Effectiveness of a brief training program in relational/communication skills for medical residents

ObjectiveTo assess the effectiveness of a brief training program in relational/communication skills (RCS) for medical residents.MethodsThis longitudinal study enrolled 64 medical residents who participated in a RCS training program in small groups. Teaching was based on interviews with standardized patients and reflective practice. Video-recorded consultations were coded according to the Verona-Coding-Definitions-of-Emotional-Sequences (VR-CoDES) and a coding system developed to assess ten communication skills for breaking bad news. The outcome measures were: independent raters’ score in RCS for breaking bad news and the percentage of providing space and empathic responses, by comparing baseline (T1) skills with those after three-days (T2) and three-months (T3).ResultsAfter the training program residents provided more space for further disclosure of cues and concerns according to VR-CoDES definitions. There were significant improvements in seven of the ten communication skills for breaking bad news. All of these improvements were observed either at T2 or at T3.ConclusionThis study demonstrates the effectiveness of a brief RCS training program designed to improve medical residents’ ability to respond appropriately to patients’ cues and concerns and to conduct a breaking bad news encounter.Practice implicationsBrief RCS training programs adopting multiple approaches, should be offered as mandatory during residency programs.     

Reflective writing in the teaching of communication skills for medical students—A systematic review

ObjectiveTo analyse the use, assessment, and measured outcomes of reflective writing (RW) in teaching communication to medical students.MethodsSystematic search of seven electronic databases, focused on using RW in teaching communication skills. Three reviewers selected and prepared the synthesis of the studies. The synthesis was based on thematic analysis using Braun and Clarke’s approach.ResultsWe identified 1325 studies, reviewed 101 full-text articles, and included 12 articles in the analysis. The four themes identified showed that RW is not a stand-alone practice. RW is blended with other teaching strategies. Through RW, students identified structural, emotional, and relational aspects and challenges of communication. Only a few studies found a positive correlation between reflective ability and communication skillsConclusionRW can be integrated with various teaching methods, at all stages of learning, to stimulate discussion of interpersonal and intrapersonal topics. Through RW, students explore theirs and their patient’s emotions, values, behaviours, and needs identifying challenges and practices relevant to communication. Practice implications: RW can address different structural, relational, and emotional issues that are relevant to communication learning. Further educational development and high-quality empirical research on the use of RW and unique outcomes are needed to support communication skills learning.     

Assessing patients´ preferences for breaking Bad News according to the SPIKES-Protocol: the MABBAN scale

ObjectiveQuality of breaking bad news can seriously affect the course of disease. A frequently applied guideline is the SPIKES-Protocol that have been designed from the physician’s perspective. Little is known about patients’ preferences in breaking bad news. Our aim was to develop a questionnaire based on the SPIKES-protocol to detect patients´ preferences for breaking bad news communication.MethodsTheMarburg Breaking Bad News Scale (MABBAN) was developed and administered to 336 cancer patients. We used exploratory factor analysis. To examine potential relationships according to demographic and medical variables, regression analyses were conducted.ResultsThe novel questionnaire supported the six SPIKES-components of breaking bad news: Setting, Perception, Invitation, Knowledge, Emotions, and Strategy. Perception and Invitation clustered together to one subscale. Depending on clinical and demographic variables different components were rated as important.ConclusionCommunication preferences in breaking bad news can be assessed using a SPIKES-based questionnaire. Physicians should improve the setting, share knowledge in all clarity, involve the patients in further planning, and consider demographical variables.Practice implicationsUsing SPIKES as a framework can optimize breaking bad news conversations but it seems important to emphasize the individual preferences beyond the six steps and tailor the communication process to the individual.     

What keeps you up at night? Genetics professionals' distressing experiences in patient care

PurposeTo explore specific patient care experiences that genetics professionals associate with distress and the emotions engendered by those experiences.MethodsWe conducted semistructured telephone interviews with clinical geneticists, genetic counselors, and genetic nurses that focused on a single distressing experience.ResultsFourteen clinical geneticists, 25 genetic counselors, and 14 nurses were interviewed. We categorized the situations that interviewees associated with distressing patient care experiences into seven major types: patient/family decisions (27% of total situations), giving bad news (17%), colleague behavior (15%), end-of-life issues (12%), unintended outcomes (12%), difficult patients (8%), and injustice/inhumanity (8%). Interviewees reported experiencing a variety of negative emotions during these situations, including anger, guilt, helplessness, and inadequacy.ConclusionsThe distress and resulting emotions experienced by genetic service providers must be acknowledged. Interventions are needed to assist the clinician in becoming self-aware by reflecting on experienced emotions, examining belief systems and values, and understanding the connection between their emotions and behavior. Involvement in mindfulness meditation, reflective writing, peer support groups or additional communication skill-based training could address this need. In addition, clinicians should seek ways to increase personal meaning derived from providing patient care.     

Learning communication from erroneous video-based examples: A double-blind randomised controlled trial

ObjectiveAppropriate training strategies are required to equip undergraduate healthcare students to benefit from communication training with simulated patients. This study examines the learning effects of different formats of video-based worked examples on initial communication skills.MethodsFirst-year nursing students (N = 36) were randomly assigned to one of two experimental groups (correct v. erroneous examples) or to the control group (no examples). All the groups were provided an identical introduction to learning materials on breaking bad news; the experimental groups also received a set of video-based worked examples. Each example was accompanied by a self-explanation prompt (considering the example’s correctness) and elaborated feedback (the true explanation).ResultsParticipants presented with erroneous examples broke bad news to a simulated patient significantly more appropriately than students in the control group. Additionally, they tended to outperform participants who had correct examples, while participants presented with correct examples tended to outperform the control group.ConclusionThe worked example effect was successfully adapted for learning in the provider-patient communication domain.Practice ImplicationsImplementing video-based worked examples with self-explanation prompts and feedback can be an effective strategy to prepare students for their training with simulated patients, especially when examples are erroneous.     

Ignitions of empathy. Medical students feel touched and shaken by interacting with patients with chronic conditions in communication skills training

ObjectiveTo explore what and how medical students learn from patients with chronic conditions in the context of communication skills training.MethodsSemi-structured interviews and focus groups with 32 medical students. Interviews were recorded, transcribed, analyzed inductively and organized into four main narrative themes.ResultsLearning from patients provided medical students opportunities to see the world through the patients’ eyes, understand the diversity of patients’ needs, and recognize the importance of matching patients’ and doctors’ perspectives. Consequently, students expressed emotional responses on challenges in interactions with the patients related to performing the role as ‘medical expert’. Difficulty empathizing became visible in the students’ interaction with patients.ConclusionThe patients’ authentic contributions provided the students with unique opportunities to engage with their own emotions and capacity for empathy. However, for students to benefit from this affective practical training, they need guidance to balance professional and personal aspects in encounters. There is a need to introduce the ‘doctor as person’ in medical education.Practice implicationsPatients with chronic conditions strengthen students’ learning of empathy as part of transformative learning. Doing so with patients is a challenging way of learning. Thus, faculty and educators must provide explicit guidance for students to benefit.     

Reflective practice in the teaching of communication skills

Reflective practice is encouraged in medical education in general and in teaching communication skills in particular to develop into a reflective practitioner. However, the term is complex to understand and multidimensional thus challenging to grasp, describe and teach. Furthermore, though used frequently little guidance exists on how to promote reflective ability in teaching communication skills. This paper builds on a keynote address delivered at the International Conference of Communication in Healthcare (ICCH 2019) and is based on the vast literature on reflection and the author’s personal experience as a researcher and educator. It discusses the components of reflective practice as well as exemplifies the importance of reflective practice to student’s capability to learn communication skills.     

Completing the picture on student performances in OSCEs: A mixed-methods study on integration of a standardized patient rating

ObjectiveGood physician communication skills increase patient satisfaction and improve healing processes. Although physicians and patients appear to value communicative competencies differently, students are often evaluated solely by physicians. This study examines whether additional assessment of students by ‘standardized patients’ (SPs) is useful.MethodsDuring their Objective Structured Clinical Examination (OSCE) 238 medical students were additionally rated by SPs at 9 stations according to two items that defined the ‘physician–patient relationship’ and ‘communication’. SPs were informed that their assessment was for research purposes only, with no impact on the assessment of the students. SPs also had the opportunity to comment on their rating of the students.ResultsThe SPs rated the communicative competencies of students differently than physicians. The two parts of the SP rating are closely related. Inclusion of SP rating in the OSCE would provide higher measurement precision, with more students failing. SPs considered five factors relevant in their rating: ‘human connection’, ‘information flow’, ‘professionalism’, ‘competence’, and ‘exam situation’.ConclusionOur study suggests inclusion of SP rating as additional assessment of student communication skills.Practice ImplicationsAddition of SP rating in assessments is worthwhile, as it appears to complete the picture of the student performance in their OSCEs.     

The use of simulation in medical student education on the topic of breaking bad news: A systematic review

BackgroundSimulated patients (SPs) are widely used, but the most effective way of utilising them in undergraduate breaking bad news (BBN) medical education is unknown.ObjectivesTo conduct a systematic review into SP’s use in developing BBN skills in medical students.Methods14 databases searched with the terms “Medical education”, “Patient simulation”, “Bad news”. Data was systematically extracted, and thematic analysis undertaken.ResultsOf 2117 articles screened, 29 publications met the inclusion criteria. These demonstrated a variety of SP models, including actors as patients (65.5%), peers (7.0%), and cancer survivors (3.5%). with delivery at varying times in the curricula. SPs are uniformly reported as having positive impact, but there is a lack of high-quality evidence comparing the use of differing forms of training. There was some evidence that virtual SPs were as useful as in-person SPs.ConclusionsSPs allow students to practise vital BBN communication skills without risking detriment to patient care. Despite the heterogeneity of ways in which SPs have been used, the benefits of different approaches and when and how these should be delivered remains unclear.Practice implicationsFurther educational development and research is needed about the use of SPs to support undergraduate BBN communication skills development.     

Learning how to break bad news from worked examples: Does the presentation format matter when hints are embedded? Results from randomised and blinded field trials

ObjectivesVideo-based worked examples enable medical students to successfully prepare for breaking-bad-news (BBN) encounters with simulated patients (SPs). This is especially true when examples include hints that signal important content. This paper investigates whether the beneficial effect of hints only applies to video-based worked examples or also text-based examples.MethodsOne-hundred-and-forty-seven fourth-year medical students attending a BBN training participated in either of two equally scaffolded, randomised field trials. Prior to encountering SPs, the students worked through an e-learning module introducing the SPIKES protocol for delivering bad news; it contained the same worked example presented to either of four groups as text or video, with or without additional hints denoting the SPIKES steps being implemented.ResultsOnly a main effect of ‘hints’ was revealed, implying that students in the hints groups delivered the news to an SP significantly more appropriately than those in the without-hints groups.ConclusionsIndependent of their presentation format, worked examples with hints best foster students’ BBN skills learning.Practice implicationsIn addition to video, text-based worked examples can effectively prepare students for BBN simulations if hints are included. This offers an affordable alternative to video examples, as text examples can be generated with less effort.     

Challenges in delivering bad news in a multi-ethnic intensive care unit: An ethnographic study

ObjectiveDuring critical care, physicians are frequently confronted with bad-news communication because of patients’ frail conditions. Delivering bad news is not easy, certainly not when patients from ethnic minority groups are involved. In this study we investigate the delivery of bad news in a multi-ethnic critical care context.MethodsEthnographic fieldwork in one intensive care unit of a multi-ethnic urban hospital in Belgium. Data were collected through negotiated interactive observation, in-depth interviews and from reading patients’ medical records. Data were thematically analysed.ResultsBad-news communication was primarily dominated by physicians. Patients’ and relatives’ input and other professionals’ involvement in the communication was limited. Staff encountered ethno-cultural related difficulties, firstly, in choosing suitable conversation partner(s); secondly, in choosing the place of conversations and thirdly, in the information exchange. Staff usually tried to address these problems themselves on the spot in a quick, pragmatic way. Sometimes their approaches seemed to be more emotion-driven than well thought-out.ConclusionDelivering bad news in a multi-ethnic intensive care unit has a number of specific difficulties. These can have negative consequences for parties involved.Practice implicationsThe challenges of an adequate delivery of bad news need a team-approach and a well thought-out protocol.     

Communication skills preparedness for practice: Is there a key ingredient in undergraduate curricula design?

ObjectiveTo characterize medical interns’ experience regarding communication skills education and to explore potential associations with preparedness for practice.MethodsTwo hundred sixty-six medical interns answered an original questionnaire specifically developed to explore how well they feel their undergraduate training had prepared them in key aspects of medical communication. Instrument’s psychometric properties were tested. Medical schools’ curricula were considered and associations explored using non-parametric tests.ResultsThe questionnaire reliability was high, with Cronbach’s alphas ranging from 0.89 to 0.94 on all the factors. Core communication skills were highly rated. Perceived preparedness was lower in aspects concerning dealing with emotion, breaking bad news and communicating with speech impaired patients. Better preparedness was associated with a longitudinal integration of communication skills throughout the curriculum, simulation with standardized patients and real patient interviewing with feedback on communication skills.ConclusionsIntegrated programs, standing on a strong experimental component, particularly combining patient-simulation strategies with continuous supervision and learner centred feedback, were associated with higher preparedness. These results support the expansion of an educational model based on simulation strategies and structured longitudinally throughout the undergraduate medical curriculum.Practice implicationsThis study intends to inform educational background and to support further development of communication skills curricula.     

Medical student empathy and breaking bad news communication in a simulated consultation

ObjectivesThis study examined the relationship between self-reported empathy and breaking bad news (BBN) communication skills performance in a sample of undergraduate medical students (n = 100) in the clinical years of their program.MethodsCorrelational and regression analysis examined the relationship between Jefferson Scale of Physician Empathy (JSPE-S) and Empathy Quotient (EQ) scores, and communication skills performance based on students’ application of the SPIKES protocol to a BBN scenario in a simulated encounter.ResultsHigher BBN communication skills performance was positively correlated with scores on the “Social Skills” EQ sub-scale (r (99) = 0.31, p = 0.002), which measures spontaneous and context-independent use of social skills. Multiple regression confirmed that “Social Skills” sub-scale variation predicted BBN score variation (B = 2.17, 95% CI = 0.65–3.69, p < 0.01). A weak positive association was also observed between BBN score and the “Standing in Patient’s Shoes” JSPE sub-scale (r (99) = 0.22, p = 0.03).ConclusionsFindings suggest that specific aspects of dispositional empathy may moderate BBN communications skills competence in medical students.Practice implicationsA better understanding of the moderating role of personality may lead to more tailored BBN communications skills training interventions and improved transfer of skills to workplace settings.     

Teaching medical students to express empathy by exploring patient emotions and experiences in standardized medical encounters

ObjectivesTo increase medical students’ ability to detect contextual and emotional cues and to respond empathetically to patients.Methodsa training course in communication skills and patient-centered care with different teaching activities (didactic, reflective and interactive: workshops and encounters with simulated patients) was delivered to third-year medical students just before their clerkships. The program was evaluated by an external observer (OE) and simulated patients (SP) in 2 or 3 videotaped encounters.ResultsStudents improved significantly from baseline to 3rd interview in all communicative skills and domains explored both in OE (32.4%) and SP (38.3%) measurement. At the end of the course students detected significantly more clues and made more empathetic expressions.ConclusionsThe course seems to improve the ability of students to explore the illness experience, showing more empathy in a more genuine way. This was carried out in consultations lasting 10 min.Practical implicationsThe program is effective and feasible to be applied as a regular formative activity. Further research is needed to assess whether this training program is applicable to students in more advanced educational levels and if it has any additional outcomes.     

An experimental investigation of the dilemma of delivering bad news

ObjectiveThis randomly controlled experiment tested a theory of how experienced physicians solve the dilemma of communicating bad news by using implicit language.Methods8 physicians delivered both bad and good news to 16 analogue patients. Microanalysis of their news delivery reliably identified departures from explicit language.ResultsAs predicted, the physicians used implicit language at a significantly higher rate when delivering bad news than good news. For bad news, they tended to use alternative terms for the diagnosis, to qualify their evaluation, to underemphasize certainty, and to subtly separate the patient from the disease. The evidence both within and after the interview indicated that recipients still understood the bad news.Conclusion(1) The skilful use of implicit language is a solution to the dilemma of honest but not harsh communication of bad news. (2) Experimental methods can complement surveys and qualitative studies for investigating bad news delivery by providing a theoretical foundation and controlled conditions.Practice implicationsPhysicians can deliver bad news honestly without being blunt by skilfully incorporating implicit language. The theory, data, and examples presented here provide insights into the nature and functions of implicit language, from which students and practitioners can develop their individual styles.     

Reflective practice and its role in facilitating creative responses to dilemmas within clinical communication - a qualitative analysis

Background

Good communication is a major factor in delivering high quality in care. Research indicates that current communication skills training alone might not sufficiently enable students to find context-specific creative solutions to individual complex personal and interpersonal challenges in the clinical context. This study explores medical students’ experiences with real communication dilemmas in a facilitated group setting. The aims were to gain a better understanding of whether and, if so, how reflective practice can enhance students’ ability to find creative individual solutions in difficult communication situations and to identify factors within the reflective setting that foster their creative competency.

Methods

Thematic content analysis was used to perform a secondary analysis of semi-structured interview data from a qualitative evaluation of a group reflective practice training for final-year medical students. The categories that arose from the iterative deductive-inductive approach were analyzed in light of current scientific understandings of creativity.

Results

Reflection on real difficult clinical communication situations appears to increase medical students’ ability to handle such situations creatively. Although group reflection on clinical dilemmas involving personal aspects can stir up emotions, participating students stated they had learned a cognitive process tool that enhanced their communicative competence in clinical practice. They also described changes in personal attitudes: they felt more able to persevere and to tolerate ambiguity, described themselves more open and self-efficient in such complex clinical communication situations and thus more motivated. Furthermore, they reported on factors that were essential in this process, such as reflection on current and real challenges, a group format with a trainer.

Conclusions

Reflective practice providing a cognitive process tool and using real clinical challenges and trainer support in communication education may provide learners with the skills and attitudes to develop creativity in practice. Implementing reflection training in clinical communication education may increase students’ overall communicative competency.

     

Shadowing patients: experimentar empatía en estudiantes de Medicina

IntroductionShadowing patients is one of the educational proposals to maintain and experience empathy in medical students. It is about observing, from the sidelines, a patient during a medical visit. The objective of this pilot study is to analyze the perceived and observed patients’ emotions during the experience of shadowing patients, and their relationship with medical empathy.MethodsTwenty-three fifth-year medical students (69.6% women, aged 22.6 ± 1.1 years) participated in the theoretical-practical workshop based on the observation and identification of patients’ emotions in a hospital waiting room. The Jefferson Scale of Physician Empathy (Hojat, 2002) and the Self-Assessment Manikin (Bradley and Lang, 1994) were applied.ResultsMost students experienced sadness (87%), and observed sadness (87%) and impatience (8.7%) in the patients. No statistically significant correlation between medical empathy and valence/arousal of experienced emotions was observed.DiscussionThe workshop of shadowing patient was low cost and easy to implement, stimulated the observation ability to identify the patients’ emotions, helped medical student to be more aware of their empathic skills, and complemented the theoretical training of medical students.