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.     

Teaching interviewing skills to paediatric junior clerks using simulated mothers

In this article a training programme is described for improving interviewing skills of students in the fifth year (junior clerkship) of the medical curriculum. Two interviews with a 'simulated mother' form the core of the programme. The interviews are immediately followed by a feedback session in which the simulated mother discusses the strong and the weak points of the interview. In the feedback she makes use of a checklist with relevant points concerning the content and the process of the interview. Where required the comments are substantiated with fragments of the videotaped interview. In a 2-hour theoretical session, students are told how to prepare themselves for the interview. The learning effects of the training programme using simulated mothers were evaluated in order to determine: (1) the subsequent improvement in interviewing skills; and (2) the effect of the feedback session. It was found that students' interviewing skills improved significantly on the content and the process aspects after one or two interviews. In addition the feedback sessions proved very helpful, although no significant differences were revealed, when comparing the mean group scores for students who had had feedback sessions with the scores for those who had not. The results also revealed that two interviews were insufficient and that the training should include at least three interviews. This was borne out by the large number of students who asked for more interviews with simulated mothers. In the training programme the simulated mothers perform two functions: (1) playing the role of the mother of a sick child; and (2) giving feedback to students regarding their interviewing skills.(ABSTRACT TRUNCATED AT 250 WORDS)     

Behavioural assessment of the effectiveness of a communication programme for medical students

Summary. This study evaluated the effectiveness of a communication programme taught to medical students at the University of Melbourne in their preclinical years. The effectiveness of the programme was assessed by comparing videotaped history-taking interviews completed by a cohort of first-year clinical students in 1986, who had not undertaken the communication programme, with a similar cohort of first-year clinical students in 1992 who had undertaken the programme. The students from the 1986 cohort who had not undertaken communication training in their preclinical course completed their videotaped interviews as part of the experimental evaluation of a consulting skills training programme carried out in 1986-87. A comparison of ratings given by two experimentally naive, independent observers revealed that the 1992 student cohort demonstrated some significantly better skills at questioning and facilitating communication with patients. By contrast, the 1986 student cohort showed significantly greater skills at maintaining relevance in their interviews and greater capacity to explore patients' psychosocial concerns. These data suggest that students acquire the most effective interview skills when interacting with patients during their clinical training.     

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.     

Interactional skills of students from traditional and non-traditional medical schools before and after alcohol education

OBJECTIVE: To compare alcohol-related intervention and general interactional skills performance of medical students from a traditional (Sydney) and a non-traditional (Newcastle) medical school, before and after participation in an alcohol education programme about brief intervention. DESIGN: In two controlled trials, students received either a didactic alcohol education programme or didactic input plus skills-based training. Prior to and after training, all students completed videotaped interviews with simulated patients. SETTING: The Faculties of Medicine at the University of Newcastle and the University of Sydney, Australia. SUBJECTS: Fifth-year medical students (n=154). RESULTS: Both alcohol-related intervention and general interactional skills scores of the Newcastle students were significantly higher than those of the Sydney students at pre-test but not after training. Although alcohol-related interactional skills scores improved after training at both universities, they did not reach a satisfactory level. The educational approach used had no effect on post-test scores at either university. CONCLUSIONS: Significant baseline differences in interactional skills scores favouring non-traditional over traditional students were no longer evident after both groups had been involved in an alcohol education programme. Further research is required to develop more effective alcohol intervention training methods.     

Training medical practitioners in information transfer skills: the new challenge

Summary. Traditionally, undergraduate medical education has concentrated on teaching students how to gather information or take medical histories from their patients. However, research increasingly indicates that there is a need for medical practitioners to improve their skills in information transfer in a way which will increase the probability that patients are active collaborators in their treatment. Consequently, Newcastle Medical School has sought to develop training packages for medical students in information transfer skills. This paper describes the resulting training programme with particular emphasis on the areas selected for training, the methods by which students are taught, the necessary interactional skills and the assessment procedures which are applied.     

Retention of interviewing skills learned by first-year medical students: a longitudinal study

A pilot interviewing course was offered as an elective to first-year medical students in the spring of 1985. A quasi-experimental pre-test/post-test control group demonstrated that students who took the course exhibited a significant increase in interviewing skills. Subjects, 15 in the experimental group and 11 in the control group, were assessed in each of the following 3 years. Data consisted of five 10-minute videotaped interviews with real or stimulated patients for each subject and subject's responses on a degree of confidence, familiarity and anxiety scale. Interviews were rated on 43 behaviours by two independent coders with a 90% simple agreement. The experimental group did not maintain their scores on interviewing skills and both groups showed a significant decline in nine skills comprising empathy. The only significant difference between the groups in fourth year was on the degree of confidence experienced. While interviewing skills can be learned they decline in the clinical years as students learn medical problem-solving. If medical students are to graduate with their original empathy intact, a follow-up course in fourth year is indicated.     

An evaluation of medical student behaviours in communication

An evaluation of fourth-year medical student behaviours in communication with real patients in general practice is reported using two different formats of rating scale. The study was performed in the clinical base of the Department of General Practice, the Queen's University, Dunluce Health Centre, Belfast. In all, 475 interviews were rated, 238 being first interviews and 237 second interviews. The format of the rating scale was not found to be a significant variable. Factor analysis of the rating scale item scores produced five factors, which fell into two clear groupings. Factors 2 and 4 represent communication skills, which could have been acquired through normal social learning. Factors 1, 3 and 5 constitute more technical and professional skills not usually employed in normal social intercourse. Analysis of data from first and subsequent interviews indicates that the students in the study had acquired professional skills, which require special teaching. These are identified in Factors 1, 3 and 5 and require a proper emphasis in training.     

Lectures and skills workshops as teaching formats in a history-taking skills course for medical students

The consulting skills acquired by medical students during their training are an important determinant of their ability to conduct adequate and efficient clinical interviews. These skills comprise: the acquisition of medical knowledge and the ability to apply this; and communication skills required to obtain full, accurate clinical histories from patients and to be able to give to patients the information they need to comply with prescribed regimens. Until recently, consulting skills training has certainly not had a high profile in medical curricula, despite evidence that students do not gain sufficient expertise during their medical training. A history-taking skills course within the Austin Hospital Clinical School, utilizing mass lecture and small-group skills workshops is described. Independent evaluation of students' videotaped interviews with patients, completed before training, after mass lectures and following small-group workshops, showed that students trained in consulting skills demonstrated significant improvements in interview skills and techniques, compared with a similar group of students for whom training followed the more traditional model. Whilst there were some improvements after mass lectures, most significant gains in history-taking skills were obtained following skills workshops. Ongoing evaluation of these students will determine if these short-term improvements in consultation skills persist over their clinical training and internship.     

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.     

Factors influencing the communication skills of first-year clinical medical students

The aim of this study was to examine the factors influencing medical students' communication skills. The sample comprised all first-year clinical students. Thirty-two received teaching in communication skills during the year; the remaining 56 did not. Students' career preferences, attitudes towards communication skills and confidence in their ability to communicate with patients were assessed by questionnaire at the beginning and end of the year. At the end of the year each student was videotaped interviewing a simulated patient. Students' communication skills were assessed on the basis of this interview by raters using a standardized rating scale, and by patient questionnaires. While there was some evidence that brief communication skills training improved skills, sex of student was a more significant predictor of level of skill. Students who perceived communication skills as less relevant to medicine and those who were more confident about their own communication skills were more likely to prefer a career in hospital medicine. Students' judgements of their ability to communicate effectively were poor. In the main there was no relationship between confidence and level of skill: where they were related, the association was negative. The benefits from communication skills training might be enhanced by involving hospital doctors in the teaching, and providing students with detailed video feedback on their skills at the outset.     

Refugees and medical student training: results of a programme in primary care

CONTEXT: Medical schools have responded to the increasing diversity of the population of the USA by incorporating cultural competency training into their curricula. This paper presents results from pre- and post-programme surveys of medical students who participated in a training programme that included evening clinical sessions for refugee patients and related educational workshops. METHODS: A self-assessment survey was administered at the beginning and end of the academic year to measure the cultural awareness of participating medical students. RESULTS: Over the 3 years of the programme, over 133 students participated and 95 (73%) completed pre- and post-programme surveys. Participants rated themselves significantly higher in all 3 domains of the cultural awareness survey after completion of the programme. CONCLUSIONS: The opportunity for medical students to work with refugees in the provision of health care presents many opportunities for students, including lessons in communication, and scope to learn about other cultures and practise basic health care skills. An important issue to consider is the power differential between those working in medicine and patients who are refugees. To avoid reinforcing stereotypes, medical programmes and medical school curricula can incorporate efforts to promote reflection on provider attitudes, beliefs and biases.     

The views of senior students and young doctors of their training in a skills laboratory

The study was carried out in the Faculty of Medicine and Health Sciences (FMHS), United Arab Emirates (UAE) University, UAE, where a skills laboratory was set up in 1988 to train medical students in clinical skills before they use such skills on patients. The students learn clinical skills using simulated patients, models and mannequins. The training starts in the first year of the 6-year undergraduate curriculum and continues until the end of the fourth year, after which students rotate through the clinical specialties. This study sought to identify: (1) the views of senior clerks (sixth year) and interns (first postgraduate year) regarding the clinical skills training in the skills laboratory (SKL) during the early years of the medical curriculum; (2) the differences in views between senior clerks and interns; (3) the differences in views between women and men students. Students' views about communication, interviewing, physical examination, therapeutic, diagnostic and laboratory skills were investigated. The results indicated that prior training in clinical skills was helpful to the senior clerks and the interns. Statistically significant differences in opinion were noted between the senior clerks and the interns, the interns being more positive about the usefulness of the SKL training compared with learning clinical skills directly on patients. There was no difference between men and women students except that women students were not comfortable with allowing their peers to examine any part of their bodies. The findings of the study have direct implications for the SKL programme.     

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.     

The Objective Structured Video Exam for assessment of communication skills

OBJECTIVES: (i) To design a new, quick and efficient method of assessing specific cognitive aspects of trainee clinical communication skills, to be known as the Objective Structured Video Exam (OSVE) (Study 1); (ii) to prepare a scoring scheme for markers (Study 2); and (iii) to determine reliability and evidence for validity of the OSVE (Study 3). METHODS: Study 1 describes how the exam was designed. The OSVE assesses the student's recognition and understanding of the consequences of various communication skills. In addition, the assessment taps the number of alternative skills that the student believes will be of assistance in improving the patient-doctor interaction. Study 2 outlines the scoring system that is based on a range of 50 marks. Study 3 reports inter-rater consistency and presents evidence to support the validity of the new assessment by associating the marks from 607 1st year undergraduate medical students with their performance ratings in a communication skills OSCE. SETTING: Medical school, The University of Liverpool. RESULTS: Preparation of a scoring scheme for the OSVE produced consistent marking. The reliability of the marking scheme was high (ICC=0.94). Evidence for the construct validity of the OSVE was found when a moderate predicted relationship of the OSVE to interviewing behaviour in the communication skills OSCE was shown (r=0.17, P < 0.001). CONCLUSION: A new video-based written examination (the OSVE) that is efficient and quick to administer was shown to be reliable and to demonstrate some evidence for validity.     

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.     

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.     

Longitudinal and Concentrated Communication Skills Programmes: Two Dutch Medical Schools Compared

Aim of the study:The communication skills of students of the Dutch medical schools of Maastricht and Leiden were compared, to assess the effectiveness of these schools' different approaches to communication skills training. Both schools have a six-year undergraduate medical curriculum, divided into four preclinical years and two years of clinical clerkships. The Maastricht problem-based curriculum offers an integrated clinical skills training programme, including communication skills, which runs throughout the first four years. Communication skills training in Leiden is concentrated in courses in the preclinical phase, at the beginning of the clinical phase and preceding two clerkships. Method:Communication skills of fourth-year and sixth-year students (N = 161) of both universities were assessed using four OSCE stations in which students did entire consultations with standardised patients. Trained observers rated these consultations, using a checklist. Results:Maastricht students of both year groups obtained significantly higher checklist scores for their communication skills than their Leiden colleagues. The Leiden students' scores increase between years 4 and 6, whereas those of the Maastricht students showed no significant change. Discussion:The higher scores obtained by the Maastricht students indicate a greater overall effectiveness of a longitudinal, integrated approach compared with concentrated courses. Absence of formal training in the clinical phase in Maastricht leads to stabilisation of communication skills, whereas the increase in the Leiden students' scores between years 4 and 6 offers evidence that formal communication skills training during the clinical phase does pay off. These findings suggest that the preferred approach to communication skills training would be an integrated, longitudinal programme, which continues during the clinical years. This revised version was published online in June 2006 with corrections to the Cover Date.     

Communication skills and undergraduate medical education

This paper reports some aspects of teaching communication skills based on experience with over 100 pre-clinical students in each of two years. Students interviewed patients selected by general practitioner tutors from their practices and 214 interviews, recorded on videotape, were subsequently analysed. Without having been given detailed instruction, approximately two-thirds of each class of second year students (mean age 194 years) sustained a consultation for 5 minutes or more. Over one half of the students elicited the salient features of the patients' problems within this short time. Anxiety exhibited by the majority of students could be seen to influence the interviews in several ways. These manifestations and the ways in which the interview was affected are briefly described. When some of the patients were subsequently interviewed by postgraduate trainees in general practice, the consultations differed in a number of respects. These differences are described, and the possible significance of the observations is discussed in relation to medical education.     

The surgical clerkship: characteristics of the effective teacher

A good relationship between medical students and clinicians is crucial to a positive learning experience. To increase contact between surgical teaching staff and students, a teacher programme was instituted in the problem-based surgical clerkship at the University of Kentucky. This study examined the teacher traits and skills that medical students perceive as distinguishing effective from ineffective teachers. The 312 evaluations collected from students in successive surgical clerkship rotations (87% response rate) were used to determine the characteristics of the effective teacher. Results suggest that students rate increased contact with surgical teaching staff highly and that they value increased mentoring by the staff. The traits of teachers rated highly by students in the surgical clerkship include: being a positive role model, encouraging communication, and being well organized. Comparing data from the 2 years of the clerkship also revealed that providing feedback to staff on their performance as teachers enabled them to improve their instructional skills.