A communication skills course for preclinical students: evaluation of general practice based teaching using group methods

Summary. Teaching preclinical medical students about doctor-patient communication gives them an opportunity to develop their interviewing skills prior to their having to elicit lists of symptoms in their clinical years. General practitioners should be among the more efficient interviewers in clinical medicine and therefore able to make important contributions to the teaching of interviewing skills. This paper describes the aims, objectives and methods of the preclinical communications skills course at St George's Hospital Medical School. The contribution of the Division of General Practice and Primary Care to the teaching of interviewing skills in the preclinical course has been evaluated using rapid group methods. Students were asked to identify examples of specific interviewing behaviours in videotaped general practice consultations, and to judge whether the behaviours were helpful or unhelpful in eliciting relevant information from the patient. Students who had been given experience in interviewing patients in small groups led by general practitioners identified significantly more helpful and unhelpful interviewing behaviours in the taped consultations than students who had not received the small-group teaching. Students rated the teaching as relevant and effective in terms of giving insights into the interviewing skills they needed to develop. Group methods of evaluation such as these might prove useful to other medical schools with class sizes of 150 students or more.     

A skills programme for preclinical medical students

An education programme in which preclinical medical students are introduced to common procedural skills is described. This programme is presented by a multidisciplinary health care team using short lectures, demonstrations, mannequin practice, and, in selected instances, practice on class-mate volunteers. The programme was evaluated by the students immediately following the presentation and for one class during their clinical activities one year later. The students' support for this programme was generally enthusiastic and remained undiminished upon reflection 12 months later.     

Medical statistics: content and objectives of a core course for medical students

Summary. British medical school teachers of medical statistics aspire to teach statistical concepts without requiring medical students to undertake every statistical technique in the book. In the typical course of 20–30 hours, about 50 topics are taught, usually requiring the student to perform a technique. In a survey of current practice in 20 courses it is shown that a core syllabus of 36 topics, including 14 techniques to be performed, is feasible for almost all existing courses. Clear student learning objectives now need to be agreed to encapsulate this syllabus.     

Teaching clinical methods to medical students

Summary. This paper demonstrates that it is feasible to teach clinical methods in general practice and describes the organization of an appropriate attachment. Willing practitioners, properly briefed, are competent to undertake clinical methods teaching and the attachment provides satisfaction to both students and teachers. It is possible to provide in primary care the elements which seem to be the key to this outcome — protected time, teaching in very small groups, direct observation and concentration on systematic examination rather than on particular physical signs. There is a strong case for the promoting of clinical methods teaching by general practitioners.     

An evaluation of early patient contact for medical students

Summary. The introduction of early patient contact for first-year medical students in the form of talking with a patient at an out-patient clinic was evaluated. The aim of the session was to give students an insight into the patient's view of the illness and treatment, and the effect of the condition on his or her lifestyle. Students found the visit useful and enjoyable. Students were asked to complete an evaluation questionnaire after the visit. Students said that they had learned a variety of things from the visit. These included: how it felt to be a patient (27%); the need to communicate clearly (23%); about doctor-patient interaction (23%); and the effect of illness on the patient (16%). Students also said that they would like to remember things from the visit to put into practice later on, particularly concerning the area of communication. The visit appeared to be a successful integration of preclinical and clinical disciplines.     

How ambulatory care is different: a paradigm for teaching and practice

Summary. This paper reviews the issues regarding an increased emphasis on medical education and practice in the ambulatory care setting. A paradigm for ambulatory medicine is offered which combines the elements of ‘traditional’ medical care and teaching with the more ‘distinctive’ elements representative of the ambulatory setting. The former includes aetiology, history, physical examination, laboratory tests and therapy; while the latter includes continuity, context, health education, economics and responsibility. The paradigm is illustrated in relation to the problem of hypertension. The ambulatory medicine paradigm is further discussed with respect to potential barriers to its acceptance. These include: (1) the assumption that ‘traditional’ medical education does teach all 10 elements of the paradigm; (2) the axiom that if one learns to care for the sickest patients, the less ill ones should be manageable; (3) the intuitive aspects of the ‘art’ of practising ambulatory medicine; (4) the recognition that this teaching will require a longitudinal experience; and (5) perception that the five distinctive elements are not ‘hard’ science and objectively measurable. Nevertheless, the changing face of medical practice requires the adoption of an ambulatory medicine paradigm in medical education.     

Teaching plastic surgery to medical students

A plastic surgery syllabus for third-year medical students is described. It is intended for a teaching programme in which plastic surgery is integrated into the surgical teaching on the same basis as the other surgical specialties. The syllabus was designed to concentrate on aspects of plastic surgery relevant to the needs of undergraduates. An audit of the teaching showed that the students were readily interested and considered the teaching to be relevant to their examinations and to their future as doctors. A survey of all plastic surgery centres in the British Isles showed that similar teaching was being undertaken in 11 centres out of 51.     

Behavioural sciences and the real world: report of a community interview scheme for medical students

Summary. A community interview scheme was designed to provide preclinical medical students with an opportunity to investigate the role of social and psychological variables in patient care and gain insight into interpersonal aspects of the interview process. Evaluation of the scheme showed that students and community interviewees found their participation valuable. Eighty per cent of interviewees were willing to take part in the scheme in the following year. The strongest predictor of willingness to participate was interviewees' rating of the extent to which they had enjoyed the experience. Students valued the opportunity to meet ‘real people’, to explore social and psychological determinants of health and illness and to develop communication skills. A significant positive change in perceived interviewing competence was observed. It is suggested that the scheme might be further developed by using feedback from interviewees to provide students with evidence of both their own skill development and the benefits of self-disclosure to the patients involved.     

Hopes and concerns of a first-year medical school class

Summary. To assess the hopes and concerns of first-year medical students, the 1991 Oregon Health Sciences University (OHSU) Medical School class was surveyed during orientation. Using qualitative research methods, student responses were grouped into general categories. The most common ‘hopes’ were to provide personal care and develop relationships with patients, to attain self-fulfilment, and to enjoy the personal challenge and variety of medicine. Common ‘concerns’ were family issues, outside intervention into medicine, and loss of self. The hopes and concerns of this class revolve primarily around personal issues, rather than issues relating to their local community or to society. This information may be useful in student counselling and curriculum development. Further research is necessary to evaluate changes in this class's attitudes over time. The methodology of this study may be useful in the evaluation of the attitudes of subsequent first-year medical school classes at OHSU, and at other institutions.     

Multiple choice question tests in physiology: a preliminary attempt to apply the minimum pass level§

Summary. At the mid-term test in Part I Physiology at the University of Zagreb the students (n= 280) were graded by our standard pass level (SPL) arbitrarily set at 54% correct answers (SPL = 0.54). The test consisted of 50 items of the one best answer type. Items were selected from the pool by one examiner to conform, by his judgement, to the predetermined SPL. Post hoc the minimum pass level (MPL) was assessed independently by eight examiners and an MPL value of 0.60 for the whole test was obtained. The original Nedelsky scale was used in assessment of MPL but for statistical analysis the data was expressed as log(1/MPL) to linearize the scale of measurements and to reduce the variances. The data showed a large difference between examiners in their assessment of MPL. Nevertheless, the average log(1/MPL) value of individual items showed a significant negative linear relationship with the item difficulty indices as calculated from student's answers, indicating that despite the large heterogenity in assessment the average item log(1/MPL) may be acceptable as a reasonable prediction of item difficulty. Finally, ‘subtests’ were formed from the whole test by grouping items according to their log(1/MPL) value. The passing rate at these subtests was found to be identical despite the fact that they considerably differed in their MPL values. Therefore, the MPL value seems to be useful in setting objective standards for the decision of pass or fail, even when the MPL was assessed in a very heterogenous way.     

Medical training and English language proficiency

Summary. Concern is often expressed about the English language proficiency (ELP) of students engaged in professional training. This report assesses the ELP of the 1990 and 1991 intakes into medicine at the University of Sydney. A quick screening test and individual in-depth tests were used in a two-stage design. Admission to the course is highly competitive and most students are selected from the top 0.75% of Higher School Certificate results but 15% and 19% of the year cohorts were found to be below average in ELP. English proficiency was found to be consistently correlated with first- and second-year university results. Initiatives taken to support students with language disadvantages and to ensure that graduates will be able to communicate effectively with patients are outlined.     

Teaching skills improvement programmes in US internal medicine residencies†

Summary. The prevalence and nature of resident teaching skills improvement programmes (TSIP) are unknown. Although residents perceive themselves as important teachers of students, there is little information on how programme directors (PDs) view residents as teachers. A comprehensive questionnaire was sent to all 428 US internal medicine PDs in December 1990, of which 60% (n= 259 ) responded. Of the 259 responding programmes, only 20% (n= 51 ) had TSIPs. Characteristics of TSIPs were not uniform. Mean instructional time was 9 hours (range, 1–24 hours). The teacher most frequently utilized to develop and facilitate the TSIP was the PD. PDs from residencies with a TSIP indicated more strongly than PDs without a TSIP that residents contributed to students' learning. Fifty-one per cent of TSIPs required residents to attend. Evaluation/feedback as a teaching method was the most common topic covered in TSIPs. Long-term assessment of teaching skills after programme participation was done in 15% of TSIPs. Although PDs value the resident's role as teacher, current TSIPs in internal medicine residencies are few in number and lack standardization. PDs' attitudes probably influence whether residents are taught teaching skills and whether teaching skills are evaluated. Further investigation of appropiate curriculum for TSIPs and assessment of long-term effectiveness of TSIPs are needed.     

Education in family and community health: the challenge faced by a new medical school

This paper describes the efforts of the Department of Family and Community Health at Sultan Qaboos University in providing opportunities for the development of 'hands-on' problem-solving skills appropriate for Oman. The curriculum of the Department is discussed, highlighting the unusual emphasis of this discipline in both the preclinical and clinical curriculum of the College of Medicine. The importance of continuous assessment and supervision of students is discussed. Course-work in the preclinical curriculum of the Department is kept to a minimum. Field-work forms an important part of preclinical training, where application and problem-based learning are emphasized. During the clinical years the students are exposed to an integrated series of lectures and practicals covering core knowledge in clinical medicine. Practical clinical training, over a total period of 15 weeks, takes place at a variety of sites where common problems in primary health care in Oman are handled by students under supervision.     

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.     

A comparison between students in problem-based and traditional curricula at the same medical school: preparing for the NBME Part I

Summary. Eighteen of 22 students in a problem-based curriculum and 62 of 79 students in a traditional curriculum at the same medical school completed a survey 10 weeks after completing Part I of the National Boards. The survey asked students to report the average time they had spent each week during the first 2 years of medical school preparing for the Part I examination. Students were also asked to rate the usefulness of a variety of learning resources. The purpose of the survey was to compare the preparation activities of students in the two curricula. The results of the survey revealed that students in the problem-based curriculum tended to study many more hours for Part I than did students in the traditional curriculum, especially during their second year. The results also found problem-based curriculum students tended to rate textbooks and the PreTest Series as more valuable than did their peers in the traditional curriculum. The effects of the format and goals of the two curricula on the students' preparation activities are explored.     

Experiences with a method for obtaining feedback on a medical curriculum undergoing change

Summary. Successful innovation and change in the way medical students are prepared are notoriously difficult. The relationship between the administrative structures of the medical school and its teaching hospitals, other responsibilities of its teachers and administrators, and the intricacies of the curriculum as a system of interrelated components, mean that any real change has wide repercussions. An opportunity for evaluation of a curriculum undergoing change was presented at the University of New South Wales, when the Faculty of Medicine introduced a new 6-year medical curriculum in 1988. The change was made to address a number of problems experienced with the old 5-year curriculum. The Course Evaluation Committee was in a unique position to conduct an ongoing evaluation of the new curriculum, year by year, as it was being introduced. A method for obtaining feedback from both staff and students on a medical curriculum undergoing change, is described. While some sample results are presented, the paper concentrates on the advantages and disadvantages of, and our experiences with, this method. Advantages include the specificity and timing of the information collected, and the high response rate. One disadvantage was the repeated use of the same cohort of students. Some staff still perceived the evaluation process as a threat, or were sceptical about the value and validity of student feedback. Whether staff acknowledged ownership of the new curriculum also affected the use of feedback.     

A comparison of the interviewing skills of first-and final-year medical students

This study compared the communication skills of randomly chosen first- and final-year medical students. The intention was to follow up previous research, conducted over 10 years ago, into the effects of the medical curriculum on communication skills. It was hypothesized that there would be little improvement in such skills over the period of training, with the possibility that the final-year students might be less caring, empathic and supportive, more directive, and less concerned with psychosocial information. All students interviewed a simulated patient in the role of a mother of a child with cerebral palsy, where the main problems were psychological and social. The interviews were recorded on videotape and analysed by an independent observer for the presence or absence of a set of communication behaviours considered important in facilitating an effective relationship and in the exploration and understanding of the problem. The results failed to support the hypotheses. The final-year students were superior to their juniors on several measures, indicating improvements in relating to the patient in a caring, empathic, facilitative and listening manner. They also elicited more information relevant to the problem. The indications were that these final-year students were more skilled than in earlier studies, suggesting that the general change in attitudes to communications skills and the limited, but increased input into the curriculum may be having effect, even though there remains a need for considerably more training.