the programmes tended to be younger than those who did not. The commonest reason given for non-participation in the programme was lack of time. Following the interviews at least five doctors, who had not previously done so, used the programmes.     

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

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

加强医患沟通是构建和谐医患关系的保障

文章提出了医患沟通的规范内容和要求。医生要掌握医患沟通的技巧和方法,提高沟通的有效性。加强医患沟通管理,建立医患沟通考评标准,提高医患双方满意度。     

The anxieties of new clinical students

The specific anxieties of 74 medical students beginning their clinical training were assessed by means of a questionnaire at the start of the clinical introductory course at St Mary's Hospital Medical School, London. Situations differed in the amount of anxiety that they engendered, and students also differed in the number of situations that they found anxiety producing. Students particularly reported that interactions with senior staff on ward rounds were anxiety provoking. The same questionnaire was also distributed to 52 teaching hospital doctors who were asked to complete the questionnaire as they thought the students had done. Compared with students, the doctors considered more situations to be anxiety provoking, and they differed in their rank ordering of the situations. Doctors tended to overestimate anxiety concerning communication problems, and to underestimate anxiety concerning routine clinical tasks such as phlebotomy.     

临床护理中护患沟通技巧的应用与效果

目的在临床护理中实施护患沟通,提高护士的业务水平,防止护患纠纷的发生。方法对护理人员进行护患沟通技巧的培训,一年后采用问卷调查法,向医生发放问卷70份,内容为护士的沟通技巧知识掌握情况评价,收回有效问卷70份;向患者及家属发放问卷100份,内容为对护士护理服务的满意度,收回有效问卷98份;并与开展＂优质护理服务工程＂前的2009年各项指标进行对比。结果护士的沟通技巧知识掌握率由2009年的66.7%提高到2010年的95.7%;患者及家属对护理人员的满意度由2009年的74.5%提高到2010年的96.9%;护患纠纷由2009年的5例下降到2010年的1例,下降80%,比较差异具有统计学意义（P〈0.05）。结论良好有效的护患沟通能保证护理措施的有效实施,促进患者疾病的康复,提高护理质量。