Preliminary evaluation of "interpreter" role plays in teaching communication skills to medical undergraduates

RATIONALE AND OBJECTIVES: Multiculturalism presents linguistic obstacles to health care provision. We explored the early introduction of "interpreter" role-play exercises in teaching medical undergraduates communication skills. The interpreter role creates a natural barrier in communication providing an active prompt for recognizing learning needs in this area. METHODS: Bilingual Cantonese first-year medical students (n=160) were randomly allocated to either "Observer" or "Interpreter" role plays at a small-group introductory communication skills workshop using a quasi experimental design, counterbalanced across tutors. Students assessed their own skill competence before and, together with their perceptions of the different role plays' effectiveness, again after the workshop, using an anonymous 16 item Likert-type scale, analysed using ANOVA and MANOVA. RESULTS: Students' assessments of their skills improved significantly following the workshop (F=73.19 [1,156], P=0.0009). Students in the observer group reported greater changes in their scores following the workshop than did students in the interpreter group (F=4.84 [1,156], P=0.029), largely due to improvement in perceived skill (F=4.38 [1,156], P=0.038) rather than perceived programme effectiveness (F=3.13 [1,156], P > 0.05). Subsequent MANOVA indicated no main effect of observer/interpreter conditions, indicating these differences could be attributed to chance alone (F=1.41 [16 141], P > 0.05). CONCLUSION: The workshop positively influenced students' perceived communication skills, but the "Interpreter" role was less effective than the "Observer" role in achieving this. Future studies should examine whether interpreter role plays introduced later in the medical programme are beneficial.     

A study of pre-registration house officers' clinical skills

BACKGROUND: Little is known about the ability of pre-registration house officers (PRHOs) to perform basic clinical skills just prior to entering the medical register. OBJECTIVES: To find out whether PRHOs have deficiencies in basic clinical skills and to determine if the PRHOs themselves or their consultants are aware of them. METHOD: All 40 PRHOs at the Chelsea and Westminster and Whittington Hospitals were invited to undertake a 17 station OSCE of basic clinical skills. Each station was marked by one examiner completing an overall global score after completing an itemised checklist. An adequate station performance was the acquisition of a pass/borderline pass grade. Prior to the OSCE, a questionnaire was given to each PRHO asking them to rate their own abilities (on a 5-point scale) in the skills tested. A similar questionnaire was sent to the educational supervisors of each PRHO asking them to rate their house officer's ability in each of the same skills. RESULTS: Twenty-two PRHOs participated. Each PRHO failed to perform adequately a mean of 2.4 OSCE stations (SD 1.8, range 1-8). There were no significant correlations between OSCE performance and either self- or educational supervisor ratings. The supervisor felt unable to give an opinion on PRHO abilities in 18% of the skills assessed. DISCUSSION: This study suggests that PRHOs may have deficiencies in basic clinical skills at the time they enter the medical register. Neither the PRHOs themselves nor their consultants identified these deficiencies. A large regional study with sufficient power is required to explore the generalizability of these concerns in more detail.     

Parents-as-teachers: design and establishment of a training programme for paediatric residents

OBJECTIVES: To improve the training of paediatric residents in general and to provide more meaningful insights into family functioning. DESIGN: The programme is one facet of a 1-month developmental disabilities rotation for paediatric PL2 residents. It incorporates elements of family-centred care whereby physicians learn through home and community site visits about the importance of developing partnerships with parents and service providers in order to give better care to children with chronic conditions. SETTING: Gillette Specialty Health Care Center, St Paul, Minnesota. SUBJECTS: Paediatric PL2 residents and a parent group. RESULTS: Of 18 residents, 11 completed written and 18 completed oral feedback evaluations. There were infrequent but consistent complaints relating to logistics; more positive comments were made about the programme and individuals involved. CONCLUSIONS: In the minds of all participants, the Parents-as-Teachers (PAT) programme has been highly successful, as documented by short-term objective and subjective parent and resident feedback. The PAT experience represents a unique opportunity for parents and physicians-in-training to improve their mutual understanding. While not analysed in this report, the inclusion of a complementary programme involving on-site teaching in various community agencies also appears to be of value.     

The development and evaluation of a personal learning log for Senior House Officers

OBJECT: To develop and evaluate the effect of having a personal learning log on Senior House Officers knowledge and confidence. METHODS: A multiple choice paper and a confidence checklist for two hospital specialties were developed to assess knowledge and confidence. These were administered to a control group and to an intervention group who had the learning log. Both groups completed an evaluation at the end of the post. SETTING: The study took place in Accident & Emergency and Obstetric & Gynaecology posts in Greater Glasgow and Lanarkshire. SUBJECTS: 79 Senior House Officers in Accident & Emergency and 78 Senior House Officers in Obstetrics & Gynaecology. RESULTS: The mean scores in the MCQ and the mode in the confidence checklist increased significantly in both specialties during the post, but there was no significant difference between the control and intervention groups. Forty two learning logs were returned at the end of the study and analysis of these revealed that there was great scope for learning but few documented the specific learning achieved. Evaluation of the posts revealed that some improvements had taken place in teaching and assessment frequency, however, there was scope for further improvement. CONCLUSION: While the problems of hospital training are well documented, an attempt to improve the situation using a learning log did not have a statistically significant impact on SHO knowledge or confidence. A six-month hospital post appears to present many opportunities for learning but these are not exploited. It is suggested that three things are needed. Firstly, active participation by and personalized feedback from a senior member of staff, with training where needed. Secondly, protected time for tutorials with a planned system of formative assessment, and thirdly, a more positive approach to learning by both SHOs and consultants. Once this occurs, a learning log may have a more significant impact on training.     

Attitudes of medical faculty physicians about taking occupational history

OBJECTIVES: To evaluate occupational history taking, as a detailed occupational history is the most effective means for proper diagnosis of occupational illness. METHODS: In order to determine the attitudes of 66 physicians working in Dokuz Eylül Medical Faculty Hospital about taking occupational history, 269 patient records were examined. RESULTS: It was detected that 43.9% of physicians took no occupational history from any of their patients. Occupational history was obtained from 81.8% of the patients in clinics where standard examination forms were in regular use. CONCLUSION: We found that physicians were not in the habit of taking occupational histories.     

Training physicians in communication skills with adolescents using teenage actors as simulated patients

Role-play exercises with simulated patients may serve the purpose of training professionals to develop appropriate communication skills with adolescents. Authentic adolescent responses toward the physicians may be achieved by actors who themselves are in their teenage years. We describe our experience in continuing medical education programmes for primary care physicians aimed at improving their skills in communicating with adolescents, using simulation methodology with teenage actors. Eight 16-17-year-old actors from the drama department of a high school for the arts were trained to simulate 20 cases with characteristic adolescent medical problems, as well as confidentiality issues and home and school problems. The actors performed in front of large groups of 20-30 paediatricians, family practitioners, or gynaecologists in continuing medical education. Diagnostic issues as well as therapeutic and management approaches were discussed, while the actors provided feedback to the trainees about their understanding and their feeling regarding the issues raised during the exercises. Normally, smaller learning groups are more suitable for such training purposes; nevertheless the participants could appreciate learning the principles of careful listening, a non-judgmental approach and assuring confidentiality. A collaboration of medical schools and postgraduate programmes with high schools which have drama departments may be fruitful in the teaching of adolescent medicine with special emphasis on communication skills with teenagers.     

Identifying core skills for the medical curriculum

A survey was undertaken at the University of Sheffield Medical School to identify clinical and other professional skills which are required on graduation and to assess whether and when these skills have been acquired. The purpose of the survey was to identify core practical skills, defined as skills which the majority of clinical firms require and which, in addition, were used by the majority of Pre-registration house officers (PRHOs). The survey was conducted by questionnaires which were circulated to the following four sample groups (number in sample: % response rate): (1) consultants in clinical firms taking undergraduates and post-graduates from Sheffield Medical School (63: 75%); (2) house officers starting their pre-registration year (118: 52%); (3) house officers ending their pre-registration year (120: 43%); and (4) undergraduates starting their final year (110: 65%). The questionnaire contained a stimulus list of 31 clinical and four personal skills with an opportunity for respondents to list other skills they felt to be important. Of the 35 skills listed on the questionnaire, 26 were identified as core practical skills. Fifteen of the core skills had been acquired by the majority of students by the time they graduated, 13 of which were acquired prior to the final undergraduate year. Core skills not acquired as an undergraduate were acquired as a PRHO. The survey acted as a quality control mechanism for teaching at both undergraduate and post graduate levels and provided the basis of a medical school core of practical skills on the basic medical education continuum.     

Education and training in the senior house officer grade: results from a cohort study of United Kingdom medical graduates

INTRODUCTION: This paper shows the findings from a survey of 439 senior house officers undertaken as part of the British Medical Association cohort study of 1995 medical graduates. The aim of the study was to assess the quality of senior house officer training in the United Kingdom. METHOD: In July 1997 a postal questionnaire was sent to a sample of 545 doctors who graduated from medical school in 1995. Responses were received from 515 (95%). Only those doctors who had worked as a senior house officer in the previous 12 months were included in the analysis (n = 439). RESULTS: Encouraging results are that 69% of the senior house officers surveyed had discussed their progress directly with their consultant, and 24% rated their supervision by their consultant as 'excellent'. Of concern are the findings that 47% of respondents did not receive protected teaching time and 16% were unable to take study leave. DISCUSSION: The study revealed wide variability in the quality of training received by senior house officers in the United Kingdom. Whilst some respondents - notably those in general practice, accident and emergency, paediatrics and psychiatry - had enjoyed a high standard of education and training, it was clear that a minority of posts continue to offer little if any educational value to the post holder. The results point to a need for a more systematic approach to maintaining standards in senior house officer training with greater incentives for under-performing trusts.     

Meeting the needs of future physicians: a core curriculum initiative for postgraduate medical education at a Canadian university

In addition to possessing medical expertise, contemporary physicians are expected to be skilled communicators, critical consumers and users of medical research, teachers, collaborators, health care advocates, and managers. A core curriculum is a common set of learning experiences designed to help prepare physicians for these complex roles. PURPOSE: This article describes the design and implementation of one core curriculum, summarizes the feedback received from residents, and shares some of the lessons we are learning as we use feedback to develop our programme. METHOD: The core curriculum described was implemented at a Canadian university which offers 56 residency programmes with a total enrollment of approximately 360 students. The curriculum consisted of 30 sessions organized around four themes: biostatistics and epidemiology; communications and teaching skills; healthcare management, and ethical, medicolegal and lifestyle issues. Each session in the Core Curriculum was evaluated by residents with respect to the timing, quality, and value of the learning experience. In addition, residents participated in focus group discussions of their Core Curriculum experiences. RESULTS: Key findings related to the characteristics of effective core curriculum learning experiences and to the barriers to implementing a core curriculum across programmes. Of particular salience were findings related to explicit issues of attendance and the diverse needs of learners and programmes, and to more implicit issues of communication and managing change. The specific content and format of the Core Curriculum and the results of the evaluation process will be of interest to others considering a core curriculum for postgraduate medical programmes.     

Examiner fatigue in communication skills objective structured clinical examinations

CONTEXT: The assessment of undergraduates' communication skills by means of objective structured clinical examinations (OSCEs) is a demanding task for examiners. Tiredness over the course of an examining session may introduce systematic error. In addition, unsystematic error may also be present which changes over the duration of the OSCE session. AIM: To determine the strength of some sources of systematic and unsystematic error in the assessment of communication skills over the duration of an examination schedule. METHODS: Undergraduate first-year medical students completing their initial summative assessment of communication skills (a four-station OSCE) comprised the study population. Students from three cohorts were included (1996-98 intake). In all 3 years the OSCE was carried out identically. All stations lasted 5 minutes with a simulated patient. Students were assessed using an examiner (content expert) and a simulated-patient evaluation tool, the Liverpool Communication Skills Assessment Scale (LCSAS) and the Global Simulated-patient Rating Scale (GSPRS), respectively. Each student was assigned a time slot ranging from 1 to 24, where 1, for example, would denote that the student entered the exam first and 24 indicates the final slot for entry into the examination. The number of students who failed this exam was noted for each of the 24 time slots. A control set of marks from a communication skills written exam was also adopted for exploring a possible link with the time slot. Analysis was conducted using graphical display, covariate analysis and logistic regression. RESULTS: No significant relationship was found between the schedule point that the student entered the OSCE exam and their performance. The reliability of the content expert and simulated-patient assessments was stable throughout the session. CONCLUSION: No evidence could be found that duration of examining in a communication OSCE influenced examiners and the marks they awarded. Checks of this nature are recommended for routine inspection to confirm a lack of bias.     

Physician communication skills training: a review of theoretical backgrounds,objectives and skills

CONTEXT: Significant shortcomings have been noted in the literature in communication skills training for practising doctors. Given the importance of competent communication to the doctor-patient relationship and health care in general, these shortcomings should be addressed in future research. OBJECTIVE: Research into physician communication skills training is examined with respect to the communication objectives and behaviours that are addressed. METHODS: A Medline search of literature from 1990 to the present was conducted. RESULTS: A total of 26 studies of doctor communication skills training were found. The majority of studies included insufficient information about the communication behaviours taught to participants. In several studies, there was a mismatch between stated behaviours and instruments or procedures used to assess them. CONCLUSION: Three recommendations are suggested. Firstly, future researchers should take greater care in matching assessment instruments with stated communication skills. Secondly, researchers should provide and use a theoretical framework for selecting communication skills to address in interventions, and thirdly, the timing of communication skills within the interview context should be part of the instruction in interventions.     

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.     

Assessing the development of communication skills in undergraduate medical students

CONTEXT: The teaching of clinical communication skills' teaching has become an important part of medical school curricula. Many undergraduate medical courses include communication skills training at various points in their curriculum. Very few reports have been published on the development of communication skills over the duration of a medical undergraduate training. AIMS: To determine the change in communication skills between early and mid-stages of the students' 5-year curriculum, and to investigate the predictive and theoretical significance of knowledge and understanding of communication skills in relation to observed performance. PARTICIPANTS: Students entering as the first cohort to the new medical curriculum at Liverpool Medical School (n=207). Nine students withdrew leaving 198 students who completed two summative assessments in June 1997 (level 1) and November 1998 (level 2). STATISTICAL ANALYSIS: Repeated measures multivariate ANOVAS were applied to the main study data to detect any change in performance between levels 1 and 2. RESULTS AND CONCLUSIONS: An improvement in communication skills was found in medical students over 17 months of their undergraduate teaching: that is from the level 1 to the level 2 assessment. Knowledge and understanding of communication skills at initial assessment did not show the predicted association with performance at level 2.     

A modified essay question evaluation of pre-clinical teaching of communication skills

This paper describes the use of a modified essay question to investigate the nature of certain cognitive changes associated with some quite specific preclinical teaching. Although the teaching was aimed at developing communication skills, it appeared to draw attention to some broader aspects of health and the role of the general practitioner. The MEQ indicated that a number of important changes appeared to be associated with the teaching experience.     

Workshops for consultants on the teaching of clinical communication skills

Summary. A group of senior medical school staff concerned about the short-lived effects of communication training formed the Medical Interview Teaching Association. They felt that communication training needed to be reinforced throughout the curriculum and that this would need active involvement by large numbers of consultants. To achieve this they planned a series of workshops. Seventeen consultants and eight other senior staff agreed to participate in the pilot workshop. This was a 3 1/2-day residential workshop. The structure was adapted from a ‘faculty development’ model used successfully in the USA. Participants worked mostly in small groups helped by experienced facilitators. The teaching style was learner centred and therefore the details of the problem-based agenda and the choice of working methods were largely determined by the participants themselves. There were also some conventional lectures and demonstrations. Evaluation was by postal questionnaire 2 weeks later. This requested both qualitative comments and Likert scale ratings about every aspect of process and outcome. Most responses were strongly positive. Participants felt they made good progress in developing new skills and new curriculum ideas. They also felt more motivated and self-aware as teachers. The learner-centred approach and the diversity of learning activities were seen as very useful. The unstructured approach to self-awareness training was felt to be less useful. It is concluded that such workshops could well lead to more effective communication training and may also have wider implications for medical education.     

Teaching skills in communication to medical students— a critical review of the methodology

Over the past decade, there has been a substantial increase in papers concerned with training medical students in communication skills. In this paper, we consider what constitutes an adequate methodology for such research and whether recent papers meet this standard.     

Evaluation of a programme of workshops for promoting the teaching of critical appraisal skills

The aim of this study was to assess the effectiveness of four training workshops at the inception of a programme to cascade critical appraisal skills training throughout Scotland. Data were collected from all participants and organizers at four commissioned critical appraisal skills training workshops in Scotland. The collection of data involved three components: a survey of workshop participants before and after each workshop to determine knowledge of the principles of clinical effectiveness; semi-structured interviews with organizers before, during and after the programme of commissioned workshops to assess views on the workshops; and a postal survey to determine involvement in critical appraisal activities following the initial workshops. The main outcome measures were 'change in knowledge' and subsequent involvement in teaching. An average of 41 people attended each workshop. Participants improved their scores on understanding of clinical effectiveness. Not all of the improvement can be ascribed to the workshops, however, because control item scores also improved, albeit to a lesser extent. The workshops were perceived as an acceptable way of acquiring critical appraisal skills, but doubts were expressed about whether participants would be able to roll out the programme on their own. Of the 32 (42%) attendees who were involved in CASP-style workshops after the initial workshops, 26 (34%) providing aspects of teaching, and a further six (8%) were participants. The evaluation of the CASP workshop technique suggests that it does improve knowledge of clinical effectiveness, but concerns remain about the viability and reliability of this approach as it rolls out training within Scotland.     

Context-bound communication skills training: development of a new method

OBJECTIVES: To examine how communication skills training might be integrated into everyday clinical practice in a manner that is acceptable to clinicians. DESIGN: General practitioners from 3 group practices agreed to take part, in turn, in a study of how to manage difficult consultations about antibiotic prescribing for acute respiratory infections. This provided the opportunity to conduct communication skills training in which lessons learned from one practice were taken into the next. SETTING: United Kingdom general practices. SUBJECTS: Three groups of general practitioners. FINDINGS: Difficulties with the acceptability of a traditional off-site workshop approach, using role play as the main teaching method, led to the development of a new training method (context-bound training), which proved to be practical and acceptable to experienced clinicians. The main features of the method were the delivery of training in the clinicians' place of work, and the transformation of their reported difficult cases into scenarios which they then encountered with a standardized simulated patient before and after brief seminars. Everyday clinical experience was kept in the foreground and 'communication skills' in the background. CONCLUSIONS: The method is acceptable to clinicians and adaptable to a range of clinical situations. It offers potential for improving the communication skills of clinicians both in hospital and primary care settings.     

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.