Explanations in consultations: the combined effectiveness of doctors' and nurses' communication with patients

BACKGROUND: Multidisciplinary and interprofessional working is currently a priority in health care policy, in caring for patients and in health professional education. Realising multidisciplinary approaches presents challenges in the context of changes in doctors' and nurses' roles and the increased emphasis placed on communication with patients. In communication in consultations, explanations are employed in the service of numerous activities, including decision making, diagnosis and physical examination, but they have been little studied. SETTING: This paper presents findings from a comparative study of doctors' and nurses' communication with patients in multidisciplinary health care, focusing on diabetes in primary care. METHODS: Video- and audio-recorded consultations were subjected to conversation analysis. Output from discussion groups with patient representatives and health professionals underwent qualitative analysis. FINDINGS: Distinctive features of explanations in nurses' and doctors' consultations with patients were identified. These can be understood by reference to patterns of communication. Nurses' communication was mediated by patients' contributions; doctors' communication gave an overarching direction to the consultation as a whole. While nurses' explanations began from the viewpoint of a patient's responsibility and behaviour, doctors' explanations began from the viewpoint of biomedical intervention. Their consultations lent different opportunities for patients' involvement. CONCLUSION: Nurses' and doctors' communications each exhibit their own distinct features. Specification of these features, when considered in the context of a particular consultation activity such as explanations, allows both recognition of the distinct contributions each profession can offer and identification of ways of combining these to maximum effect. This has implications for policy, for practice and for interprofessional education.     

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.     

Assessment of a matched-pair instrument to examine doctor-patient communication skills in practising doctors

OBJECTIVES: To develop and psychometrically assess the feasibility, reliability and validity of an assessment tool in which both doctor and patient perceptions of the communication that occurred in a single office visit are captured. METHODS: Two 19-item (5-point scale) questionnaires, with parallel content, were developed for doctor and patient completion following a visit. Both process and content were queried. Family doctors and specialists across Canada were recruited to provide data from 25 visits. We assessed feasibility by examining recruitment and percentages of people 'unable to assess' each item. Evidence for validity was examined through exploratory factor analysis, the correlations between doctor and patient data and linear regression. Reliability was assessed through internal consistency reliability and generalisability coefficient analyses. RESULTS: Data from 1845 doctor-patient dyads (91 doctors) showed similarly high ratings (> 4/5) for both doctors and patients, with few unable-to-assess items. There were low correlations between items and questionnaires. The principle components analysis indicated 2 factors, process and content, accounting for 52% and 7% of the doctor variance and 60% and 6% of the patient variance, respectively. The linear regression showed that only gender accounted for any of the variance in ratings. Cronbach's alphas for both doctor and patient questionnaires were > or = 0.96. The G analysis provided a G = 0.98 and 0.40 (standard errors of 0.003 and 0.02) for doctors and patients, respectively. CONCLUSIONS: The data suggest this is a feasible tool with which to assess communication skills and that there is evidence for its validity and reliability.     

Evaluating medical students' non-verbal communication during the objective structured clinical examination

OBJECTIVES: Non-verbal communication (NVC) in medical encounters is an important method of exchanging information on emotional status and contextualising the meaning of verbal communication. This study aimed to assess the impact of medical students' NVC on interview evaluations by standardised patients (SPs). METHODS: A total of 89 medical interviews in an objective structured clinical examination (OSCE) for post-clerkship medical students were analysed. All interviews were videotaped and evaluated on 10 non-verbal behaviour items. In addition, the quality of the interview content was rated by medical faculty on 5 items and the interview was rated by SPs on 5 items. The relationships between student NVC and SP evaluation were examined by multivariate regression analyses controlling for the quality of the interview content. RESULTS: Standardised patients were likely to give higher ratings when students faced them directly, used facilitative nodding when listening to their talk, looked at them equally when talking and listening, and spoke at a similar speed and voice volume to them. These effects of NVC remained significant after controlling for the quality of the interview content. CONCLUSIONS: This study provided evidence of specific non-verbal behaviours of doctors that may have additional impacts on the patient's perception of his or her visit, independently of the interview content. Education in basic NVC should be incorporated into medical education alongside verbal communication.     

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.     

Conversation analysis, doctor-patient interaction and medical communication

INTRODUCTION: This paper introduces medical educators to the field of conversation analysis (CA) and its contributions to the understanding of the doctor-patient relationship. THE CONVERSATION ANALYSIS APPROACH: Conversation analysis attempts to build bridges both to the ethnographic and the coding and quantitative studies of medical interviews, but examines the medical interview as an arena of naturally occurring interaction. This implies distinctive orientations and issues regarding the analysis of doctor-patient interaction. We discuss the CA approach by highlighting 5 basic features that are important to the enterprise, briefly illustrating each issue with a point from research on the medical interview. These features of conversation analytic theory and method imply a systematic approach to the organisation in interaction that distinguishes it from studies that rely on anecdote, ethnographic inquiry or the systematic coding of utterances. CONVERSATION ANALYSIS AND THE MEDICAL INTERVIEW: We then highlight recent CA studies of the "phases" of the internal medicine clinic and the implications of these studies for medical education. We conclude with suggestions for how to incorporate CA into the medical curriculum. It fits with biopsychosocial, patient-centred and relationship-centred approaches to teaching about medical communication.     

The role of empathy in establishing rapport in the consultation: a new model

CONTEXT: Considerable research has been conducted recently into the notion of patient-centred consulting. The primary goal of this approach is to establish a clear understanding of the patient's perspective on his or her problem, and to allow this understanding to inform both the explanation and planning stages of the consultation. The quality of this understanding is largely determined by the empathic accuracy achieved by the doctor; the primary benefit is a therapeutic rapport between doctor and patient. METHODS: To highlight the role of empathy and communication skills in establishing rapport, we initially developed a model which seeks to draw the various motivational and skill elements identified in separate research papers into a comprehensive model of the journey towards shared understanding between doctor and patient. We then conducted an initial validation of the model via qualitative analysis involving general practitioners (GPs) and clinical psychologists. RESULTS: The validation offered encouraging support for the principal elements of the model. Specific suggestions for clarification and extension were then incorporated in a revised model. CONCLUSIONS: The model appears to capture the dynamic process of establishing a therapeutic relationship (rapport) between doctor and patient, defined by the quality of the doctor's understanding of the patient's perspective on his or her problem. Arguably, the most important contribution of the model is to highlight the fact that 'empathy' and consequent 'rapport' are not mystical or exclusive concepts but, rather, involve the use of specific skills accessible at some level by all.     

Components of postgraduate competence: analyses of thirty years of longitudinal data

CONTEXT: The conceptualisation and measurement of competence in patient care are critical to the design of medical education programmes and outcome assessment. OBJECTIVE: We aimed to examine the major components and correlates of postgraduate competence in patient care. METHODS: A 24-item rating form with additional questions about resident doctors' performance and future residency offers was used. Study participants comprised 4560 subjects who graduated from Jefferson Medical College between 1975 and 2004. They pursued their graduate medical education in 508 hospitals. We used a longitudinal study design in which the rating form was completed by programme directors to evaluate residents at the end of the first postgraduate year. Factor analysis was used to identify the underlying components of postgraduate ratings. Multiple regression, t-test and correlational analyses were used to study the validity of the components that emerged. RESULTS: Two major components emerged, which we labelled 'Knowledge and Clinical Capabilities' and 'Professionalism', and which addressed the science and art of medicine, respectively. Performance measures during medical school, scores on medical licensing examinations, and global assessment of Medical Knowledge, Clinical Judgement and Data-gathering Skills showed higher correlations with scores on the Knowledge and Clinical Capabilities component. Global assessments of Professional Attitudes and ratings of Empathic Behaviour showed higher correlations with scores on the Professionalism component. Offers of continued residency and evaluations of desirable qualities were associated with both components. CONCLUSIONS: Psychometric support for measuring the components of Knowledge and Clinical Capabilities, and Professionalism provides an instrument to empirically evaluate educational outcomes to medical educators who are in search of such a tool.     

Clinical skills education: outcomes of relationships between junior medical students, senior peers and simulated patients

Objectives  Peer-assisted learning (PAL) has been reported to have educational benefits in cross-year, small-group teaching in other contexts. Accordingly, we explored whether senior medical students are effective tutors for their junior peers in clinical skills education, and how the participants in the learning triad (tutors, learners and simulated patients [SPs]) perceive the learning environment created in PAL.
Methods  Year 2 students were randomly allocated to one of two groups for skills training. Group 1 ( n  = 64) were tutored by volunteer Year 6 students, and Group 2 ( n  = 67) by paid doctors. The results of both groups in a clinical skills examination were compared using an independent samples t -test. Qualitative data, obtained from Year 2 students ( n  = 125) by written questionnaire and Year 6 students ( n  = 11) and SPs ( n  = 3) by focus group interviews, were analysed for themes.
Results  Students receiving PAL did at least as well in the clinical skills examination as students with qualified tutors (difference in mean total score: 0.7 marks out of 112; 95% confidence interval − 3.8 to 2.4). The PAL environment was perceived as 'comfortable' and fostered the development of confidence in all participants. Peer tutors created a more active learning environment than doctor tutors for both learners and SPs and reported personal benefits from teaching.
Conclusions  With appropriate support, volunteer Year 6 student tutors are as effective as graduate doctors for small-group structured tutorials in clinical skills. Educational relationships were forged between all participants in the learning triad.     

Medical students' perceptions of identity in communication skills training: a qualitative study

Objectives  Communication skills training in undergraduate medical education is considered to play an important role in medical students' formation of their professional identity. This qualitative study explores Year 1 students' perceptions of their identities when practising communication skills with real patients.
Methods  A total of 23 individual semi-structured interviews and two focus group discussions were conducted with 10 students during their first year of communication skills training. All interviews and discussions were audio-recorded, transcribed and analysed for emergent themes relating to identity.
Results  Students struggled to communicate professionally with patients because of a lack of clinical knowledge and skills. Consequently, students enacted other identities, yet patients perceived them differently, causing conversational ambiguities.
Discussion  Students' perceptions challenge educational goals, suggesting that there is limited potential for the formation of professional identity through early training. Teacher-doctors must acknowledge how students' low levels of clinical competence and patients' behaviour complicate students' identity formation.     

Genesis of the professional-patient relationship in early practical experience: qualitative and quantitative study

CONTEXT: As a rule, undergraduate medical students experience everyday work in health care as spectators. They are not allowed to participate in real-life interaction between professionals and patients. We report on an exception to this rule. OBJECTIVES: The aim of this study was to examine undergraduate students' experiences in developing their first professional-patient relationships on the basis of being responsible for the care of patients. METHODS: The study involved 2 cohorts (2002 and 2003) of medical students, amounting to 503 students. They had all worked in hospitals and/or nursing homes for 4 weeks at the end of their first year of study. Subsequent to this, they produced a case presentation of experiences in this work they perceived as important. These important experiences were the focus of our analysis. RESULTS: Five categories of important experiences were identified. Four of the 5 categories are logically interrelated in that they collectively cover the range of players involved in a caring situation and provide student insights into the interaction between these players. The fifth category is a heterogeneous residue category. Analysis and quantification of these 5 categories reveals a general similarity: students, to an overwhelming degree, are concerned with developing patient-centred care. DISCUSSION: If they are given real responsibility for patient care, undergraduate medical students, of their own accord, tend to develop patient-centred relationships in accordance with the principles of the new professionalism, sometimes in opposition to institutional and/or collegial constraints.     

The effect of professional skills training on patient-centredness and confidence in communicating with patients

OBJECTIVES: The effect of introducing professional skills training on students' patient-centred attitudes and perceptions of ability to communicate was examined. The professional skills training included weekly training in communication skills, ethics and law, and clinical skills. METHODS: Consecutive cohorts of medical students receiving a traditional pre-clinical curriculum (n = 199) and a new curriculum including professional skills training (n = 255) were compared. Students completed the Doctor-Patient Scale to assess patient-centred attitudes and an 11-item scale to assess confidence in their ability to communicate with patients. Students completed the measures at the start of Year 1 and the end of Year 2. RESULTS: Students receiving the professional skills training showed increased confidence in communicating with patients and increases in 2 dimensions of patient-centredness ('holistic care' and 'patient decision making'). Students receiving the traditional curriculum showed increased nervousness in talking to patients. Gender and ethnic differences were found in patient-centredness and confidence in communicating, which were maintained over time. CONCLUSIONS: The introduction of professional skills training was successful in improving students' confidence in their ability to perform specific communicative behaviours and increasing patient-centredness relative to a traditional curriculum.     

Theme-oriented discourse analysis of medical encounters

APPROACH: Theme-oriented discourse analysis looks at how language constructs professional practice. Recordings of naturally occurring interactions are transcribed and combined with ethnographic knowledge. Analytic themes drawn primarily from sociology and linguistics shed light on how meaning is negotiated in interaction. Detailed features of talk, such as intonation and choice of vocabulary, trigger inferences about what is going on and being talked about. These affect how interactants judge each other and decisions are made. Interactions also have larger rhetorical patterns used by both patients and doctors to persuade each other. EXAMPLES: Two settings are used to illustrate this approach: genetic counselling and primary care consultations in multilingual areas. In genetic counselling, interactions are organised around the tension between the risks of knowing and the risks of occurrence. This can lead to a 'rhetorical duel' between health professionals and patients and their families. In intercultural primary care settings, talk itself may be the problem when interpretive processes cannot be taken for granted. Even widely held models of good practice can lead to misunderstandings under these conditions. CONCLUSION; Through discourse analysis, the talk under scrutiny can be slowed down to show the interpretive processes and overall patterns of an activity. Discourse analysts and health professionals, working together, can look at problems in new ways and develop interventions and tools for a better understanding of communication in medical life.     

Low- to high-fidelity simulation – a continuum of medical education?

Context  Changes in medical training and culture have reduced the acceptability of the traditional apprenticeship style training in medicine and influenced the growth of clinical skills training. Simulation is an educational technique that allows interactive, and at times immersive, activity by recreating all or part of a clinical experience without exposing patients to the associated risks. The number and range of commercially available technologies used in simulation for education of health care professionals is growing exponentially. These range from simple part-task training models to highly sophisticated computer driven models.
Aim  This paper will review the range of currently available simulators and the educational processes that underpin simulation training. The use of different levels of simulation in a continuum of training will be discussed. Although simulation is relatively new to medicine, simulators have been used extensively for training and assessment in many other domains, most notably the aviation industry. Some parallels and differences will be highlighted.     

Factors inhibiting assessment of students' professional behaviour in the tutorial group during problem-based learning

CONTEXT: We addressed the assessment of professional behaviour in tutorial groups by investigating students' perceptions of the frequency and impact of critical incidents that impede this assessment and 5 factors underlying these critical incidents. METHODS: A questionnaire asking students to rate the frequency and impact of 40 critical incidents relating to effective assessment of professional behaviour on a 5-point Likert scale was developed and sent to all undergraduate medical students in Years 2-4 of a 6-year undergraduate curriculum. RESULTS: The response rate was 70% (n = 393). Important factors underlying critical incidents are: lack of effective interaction; lack of thoroughness; tutors' failure to confront students with unprofessional behaviour; lack of effort to find solutions, and lack of student motivation. Confirmatory factor analysis showed a good model fit. Because the relationship between frequency of occurrence and degree of impediment varies, the best information about the true impact of critical incidents and the underlying factors is provided by the product of frequency and degree of impediment. Frequency of occurrence remains stable and degree of impediment increases in Years 2-4. CONCLUSIONS: The results of this study can be used to design and improve faculty development programmes aimed at improving assessment of professional behaviour. Training programmes should motivate tutors by providing background information as to why and how sound assessment of professional behaviour is to be performed and encourage tutors to confront students with and discuss all aspects of professional behaviour, as well as provide appropriate feedback.     

Evaluation of self-directed clinical education: validation of an instrument

AIM: To explore the evaluation of self-directed, integrated clinical education. METHODS: We delivered a quantitative and qualitative, self-report questionnaire to students through their web-based learning management system. The questionnaire was distributed 4 times over 1 year, each time in 2 parts. A generic part evaluated boundary conditions for learning, teaching activities and "real patient learning". Factor analysis with varimax rotation was used to validate the constructs that made up the scale and to stimulate hypotheses about how they interrelated. A module-specific part evaluated real patient learning of the subject matter in the curriculum. RESULTS: A total of 101 students gave 380 of a possible 404 responses (94%). The generic data loaded onto 4 factors, corresponding to: firm quality; hospital-based teaching and learning; community and out-patient learning, and problem-based learning (PBL). A 5-item quality index had content, construct and criterion validity. Quality differed greatly between firms. Self-evaluation of module-specific, real patient learning was also valid. It was strongly influenced by the specialty interests of hospital firms. CONCLUSIONS: Quality is a multidimensional construct. Self-report evaluation of real patient learning is feasible, and could be capitalised on to promote reflective self-direction. The social and material context of learning is an important dimension of educational quality.     

How clinical communication has become a core part of medical education in the UK

Context  This paper sets out to analyse and interpret the complex events of the last 20 years in order to understand how the teaching and learning of clinical communication has emerged as a core part of the modern undergraduate medical curriculum in most medical schools in the UK.
Methods  The paper analyses the effects of key political, sociological, historical and policy influences on clinical communication development.
Results  Political influences include: the effects of neo-liberalism on society and on the professions in general; the challenging of traditional notions of professionalism in medicine; the creation of an internal market within the National Health Service, and the disempowerment of the medical lobby. Sociological influences include: the effects of a 'marketised' society on medicine and subtle shifts in the doctor−patient relationship because of this; the emergence of globalised information through the Internet, and the influence of increased litigation against doctors. Historical influences include: the effects of a change in emphasis for medical education away from an inflated factual curriculum towards a curriculum that recognises the importance of student attitudes and the teaching and learning of clinical communication skills. Policy influences include the important effects of Tomorrow's Doctors and the Dearing Report on the modern medical curriculum.
Conclusions  The paper concludes with a developmental map that charts the complex influences on clinical communication teaching and learning and a brief commentary on the growing body of teachers who deliver and develop the subject today.     

Simulation and clinical practice: strengthening the relationship

INTRODUCTION: This discussion paper argues for a creative synthesis between simulation and clinical practice, where an iterative process of continual interaction ensures that skills are learned and reinforced within the context of everyday professional life. BACKGROUND: Evidence is mounting that long-established approaches to surgical training are no longer acceptable in the current ethical and professional climate. This paper considers alternatives to the traditional approach of 'learning by doing' in a clinical context, focusing on recent developments in the technology of simulation and virtual reality. Clinical expertise is a complex phenomenon and no single theory can account for its acquisition. After a brief contextualising overview, Vygotsky's 'zone of proximal development' is proposed as a conceptual framework for task-based surgical learning that takes place within skills laboratories. The discussion is located within a wider context of educational theory, drawing on current thinking about situated learning and apprenticeship. The notion of 'legitimate peripheral participation' in a complex professional environment places technical skill alongside a range of other competencies that are necessary to safe practice. CONCLUSIONS: Simulation offers a safe environment within which learners can repeatedly practise a range of clinical skills without endangering patients. Comprehensive simulated environments allow a move away from isolated tasks to more complex clinical situations, recreating many of the challenges of real life. Such simulations, however, can operate in isolation from their clinical context, ignoring the learning needs of individuals within a real health care environment. To realise its full potential as a learning aid, simulation must be used alongside clinical practice and linked closely with it.