Sensitivity to patient''s psychosocial concerns: Relationships among ratings by primary care and traditional internal medicine house officers and patient self-assessments

This study examined house officers' sensitivity to patients' psychosocial concerns. Primary care house officers, traditionally trained internal medicine house officers, a social worker, and 104 ambulatory care patients independently completed an assessment instrument to indicate the extent to which a set of 20 defined psychosocial issues concerned the patients. We examined the magnitude of difference and extent of correlation in the independent reports of the patient, house officer, and social worker. These analyses were conducted on both the individual psychosocial issues and on sets of concerns derived from an oblique rotation factor analysis of the patients' responses. Primary care trainees' assessments of their patients' concerns correlated more frequently with the independent assessments of the patients and a social worker than did the judgments of the traditionally trained house officers. The factor analysis identified six factors that accounted for 64.4% of the variance in patients' responses. The correlations between the primary care trainees' and patients' assessments were statistically significant on five of these six factors; the correlations between the traditionally trained residents' and patients' assessments were statistically significant on two of the factors. These results provide evidence of the primary care house officer training program's achievement of the goal of enhanced physician awareness of patients' psychosocial concerns. The results also support training efforts aimed at increasing physicians' ability to assess their patients' psychosocial concerns.     

Alligator attack: an illustration of the impact of early clinical exposure

CONTEXT AND PROCESS: The authors recount the importance of mentoring during medical education. A personal narrative of clinical exposure as a University of South Florida (USF) student at Tampa General Hospital illustrates the unparalleled value of unique clinical situations such as the emergency care of a patient following an alligator attack. The benefits of early clinical experience and integrated medical education to be obtained through a mentor relationship are explored. CONCLUSION: The clinical exposure of medical students is central to their development as clinicians.     

Attending rounds on in-patient units: differences between medical and non-medical services

Summary. The objective of this cross-sectional observational study was to quantify communication patterns between teachers and trainees on in-patient attending ward rounds and assess trainees' perceptions of the effectiveness of teaching interactions. Sixty-nine in-patient ward rounds on medical and non-medical teaching services at a university hospital and its affiliated VA Medical Center were studied. Teaching rounds were observed and audiotaped, and trained raters coded verbal interchange for its location, speaker identity and topic of the exchange. One to three days following the teaching rounds, residents and students were interviewed and completed a questionnaire concerning recollections of the content of the session. Medical rounds lasted a mean of 90 minutes, while non-medical rounds averaged 38 minutes. Medical teams spent more time than non-medical teams on case presentations and discussions of diseases not directly related to patient care. Both groups averaged approximately 10 minutes directly interacting with patients, and equal times were spent speaking by the teacher and trainees. The role of postgraduate year 1 residents and medical students primarily was to recite details of patients' clinical condition. Twenty-nine per cent of trainees were unable to recall a specific teaching point from rounds when interviewed 1–3 days later. Duration and content of in-patient rounds differed on medical and non-medical services. For both, discourse tended to be hierarchical, with those at different training levels adhering to specific roles. Bedside patient interactions were limited. The content recalled by students and house staff suggests that new, more effective educational paradigms are needed.     

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.     

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.     

The curriculum of communication skills teaching at Maastricht Medical School

In the Skillslab at Maastricht Medical School students are prepared for their first encounters with patients. Students can focus on individual skills, separately mastering each skill in a controlled systematic manner. With this foundation students are better equipped to face the complex intellectual and emotional demands of real patients. A large proportion of training concerns communication skills. Features of Skillslab communication skills training programme are: (1) its continuity (once every 2 weeks, from year 1 to year 6); (2) a gradual increase of complexity in skills (basic interview skills, phases of interviews, entire interviews, problem patients); (3) a gradual increase of complexity in practice situations (apparatus, role-playing, simulated patients, real patients). Evaluation shows students' and teachers' satisfaction with the programme. Comparison with conditions required for interpersonal skills training shows that these are fully met. However, there are drawbacks, which are described.     

Extending the general practice training year: experience of one model in Scotland

OBJECTIVES: These were: to describe the implementation of a scheme to extend the general practice registrar component of vocational training to 18 months in Scotland; to determine the effect of the additional attachment on registrars' confidence and skill deficits, and compare changes in these parameters with a control group of registrars who did not extend their training, and to determine whether trainers required a different training style for experienced registrars. SUBJECTS: 35 registrars extending their training, their trainers, and 39 controls who did not extend their training. SETTING: Scottish training practices. METHODS: Pre-attachment and post-attachment questionnaires for registrars, triangulated by semistructured telephone interviews, and post-attachment questionnaires for trainers. RESULTS: Extended attachments were popular with registrars and with trainers, who felt they should be a normal part of training. Registrars with extended training declared themselves to have increased in confidence and addressed skill deficits better than controls. Projects completed were assessed as being of high quality. Trainers found 10% of registrars to have a remediable, important deficit in their skills. CONCLUSION: Extended attachments appear to improve registrar confidence and to address knowledge deficits. However, only a minority of registrars had important remediable knowledge deficits and while such attachments may be desirable they may not be essential for most registrars. Overall the outcome appears to have been positive, and supports those who have argued for a change in the proportion of time spent in general practice training, but the scheme is expensive and it is difficult to set a value on what has been gained. Future schemes should have clear training objectives and be tailored towards these.     

The teaching of communication skills in United Kingdom medical schools

A survey was carried out of the teaching of communication skills in medical schools in the United Kingdom during the academic year 1989/90. Comparison with previous surveys shows a considerable development over the last 10 years. Departments of psychiatry and general practice continue to play a major part in such teaching. There was wide variation in educational objectives and in the curricular time available. Concern is expressed about the methods of assessment and the degree of integration between departments. Future plans and the perceived barriers are reported and the implications discussed.     

Healing

My personal ethos of healing is an expression of the belief that I can and do act to heal patients while I attend to the traditional goals of medicine. The 7 supporting principles that inform my ethos are dignity, authenticity, integrity, transparency, solidarity, generosity, and resiliency. I invite others, including medical students, residents, and practicing physicians, to reflect and discover their own ethos of healing and the principles that guide their professional growth. A short digital documentary accompanies this essay for use as a reflective prompt to encourage personal and professional development.     

Increasing empathy among medical students

The objective of the research was to evaluate the short- and long-term effectiveness of teaching medical students interviewing skills. Methods of teaching communication skills included a workshop for clinical instructors, as an indirect approach, a workshop for medical students, as a direct approach, and a combination of both. Results demonstrated that in order to stimulate medical students to use supporting-interview skills, they themselves should participate in an interpersonal skills workshop. Being taught these skills by teachers who have participated in the workshop does not have the same positive effect.     

Setting up a clinical skills learning facility

Objective  This paper outlines the considerations to be made when establishing a clinical skills learning facility.
Considerations  Establishing a clinical skills learning facility is a complex project with many possible options to be considered. A number of professional groups, undergraduate or postgraduate, may be users. Their collaboration can have benefits for funding, uses and promotion of interprofessional education. Best evidence and educational theory should underpin teaching and learning. The physical environment should be flexible to allow a range of clinical settings to be simulated and to facilitate a range of teaching and learning methods, supported by computing and audio-visual resources. Facilities should be available to encourage self-directed learning. The skills programme should be designed to support the intended learning outcomes and be integrated within the overall curriculum, including within the assessment strategy. Teaching staff may be configured in a number of ways and may be drawn from a variety of backgrounds. Appropriate staff development will be required to ensure consistency and quality of teaching with monitoring and evaluation to assure appropriate standards. Patients can also play a role, not only as passive teaching material, but also as teachers and assessors. Clinical, diagnostic and therapeutic equipment will be required, as will models and manikins. The latter will vary from simple part task trainers to highly sophisticated human patient simulators. Care must be taken when choosing equipment to ensure it matches specified requirements for teaching and learning.
Conclusion  Detailed planning is required across a number of domains when setting up a clinical skills learning facility.     

Assessment of general practice consultations: content validity of a rating scale

A rating scale for assessing clinical performance of trainee general practitioners was constructed based on a contemporary definition of knowledge, skills and attitudes necessary for competent general practice in Australia. The purpose of the rating scale is the provision of feedback to the trainee by both self-evaluation and evaluation by training supervisors. As part of a wider study into the use of videotaped genuine general practice consultations for teaching purposes, the content validity of the scale was examined by comparing the scale data with an open-ended rating form. The comparison resulted in six suggestions which might improve the precision of the instrument, and produce a compact practical scale suitable for the evaluation of general practice consultation.     

Psychological tests to measure the effects of medical education on students'' interpersonal skills

The consulting skills required of medical students and practitioners have been categorized into a number of specific skills, two of which are: students' ability to empathize with the patient; and ability to decode non-verbal cues given by the patient in the interview. Training programmes to improve students' consulting skills are usually evaluated using analysis of students' actual interview behaviours with patients. Broad psychological and personality tests have also been used to measure changes in students' interviewing skills, but have generally not been successful. The hypothesis is advanced that more specific tests of the skills of interviewing, such as non-verbal sensitivity and empathy, would detect changes in students' ability to display these skills. As part evaluation of a consulting skills training programme, clinical students completed psychological tests of empathy and non-verbal sensitivity. Subsequent comparisons between trained and control student groups revealed no clear pattern in test results. These data suggest that specific psychological tests of empathy and non-verbal sensitivity may be no more effective in detecting changes in students' interpersonal skills than global personality measures.     

Televised paediatric consultations: a student evaluation of a multipurpose learning strategy

Since 1984, each student in the sixth-year paediatric rotation in the Department of Paediatrics and Child Health at the University of the Witwatersrand has been videotaped while undertaking a comprehensive paediatric primary care consultation. Video replay of the consultation by each individual student was evaluated by the student together with medical and social work tutors. This incorporated psychosocial aspects, communication skills, doctor-mother-child interactions, as well as essential medical content, clinical examination techniques, and management strategies. The student was expected to provide comprehensive health care, viz. dealing with the presenting health problems, identifying any possible hidden agenda, giving due attention to nutrition, immunization, development, optimal use of available records, health surveillance and appropriate education. This teaching programme was introduced in 1984. In 1988, 68 consecutive final-year medical students completed an anonymous Likert-type evaluation form scoring their perceived learning. They affirmed that the use of television in medical education provides a unique multipurpose learning strategy and in particular enhances awareness of self and of patient/family needs. The time, cost and effort invested in this programme are considered justified.     

Learning together: clinical skills teaching for medical and nursing students

OBJECTIVE: To evaluate the feasibility and effectiveness of shared learning of clinical skills for medical and nursing students at the University of Manchester. DESIGN: Medical and nursing students learned clinical skills in either uniprofessional or multiprofessional groups. These groups rotated through skills stations taught by multiprofessional facilitators. The groups stayed together for a series of 3 sessions held at weekly intervals (an induction meeting followed by 2 3-hour teaching sessions). Both quantitative and qualitative methods were used to evaluate the project. CONTEXT: A total of 113 Year 3 students registered on the Medical (n = 41), Bachelor of Nursing (Honours) (n = 43) or the Diploma for Professional Studies in Nursing (n = 29) courses participated in the project which was set in the clinical skills unit of a teaching hospital. RESULTS: Pre- and post self-evaluation of confidence levels for the taught skills revealed a statistically significant increase for all skills. The primary reason students gave for participation in the project was to learn or consolidate skills. An additional inducement for participation was the opportunity to share knowledge and observations between professional groups. Tutors also evaluated the experience favourably, particularly with regard to small group discussions. They indicated that the programme provided an opportunity to standardise clinical skills teaching. CONCLUSION: Collaborative learning opportunities for nursing and medical students are feasible and add value to the learning experience. Data indicate positive outcomes of learning in multiprofessional groups, comprising increased confidence levels, increased understanding of others' professional roles and personal development.     

Patients' global ratings of student competence. Unreliable contamination or gold standard?

Purpose To determine whether global ratings by patients are valid and reliable enough to be used within a major summative assessment of medical students' clinical skills. Method In 11 stations of an 18‐station objective structured clinical examination (OSCE), where a student was asked to educate or take a history from a patient, the patient was asked, ‘How likely would you be to come back and discuss your concerns with this student again?’ These 11 opinions were aggregated into a single patient opinion mark and correlated with other measures of student competence. The patients were not experienced in student assessment. Results A total of 204 students undertook the OSCE. Reliability of patient opinion across all 11 stations revealed a Cronbach alpha of 0·65. The correlation coefficient between the patient ratings and the total OSCE score was good (r = 0·74; P < 0·001) and was better than the correlation between any single OSCE station and the total OSCE score. It was also better than the correlation between the aggregated patient opinion and tests of student knowledge (r = 0·47). Conclusion It is known that patients can reliably complete checklists of clinical skills and that doctors can reliably provide global ratings of students. We have now shown that, by controlling the context, asking the right question and aggregating several opinions, untrained patients can provide a reliable and valid global opinion that contributes to the assessment of a student's clinical skills.     

Training and experience of examiners

Variation in the accuracy of examiner judgements is a source of measurement error in performance-based tests. In previous studies using doctor subjects, examiner training yielded marginal or no improvement in the accuracy of examiner judgments. This study reports an experiment on accuracy of scoring in which provision of training and background of examiners are systematically varied. Experienced teaching staff, medical students and lay subjects were randomly assigned to either training or no-training groups. Using detailed behavioural check-lists, they subsequently scored videotaped performance on two clinical cases, and accuracy of their judgments was appraised. Results indicated that the need for and effectiveness of training varied across groups: it was least needed and least effective for the teaching staff group, more needed and effective for medical students, and most needed and effective for the lay group. The accuracy of the lay group after training approached the accuracy of untrained teaching staff. Trained medical students were as accurate as trained teaching staff. For teaching staff and medical students training also influenced the nature of errors made by reducing the number of errors of commission. It was concluded that training varies in effectiveness as a function of medical experience and that trained lay persons can be utilized as examiners in performance-based tests.     

Dissatisfied patients: improving general practitioners' initial reactions

Summary. General practitioners often have difficulty in dealing with dissatisfied patients. One underlying reason could be the disturbed relationship between the doctor and the dissatisfied patient. A training course has been developed taking the relationship as a starting-point. Based on Watzlawick et al.'s theory on communication GPs have been trained to react to a dissatisfied patient on a relational level (‘Are you dissatisfied with my treatment?’) rather than on a contents level (‘How long have you been suffering from this?’). This method seeks to improve the relationship and the satisfaction of both doctor and patient. Three types of initial reaction to dissatisfied patients were offered to four groups of GPs (19 trainees in general practice and 19 trainers in general practice). Pre-and post-measurement were executed by means of registering the initial reactions on videore-corded vignettes of re-enacted dissatisfied patients. Subsequently the reactions were categorized blind by two judges. The 12 possible categories can be subdivided into categories primarily aimed at the contents or primarily aimed at the relationship. The results show that, as compared to the pre-measurement, GPs more frequently use empathic reactions and reactions in which they bring their own actions up for discussion. The number of responses in which doctors ask a further clinical question or in which GPs expect a solution whether from themselves or from others, decrease. It is concluded that the course appears to change for the better the GPs' initial reaction to dissatisfied patients.     

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.