An evaluation of microcouseling as an interviewer training tool

"We're All Time Poor": Experienced Clinicians' and Students' Perceptions of Challenges Related to Patient Communication

PHENOMENON

Communication is a complex and essential element of clinical practice. It is widely accepted that communication skills can be taught and learned, but challenges remain for clinicians in achieving effective communication with patients. This study explored the patient-communication challenges faced by both medical students and experienced clinicians.

APPROACH

Semi-structured interviews were conducted with twenty medical students and nineteen experienced clinicians from a range of medical disciplines. Interviews were recorded and transcribed, and transcriptions subjected to thematic analysis and coding to quantify the challenges discussed.

FINDINGS

There was remarkable consistency in the challenges described by both groups of participants, with eight predominant challenges identified: time constraints and chaotic environments, rapport building, patient characteristics, reluctance, omissions, assumptions, decision-making, and keeping conversations focused.

INSIGHTS

Medical curricula often focus on communication challenges associated with complex or sensitive clinical situations, but many of the challenges identified occur in routine consultations. Both pre-service and post-graduate medical training should adopt strategies to help build students' and clinicians' skills in managing these challenges from the outset of training.

Interventions for improving medical students' interpersonal communication in medical consultations

BACKGROUND

Communication is a common element in all medical consultations, affecting a range of outcomes for doctors and patients. The increasing demand for medical students to be trained to communicate effectively has seen the emergence of interpersonal communication skills as core graduate competencies in medical training around the world. Medical schools have adopted a range of approaches to develop and evaluate these competencies.

OBJECTIVES

To assess the effects of interventions for medical students that aim to improve interpersonal communication in medical consultations.

SEARCH METHODS

We searched five electronic databases: Cochrane Central Register of Controlled Trials, MEDLINE, Embase, PsycINFO, and ERIC (Educational Resource Information Centre) in September 2020, with no language, date, or publication status restrictions. We also screened reference lists of relevant articles and contacted authors of included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), cluster-RCTs (C-RCTs), and non-randomised controlled trials (quasi-RCTs) evaluating the effectiveness of interventions delivered to students in undergraduate or graduate-entry medical programmes. We included studies of interventions aiming to improve medical students' interpersonal communication during medical consultations. Included interventions targeted communication skills associated with empathy, relationship building, gathering information, and explanation and planning, as well as specific communication tasks such as listening, appropriate structure, and question style.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Two review authors independently reviewed all search results, extracted data, assessed the risk of bias of included studies, and rated the quality of evidence using GRADE.

MAIN RESULTS

We found 91 publications relating to 76 separate studies (involving 10,124 students): 55 RCTs, 9 quasi-RCTs, 7 C-RCTs, and 5 quasi-C-RCTs. We performed meta-analysis according to comparison and outcome. Among both effectiveness and comparative effectiveness analyses, we separated outcomes reporting on overall communication skills, empathy, rapport or relationship building, patient perceptions/satisfaction, information gathering, and explanation and planning. Overall communication skills and empathy were further divided as examiner- or simulated patient-assessed. The overall quality of evidence ranged from moderate to very low, and there was high, unexplained heterogeneity. Overall, interventions had positive effects on most outcomes, but generally small effect sizes and evidence quality limit the conclusions that can be drawn. Communication skills interventions in comparison to usual curricula or control may improve both overall communication skills (standardised mean difference (SMD) 0.92, 95% confidence interval (CI) 0.53 to 1.31; 18 studies, 1356 participants; I² = 90%; low-quality evidence) and empathy (SMD 0.64, 95% CI 0.23 to 1.05; 6 studies, 831 participants; I² = 86%; low-quality evidence) when assessed by experts, but not by simulated patients. Students' skills in information gathering probably also improve with educational intervention (SMD 1.07, 95% CI 0.61 to 1.54; 5 studies, 405 participants; I² = 78%; moderate-quality evidence), but there may be little to no effect on students' rapport (SMD 0.18, 95% CI -0.15 to 0.51; 9 studies, 834 participants; I² = 81%; low-quality evidence), and effects on information giving skills are uncertain (very low-quality evidence). We are uncertain whether experiential interventions improve overall communication skills in comparison to didactic approaches (SMD 0.08, 95% CI -0.02 to 0.19; 4 studies, 1578 participants; I² = 4%; very low-quality evidence). Electronic learning approaches may have little to no effect on students' empathy scores (SMD -0.13, 95% CI -0.68 to 0.43; 3 studies, 421 participants; I² = 82%; low-quality evidence) or on rapport (SMD 0.02, 95% CI -0.33 to 0.38; 3 studies, 176 participants; I² = 19%; moderate-quality evidence) compared to face-to-face approaches. There may be small negative effects of electronic interventions on information giving skills (low-quality evidence), and effects on information gathering skills are uncertain (very low-quality evidence).  Personalised/specific feedback probably improves overall communication skills to a small degree in comparison to generic or no feedback (SMD 0.58, 95% CI 0.29 to 0.87; 6 studies, 502 participants; I² = 56%; moderate-quality evidence). There may be small positive effects of personalised feedback on empathy and information gathering skills (low quality), but effects on rapport are uncertain (very low quality), and we found no evidence on information giving skills. We are uncertain whether role-play with simulated patients outperforms peer role-play in improving students' overall communication skills (SMD 0.17, 95% CI -0.33 to 0.67; 4 studies, 637 participants; I² = 87%; very low-quality evidence). There may be little to no difference between effects of simulated patient and peer role-play on students' empathy (low-quality evidence) with no evidence on other outcomes for this comparison. Descriptive syntheses of results that could not be included in meta-analyses across outcomes and comparisons were mixed, as were effects of different interventions and comparisons on specific communication skills assessed by the included trials. Quality of evidence was downgraded due to methodological limitations across several risk of bias domains, high unexplained heterogeneity, and imprecision of results. In general, results remain consistent in sensitivity analysis based on risk of bias and adjustment for clustering. No adverse effects were reported.  AUTHORS' CONCLUSIONS: This review represents a substantial body of evidence from which to draw, but further research is needed to strengthen the quality of the evidence base, to consider the long-term effects of interventions on students' behaviour as they progress through training and into practice, and to assess effects of interventions on patient outcomes. Efforts to standardise assessment and evaluation of interpersonal skills will strengthen future research efforts.

Strategies for Training Adult Counselors

Adult counselors can benefit from applied skill training to increase their effectiveness as helpers. This article outlines the eclectic training model developed to train paraprofessional counselors at the Continuum Center for Adult Counseling and Leadership Training. It then describes three major training approaches in use today: Carkhuff's Systematic Human Relations Training, Ivey's Microcounseling, and Kagan's Interpersonal Process Recall; and makes some comparisons among the four training models. The authors conclude that training for adult counselors must be designed so that trainees can identify their own strengths and add new skills to their existing repertoire.

Teaching Clinical Interviewing in the Health Professions

Empirical research on the teaching of interview skills has consistently shown significant (at p≤.05 level) changes on cognitive tests, affective measures, and observational data for students of various programs in the health professions. Most studies were simply comparisons of stu dents' pretest and posttest scores, with little control over possible confounding factors. Relatively few studies have in cluded direct comparisons of alternative approaches to the teaching of interview skills. These studies are examined in de tail, and trends among them are noted for the design of instructional programs. Also noted are the implications of these studies for future research.

Macrotraining: a "how-to" primer for using serial role-playing to train complex clinical interviewing tasks such as suicide assessment

Macrotraining is an educational technique for using serial role-playing and microtraining to teach complex interviewing tasks such as the assessment of suicide, domestic violence, and incest. This article provides a practical introduction to macrotraining and subsequently models its utilization for the training of residents in the use of the Chronological Assessment of Suicide Events (the CASE Approach), an interview strategy for uncovering suicidal ideation and intent.

An evaluation of a communication skills course for health visitor students

This paper presents part of the findings of an extensive empirical evaluation of a communication skills training programme for health visitor students. The programme was designed to develop the health visitors' ability to communicate with clients. A wide range of interpersonal skills were addressed and the training format involved skill analysis, roleplay practice and video-recorded feedback. The method of evaluation included an appraisal of the health visitors' social behaviour in a roleplay of a home-visit to a pregnant client. Data were collected, both before and following training, in an attempt to assess changes in trainee behaviour. The analysis took the form of a detailed frequency measurement of behavioural elements of health visitor performance, and a global rating of social competence by independent judges. Results of the analyses indicated that 14 out of the 20 behavioural variables changed in the desired direction. Thus, for example, following training the health visitors used significantly more open questions and verbal encouragers, and significantly fewer multiple questions and interruptions when communicating with the client. They were also rated significantly higher on the rating scale for social competence following training. These findings would seem to suggest that the training programme had a considerable degree of success. The findings are discussed in terms of the implications for development of health visitors' social skills, the need for more sophisticated measures of social behaviour and for the formulation of a model of competent professional practice in this area.

Using Microcounseling to Teach RN Nursing Students Skills of Therapeutic Communication

This study assessed the degree to which nursing students acquired and retained six generic skills of communication. Fifty-three second year female RN students were randomly assigned to either an experimental group (E-group) which received microtraining, or a nonattention control group (C-group). All subjects completed both the Carkhuff Indices of Communication and Discrimination as pretests. The E-group then had approximately 25 hours of microtraining in six basic communication skills. Following training, each subject completed the Carkhuff Indices again, the Empathy Construct Rating Scale, and a 10- to 15-minute audiotaped interview in which she assumed the role of a helping nurse. Multivariate analysis of covariance indicated a significant main effect suggesting that the E-group performed better than the C-group when all the measures were combined together. As well, the experimental trainees performed significantly better than the control trainees on empathy, reflection of feeling, and summarizing. The E-group made fewer communication errors, asked fewer closed-questions, made more Good responses, and showed a significant increase in empathy over training. At the nine-month follow-up, while there were no statistically significant differences between the groups on any dependent measure, the E-group outperformed the C-group on all dependent measures.

Evaluation of student performance in psychotherapy

In 1970, the APA's Psychotherapy Curriculum and Consultation Committee on Psychotherapy Training recommended that the faculty of training programs should formulate and publish explicit criteria by which the student's practice of psychotherapy can be evaluated. An informal survey of advanced clinical psychology graduate students (N = 17) of an APA-approved program indicated that during their first year of psychotherapy training, 77% of the students either did not know the criteria used to evaluate their performance as psychotherapists or thought that the evaluation was based on the professor's personal biases. The issue of using client outcome vs. competence in explicitly specified therapeutic skills as evaluative criteria was discussed. A combination of both criteria was recommended for implementation in training programs.

The Way we Teach… Interviewing Skills

Being able to interview well-eliciting elearly the information required whilst establishing and maintaining a rapport with the patient-is one of the doctor's greatest assets. Yet very little attention is paid to the teaching of interviewing skills. In this article Dr Maguire describes a short, successful course in interviewing skills which he and his colleagues at Manchester teach to medical students during their psychiatric attachment. Students receive feedback on their taped interviews with patients and are required to complete an interview rating scale. Role play is introduced where students have particular difficulty covering a given area, e.g. recent bereavement, or mastering a particular technique.

Teaching psychiatry to non-psychiatrists: I. The application of educational methodology

It is becoming increasingly clear that psychiatric and psychosocial needs of medical patients are not being adequately met. This need has led to an increasing emphasis on the psychiatric education of nonpsychiatrists, at varying levels of experience. Given the many problems involved in these educational efforts as well as the paucity of evaluation studies and the uncertainty of results, the authors argue that the systematic application of empirically validated educational principles may lead to greatly improved effectiveness. In this first section of a two-part series, the authors review educational methodology as it relates to the development of training objectives, the selection of teaching procedures, and the use of evaluation techniques. Part two presents a detailed "model" curriculum for primary care residents, developed according to the principles of educational methodology.

Improving physician-patient interactions: a review

The interaction between physician and patient comprises aspects of communication common to any two human beings and other aspects peculiar to the roles exclusively adopted by physicians and patients. In this review, nonverbal and verbal elements of general communication are discussed, detailing important aspects of vocal tone, body postures, appearance, and verbal cues that may influence attributions made of physicians by patients. Role-related elements of physician-patient interactions are discussed in light of findings from research on interactions between physicians and patients. Developmental elements of general communication are discussed, relating stages tht evolve in interactions to physician-patient interactions. Finally, an examination is made of how interpersonal skills are taught to physicians and medical students. Discussion of what skills are specified for teaching, whether they are effectively taught, and whether the learning of these skills produces desired patient health-related outcomes is presented.

An Assessment of a Microcounseling Model for Nurse Training in Facilitative Interpersonal Skills

Many large psychiatric hospitals, being overcrowded and understaffed, lack a healthy treatment atmosphere. The need for maximizing every staff member's potential cannot thus be overemphasized. Although psychiatric nursing staff have maximum contact with patients, they frequently lack training in interpersonal skills.

The aim of the study was to tentatively assess the feasibility of implementing a brief counselling training programme for psychiatric nurses in a hospital context. A set of skills, conducive to the establishment of a therapeutic milieu, was selected. A number of available programmes were assessed in terms of their suitability for training these specific skills, and a microcounseling programme was chosen and implemented. A small sample of nurses was drawn, and no control group was utilized. An own-control, time-series design was used, and methodological difficulties relating to implementation and assessment are discussed.

Significant trainee gains were demonstrated, although methodological shortcomings allowed only tentative conclusions. The value of a more rigorous design and extensive process analyses is stressed.

Training counseling and problem-solving skills with university students

Often nonprofessionals lack specific instruction in relevant counseling and problem-solving skills. The effects of training procedures on counseling and problem-solving behaviors were examined experimentally with university students. The procedures involved the use of behavioral specifications, rationales, situational examples, study guides, and practice plus feedback on performance. Following training, the average percentage of occurrence of counseling and problem-solving behaviors increased to 89%. Generalization data in sessions with actual clients and expert ratings of the overall quality of counseling provided evidence of generalization to other settings and other evaluative dimensions of counseling and problem-solving performance.

Training counseling skills: an experimental analysis and social validation

A community development perspective suggests the value of using local resources to solve local problems. Two low-income staff of a community service center served as nonprofessional counselors after receiving a training program consisting of written instructions, practice, and performance feedback. The effects of the 40-hour training program were positive for both counseling and problem-solving skills. There was also evidence of generalization of counseling performance across clients, problems, and time. In addition, expert judges' ratings of performance were obtained as a measure of social validity. These findings suggest that the training procedures are effective in enhancing the counseling and problem-solving skills of low-income nonprofessionals.

Original research: a process model for teaching and learning communications skills

This paper describes a model which specifies what teachers of communication skills should be teaching and what students in primary health care should be learning.

A teachers' guide to teaching medical interviewing

Success in teaching a course in medical interviewing requires competence on the part of instructors, who also need training, and have to provide a structured approach. Problems encountered by course coordinators at the Department of Family Medicine, University of Miami School of Medicine, Miami, Florida have been: (1) a shortage of skilled teachers; (2) inadequate motivation of instructors for teaching the course; (3) differences in content, teacher's style, and outcomes from small groups; and (4) ambiguities in structure or guidelines provided for teachers. The development of a teacher's guide, giving specific objectives and step-by-step methods for teaching significantly improved teacher satisfaction and commitment to the course, as well as student learning.

Simulated patients and the assessment of medical students' interpersonal skills

While the use of simulated patients for the assessement of medical students' skills is increasing there is little data on whether students perform differently vs real patients. The present study examined this issue using second-year medical students' ability to empathize with simulated and genuine patients. Forty second-year students each conducted two interviews which were audio-recorded and later rated by raters who had achieved a high degree of reliability using the 9-point accurate empathy scale (Truax, 1967). Ten students saw a genuine patient for each interview while ten students saw simulators on both occasions. Of the remaining twenty students, ten saw genuine patients at the first interview and simulated patients at the second session. This order was reversed for the remaining ten students. No significant differences were found in the levels of empathy between students' interaction with genuine or simulated patients. As the students were also unable to discriminate between the two groups of patients it was concluded that simulators represent a viable procedure given the skill to be assessed in the present research and the experience of the students.

Long-term effects of empathy training on the interview skills of medical students

A study examining the effects of empathy training, three years after completion of the program, is reported. The results indicate that, while the students' ability to empathize declines significantly with time, their level of skill is still higher than that of students who receives no training and are at a comparable stage in their medical education. The findings provide further support for requiring a continuing emphasis on training undergraduates in communication skills throughout their medical curriculum.

The value of feedback in teaching interviewing skills to medical students

Forty-eight medical students took part in a study to assess the value of giving students some feedback about their interviewing skills. During the study they all received training from their clinical firms. In addition, 36 of the students received 1 of 3 types of feedback training. This was given by tutors who used television replays, audiotape replays or ratings of practice interviews conducted by the students. As in previous studies there was little improvement in the interviewing skills of those students who only received training from their clinical firms. In contrast, all 3 feedback groups improved their ability to elicit accurate and relevant information. However, only the television and audiotape groups also showed gains in techniques. While the differences between these 2 groups were not significant, they all favoured the television group.