Teaching communication in clinical clerkships: models from the macy initiative in health communications

Expert consensus on gender criteria for assessment in medical communication education

OBJECTIVE

The aim of this study is to develop gender criteria that can be included in communication skills assessment in medical education.

METHODS

A three-round Delphi study was conducted. The invited 59 participants were experts in the field of gender medicine education (n = 28) and doctor-patient communication (n = 31). Each Delphi round comprised a questionnaire, an analysis, and a feedback report. In the first round, gender experts explored gender themes in doctor-patient communication from which initial gender criteria were defined. The second and third rounds were used to validate the importance and feasibility of gender criteria. Consensus was defined as a 75% panel agreement and a mean of 4 or higher on a 5-point Likert scale.

RESULTS

Four gender criteria achieved consensus after the third round. The importance of including the gender criteria in communication skills assessment was rated consistently higher than its feasibility. Gender criteria relating to the patients' perspective, to gathering information and to gender and power were considered the most important.

CONCLUSION

Using a Delphi study, we have developed gender criteria for inclusion in communication skills assessment to promote good communication between doctors and patients.

PRACTICE IMPLICATIONS

Gender influences medical communication. Incorporating gender in communication skills assessment may be useful to improve the teaching and learning of communication skills.

Perspective: beyond counting hours: the importance of supervision, professionalism, transitions of care, and workload in residency training

The medical education community's conversations about residents' duty hours have long focused solely on the number of those hours. In July 2011, the Accreditation Council for Graduate Medical Education (ACGME) enacted its most recent iteration of standards regarding duty hours. Those standards, as well as a 2008 Institute of Medicine report, look beyond the quantity of duty hours to address their quality as well. Indeed, the majority of the 2011 ACGME standards specify requirements for the qualitative components of residents' working and learning environments, including supervision of residents; professionalism, personal responsibility, and patient safety; transitions of care; and clinical responsibilities (including workload). The authors believe that focusing on these qualitative (rather than quantitative) components of the resident's working and learning environment provides the greatest promise for balancing patient care with resident education, thus optimizing the safety and effectiveness of both. For each of the four qualitative components that the authors discuss (enhancing supervision, nurturing professionalism and personal responsibility, ensuring safe transitions of care, and optimizing workloads and cognitive loads), they offer agendas for faculty development, educational program planning, and research. Thus, the authors call on the medical education community to expand its discussion beyond counting duty hours to focus on these critical issues that ensure quality resident education and patient care and to implement necessary strategies to address them.

Effect of sitting vs. standing on perception of provider time at bedside: a pilot study

OBJECTIVE

Patients commonly perceive that a provider has spent more time at their bedside when the provider sits rather than stands. This study provides empirical evidence for this perception.

METHODS

We conducted a prospective, randomized, controlled study with 120 adult post-operative inpatients admitted for elective spine surgery. The actual lengths of the interactions were compared to patients' estimations of the time of those interactions.

RESULTS

Patients perceived the provider as present at their bedside longer when he sat, even though the actual time the physician spent at the bedside did not change significantly whether he sat or stood. Patients with whom the physician sat reported a more positive interaction and a better understanding of their condition.

CONCLUSION

Simply sitting instead of standing at a patient's bedside can have a significant impact on patient satisfaction, patient compliance, and provider-patient rapport, all of which are known factors in decreased litigation, decreased lengths of stay, decreased costs, and improved clinical outcomes.

PRACTICE IMPLICATIONS

Any healthcare provider may have a positive effect on doctor-patient interaction by sitting as opposed to standing during a hospital follow-up visit.

Standardized patient-narrated web-based learning modules improve students' communication skills on a high-stakes clinical skills examination

BACKGROUND

Use of web-based standardized patient (SP) modules is associated with improved medical student history-taking and physical examination skills on clinical performance examinations (CPX), but a benefit for communication skills has not been shown.

AIM

We describe an innovative web-based SP module using detailed SP and faculty commentary to teach communication skills.

SETTING

A public medical school in 2008-2009.

PARTICIPANTS

Fourth-year medical students.

PROGRAM DESCRIPTION

A 90-minute web-based module with three simulated clinical encounters was narrated by an expert clinician and SP to explain expected history-taking, physical examination, and communication skills behaviors. All 147 students were encouraged to review the module one month before the CPX.

PROGRAM EVALUATION

One hundred and six students (72%) viewed the web-based module. Students who watched the module performed significantly higher on the CPX communication score (+2.67%, p < 0.01) and overall score (+2.12%, p = 0.03), even after controlling for USMLE Step 1 and clerkship summary ratings. Use of the module did not significantly affect history/physical examination scores (+1.89%, p = 0.12).

DISCUSSION

Students who watched an optional web-based SP module prior to the CPX performed higher than those who did not on communication skills. The web-based module appears to be an effective CPX preparatory activity to enhance communication performance.

Patient-physician Communication Barrier: A Pilot Study Evaluating Patient Experiences

This study aims to identify the patient-physician communication barriers in the primary healthcare setting in Pulau Penang, Malaysia. A cross-sectional study was designed to attain the objectives of the study. A self-developed 17-item study tool was used to explore respondent's perception about the barriers they have faced while communicating with physician. The reliability scale was applied and internal consistency of the study tool was estimated on the basis of Cronbach's alpha (α = 0.58). The data analysis was conducted using statistical package for social sciences students SPSS 13(®). Chi Square test was used to test the difference between proportions. A total of n = 69 patients responded to this survey. A higher participation was seen by the male respondents, 39 (56.5%). About 52 (76.5%) of the respondents were satisfied with the information provided by the physician. In an effort to identify the patient-physician barriers, a poor understanding among the patients and physician was revealed. 16 (23.5%) respondents disclosed lack of satisfaction from the information provided to them. Overall, it is seen that lack of physician-patient understanding was the main reason that result hindrance in the affective communication. Moreover, there is a possibility that a low level of health literacy among the patients and inability of the physician to affectively listen to patients may be the other factors that result in a deficient communication.

An interdisciplinary, family-focused approach to relational learning in neonatal intensive care

OBJECTIVE

The aim of this study is to show the efficacy of the Program to Enhance Relational and Communication Skills-Neonatal Intensive Care Unit (PERCS-NICU).

STUDY DESIGN

In this study, 74 practitioners attended workshops and completed baseline, post-training and follow-up questionnaires.

RESULT

On yes/no questions, 93 to 100% reported improved preparation, communication skills and confidence post-training and follow-up. A total of 94 and 83% improved their ability to establish relationships, and 76 and 83% reported reduced anxiety post-training and follow-up, respectively. On Likert items, 59 and 64% improved preparation, 45 and 60% improved communication skills and confidence, 25 and 53% decreased anxiety and 16 and 32% improved relationships post-training and follow-up, respectively. Qualitative themes included integrating new communication and relational abilities, honoring the family perspective, appreciating interdisciplinary collaboration, personal/human connection and valuing the learning. In total, 93% applied skills learned, three-quarters transformed practice and 100% recommended PERCS-NICU.

CONCLUSION

After PERCS-NICU, clinicians improved preparation, communication and relational abilities, confidence and reduced anxiety when holding difficult neonatal conversations.

Attention to gender in communication skills assessment instruments in medical education: a review

CONTEXT

Gender is increasingly regarded as an important factor in doctor-patient communication education. This review aims to assess if and how gender is addressed by current assessment instruments for communication skills in medical education.

METHODS

In 2009 at Radboud University Nijmegen Medical Centre, an online search was conducted in the bibliographic databases PubMed, PsycINFO and ERIC for references about communication skills assessment instruments designed to be completed by trained faculty staff and used in medical education. The search strategy used the following search terms: 'consultation skills'; 'doctor-patient communication'; 'physician-patient relations'; 'medical education'; 'instruments'; 'measurement', and 'assessment'. Papers published between January 1999 and June 2009 were included. The assessment instruments identified were analysed for gender-specific content.

RESULTS

The search yielded 21 communication skills assessment instruments. Only two of the 17 checklists obtained explicitly considered gender as a communication-related issue. Only six of 21 manuals considered gender in any way and none gave specific details to explain which aspects of communication behaviour should be assessed with regard to gender.

CONCLUSIONS

Very few communication assessment instruments in medical education focus on gender. Nevertheless, interest exists in using gender in communication skills assessment. The criteria for and purpose of assessing gender in communication skills in medical education are yet to be clarified.

A course for nurses to handle difficult communication situations. A randomized controlled trial of impact on self-efficacy and performance

OBJECTIVE

to evaluate the impact of a communication skills course for nurses on how to handle difficult communication situations in their daily work.

METHODS

a 7-h course was developed using a construct of "Awareness, Feelings, Listen, Solve" (AFLS). A pedagogy of experiential, learner-centered learning was adopted. The course evaluation used a randomized controlled design with pre- and post-measures of self-efficacy and performance.

RESULTS

forty-one nurses volunteered and thirty-three nurses completed all assigned parts of the study. On self-assessment, there was significant improvement for self-efficacy (F=24.43, p<0.001), but not for emotional awareness. On performance, there was no significant improvement between intervention and control groups (F=3.46, p=0.073).

CONCLUSION

a short course for nurses on handling difficult communication situations achieved significant improvements in self-efficacy but not in performance.

PRACTICE IMPLICATIONS

teaching communication skills in community-based settings is important for the safety and effectiveness of patient care. Sponsoring organizations should weigh trade-offs between feasibility and achievement of measurable improvements in performance. One possible approach is to focus on specific communication skills rather than a full suite of skills.

Humanities in undergraduate medical education: a literature review

PURPOSE

Humanities form an integral part of undergraduate medical curricula at numerous medical schools all over the world, and medical journals publish a considerable quantity of articles in this field. The aim of this study was to determine the extent to which the literature on humanities in undergraduate medical education seeks to provide evidence of a long-term impact of this integration of humanities in undergraduate medical education.

METHOD

Medline was searched for publications concerning the humanities in undergraduate medical education appearing from January 2000 to December 2008. All articles were manually sorted by the authors. Two hundred forty-five articles were included in the study. Following a qualitative analysis, the references included were categorized as "pleading the case," "course descriptions and evaluations," "seeking evidence of long-term impact," or "holding the horses."

RESULTS

Two hundred twenty-four articles out of 245 either praised the (potential) effects of humanities on medical education or described existing or planned courses without offering substantial evidence of any long-term impact of these curricular activities on medical proficiency. Only 9 articles provided evidence of attempts to document long-term impacts using diverse test tools, and 10 articles presented relatively reserved attitudes toward humanities in undergraduate medical education.

CONCLUSIONS

Evidence on the positive long-term impacts of integrating humanities into undergraduate medical education is sparse. This may pose a threat to the continued development of humanities-related activities in undergraduate medical education in the context of current demands for evidence to demonstrate educational effectiveness.

Emergency medicine clerkship curriculum: an update and revision

In 2006, the latest version of a national curriculum for the fourth-year emergency medicine (EM) clerkship was published. Over the past several years, that curriculum has been implemented across multiple clerkships. The previous curriculum was found to be too long and detailed to cover in 4 weeks. As well, updates to the Liaison Committee on Medical Education (LCME)'s form and function document, which guides the structure of a clerkship, have occurred. Combining experience, updated guidelines, and the collective wisdom of members of the national organization of the Clerkship Directors in Emergency Medicine (CDEM), an update and revision of the fourth-year EM clerkship educational syllabi has been developed.

Effect of patient-centered communication training on discussion and detection of nonadherence in glaucoma

PURPOSE

To assess communication about adherence and to determine the impact of communication skills training on physicians' approach to nonadherence.

DESIGN

Sociolinguistic analysis of videotaped community ophthalmologists' encounters with patients with glaucoma before and after training. Patients in both phases and physicians in phase I knew communication was being studied but not what the focus of the study was. In phase II, physicians knew the targeted communication behaviors.

PARTICIPANTS

Twenty-three ophthalmologists and 100 regularly scheduled patients with glaucoma (50 per phase).

METHODS

An educational program with videotaped vignettes of simulated patient encounters using audience response and role play to teach patient-centered communication skills, including a 4-step adherence assessment and the use of open-ended questions in ask-tell-ask sequences.

MAIN OUTCOME MEASURES

Physician eliciting an acknowledgment of nonadherence during a clinical encounter compared with acknowledgment of nonadherence during a postvisit research interview (primary outcome), and performance of targeted communication and substantive discussion of adherence.

RESULTS

After intervention, physicians increased the proportion of open-ended questions (15% vs 6%; P = 0.001) and specifically about medication taking (82% compared with 18% of encounters; P<0.001). Compared with the absence of ask-tell-ask communication, 32% of phase II encounters included a complete ask-tell-ask sequence, 78% included an ask-tell sequence, and 32% a tell-ask sequence (P<0.001). Three of 4 steps for assessment of adherence were more common in phase II, and substantial discussions of adherence occurred in 86% versus 30% of encounters (P<0.001). In phase II, physicians elicited acknowledgment of nonadherence in 78% (7/9) of those who acknowledged nonadherence in the postvisit interview compared with 25% in phase I (3/12; P = 0.03).

CONCLUSIONS

This study demonstrates that experienced community physicians significantly improved their communication strategies and ability to detect and address nonadherence after a 3-hour educational program.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Contextualizing SEGUE: Evaluating Residents' Communication Skills Within the Framework of a Structured Medical Interview

BACKGROUND

The SEGUE (Set the stage, Elicit information, Give information, Understand the patient's perspective, and End the encounter) Framework is a checklist-style rating scale to facilitate the teaching and assessment of communication skills in medical learners. It has been used for over 15 years, and it is recommended in the Accreditation Council for Graduate Medical Education toolbox of assessment methods for resident training. When it was developed, its ability to provide objective scoring was a substantial improvement over global ratings.

METHODS

In this article we describe the strengths and weaknesses of the SEGUE Framework. We highlight one residency program's experience with using the SEGUE Framework to evaluate residents' communication skills. Specifically, we cite previous studies and describe our own analysis of resident interviewing performance that demonstrates how the SEGUE Framework did not distinguish between different levels of interviewing skill level in our sample.

RESULTS

Two case examples illustrate how the SEGUE Framework is not an ideal instrument to measure either the quality or the process of medical interviews.

CONCLUSION

Therefore, we propose a new method of contextualized assessment that builds on the SEGUE Framework. Our system evaluates discrete interviewing behaviors within the context of an ambulatory medical interview. We describe our interview structure, as well as a new instrument (the Wy-Mii, pronounced "why me"), to assess both communication and interpersonal skills. We expect that our new method of contextualized assessment will better differentiate between beginning and advanced levels of medical interviewing skills for residents.

Development of a communication curriculum for emergency medicine residents

BACKGROUND

The Accreditation Council for Graduate Medical Education requires residency training programs to develop methods to teach and assess communication skills in residents to ensure competence as a practitioner. In response, we piloted a communication curriculum for emergency medicine residents. We describe the curriculum and suggest future directions for development based on the strengths and weaknesses of residents' performance and their reactions to the curriculum.

DESCRIPTION

Twenty-six residents in a 3-year program at a university-affiliated county hospital participated. Curriculum components were an introductory session, a single standardized patient encounter using a locally written, unvalidated checklist assessing residents' communication skills, a videotape-facilitated self-assessment, and a private feedback session.

EVALUATION

Residents demonstrated greatest strengths in basic interpersonal skills and efficient information gathering and greatest weakness in empathy. Residents rated the curriculum favorably.

CONCLUSION

The curriculum as implemented offers an initial foundation for teaching and learning critical care communication. Instruction in empathy requires improvement.

Trained lay observers can reliably assess medical students' communication skills

CONTEXT

Our project investigated whether trained lay observers can reliably assess the communication skills of medical students by observing their patient encounters in an out-patient clinic.

METHODS

During a paediatrics clerkship, trained lay observers (standardised observers [SOs]) assessed the communication skills of Year 3 medical students while the students interviewed patients. These observers accompanied students into examination rooms in an out-patient clinic and completed a 15-item communication skills checklist during the encounter. The reliability of the communication skills scores was calculated using generalisability analysis. Students rated the experience and the validity of the assessment. The communication skills scores recorded by the SOs in the clinic were correlated with communication skills scores on a paediatrics objective structured clinical examination (OSCE).

RESULTS

Standardised observers accompanied a total of 51 medical students and watched 199 of their encounters with paediatric patients. The reliability of the communication skills scores from nine observed patient encounters was calculated to be 0.80. There was substantial correlation between the communication skills scores awarded by the clinic observers and students' communication skills scores on their OSCE cases (r = 0.53, P < 0.001). Following 83.8% of the encounters, students strongly agreed that the observer had not interfered with their interaction with the patient. After 95.8% of the encounters, students agreed or strongly agreed that the observers' scoring of their communication skills was valid.

CONCLUSIONS

Standardised observers can reliably assess the communication skills of medical students during clinical encounters with patients and are well accepted by students.

Teaching breaking bad news using mixed reality simulation

BACKGROUND

Our novel teaching approach involved having students actively participate in an unsuccessful resuscitation of a high fidelity human patient simulator with a gun shot wound to the chest, followed immediately by breaking bad news (BBN) to a standardized patient wife (SPW) portrayed by an actress.

METHODS

Brief education interventions to include viewing a brief video on the SPIKES protocol on how to break bad news, a didactic lecture plus a demonstration, or both, was compared to no pretraining by dividing 553 students into four groups prior to their BBN to the SPW. The students then self-assessed their abilities, and were also evaluated by the SPW on 21 items related to appearance, communication skills, and emotional affect. All received cross-over training.

RESULTS

Groups were equal in prior training (2 h) and belief that this was an important skill to be learned. Students rated the experience highly, and demonstrated marked improvement of self-assessed skills over baseline, which was maintained for the duration of the 12-wk clerkship. Additionally, students who received any of the above training prior to BBN were rated superior to those who had no training on several communication skills, and the observation of the video seemed to offer the most efficient way of teaching this skill in a time delimited curriculum.

CONCLUSION

This novel approach was well received and resulted in improvement over baseline. Lessons learned from this study have enhanced our curricular approach to this vital component of medical education.

Assessment of communication skills and self-appraisal in the simulated environment: feasibility of multirater feedback with gap analysis

INTRODUCTION

Multirater assessment is a powerful means of measuring communication skills. The use of gap analysis to assess self-appraisal is a strength of this technique. On the basis of Kalamazoo Consensus Statement framework and 360-degree assessment models, we developed a multirater instrument with gap analysis, with the goals of examining both communication skills and situational self-appraisal, and assessing the feasibility of the combined approach.

METHODS

The multirater communication skills instrument was used to assess Pediatric and Neonatal Intensive Care fellows after participation in seven simulated family meetings. Instrument reliability was determined using Cronbach's Alpha and Factorial Analysis. Correlations between rater groups were examined with Spearman's Rank Coefficient. Gap analyses and rater perceptions of the instruments were analyzed using descriptive statistics.

RESULTS

Seven pediatric intensive care unit and neonatal intensive care fellows were each assessed by 11 to 18 raters (108 total assessments). Correlations were identified between disciplinary groups within each encounter. Among the 7 fellows, 30 communication strengths or areas needing improvement and 24 significant gaps were identified, indicating self under-appraisals, 9 (38%) of which overlapped. The instrument was logistically feasible and well received.

CONCLUSIONS

Our multirater communication skills instrument with gap analysis proved useful in identifying areas of strength and areas needing improvement, and in highlighting areas of self over- and under-appraisal that require focused feedback. The use of multirater assessment with gap analysis, in a simulated and "safe" environment, may assist in the delivery of feedback to trainees.

Medical students' interviews with older adults: an examination of their performance

During a geriatrics/gerontology curriculum designed to develop positive attitudes toward older adults, promote understanding about the psychosocial aspects of normal aging, and provide experience with intergenerational communication, students in a combined BA/MD degree program participated in learning activities that focused on interacting with and interviewing older adults. This article describes medical students' performance during an intergenerational interview, examines differences between students' self-assessments and evaluators' ratings of students' performance, and presents statistical relationships among communication apprehension, situation anxiety, competence, and performance. Data analysis indicates that the majority of students demonstrated competent intergenerational interviewing skills during their standardized communication assessment. The discussion elaborates on the study findings, acknowledges limitations, and addresses practical implications of the study.

Communication skills improvement of medial students according to length and methods of preclinical training

PURPOSE

The purpose of this study is to evaluate the changing pattern of communication skills of medical students according to length and methods of training.

METHODS

We evaluated a 1-week communications training course in 2003, a 1-year course in 2004, and a 1-semester course in 2005 during development of our curriculum. We have conducted the 10-minute CPX on abdominal pain annually since 2002 to assess the clinical performance of medical students who have completed the 3rd year clerkship. We selected CPX videos that were appropriate for assessment. One hundred sixty-four videos were available (1-week didactics: 42 cases, 1-week training: 28 cases, 1-semester training: 50 cases, 1-year training: 44 cases). We developed a 10-item global rating checklist to assess communication skills. A 5-point Likert scale was used to evaluate each item (4-very likely, 0-least likely). Two expert standardized patient (SP) raters evaluated the communication skills of students independently. We analyzed the outcomes based on the training length and methods. The reliability (G coefficient) was 0.825 with 2 SPs and 1 station.

RESULTS

The communication skills of students improved with practice and longer training, especially with regard to opening the interview, expressing empathy, understanding the patient's perspective, and preparing for the physical examination. Rapport-building, organization of the interview, understandable explanation, nonverbal communication, active listening and consideration during the physical examination was unchanged between durations of training. The scores for empathetic expression, active listening and understanding the patient's perspective were low across all groups.

CONCLUSION

We should concentrate our efforts to improve students' skills in empathetic expression, active listening and understanding the patient's perspective.

The effect of undergraduate education in communication skills: a randomised controlled clinical trial

PURPOSE

To determine whether students improve their communication skills as a result of supervised patient care and whether a newly implemented communication course could further improve these skills.

METHOD

We conducted a randomised, controlled trial including all participants of the first clinical treatment course (n = 26) between October 2006 and February 2007. Randomisation was balanced by gender and basic communication skills. The test group practised dentist-patient communication skills in small groups with role-plays and videotaped real patient interviews, whereas the control group learned in problem-based workshops both on a weekly basis. Before and after the interventions (two group pre- and post-design) all students conducted two interviews with simulated patients. The encounters were rated using a 10-item checklist derived from the Calgary-Cambridge Observation Guide I.

RESULTS

Repeated measures ANOVA (alpha = 0.05) showed a significant difference of the sum scores of the ratings between test and control group (P = 0.004). The participants educated in communication skills improved significantly (Delta = +14.9; P = 0.004), whereas in the control group no accretion of practical communication competence was observed (Delta = -3.9; P = 0.23).

CONCLUSION

It could be demonstrated that solely interacting with patients during a clinical treatment course did not inevitably improve professional communication skills. In contrast, implementation of a course in communication skills improved the practical competence in dentist-patient interaction.

Applying patient perspectives on caring to curriculum development

OBJECTIVE

To report how patient viewpoints on caring inform curriculum development for teaching sessions on delivering bad news, making the transition to palliative care, and communicating about a medical error.

METHODS

We conducted focus groups that used patients recruited from the surrounding community to view videotapes of physicians delivering bad news, talking with a patient about palliative care, and communicating about a medical error. We used focus group results, combined with evidence from the medical literature to inform curriculum content for workshops conducted with Internal Medicine and Family Medicine residents at the University of Massachusetts Medical School.

RESULTS

Patient perspectives on caring gathered through focus groups differed in significant ways from the existing medical literature on caring when providers are communicating in the challenging situations that were depicted. Our data pointed out that individual reactions were unique and sometimes contradictory in that one person saw behavior as caring that others thought was uncaring. Participants often used qualifiers in their comments like "appropriate" amounts of information, "measured" empathy, chooses words carefully to reflect the relative nature of caring. "Arranges to meet healthcare needs," an issue that extends beyond the encounter, was seen as a new component of caring not previously described. Applying these concepts to curriculum required that we not only focus on the behavioral skills involved in these tasks, but also the processes of assessing patient's informational and emotional needs, and then taking steps to meet them, while adjusting behavior in real time to meet patients needs for caring. Workshops delivered were highly evaluated by residents.

CONCLUSION

Patient perspectives on caring when providers deliver bad news, discuss transitions to palliative care, and communicate about a medical error reinforce that patient expectations for caring are highly contextualized and physician behavior needs to be individualized. We taught residents not only behavioral skills, but also the process skills of anticipating patient reactions, recognizing patient clues, planning and choosing effective strategies on the fly, and assessing one's own performance characteristic of communication expertise.

PRACTICE IMPLICATIONS

Teaching caring attitudes with challenging communication tasks requires that learners appreciate and value not only caring behaviors but also learn the process by which they must adjust and titrate their actions to meet patient needs.

Working with patients with alcohol problems: a controlled trial of the impact of a rich media web module on medical student performance

INTRODUCTION/AIMS

We designed an interactive web module to improve medical student competence in screening and interventions for hazardous drinking. We assessed its impact on performance with a standardized patient (SP) vs. traditional lecture.

SETTING

First year medical school curriculum.

PROGRAM DESCRIPTION

The web module included pre/posttests, Flash(c), and text didactics. It centered on videos of two alcohol cases, each contrasting a novice with an experienced physician interviewer. The learner free-text critiqued each clip then reviewed expert analysis.

PROGRAM EVALUATION

First year medical students conveniently assigned to voluntarily complete a web module (N = 82) or lecture (N = 81) were rated by a SP in a later alcohol case. Participation trended higher (82% vs. 72%, p < .07) among web students, with an additional 4 lecture-assigned students crossing to the web module. The web group had higher mean scores on scales of individual components of brief intervention (assessment and decisional balance) and a brief intervention composite score (1-13 pt.; 9 vs. 7.8, p < .02) and self-reported as better prepared for the SP case.

CONCLUSIONS

A web module for alcohol use interview skills reached a greater proportion of voluntary learners and was associated with equivalent overall performance scores and higher brief intervention skills scores on a standardized patient encounter.

Critical care recognition, management and communication skills during an emergency medicine clerkship

BACKGROUND

Medical students need to learn how to recognize and manage critically ill patients; to communicate in critical situations with patients, families, and the healthcare team; and finally, to integrate technical knowledge with communication skills in caring for these patients. Meeting their needs will help prepare them to demonstrate, as physicians, the ability to synthesize information while simultaneously caring for patients, that the American Medical Association recently characterized as vital.

AIMS

Responding to these needs, we developed and implemented a curriculum to enable students in a required emergency medicine clerkship to recognize, manage, and simultaneously communicate with critically ill patients.

METHODS

The curriculum consisted of lectures and exercises on caring for the critically ill including: an introduction to the systematic approach; an interactive lecture on comprehensive communication; observation and discussion of real patients in the emergency department; participation in a single standardized patient encounter while peers and a faculty member observed them; assessment of students' own videotaped performance of the examination by using critical care and communication/interpersonal skills checklists; and receipt of private feedback based on the checklists from the faculty and the standardized patient. Students evaluated the curriculum at the end of the clerkship.

RESULTS

Complete performance data for 46 students and curriculum evaluation data from 42 students were available. According to faculty assessment, students as a group performed 79.6% (SD 0.15) of the critical care and 70.9% (SD 11.5%) of the communication skills. Students most often demonstrated Basic Interpersonal Skills (97.9%, SD 0.056) and least often demonstrated Empathy skills (41.7%, SD 0.235). Students rated the curriculum positively.

CONCLUSIONS

It is feasible to integrate the teaching of communication skills with the recognition and management of critically ill patients. The next step will be to revise the curriculum to address student deficiencies and to evaluate its effectiveness more rigorously.

Using Bedside Rounds to Teach Communication Skills in the Internal Medicine Clerkship

BACKGROUND

Physicians' communication skills, which are linked to important patient outcomes, are rarely explicitly taught during the clinical years of medical school. This paper describes the development, implementation, and evaluation of a communication skills curriculum during the third-year Internal Medicine Clerkship.

METHODS

In four two-hour structured bedside rounds with trained Internal Medicine faculty facilitators, students learned core communication skills in the context of common challenging clinical situations. In an end-of-clerkship survey students evaluated the curriculum's educational effectiveness.

RESULTS

Over the course of a year, 160 third-year students and 15 faculty participated. Of the 75/160 (47%) of students who completed the post-clerkship survey, almost all reported improvement in their communication skills and their ability to deal with specific communication challenges.

CONCLUSIONS

The curriculum appears to be a successful way to reinforce core communication skills and practice common challenging situations students encounter during the Internal Medicine Clerkship.

Teaching the medical interview: methods and key learning issues in a faculty development course

OBJECTIVE

To describe the American Academy on Communication in Healthcare's (AACH) Faculty Development Course on Teaching the Medical Interview and report a single year's outcomes.

DESIGN

We delivered a Faculty Development course on Teaching the Medical Interview whose theme was relationship-centered care to a national and international audience in 1999. Participants completed a retrospective pre-post assessment of their perceived confidence in performing interview, clinical, teaching, and self-awareness skills.

PARTICIPANTS AND SETTING

A total of 79 participants in the 17th annual AACH national faculty development course at the University of Massachusetts Medical School in June 1999.

INTERVENTION

A 5-day course utilized the principles of learner-centered learning to teach a national and international cohort of medical school faculty about teaching the medical interview.

MEASUREMENTS AND MAIN RESULTS

The course fostered individualized, self-directed learning for participants, under the guidance of AACH faculty. Teaching methods included a plenary session, small groups, workshops, and project groups all designed to aid in the achievement of individual learning goals. Course outcomes of retrospective self-assessed confidence in interview, clinical, teaching, self-awareness, and control variables were measured using a 7-point Likert scale. Participants reported improved confidence in interview, clinical, teaching, and self-awareness variables. After controlling for desirability bias as measured by control variables, only teaching and self-awareness mean change scores were statistically significant (p < .001).

CONCLUSIONS

The AACH Faculty Development course on Teaching the Medical Interview utilized learner-centered teaching methods important to insure learning with experienced course participants. Perceived teaching and self-awareness skills changed the most when compared to other skills.

Why there can be no sustainable national healthcare IT program without a translational health information science

Health information technology research has historically suffered from the persistence of paper-based systems as a barrier to research and refinement of information models. While the field of (non-medical) information science offers a potentially rich source of data, there exist relatively few theoretical links between medical and non-medical information models. This paper argues that the establishment of an integrated translational research pathway is not only useful, but is a critical and necessary step in the realization of a national health information infrastructure in the USA.

Development of progressive oral presentations in a therapeutics course series

OBJECTIVES

To develop and implement a series of progressive evidence-based, oral presentation activities within the therapeutics series to strengthen interprofessional oral communication and literature evaluation skills.

DESIGN

A step-wise progression of oral presentations was created to establish interprofessional communication skills and reinforce such skills in successive modules. Students progressed from a basic oral presentation to a brief clinical trial presentation, followed by a full journal club, culminating with a therapeutic debate. Guidelines and assessment tools were developed for each presentation focusing on style, content and organization, and analytic approach. Feedback was obtained from students and faculty members through the administration of survey instruments at the midpoint of advanced pharmacy practice experiences (APPE).

ASSESSMENT

The majority of students successfully completed each oral presentation. Most felt prepared for APPE presentations due to increased Microsoft PowerPoint skills, literature exposure/evaluation, and comfort/confidence in presenting before an audience. Faculty members stated that the innovation organized students' thoughts and increased presentation clarity, resulting in less need to offer student assistance during APPEs.

CONCLUSION

Our progressive approach to oral presentations has been successful and well received by students and faculty members. Our innovation has fostered oral interprofessional communication skills in our pharmacy students, and we will continue to utilize this approach.

Teaching Communication Skills on the Surgery Clerkship

BACKGROUND

Physician communication skills, linked to important patient outcomes, are rarely formally addressed after the pre-clinical years of medical school. We implemented a new communication skills curriculum during the third year Surgery Clerkship which was part of a larger curriculum revision found in a controlled trial to significantly improve students' overall communication competence.

DESCRIPTION

In three 2 hour workshops students, learned to address common communication challenges in surgery: patient education, shared decision-making, and delivering bad news. Each 2 hour, surgeon facilitated session was comprised of a 30 minute introductory lecture, a 15 minute checklist driven video critique, a 15 minute group discussion, a 45 minute standardized patient (SP) exercise with feedback from the SP, peers, and faculty member, and a 15 minute closing summary. To date, over 25 surgery faculty have been trained to conduct these sessions. In an end-of-clerkship survey, students reported on skill changes and assessed the curriculum's educational effectiveness.

EVALUATION

A survey was completed by 120 of the 160 (76%) third year students who participated in the curriculum. Fifty-five percent of students reported improvement in their communication skills and ability to address specific communication challenges. Students were satisfied with the amount and quality of teaching.

CONCLUSIONS

Communication skills teaching can be implemented in the surgery clerkship, and surgeons are particularly well suited to teach about patient education, discussing informed consent and shared decision making, and delivering bad news. Structured case-based sessions are acceptable to, and improve the self-assessed skills of, surgery clerkship students. Faculty development geared toward such sessions has added benefits to educational activities in a clinical department overall.

The rural physician associate program: new directions in education for competency

The Rural Physician Associate Program (RPAP) has 34 years experience in training 1097 medical students as independent distance learners in a 36-week, community-based continuity primary care experience. This program has been successful in preparing competitive students who select primary care residencies and return to rural practice. The RPAP program has been based on traditional apprentice-style clinical teaching with the support of computer-based resources to enhance distance learning. However while the clinical exposure and development of medical skills was strong, there were weaknesses in evidence-based medicine and managing healthcare, and inconsistencies in community or population health learning. New directions in the educational program for RPAP are described that have been or are being developed to address the competencies as outlined by the Accreditation Council on Graduate Medical Education. They include online and other resources, preceptor education and support, interactive journaling and cases, electronic portfolios, community projects, observed structured clinical exams and examinations. Ongoing challenges to competency-based education include developing meaningful measures and tools to assess competence for areas such as professionalism or systems-based practice; providing faculty development toward being able to practice, teach and evaluate students with an understanding of the competencies; and to build in ways of practicing, learning and improving care that involve effective teams of health-care professionals.

The SHEL model: a useful tool for analyzing and teaching the contribution of Human Factors to medical error

Recent reports on the problem of medical error pointed to a discipline that has been until recently, largely disregarded by the medical profession. The interdisciplinary science of Human Factors, the reports argue, provides a pragmatic framework for analyzing and assessing risk and reducing error in health care. The argument for applying Human Factors analysis to health care is increasingly accepted, and the application of Human Factors systems models for understanding medical error in particular have proved to be especially illuminating. The authors present a conceptual model of Human Factors--the SHEL model (named after the initial letters of its components' names, Software, Hardware, Environment, and Liveware)--that has been used in investigations of error in aviation. The authors use this simple model to examine and elucidate the Human Factors issues in a specific real-life example of medical error. The SHEL model is particularly useful in examining Human Factors issues in microsystems in health care such as the emergency room or the operating theatre; it argues that mismatches at the interface between the components in these health care microsystems are often conducive to medical errors. The authors propose that the SHEL model may have some unexploited potential in analyzing error and in training medical professionals about the science of Human Factors and its application to medical error. Empirical studies are needed, however, to ascertain the optimal amount of training needed to make clinically significant reductions in the occurrence of medical error.