The communication competency of medical students, residents and consultants

Communication skills in pediatrics: perception of medical students

BACKGROUND

Effective communication with patients and their families is a fundamental skill for medical students to cultivate during their undergraduate training. However, communicating with pediatric patients presents unique challenges. This study investigated the perceptions, attitudes, and confidence levels of undergraduate medical students regarding communication skills in pediatrics.

METHODS

A cross-sectional, quantitative, descriptive, and analytical survey was conducted by applying a validated questionnaire, the Housestaff Communication Survey (HCS), to medical students from two higher education institutions in Minas Gerais, Brazil. Data analysis was conducted using SPSS and Excel, employing descriptive statistical tests and multiple logistic regression analyses to evaluate communication, importance, and confidence.

RESULTS

A total of 520 (52%) students participated in the study, with 422 (81.15%) aged from 20 to 29 years and 365 (68.27%) women. While only 113 (21.73%) students reported receiving training in communication skills with both adults and children during their undergraduate studies, over half (270) reported no such training. Those lacking training exhibited lower confidence levels compared with those trained exclusively with adults. Although most students recognized the importance of communication skills, their confidence levels were generally below 60%. Multiple logistic regression analysis identified gender, institution, academic period, and training as significantly associated variables with communication scores.

CONCLUSIONS

Training, gender, and academic period emerged as the most significant variables influencing communication skills. Most students expressed lower confidence in interviewing children. To enhance communication with pediatric patients and their families, comprehensive training in pediatric communication skills during undergraduate studies is imperative.

Harnessing ChatGPT dialogues to address claustrophobia in MRI - A radiographers' education perspective

INTRODUCTION

The healthcare sector invests significantly in communication skills training, but not always with satisfactory results. Recently, generative Large Language Models, have shown promising results in medical education. This study aims to use ChatGPT to simulate radiographer-patient conversations about the critical moment of claustrophobia management during MRI, exploring how Artificial Intelligence can improve radiographers' communication skills.

METHODS

This study exploits specifically designed prompts on ChatGPT-3.5 and ChatGPT-4 to generate simulated conversations between virtual claustrophobic patients and six radiographers with varying levels of work experience focusing on their differences in model size and language generation capabilities. Success rates and responses were analysed. The methods of radiographers in convincing virtual patients to undergo MRI despite claustrophobia were also evaluated.

RESULTS

A total of 60 simulations were conducted, achieving a success rate of 96.7% (58/60). ChatGPT-3.5 exhibited errors in 40% (12/30) of the simulations, while ChatGPT-4 showed no errors. In terms of radiographers' communication during the simulations, out of 164 responses, 70.2% (115/164) were categorized as "Supportive Instructions," followed by "Music Therapy" at 18.3% (30/164). Experts mainly used "Supportive Instructions" (82.2%, 51/62) and "Breathing Techniques" (9.7%, 6/62). Intermediate participants favoured "Music Therapy" (26%, 13/50), while Beginner participants frequently utilized "Mild Sedation" (15.4%, 8/52).

CONCLUSION

The simulation of clinical scenarios via ChatGPT proves valuable in assessing and testing radiographers' communication skills, especially in managing claustrophobic patients during MRI. This pilot study highlights the potential of ChatGPT in preclinical training, recognizing different training needs at different levels of professional experience.

IMPLICATIONS FOR PRACTICE

This study is relevant in radiography practice, where AI is increasingly widespread, as it explores a new way to improve the training of radiographers.

Improving optometry student interpersonal skills through online patient, clinician and student evaluation and feedback

CLINICAL RELEVANCE

Interpersonal skills are crucial for successful clinician-patient interactions. To prepare future optometrists for clinical practice, pedagogical evaluation is important to support the implementation of new strategies for teaching and evaluating interpersonal skills.

BACKGROUND

Optometry students largely develop their interpersonal skills through in-person patient interactions. Telehealth is increasing, yet strategies to develop the interpersonal skills of students for teleconsulting have not been explored. This study aimed to assess the feasibility, effectiveness and perceived usefulness of an online, multisource (patients, clinicians and students) evaluation and feedback program for developing interpersonal skills.

METHODS

Via an online teleconferencing platform, optometry students (n = 40) interacted with a volunteer patient, observed by a teaching clinician. Patients and clinicians evaluated the interpersonal skills of the student in two ways: (1) qualitative written feedback, and (2) quantitative rating (Doctors' Interpersonal Skills Questionnaire). All students received written patient and clinician feedback after the session, but not their quantitative ratings. A subset of students (n = 19) completed two sessions, self-ratings, and were provided with their written feedback and an audiovisual recording from their first interaction before completing the second session. All participants were invited to complete an anonymous survey at program completion.

RESULTS

Patient and clinician overall interpersonal skills ratings were positively correlated (Spearman's r = 0.35, p = 0.03) and showed moderate agreement (Lin's concordance coefficient = 0.34). Student self-ratings did not match patient ratings (r = 0.01, p = 0.98), whereas there was moderate agreement between clinician and student ratings (Lin's concordance coefficient = 0.30). Ratings improved at the second visit (p = 0.01). Patient ratings were higher than clinicians (p = 0.01) and students (p = 0.03). All participants agreed that the program was feasible, useful and effective at fostering good interpersonal skills.

CONCLUSION

Multisource feedback about interpersonal skills contributes to improvement in student performance. Patients and clinicians can evaluate and provide useful feedback to optometry students about their interpersonal skills using online methods.

Novice medical students' perception about bad news training with simulation and spikes strategy

Objective

To analyze the medical students' perception about simulated consultations before and after training using the SPIKES protocol.

Methods

Quasi-experimental study, with a qualitative approach. It counted with the participation of 20 students as Simulated Physicians (SF), and 20 students as Simulated Patients (SP), all belonging to a medical course. Data were obtained from the responses given to a reflective question, applied before and after training with the SPIKES. The treatment and the analysis of the data were guided by the stages of thematic analysis.

Results

In the category "Simulated Medical Student's Self-Perception", the subcategories "Nervousness and Insecurity" were predominant after the first consultation, while "Tranquility and Security" after the second consultation after training. In the category "Simulated Medical Student's Perception about the Educational Process", the subcategory "Reflective Learning" emerged in the students' speeches, especially after the second consultation. In the speeches of SP, it was evidenced the improvement of the care provided by SF after training.

Conclusion

The strategy used for the development of communication skills showed evidence of short-term effectiveness.

Innovation

The research resulted in a teaching protocol for students in pre-clinical stages that involves four stages: simulation, self-assessment, feedback and new simulations.

Patient-embodied virtual reality as a learning tool for therapeutic communication skills among anaesthesiologists: A phenomenological study

OBJECTIVE

In medicine, especially in a preoperative setting, training of effective communication skills is challenging, since communication is often implicatively copied from professional environment. This phenomenological study describes the development and experience of two patient-embodied virtual reality experiences designed to be used as an educational tool.

METHOD

Two patient-embodied VR experiences from a first person patient perspective deployed negative or positive communication styles. The authors investigated the lived learning experiences of these VR tools through semi-structured interviews with ten anaesthesiologists adapting a thematic analysis framework.

RESULTS

Interviews revealed acknowledgement of the importance of good communication skills. Overall, participants learned and adapted their style of communication 'on the job'. Patient-embodied VR was effective for a full immersive experience as participants expressed to have felt as if they had been a patient. They were able to distinguish differences in communication styles and analysis of the reflection showed a shift in perception, implying effective immersive experimental learning.

CONCLUSIONS

This study elaborated the potency of experimental learning with VR in communication in a preoperative setting. Patient-embodied VR can influence beliefs and values and demonstrated effective as an educative tool.

PRACTICAL IMPLICATIONS

The findings of this study can contribute to further research and healthcare education programs avid to use immersive learning with VR.

Evaluating first year residents' communication skills: a health literacy curriculum needs assessment

BACKGROUND

High quality communication skills are necessary for competent and ethical practice. When patients present with low health literacy, physicians' skills may be lacking, which can put patients' safety and satisfaction at risk. The authors' developed and executed a simulation-based needs assessment following conflicting internal reports about the communications skills of new residents.

METHODS

The current study recruited first year residents (N = 30) during the 2019 first post-graduate year (PGY-1) orientation at a southeastern university hospital simulation center. The residents completed an Objective Structured Clinical Examination (OSCE) which focused on obtaining informed consent from a patient's health care proxy who presented with limited literacy and health literacy and poor communication skills. After completing the OSCE, the residents, simulated patients (SP), and independent observers assessed the residents' performance.

RESULTS

Residents assessed their performance higher when compared with the ratings from independent observers and patient raters. Residents who spent more time with SPs were given higher ratings by the SPs and independent observers. Finally, residents' ratings of themselves had a positive correlation with their reported confidence, but no correlation between self-confidence and the ratings provided by SPs or observers.

CONCLUSION

PGY-1 residents demonstrate a continued need for health literacy and informed consent education, despite faculty believing that these skills were covered enough in medical school. These residents also demonstrated limited self-assessment ability or skills below the expectations of health literacy experts. Curriculum changes included improving the focus on health literacy, communication skills, and additional practice opportunities throughout their internship year.

Teaching and assessing communication skills in the postgraduate medical setting: a systematic scoping review

BACKGROUND

Poor communication skills can potentially compromise patient care. However, as communication skills training (CST) programs are not seen as a priority to many clinical departments, there is a discernible absence of a standardised, recommended framework for these programs to be built upon. This systematic scoping review (SSR) aims to gather prevailing data on existing CSTs to identify key factors in teaching and assessing communication skills in the postgraduate medical setting.

METHODS

Independent searches across seven bibliographic databases (PubMed, PsycINFO, EMBASE, ERIC, CINAHL, Scopus and Google Scholar) were carried out. Krishna's Systematic Evidence-Based Approach (SEBA) was used to guide concurrent thematic and content analysis of the data. The themes and categories identified were compared and combined where possible in keeping with this approach and then compared with the tabulated summaries of the included articles.

RESULTS

Twenty-five thousand eight hundred ninety-four abstracts were identified, and 151 articles were included and analysed. The Split Approach revealed similar categories and themes: curriculum design, teaching methods, curriculum content, assessment methods, integration into curriculum, and facilitators and barriers to CST. Amidst a wide variety of curricula designs, efforts to develop the requisite knowledge, skills and attitudes set out by the ACGME current teaching and assessment methods in CST maybe categorised into didactic and interactive methods and assessed along Kirkpatrick's Four Levels of Learning Evaluation.

CONCLUSIONS

A major flaw in existing CSTs is a lack of curriculum structure, focus and standardisation. Based upon the findings and current design principles identified in this SSR in SEBA, we forward a stepwise approach to designing CST programs. These involve 1) defining goals and learning objectives, 2) identifying target population and ideal characteristics, 3) determining curriculum structure, 4) ensuring adequate resources and mitigating barriers, 5) determining curriculum content, and 6) assessing learners and adopting quality improvement processes.

A Narrative Review of Interventions to Teach Medical Students How to Break Bad News

Breaking bad news (BBN) is a key advanced communication skill that physicians must learn. Despite the breadth of literature describing patients' preferences and data citing poor physician competency in this arena, there remains significant dissatisfaction with how doctors deliver bad news. One way to solve this dilemma is to ensure that we are using the best evidence-based educational approaches to train the cadre of medical students who graduate from medical school each year. This article provides a 15-year review of articles on BBN in the undergraduate medical education curriculum that have been validated using the Medical Education Research Quality Instrument (MERSQI) (Acad Med 90:1067-76, 2015). This narrative review aims to identify articles which describe undergraduate medical education curriculum that evaluate how to best teach students to communicate bad news to patients. In the process, the authors reviewed 179 abstracts in 118 academic journals. Articles that met the inclusion criteria were evaluated using the MERSQI and those that scored higher than 11.3 were chosen for analysis. This paper summarizes the 15 articles that met the criteria. The review reveals (1) standard components which should be included in an undergraduate BBN curriculum, (2) a pressing need for utilizing a teaching and evaluation tool that incorporates nonverbal communication, and (3) a further need to test long-term curriculum retention.

Using artificial intelligence to analyse and teach communication in healthcare

Communication is a core component of effective healthcare that impacts many patient and doctor outcomes, yet is complex and challenging to both analyse and teach. Human-based coding and audit systems are time-intensive and costly; thus, there is considerable interest in the application of artificial intelligence to this topic, through machine learning using both supervised and unsupervised learning algorithms. In this article we introduce health communication, its importance for patient and health professional outcomes, and the need for rigorous empirical data to support this field. We then discuss historical interaction coding systems and recent developments in applying artificial intelligence (AI) to automate such coding in the health setting. Finally, we discuss available evidence for the reliability and validity of AI coding, application of AI in training and audit of communication, as well as limitations and future directions in this field. In summary, recent advances in machine learning have allowed accurate textual transcription, and analysis of prosody, pauses, energy, intonation, emotion and communication style. Studies have established moderate to good reliability of machine learning algorithms, comparable with human coding (or better), and have identified some expected and unexpected associations between communication variables and patient satisfaction. Finally, application of artificial intelligence to communication skills training has been attempted, to provide audit and feedback, and through the use of avatars. This looks promising to provide confidential and easily accessible training, but may be best used as an adjunct to human-based training.

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Artificial intelligence (AI) applied to health professional-patient communication enables efficient audit and feedback.

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Very recent advances have increased the ability of AI to encode the complexity in human interaction.

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AI can now encode words as well as a person does, as well as emotion and non-verbal aspects of communication.

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AI coding has been shown to be moderately to substantially reliable.

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Translation into the real world has yet to be demonstrated.

Development of a national medical leadership competency framework: the Dutch approach

BACKGROUND

The concept of medical leadership (ML) can enhance physicians' inclusion in efforts for higher quality healthcare. Despite ML's spiking popularity, only a few countries have built a national taxonomy to facilitate ML competency education and training. In this paper we discuss the development of the Dutch ML competency framework with two objectives: to account for the framework's making and to complement to known approaches of developing such frameworks.

METHODS

We designed a research approach and analyzed data from multiple sources based on Grounded Theory. Facilitated by the Royal Dutch Medical Association, a group of 14 volunteer researchers met over a period of 2.5 years to perform: 1) literature review; 2) individual interviews; 3) focus groups; 4) online surveys; 5) international framework comparison; and 6) comprehensive data synthesis.

RESULTS

The developmental processes that led to the framework provided a taxonomic depiction of ML in Dutch perspective. It can be seen as a canonical 'knowledge artefact' created by a community of practice and comprises of a contemporary definition of ML and 12 domains, each entailing four distinct ML competencies.

CONCLUSIONS

This paper demonstrates how a new language for ML can be created in a healthcare system. The success of our approach to capture insights, expectations and demands relating leadership by Dutch physicians depended on close involvement of the Dutch national medical associations and a nationally active community of practice; voluntary work of diverse researchers and medical practitioners and an appropriate research design that used multiple methods and strategies to circumvent reverberation of established opinions and conventionalisms.

IMPLICATIONS

The experiences reported here may provide inspiration and guidance for those anticipating similar work in other countries to develop a tailored approach to create a ML framework.

Focused Teaching Improves Medical Student Professionalism and Data Gathering Skills in the Emergency Department

INTRODUCTION

 Leaders in medical education have developed milestones and core competencies in an attempt to ensure that relational skills, such as communication and professionalism, are emphasized in addition to the usual skills of medical knowledge, data gathering, and emergency stabilization during students' emergency medicine (EM) medical education. Providers facile in each of these areas have better patient outcomes, patient experiences, and decreased incidence of malpractice cases. The authors attempted to demonstrate that by deliberate teaching of these skills during an EM medical student clerkship, students could significantly improve their clinical performance.

METHODS

 This prospective, randomized, single-blinded cohort study was performed at an academic, tertiary, urban ED to investigate the effects of a one-on-one preceptor shift on the clinical performance of fourth-year medical students. Students were randomized into two groups and assessed by pre- and post-intervention objective structured clinical encounters (OSCEs) with standardized patients (SPs) at weeks one and three. A crossover design was employed so that students in the control group participated in a preceptor shift after their second OSCE. Measurements were based on a five-point Likert scale assessment linked to early EM milestones as defined by the Accreditation Council on Graduate Medical Education (ACGME).  Results: The mean improvement in total overall score was significantly greater in the intervention group: 4.31 versus 2.57 (Cohen's d = 0.57, p = 0.029). When each milestone was assessed individually, students in the intervention group improved significantly in data gathering (Cohen's d = 0.47, p = 0.048) and professionalism (Cohen's d = 0.66, p = 0.011). There was a nonstatistically significant improvement for the intervention compared to control group in emergency management and communication skills. There was no improvement for either group in medical knowledge.

CONCLUSION

 A one-on-one preceptor shift can result in a statistically significant improvement in data gathering and professionalism skills as measured by OSCEs.

A Content Analysis of the ACGME Specialty Milestones to Identify Performance Indicators Pertaining to the Development of Residents as Educators

Construct: For curriculum development purposes, this study examined how the development of residents as educators is reflected in the Accreditation Council for Graduate Medical Education (ACGME) Milestones. Background: Residents teach patients, families, medical students, physicians, and other health professionals during and beyond their training. Despite this expectation, it is unclear how the development of residents as educators is reflected in the specialty-specific Milestones. Approach: We performed a textual content analysis of 25 specialty Milestone documents available as downloads from the ACGME website in December 2015. Syntactical units of interest included developmental progressions that describe the development of educators over the course of residency training and 16 key terms identified during the analysis. We then categorized the terms by associated Milestone level, ACGME core competency, and targeted learner(s). Results: We identified 10 developmental progressions and 546 instances of the 16 key terms that describe the development of physician educators. The frequency of terms among specialties was quite variable (5-46 terms per specialty, Mdn = 21). The majority of education-related terms appeared at advanced Milestone levels; there were 139 (26%) such instances in Level 4 and 296 (54%) in Level 5. Education-related terms were identified in all six ACGME core competencies, with greatest frequency in Patient Care (157, 29%). Other residents were the learners most frequently targeted by education-related Milestones (211, 40%). Conclusions: The current ACGME Milestones largely imply that resident teaching is a high-level or aspirational goal, achieved without a clear or consistently assessed developmental progression. These findings run counter to the theoretical basis that underlies the development of the Milestones. Wide variation among specialties indicates lack of consensus around the ideal skill set of the resident educator and limits the utility of these documents for curriculum development in this domain.

Communication Course for Pediatric Providers Improves Self-efficacy

BACKGROUND

Communication is essential to building a trusting, clinician-patient relationship. Multiple studies have demonstrated the effects of experiential communication training on patient experience and provider well-being and resiliency. To date, no studies have described an organization-wide communication training program for pediatric clinicians. The objective of this study was to evaluate the impact of a pediatric-focused communication course on provider satisfaction, self-efficacy, and burnout.

METHODS

Texas Children's Hospital, in collaboration with the Academy on Communication in Healthcare, designed and implemented a pediatric focused communication course entitled Breakthrough Communication. Pre, immediate-post, and 3-month postcourse completion online surveys were sent to participants 1 day before, 1 day after, and 3 months after course completion. Participant demographic information, self-assessment of communication skills, the Maslach Burnout Inventory Human Services Survey, and postcourse satisfaction data were collected.

RESULTS

Participants reported high course satisfaction and improved self-efficacy in all measured skill sets both following and 3 months after course completion. Trends indicating a reduction in provider burnout improved in 2 of the 3 Maslach Burnout Inventory domains; however, statistical significance was not achieved.

CONCLUSIONS

A pediatric-focused communication course was well received by multi-specialty clinicians within a large, academic health care organization. This course enhanced clinician self-efficacy with newly learned pediatric encounter specific communication skills.

Clinical communication skills and professionalism education are required from the beginning of medical training - a point of view of family physicians

BACKGROUND

The Brazilian undergraduate medical course is six years long. As in other countries, a medical residency is not obligatory to practice as a doctor. In this context, this paper aims to clarify what and when competencies in communication and professionalism should be addressed, shedding light on the role of university, residency and post-residency programmes.

METHODS

Brazilian family physicians with diverse levels of medical training answered a questionnaire designed to seek a consensus on the competencies that should be taught (key competencies) and when students should achieve them during their medical training. The data were analysed using descriptive statistics and correlation tests.

RESULTS

A total of seventy-four physicians participated; nearly all participants suggested that the students should achieve communication and professionalism competencies during undergraduate study (twenty out of thirty competencies - 66.7%) or during residency (seven out of thirty competencies - 23.33%). When competencies were analysed in domains, the results were that clinical communication skills and professionalism competencies should be achieved during undergraduate medical education, and interpersonal communication and leadership skills should be reached during postgraduate study.

CONCLUSION

The authors propose that attainment of clinical communication skills and professionalism competencies should be required for undergraduate students. The foundation for Leadership and Interpersonal Abilities should be particularly formed at an undergraduate level and, furthermore, mastered by immersion in the future workplace and medical responsibilities in residency.

Best Practices in Relational Skills Training for Medical Trainees and Providers: An Essential Element of Addressing Adverse Childhood Experiences and Promoting Resilience

Medical providers' ability to form strong therapeutic alliances with patients is an essential clinical skill that is associated with a higher quality of care and improved provider well-being. However, comparatively few medical providers exhibit adequate relational skills, which serve to convey respect, communicate caring, and build trust between the medical provider and the patient. A growing number of medical training programs and continuing medical education programs have begun to incorporate relational skills training, but the results have been highly variable in terms of training methods and effect. To support administrators who are considering the implementation (or improvement) of relational skills training in their organization, we provide a set of best practices for relational skills training, in the basis of a review of the literature and on our experience as clinical educators, and show the application of these best practices through a case study. We conclude with a discussion of challenges for implementing a high-quality relational skills training program, policy-level solutions for these challenges, and recommendations for future research.

Validity Evidence From Ratings of Pediatric Interns and Subinterns on a Subset of Pediatric Milestones

PURPOSE

To investigate evidence for validity of faculty members' pediatric milestone (PM) ratings of interns (first-year residents) and subinterns (fourth-year medical students) on nine subcompetencies related to readiness to serve as a pediatric intern in the inpatient setting.

METHOD

The Association of Pediatric Program Directors Longitudinal Educational Assessment Research Network (APPD LEARN) and the National Board of Medical Examiners collaborated to investigate the utility of assessments of the PMs for trainees' performance. Data from 32 subinterns and 179 interns at 17 programs were collected from July 2012 through April 2013. Observers used several tools to assess learners. At each site, a faculty member used these data to make judgments about the learner's current developmental milestone in each subcompetency. Linear mixed models were fitted to milestone judgments to examine their relationship with learner's rank and subcompetency.

RESULTS

On a 5-point developmental scale, mean milestone levels for interns ranged from 3.20 (for the subcompetency Work effectively as a member of a team) to 3.72 (Humanism) and for subinterns from 2.89 (Organize and prioritize care) to 3.61 (Professionalization). Mean milestone ratings were significantly higher for the Professionalism competency (3.59-3.72) for all trainees compared with Patient Care (2.89-3.24) and Personal and Professional Development (3.33-3.51). Mean intern ratings were significantly higher than mean subintern ratings for all nine subcompetencies except Professionalization, Humanism, and Trustworthiness.

CONCLUSIONS

The PMs had a coherent internal structure and could distinguish between differing levels of trainees, which supports their validation for documenting developmental progression of pediatric trainees.

Communication skills training: Adapting to the trends and moving forward

Communication ability is one of the core requirements of doctors' competency. Teaching communication to medical students and junior doctors has attracted much attention. With the challenge of escalating demands, the status of training communication skills has been promoted in the past several decades. The training content was integrated with other courses and various pedagogic approaches have been applied and proved to be effective. Practical strategies and mixed types were highly recommended. However, there are still many problems, including the fragmentation of the training, insufficient practice, inadequate qualified teachers, case adaptation, course localization and impediment from the environment. This paper proposes some suggestions to solve the problems.

Teaching and assessment of clinical communication skills: Lessons learned from a SWOT analysis of Portuguese Angolan and Mozambican Medical Education

HIGHLIGHTS

CCS training lacks a formal structure with substantial variation of the teaching process.The interviews promoted, amongst important stakeholders, a rise in awareness of this situation and how these skills can enhance the quality of clinical practice, encouraging curricular change.A communication skills teaching model: CoSTProMed is suggested for curriculum integration.

BACKGROUND

The importance of clinical communication skills (CCS) teaching and assessment is increasingly recognized in medical education. There is a lack of outcome-based research about CCS teaching and assessment processes in Portuguese medical education. Our goal is to conduct a SWOT analysis of this process in Portugal, Angola and Mozambique in order to contribute to the establishment of an action plan for more effective CCS teaching and assessment in medical curricula.

METHODS

Between 2010 and 2012, semi-structured interviews focused on the state of the art of teaching and assessment of clinical communication skills were conducted with key stakeholders of medical courses in Portugal, Angola and Mozambique. The design corresponds to an exploratory, descriptive and cross-sectional study, with the analysis of the recorded interviews. Interview transcripts were analyzed to identify salient themes/coding template in their discussions of the CCS teaching process. The coding and analysis of the surveys is qualitative.

RESULTS

87 interviews were performed at the 8 Portuguese, 1 Angolan and 1 Mozambican medical schools. Results indicate that the teaching and assessment process of CCS is in the beginning stages with these commonalities noted: (i) Variability amongst faculty in the teaching and assessment methods, (ii) disconnection of CCS between basic and clinical cycles, (iii) content and process skills and (iv) faculty development.

CONCLUSIONS

CCS training lacks a formal structure with considerable variation of the CCS teaching process in these countries. The interviews promoted a rise in awareness of this situation and how these skills can enhance the quality of curricular change. Some important opportunities for the development and implementation of a framework of an integrated communication skills curriculum such as curricular reforms and well-established cooperation and networks were identified. The acknowledgement of the importance of integrating these skills in ME by key stake-holders and students in institutions and the identification of champions motivated to commit to the effort are strengths that should be considered to integrate and enhance CCS in the medical curricula.

If You Could Read My Mind: The Role of Healthcare Providers' Empathic and Communicative Competencies in Clients' Satisfaction with Consultations

This article investigates the relationship between healthcare providers' empathic and communicative competencies and clients' overall satisfaction with consultations. Two aspects of empathy were included: empathic attitude (sensitivity to the clients' perspective) and empathic skills (ability to estimate clients' evaluations). Communicative competencies were narrowed down to the clarity of the information provided. In the context of work disability examinations, 90 healthcare providers (44% physicians, 56% vocational experts) participated. For each provider, up to 20 dyads with clients were investigated. Within every dyad, clients rated their experiences and healthcare providers estimated clients' scores. The results show that both aspects of empathy and clarity of information significantly contribute to clients' overall satisfaction and as such confirm the importance of empathy and communication in medical consultations. Specifically, healthcare providers' empathic dispositions, in addition to their overt communicative behavior, appear to contribute to clients' overall satisfaction. Of the two aspects of empathy, only empathic attitude is significantly related to the clarity of information.

Social worker assessment of bad news delivery by emergency medicine residents: a novel direct-observation milestone assessment

The skill of delivering bad news is difficult to teach and evaluate. Residents may practice in simulated settings; however, this may not translate to confidence or competence during real experiences. We investigated the acceptability and feasibility of social workers as evaluators of residents' delivery of bad news during patient encounters, and assessed the attitudes of both groups regarding this process. From August 2013 to June 2014, emergency medicine residents completed self-assessments after delivering bad news. Social workers completed evaluations after observing these conversations. The Assessment tools were designed by modifying the global Breaking Bad News Assessment Scale. Residents and social workers completed post-study surveys. 37 evaluations were received, 20 completed by social workers and 17 resident self-evaluations. Social workers reported discussing plans with residents prior to conversations 90 % of the time (18/20, 95 % CI 64.5, 97.8). Social workers who had previously observed the resident delivering bad news reported that the resident was more skilled on subsequent encounters 90 % of the time (95 % CI 42.2, 99). Both social workers and residents felt that prior training or experience was important. First-year residents valued advice from social workers less than advice from attending physicians, whereas more experienced residents perceived advice from social workers to be equivalent with that of attending physicians (40 versus 2.9 %, p = 0.002). Social worker assessment of residents' abilities to deliver bad news is feasible and acceptable to both groups. This formalized self-assessment and evaluation process highlights the importance of social workers' involvement in delivery of bad news, and the teaching of this skill. This method may also be used as direct-observation for resident milestone assessment.

Medication Literacy in a Cohort of Chinese Patients Discharged with Acute Coronary Syndrome

This study aims at investigating medication literacy of discharged patients with acute coronary syndrome (ACS) in China, and the important determinants of medication literacy among them. For this purpose, we conducted a prospective cohort study. Patient's demographic and clinical data were retrieved from hospital charts and medication literacy was measured by instructed interview using the Chinese version of Medication Literacy Questionnaire on Discharged Patient between 7 and 30 days after the patient was discharged from the hospital. The results show that medication literacy for the surveyed patients was insufficient: >20% did not have adequate knowledge on the types of drugs and the frequency that they need to take the drugs, >30% did not know the name of and the dosage of the drugs they are taking, and >70% did not have adequate knowledge on the effects and side effects of the drugs they are taking. Our research indicated that medication literacy scores decreased with age but increased with education. The number of medicines the discharged patient took with them and days between discharge and interview were not associated with medication literacy levels.

Communication skills of tutors and family medicine physician residents in Primary Care clinics

Aim

To determine the communicative profiles of family physicians and the characteristics associated with an improved level of communication with the patient.

Design

A descriptive multicentre study.

Location

Primary Healthcare Centres in Almeria, Granada, Jaen and Huelva.

Participants

119 family physicians (tutors and 4th year resident physicians) filmed and observed with patients.

Principal measurements: Demographic and professional characteristics. Analysis of the communication between physicians and patients, using a CICAA (Connect, Identify, Understand, Agree and Assist, in English) scale. A descriptive, bivariate, multiple linear regression analysis was performed.

Results

There were 436 valid interviews. Almost 100% of physicians were polite and friendly, facilitating a dialogue with the patient and allowing them to express their doubts. However, few physicians attempted to explore the state of mind of the patient, or enquire about their family situation or any important stressful events, nor did they ask open questions. Furthermore, few physicians summarised the information gathered. The mean score was 21.43 ± 5.91 points (maximum 58). There were no differences in the total score between gender, city, or type of centre. The linear regression verified that the highest scores were obtained from tutors (B: 2.98), from the duration of the consultations (B: 0.63), and from the age of the professionals (B: −0.1).

Conclusion

Physicians excel in terms of creating a friendly environment, possessing good listening skills, and providing the patient with information. However the ability to empathise, exploring the psychosocial sphere, carrying out shared decision-making, and asking open questions must be improved. Being a tutor, devoting more time to consultations, and being younger, results in a significant improvement in communication with the patient.

Tools to Assess Behavioral and Social Science Competencies in Medical Education: A Systematic Review

PURPOSE

Behavioral and social science (BSS) competencies are needed to provide quality health care, but psychometrically validated measures to assess these competencies are difficult to find. Moreover, they have not been mapped to existing frameworks, like those from the Liaison Committee on Medical Education (LCME) and Accreditation Council for Graduate Medical Education (ACGME). This systematic review aimed to identify and evaluate the quality of assessment tools used to measure BSS competencies.

METHOD

The authors searched the literature published between January 2002 and March 2014 for articles reporting psychometric or other validity/reliability testing, using OVID, CINAHL, PubMed, ERIC, Research and Development Resource Base, SOCIOFILE, and PsycINFO. They reviewed 5,104 potentially relevant titles and abstracts. To guide their review, they mapped BSS competencies to existing LCME and ACGME frameworks. The final included articles fell into three categories: instrument development, which were of the highest quality; educational research, which were of the second highest quality; and curriculum evaluation, which were of lower quality.

RESULTS

Of the 114 included articles, 33 (29%) yielded strong evidence supporting tools to assess communication skills, cultural competence, empathy/compassion, behavioral health counseling, professionalism, and teamwork. Sixty-two (54%) articles yielded moderate evidence and 19 (17%) weak evidence. Articles mapped to all LCME standards and ACGME core competencies; the most common was communication skills.

CONCLUSIONS

These findings serve as a valuable resource for medical educators and researchers. More rigorous measurement validation and testing and more robust study designs are needed to understand how educational strategies contribute to BSS competency development.

Creation and Assessment of a Bad News Delivery Simulation Curriculum for Pediatric Emergency Medicine Fellows

Background  Bad news in the context of health care has been broadly defined as significant information that negatively alters people's perceptions of the present or future. Effectively delivering bad news (DBN) in the setting of the emergency department requires excellent communication skills. Evidence shows that bad news is frequently given inadequately. Studies show that trainees need to devote more time to developing this skill through formalized training. This program's objectives were to utilize trained standardized patients in a simulation setting to assist pediatric emergency medicine (PEM) fellows in the development of effective, sensitive, and compassionate communication with patients and family members when conveying bad news, and to recognize and respond to the patient/parent's reaction to such news. Methods PEM fellows participated in a novel curriculum utilizing simulated patients (SPs) acting as the patient's parent and immersive techniques in a realistic and supportive environment. A baseline survey was conducted to ascertain participant demographics and previous experience with simulation and DBN. Experienced, multi-disciplinary faculty participated in a training workshop with the SPs one week prior to course delivery. Three scenarios were developed for bad news delivery. Instructors watched via remote video feed while the fellows individually interacted with the SPs and then participated in a confidential debriefing. Fellows later joined for group debriefing. Fellow characteristics, experience, and self-perceived comfort pre/post-course were collected.   Results Baseline data demonstrated that 78% of fellows reported DBN two or more times per month. Ninety-three percent of fellows in this study were present during the delivery of news about the death of a child to a parent or family member in the six-month period preceding this course. Fellows' self-reported comfort level in DBN to a patient/family and dealing with patient and parent emotions improved significantly (p=0.034 and p=0.046, respectively). Conclusions Pediatric emergency medicine fellows frequently deliver bad news. A course using SPs was well received by trainees and resulted in improvement in self-assessed skills and comfort. This curriculum provides the opportunity for fellows to receive patient/parent feedback of their communication skills and observations from skilled instructors. This methodology should be considered when creating training curricula for bad news delivery skills.

Improving patient-centered communication: Results of a randomized controlled trial

OBJECTIVE

Patient-centered communication is a key element for improving the quality of care in terms of therapeutic relationship, patient participation, and treatment process. Postgraduate trainings provide an essential way of promoting patient centeredness on the job where learning opportunities are often limited by time, patient volume, and economic pressure. In the present study, changes in patient centeredness during clinical routines of postgraduate physicians (internal medicine) after a three-day communication training were assessed.

METHODS

A randomized controlled trial was conducted in a primary care clinic. The intervention consisted of a communication training that aimed to enhance patient centeredness in postgraduate physicians. The training was based on a need assessment and the principles of deliberate practice. Workplace-based assessment of physicians' communication behavior was obtained using the Roter Interaction Analysis System.

RESULTS

Three months after the intervention, trained physicians showed significantly increased patient centeredness (F=5.36, p=.04; d=0.42).

CONCLUSION

The communication training significantly improved patient centeredness during routine clinical practice. Thus, this training provides a structured and theory-based concept to foster patient centeredness.

PRACTICE IMPLICATIONS

The results support the implementation of communication trainings as a part of faculty development and medical specialization training.

Supervisors' and residents' patient-education competency in challenging outpatient consultations

OBJECTIVES

We compared supervisors' and residents' patient-education competency in challenging consultations in order to establish whether supervisors demonstrate sufficient patient-education competency to act credibly as role models and coaches for residents.

METHODS

All consultations conducted at one, two, or three of the outpatient clinics of each of the participating physicians were videoed. Each participant selected two challenging consultations from each clinic for assessment. We assessed their patient-education competency using the CELI instrument, we calculated net consultation length for all videoed consultations and we measured patient opinion about the patient education received using a questionnaire.

RESULTS

Forty-four residents and fourteen supervisors participated in the study. They selected 230 consultations for assessment. On average, supervisors and residents demonstrated similar patient-education competency. Net consultation length was longer for supervisors. Patient opinion did not differ between supervisors and residents.

CONCLUSIONS

Supervising consultants generally do not possess sufficient patient-education competency to fulfill their teaching roles in workplace-based learning that is aimed at improving residents' patient-education competency.

PRACTICE IMPLICATIONS

Not only residents but also supervising consultants should improve their patient-education competency. Workplace-based learning consisting of self-assessment of and feedback on videoed consultations could be useful in attaining this goal.

Attitudes of Portuguese medical residents' towards clinical communication skills

OBJECTIVE

To explore the attitudes and perceptions of Portuguese residents towards Clinical Communication Skills (CCS) and the need for complementary training.

METHODS

78 medical residents responded to an on-line questionnaire which comprised demographic data, open-ended questions and a Portuguese version of the Communication Skills Attitude Scale (CSAS).

RESULTS

Residents gave significantly higher scores (P<0.001) on CSAS1 (attitudes towards communication skills in general, compared to CSAS2 (attitudes towards the teaching/learning process of CCS). Residents doing their residency training in other parts of the country, other than the north, reveal a higher perception of insufficient training (72.7% vs. 38.7%, P=0.036).

CONCLUSION

Residents showed more positive attitudes towards communication skills than towards the teaching/learning process. They admit to need more training in CCS in their residency year and highlight that the clinical cycle of undergraduate education should integrate these topics. Content analysis indicates that residents' perceptions are context-influenced.

PRACTICE IMPLICATIONS

Integration of CCS in the undergraduate education, enhanced during post-graduate training. Training of clinical faculty and supervisors/tutors and the role that stakeholders have to play in order to promote continuous training in CCS; encourage patient-centeredness and reflective practice, as to facilitate transfer of acquired skills to clinical practice.

Designing faculty development to support the evaluation of resident competency in the intrinsic CanMEDS roles: practical outcomes of an assessment of program director needs

BACKGROUND

The Royal College of Physicians and Surgeons of Canada and the College of Family Physicians of Canada mandate that faculty members demonstrate they are evaluating residents on all CanMEDS (Canadian Medical Education Directions for Specialists) roles as part of the accreditation process. Postgraduate Medical Education at the University of Ottawa initiated a 5-year project to develop and implement a comprehensive system to assess the full spectrum of CanMEDS roles. This paper presents the findings from a needs assessment with Program Directors, in order to determine how postgraduate medical faculty can be motivated and supported to evaluate residents on the intrinsic CanMEDS roles.

METHODS

Semi-structured individual interviews were conducted with 60 Postgraduate Program Directors in the Faculty of Medicine. Transcribed interviews were analyzed using qualitative analysis. Once the researchers were satisfied the identified themes reflected the views of the participants, the data was assigned to categories to provide rich, detailed, and comprehensive information that would indicate what faculty need in order to effectively evaluate their residents on the intrinsic roles.

RESULTS

Findings indicated faculty members need faculty development and shared point of care resources to support them with how to not only evaluate, but also teach, the intrinsic roles. Program Directors expressed the need to collaborate and share resources across departments and national specialty programs. Based on our findings, we designed and delivered workshops with companion eBooks to teach and evaluate residents at the point of care (Developing the Professional, Health Advocate and Scholar).

CONCLUSIONS

Identifying stakeholder needs is essential for designing effective faculty development. By sharing resources, faculties can prevent 'reinventing the wheel' and collaborate to meet the Colleges' accreditation requirements more efficiently.

Breaking bad news is a teachable skill in pediatric residents: A feasibility study of an educational intervention

OBJECTIVE

Patients and physicians identify communication of bad news as a skill in need of improvement. Our objectives were to measure change in performance of first-year pediatric residents in the delivery of bad news after an educational intervention and to measure if changes in performance were sustained over time.

METHODS

Communication skills of 29 residents were assessed via videotaped standardized patient (SP) encounters at 3 time points: baseline, immediately post-intervention, and 3 months post-intervention. Educational intervention used was the previously published "GRIEV_ING Death Notification Protocol."

RESULTS

The intraclass correlation coefficient demonstrated substantial inter-rater agreement with the assessment tool. Performance scores significantly improved from baseline to immediate post-intervention. Performance at 3 months post-intervention showed no change in two subscales and small improvement in one subscale.

CONCLUSIONS

We concluded that breaking bad news is a complex and teachable skill that can be developed in pediatric residents. Improvement was sustained over time, indicating the utility of this educational intervention.

PRACTICE IMPLICATIONS

This study brings attention to the need for improved communication training, and the feasibility of an education intervention in a large training program. Further work in development of comprehensive communication curricula is necessary in pediatric graduate medical education programs.

Exploring residents' communication learning process in the workplace: a five-phase model

Context

Competency-based education is a resurgent paradigm in professional medical education. However, more specific knowledge is needed about the learning process of such competencies, since they consist of complex skills. We chose to focus on the competency of skilled communication and want to further explore its learning process, since it is regarded as a main competency in medical education.

Objective

This study aims to explore in more detail the learning process that residents in general practice go through during workplace-based learning in order to become skilled communicators.

Methods

A qualitative study was conducted in which twelve GP residents were observed during their regular consultations, and were interviewed in-depth afterwards.

Results

Analysis of the data resulted in the construction of five phases and two overall conditions to describe the development towards becoming a skilled communicator: Confrontation with (un)desired behaviour or clinical outcomes was the first phase. Becoming conscious of one’s own behaviour and changing the underlying frame of reference formed the second phase. The third phase consisted of the search for alternative behaviour. In the fourth phase, personalization of the alternative behaviour had to occur, this was perceived as difficult and required much time. Finally, the fifth phase concerned full internalization of the new behaviour, which by then had become an integrated part of the residents’ clinical repertoire. Safety and cognitive & emotional space were labelled as overall conditions influencing this learning process.

Conclusions

Knowledge and awareness of these five phases can be used to adjust medical working and learning environments in such a way that development of skilled medical communication can come to full fruition and its benefits are more fully reaped.

Non-adherence in children with asthma reviewed: The need for improvement of asthma care and medical education

Adherence to daily inhaled corticosteroid therapy is a key determinant of asthma control. Therefore, improving adherence to inhaled corticosteroids is the most effective method through which healthcare providers can help children with uncontrolled asthma. However, identifying non-adherent patients is difficult, and electronic monitoring is the only reliable method to assess adherence. (Non-)adherence is a complex behavioural process influenced by many interacting factors. Intentional barriers to adherence are common; driven by illness perceptions and medication beliefs, patients and parents deliberately choose not to follow the doctor's recommendations. Common non-intentional barriers are related to family routines, child-raising issues, and to social issues such as poverty. Effective interventions improving adherence are complex, because they take intentional and non-intentional barriers to adherence into account. There is evidence that comprehensive, guideline-based asthma self-management programmes can be successful, with excellent adherence and good asthma control. Patient-centred care focused on healthcare provider-patient/parent collaboration is the key factor determining the success of guided self-management programmes. Such care should focus on shared decision-making as this has been shown to improve adherence and healthcare outcomes. Current asthma care falls short because many physicians fail to adhere to asthma guidelines in their diagnostic approach and therapeutic prescriptions, and because of the lack of application of patient-centred health care. Increased awareness of the importance of patient-centred communication and increased training in patient-centred communication skills of undergraduates and experienced attending physicians are needed to improve adherence to daily controller therapy and asthma control in children with asthma.

Using decision trees to characterize verbal communication during change and stuck episodes in the therapeutic process

Methods are needed for creating models to characterize verbal communication between therapists and their patients that are suitable for teaching purposes without losing analytical potential. A technique meeting these twin requirements is proposed that uses decision trees to identify both change and stuck episodes in therapist-patient communication. Three decision tree algorithms (C4.5, NBTree, and REPTree) are applied to the problem of characterizing verbal responses into change and stuck episodes in the therapeutic process. The data for the problem is derived from a corpus of 8 successful individual therapy sessions with 1760 speaking turns in a psychodynamic context. The decision tree model that performed best was generated by the C4.5 algorithm. It delivered 15 rules characterizing the verbal communication in the two types of episodes. Decision trees are a promising technique for analyzing verbal communication during significant therapy events and have much potential for use in teaching practice on changes in therapeutic communication. The development of pedagogical methods using decision trees can support the transmission of academic knowledge to therapeutic practice.

The effects of self-assessment and supervisor feedback on residents' patient-education competency using videoed outpatient consultations

OBJECTIVES

To determine the effects of residents' communication self-assessment and supervisor feedback on residents' communication-competency awareness, on their patient-education competency, and on their patients' opinion.

METHODS

The program consisted of the implementation of a communication self-assessment and feedback process using videoed outpatient consultations (video-CAF). Residents wrote down communication learning objectives during the instruction and after each video-CAF session. Residents' patient-education competency was assessed by trained raters, using the CELI instrument. Participating patients completed a questionnaire about the contact with their physician.

RESULTS

Forty-four residents and 21 supervisors participated in 87 video-CAF sessions. After their first video-CAF session, residents wrote down more learning objectives addressing their control and rapport skills and their listening skills. Video-CAF participation improved residents' patient-education competency, but only in their control and rapport skills. Video-CAF participation had no effect on patients' opinion.

CONCLUSIONS

Video-CAF appears to be a feasible procedure and might be effective in improving residents' patient-education competency in clinical practice.

PRACTICE IMPLICATIONS

Video-CAF could fill the existing deficiency of communication training in residency programs.

Competencies and frameworks in interprofessional education: a comparative analysis

Health professionals need preparation and support to work in collaborative practice teams, a requirement brought about by an aging population and increases in chronic and complex diseases. Therefore, health professions education has seen the introduction of interprofessional education (IPE) competency frameworks to provide a common lens through which disciplines can understand, describe, and implement team-based practices. Whilst an admirable aim, often this has resulted in more confusion with the introduction of varying definitions about similar constructs, particularly in relation to what IPE actually means.The authors explore the nature of the terms competency and framework, while critically appraising the concept of competency frameworks and competency-based education. They distinguish between competencies for health professions that are profession specific, those that are generic, and those that may be achieved only through IPE. Four IPE frameworks are compared to consider their similarities and differences, which ultimately influence how IPE is implemented. They are the Interprofessional Capability Framework (United Kingdom), the National Interprofessional Competency Framework (Canada), the Core Competencies for Interprofessional Collaborative Practice (United States), and the Curtin University Interprofessional Capability Framework (Australia).The authors highlight the need for further discussion about establishing a common language, strengthening ways in which academic environments work with practice environments, and improving the assessment of interprofessional competencies and teamwork, including the development of assessment tools for collaborative practice. They also argue that for IPE frameworks to be genuinely useful, they need to augment existing curricula by emphasizing outcomes that might be attained only through interprofessional activity.

Training students with patient actors improves communication: a pilot study

PURPOSE

Effective patient communication is correlated with better health outcomes and patient satisfaction, but is challenging to train, particularly with difficult clinical scenarios such as loss of sight. In this pilot study, we evaluated the use of simulated patient encounters with actors to train optometric students.

METHODS

Students were recorded during encounters with actors and assigned to an enrichment group performing five interactions with instructor feedback (n = 6) or a no-enrichment group performing two interactions without feedback (n = 4). Student performance on first and last encounters was scored with (1) subjective rating of performance change using a visual analog scale (anchors: much worse/much better), (2) yes/no response: Would you recommend this doctor to a friend/relative?, and (3) average score on questions from the American Board of Internal Medicine (ABIM) assessment of doctor communication skills. Three clinical instructors, masked to student group assignments and the order of patient encounters they viewed, provided scores in addition to self-evaluation by students and patient-actors.

RESULTS

Using the visual analog scale, students who received enrichment were rated more improved than the no-enrichment group by masked examiners (+18 vs. -11% p = 0.04) and self-evaluation (+79 vs. +27% p = 0.009), but not by actors (+31 vs. +43%). The proportion of students recommended significantly increased following enrichment for masked examiners (61% vs. 94%; p < 0.001), but not actors (100 vs. 83%). Average ABIM assessment scores were not significantly different by any rating group: masked instructors, actors, or self-ratings.

CONCLUSIONS

The findings of this study suggest five simulated patient encounters with feedback result in measurable improvement in student-patient communication skills as rated by masked examiners.

Interpersonal behaviors and socioemotional interaction of medical students in a virtual clinical encounter

BACKGROUND

The virtual clinical encounter (VCE) may function as an important support for medical students in or prior to clinical practice to train and ease communication and socioemotional interactions with patients. Few studies have however focused on the dynamics of interpersonal behaviors in clinical interviewing with a virtual patient (VP) and the affective responses evoked by such a learning experience. The study was designed to investigate the dynamics and congruence of interpersonal behaviors and socioemotional interaction exhibited during the learning experience in a VCE, and to evaluate which interaction design characteristics contribute most to the behavioral and affective engagement in medical students.

METHODS

Thirty medical students (sixth semester) participated voluntarily in an exploratory observational study with a highly interactive VP case based on a trustworthy VP encounter with a natural and realistic dialogue interface. Students worked collaboratively in pairs. They were videotaped for further behavioral analysis and self-reported (in both a survey and an interview) their personal opinions, perceptions and attitudes about the VCE. A mixed methods approach was applied.

RESULTS

All participants demonstrated an adequate, respectful and relevant clinical case management and to obtain psychosocial history. The collaborative workspace played its role and led to dynamic and engaged discussions fostering thus shared understanding. The results suggest that the VCE studied was perceived as a meaningful, intrinsically motivational and activating learning environment, and was found to socially and emotionally engage learners. We also found that VCEs have the potential to support the development of relevant and congruent interpersonal communication skills in trainees.

CONCLUSIONS

By taking advantage of socioemotional interaction, VCEs promote not only critical reflection skills or strategy-selection skills, but also to develop listening and nonverbal skills, induce self-awareness and target coping behaviours. We believe that, if applied in early medical education, this learning approach may facilitate clinical encounters at an early stage and contribute to responsible clinical decision making.

Treatment decision-making in the medical encounter: comparing the attitudes of French surgeons and their patients in breast cancer care

OBJECTIVES

To explore attitudes of French surgeons and their patients towards treatment decision-making (TDM) in the medical encounter.

METHODS

Surgeons involved in early stage breast cancer and their patients treated in a French cancer care network received a cross-sectional survey questionnaire containing examples of four different approaches to TDM: paternalistic, "some sharing", informed TDM and, shared TDM.

RESULTS

Surgeons' interaction styles were clearly distributed among paternalistic, shared and mixed. The paternalistic approach seemed to be associated with private rather than public practice and with less professional experience. Patients reported a rather low level of participation in TDM, varying by socio-demographic characteristics. One third of patients were dissatisfied with the way their treatment decision had been made.

CONCLUSION

Most surgeons reported adopting the "some sharing" approach. However, one patient out of three reported that they would have liked to participate more in the TDM process.

PRACTICE IMPLICATIONS

Surgeons need to ask patients what their preferences for involvement in TDM are and then think about ways to accommodate both their own and patients' preferences regarding the TDM process to be used in each encounter. In addition, decision aids could be offered to surgeons to help them discuss treatment options with their patients.

Strengthening student communication through pediatric simulated patient encounters

As medical students enter the role of physician, clinical outcomes not only rely on their mastery of clinical knowledge, but also on the effectiveness in which they can communicate with patients and family members. While students typically have numerous opportunities to practice clinical communication with adult patients, such practice in pediatric settings is limited. This study examines if simulated patient (SP) encounters strengthen third-year medical students' communication skills during the pediatrics clerkship. During 2011-2013, three SP encounters (comprising 3 pediatric scenarios) were incorporated into a pediatrics clerkship at one United States medical school to give students a safe venue to practice advanced communication with observation and direct feedback. Third-year medical students engaged in the scenarios and received both written and oral feedback from an evaluator observing the encounter. With IRB approval, students' self-perceived confidence and abilities at performing the advanced communication skills were measured using an eightitem, Likert scale questionnaire administered pre and post the SP encounter. Pre- and post-questionnaires (n=215; response rate, 96%) analyzed using a Wilcoxon-matched pairs signed-rank test demonstrated statistically significant increases in students' perception of their confidence and abilities regarding their performance (P<0.05; Bonferroni correction, P<0.006). There was an increases in student confidence and self-perceived ability in: first, communicating with children and family members of young patients; second, managing confrontational situations involving parents; third, performing a thorough psychosocial history with an adolescent; and fourth, using Evidence Based Medicine to motivate parents.

How to attain expertise in clinical communication?

Several factors complicate the attainment of expertise in clinical communication. Medical curricula and postgraduate training insufficiently provide the required learning conditions of deliberate practice to overcome these obstacles. In this paper we provide recommendations for learning objectives and teaching methods for the attainment of professional expertise in patient education. Firstly, we propose to use functional learning objectives derived from the goals and strategies of clinical communication. Secondly, we recommend using teaching and assessment methods which: (1) contain stimulating learning tasks with opportunities for immediate feedback, reflection and corrections, and (2) give ample opportunity for repetition, gradual refinements and practice in challenging situations. Video-on-the-job fits these requirements and can be used to improve the competency in patient education of residents and medical staff in clinical practice. However, video-on-the-job can only be successful if the working environment supports the teaching and learning of communication and if medical staff which supervises the residents, is motivated to improve their own communication and didactic skills.

Inconsistency of residents' communication performance in challenging consultations

OBJECTIVE

Communication performance inconsistency between consultations is usually regarded as a measurement error that jeopardizes the reliability of assessments. However, inconsistency is an important phenomenon, since it indicates that physicians' communication may be below standard in some consultations.

METHODS

Fifty residents performed two challenging consultations. Residents' communication competency was assessed with the CELI instrument. Residents' background in communication skills training (CST) was also established. We used multilevel analysis to explore communication performance inconsistency between the two consultations. We also established the relationships between inconsistency and average performance quality, the type of consultation, and CST background.

RESULTS

Inconsistency accounted for 45.5% of variance in residents' communication performance. Inconsistency was dependent on the type of consultation. The effect of CST background training on performance quality was case specific. Inconsistency and average performance quality were related for those consultation combinations dissimilar in goals, structure, and required skills. CST background had no effect on inconsistency.

CONCLUSION

Physician communication performance should be of high quality, but also consistent regardless of the type and complexity of the consultation.

PRACTICE IMPLICATIONS

In order to improve performance quality and reduce performance inconsistency, communication education should offer ample opportunities to practice a wide variety of challenging consultations.

Simulation: improving communication with patients

Patient-doctor communication has become a topic of increasing importance and attention, with both personal and public health ramifications. Despite this, formal training in communication is rare in later professional life, and the best way of improving these skills is unknown. Recently, attention has turned to simulation as a way to teach communication skills to medical providers. In this article, we review the history and current evidence behind utilizing simulation for patient-doctor communication teaching, as well as the challenges for future research in this field as it progresses into mainstream practice.

Education in patient-physician communication: how to improve effectiveness?

OBJECTIVE

Despite educational efforts expertise in communication as required by the CanMEDS competency framework is not achieved by medical students and residents. Several factors complicate the learning of professional communication.

METHODS

We adapted the reflective-impulsive model of social behaviour to explain the complexities of learning professional communication behaviour. We formulated recommendations for the learning objectives and teaching methods of communication education. Our recommendations are based on the reflective-impulsive model and on the model of deliberate practice which complements the reflective-impulsive model. Our recommendations are substantiated by those we found in the literature.

RESULTS

The reflective-impulsive model explains why the results of communication education fall below expectations and how expertise in communication can be attained by deliberate practice. The model of deliberate practice specifies learning conditions which are insufficiently fulfilled in current communication programmes.

CONCLUSION

The implementation of our recommendations would require a great deal of effort. Therefore we doubt whether expertise in professional communication can be fully attained during medical training.

PRACTICE IMPLICATIONS

We propose that the CanMEDS communication competencies not be regarded as endpoints in medical education but as guidelines to improve communication competency through deliberate practice throughout a professional career.

Mixed messages in learning communication skills? Students comparing role model behaviour in clerkships with formal training

BACKGROUND

Medical students learn professional communication through formal training and in clinical practice. Physicians working in clinical practice have a powerful influence on student learning. However, they may demonstrate communication behaviours not aligning with recommendations in training programs.

AIMS

This study aims to identify more precisely what differences students perceive between role model communication behaviour during clerkships and formal training.

METHOD

In a cross-sectional study, data were collected about physicians' communication performance as perceived by students. Students filled out a questionnaire in four different clerkships in their fourth and fifth year.

RESULTS

Just over half of the students reported communication similar to formal training. This was especially true for students in the later clerkships (paediatrics and primary care). Good examples were seen in providing information corresponding to patients' needs and in shared decision making, although students often noted that in fact the doctor made the decision. Bad examples were observed in exploring cognitions and emotions, and in providing information meeting patient's pace.

CONCLUSIONS

Further study is needed on actual physician behaviour in clinical practice. From our results, we conclude that students need help in reflecting on and learning from the gap in communication patterns they observe in training versus clinical practice.