Teaching pre-clinical medical students an integrated approach to medical interviewing: half-day workshops using actors

Standardized Patients in Medical Education: A Review of the Literature

The concept of standardized patients (SPs) was first introduced in the 1960s by Dr. Howard Barrows of the University of Southern California and has been applied in medical school education since that time. This practice has allowed medical students to practice skills on live persons who are teachers rather than on real patients, who may be endangered by their emerging skills. Previous studies supported the use of SPs but did not measure whether they improved clinical competence or students' confidence in their skills. This literature review evaluated whether current medical education literature supports or refutes the use of SPs compared to other modalities such as simulated patients (SiPs) and virtual reality (VR) in the improvement of student confidence, clinical performance, and interpersonal communication skills. The research questions posed for this review were as follows: do medical students in their first two years of education who have practiced skills using SPs have more self-confidence in their ability to perform skills on real patients than those students who did not use SPs, do medical students in their third and fourth years of medical school have higher clinical competency with sensitive patient examinations after using SPs in their first two years of medical education than those students who did not use SPs, and do medical students who have used SPs for discussing sensitive issues have better interpersonal skills when they encounter real patients in the clinical setting than those who have not used SPs? The methodology for this descriptive, systematic review of the literature was organized using a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart to describe how articles were collected and synthesized to evaluate the variables under study. The results of this study revealed that students learned the most when SPs were used because they were able to teach students the skills that they needed in a safe learning environment. Medical students performing sensitive patient examinations with SPs learned not only how to perform the examinations but also how to improve their communication with patients. Students and residents reported increased confidence and clinical competence when performing new skills with SPs rather than with peer practice, virtual reality, or real patients in a clinical setting. Although the utilization of SPs has been studied in multiple ways and found to be a powerful tool in the education of undergraduate medical students and interns, there is still much study to be done to address the human needs of real patients. Gaps in this literature included small sample sizes, a lack of standardized assessment tools, and the need to include a multidisciplinary approach that addresses cultural awareness and appreciation. The authors found limited studies analyzing the effect the coronavirus disease 2019 (COVID-19) pandemic had on the use of SPs in medical school education. Continued scientific inquiry in post-pandemic medical education is an essential component for dissemination as most schools have reintroduced the use of SPs, which strengthens the concept that their use is superior to the other simulation methods used when SPs were not available.

Learning patient-centredness with simulated/standardized patients: A realist review: BEME Guide No. 68

BACKGROUND

Given the positive outcomes of patient-centred care on health outcomes, future doctors should learn how to deliver patient-centred care. The literature describes a wide variety of educational interventions with standardized patients (SPs) that focus on learning patient-centredness. However, it is unclear which mechanisms are responsible for learning patient-centredness when applying educational interventions with SPs.

OBJECTIVE

This study aims to clarify how healthcare learners and professionals learn patient-centredness through interventions involving SPs in different healthcare educational contexts.

METHODS

A realist approach was used to focus on what works, for whom, in what circumstances, in what respect and why. Databases were searched through 2019. Nineteen papers were included for analysis. Through inductive and deductive coding, CIC'MO configurations were identified to build partial program theories. These CIC'MOs describe how Interventions with SPs change the Context (C→C') such that Mechanisms (M) are triggered that are expected to foster patient-centredness as Outcome.

RESULTS

Interventions with SPs create three contexts which are 'a safe learning environment,' 'reflective practice,' and 'enabling people to learn together.' These contexts trigger the following seven mechanisms: feeling confident, feeling a sense of comfort, feeling safe, self-reflection, awareness, comparing & contrasting perspectives, combining and broadening perspectives. A tentative final program theory with mechanisms belonging to three main learning components (cognitive, regulative metacognitive and affective) is proposed: Interventions with SPs create a safe learning environment (C') in which learners gain feelings of confidence, comfort and safety (affective M). This safe learning environment enables two other mutual related contexts in which learners learn together (C'), through comparing & contrasting, combining and broadening their perspectives (cognitive M) and in which reflective practice (C') facilitates self-reflection and awareness (metacognitive M) in order to learn patient-centeredness.

CONCLUSION

These insights offer educators ways to deliberately use interventions with SPs that trigger the described mechanisms for learning patient-centredness.

A clinical medicine level test at Jinan University School of Medicine reveals the importance of training medical students in clinical history-taking

Backgrounds

Training in the basic interview skills of clinical history-taking has always been a significant component of medical education.

Purpose

This study was designed to identify the factors influence medical students’ history-taking skills learning and develop a way to improve these skills.

Methods

We firstly analysed the academic performance of medical students at Jinan University School of Medicine in different disciplines of the Clinical Medicine Level Test (CMLT), to ensure the students have obtained comprehensive medical education prior to beginning their clinical internships. Next, we conducted a survey among the CMLT participants to seek the underlying causes and corresponding measures to improve history-taking in the future. Before these medical students entered their fifth-year clinical practice, we finally provide them with pre-internship training, including the history-taking workshops with standard patients (SP).

Results

The analysis of the clinical skill sections of the CMLT revealed that the students performed significantly better on clinical operations from multiple disciplines than on medical history-taking. Principal component analysis of the survey questionnaire indicated that the capability of history-taking, course assessments, and awareness of the value of medical history-taking emerged as the key factors forming a cohesive clue for sustaining history-taking implementation. The intervention workshops of employing SP had a positive impact, as evidenced by the students’ feedback and suggestions for improving their ability of history-taking.

Conclusions

This study suggests that strengthening of medical history-taking training is indispensable for training qualified medical students. Workshops with SP is a successful teaching strategy for practicing history-taking, allowing students to spot minute errors and training communication skills.

Online medical history taking course: Opportunities and limitations in comparison to traditional bedside teaching

OBJECTIVE

Obtaining a systematic medical history (MH) from a patient is a core competency in medical education and plays a vital role in the diagnosis of diseases. At the Faculty of Medicine at LMU Munich, students have their first course in MH taking during their second year. Due to the COVID-19 pandemic, the traditional bedside MH taking course had to be transformed into an online course (OC). Our objectives were to implement an online MH taking course, to evaluate its feasibility and to compare the evaluation results to a historic cohort that had undertaken the traditional bedside teaching course (BTC).

METHODS

874 second-year students participated in the OC (BTC=827). After teaching the theoretical background via asynchronous online lectures, students participated in a practical exercise with fellow students using the video communication platform Zoom where they were able to practice taking a MH on the basis of fictitious, text-based patient cases. Students were then asked to evaluate the course through a standardized online survey with 31 questions on teaching quality and self-perceived learning success, which had also been used in previous years. The survey results were compared to the results of the historic cohort using the Mann-Whitney U test.

RESULTS

A total of n=162 students (18.5%) evaluated the OC. In the historic cohort, n=252 (30.5%) completed the survey. 85.3% of the OC respondents thought that the atmosphere during the practical exercise was productive and 83.0% greatly appreciated the flexibility in terms of time management. Moreover, they appreciated the online resources as well as having the opportunity to undertake a MH taking course during the COVID-19 pandemic. 27.7% of the respondents thought that traditional BTCs should be supplemented through more online activities in the future. With respect to the ability of independently taking a MH upon completion of the course, the OC was rated significantly lower relative to the BTC (mean OC=2.4, SD=±1.1 vs. mean BTC=1.9, SD=±1.1 (1=strongly agree; 5=strongly disagree); p<0.0001).

CONCLUSION

OCs are a feasible format and seem to convey the theory and practical implementation in a peer-exercise format of MH taking to medical students. The theoretical background can be acquired with great flexibility. Nevertheless, the students' self-appraisal suggested that the traditional teaching format was more effective at teaching MH taking skills. Thus, we propose a blended learning concept, combining elements of both formats. In this context, we suggest prospective, randomized trials to evaluate blended learning approaches.

Validity and reliability of a Korean version of the Consultation and Relational Empathy (CARE) measure

BACKGROUND

No validated tool is available to assess patients' perception of physician empathy in Korea. The objective of this study was to establish a Korean version of the Consultation and Relational Empathy (CARE) measure-originally developed in English and widely used internationally-and to examine its reliability and validity.

METHODS

The CARE measure was translated into Korean and tested on 240 patients from one secondary care hospital and one tertiary care hospital in Korea. Internal consistency by Cronbach's alpha, exploratory analysis, and confirmatory factor analysis were conducted to verify the 10 items of the Korean CARE measure.

RESULTS

The Korean CARE measure demonstrated high acceptability and face validity, excellent internal reliability (Cronbach's alpha = 0.97) and moderate test-retest reliability (Pearson correlation coefficient = 0.53; Spearman correlation coefficient = 0.51). Distribution of scores showed negative skewedness. Corrected item-total correlations ranged from 0.77-0.92, indicating homogeneity. The Kaiser-Meyer-Olkin measure of sampling adequacy was 0.949, and Bartlett's test of sphericity was good (χ2 = 3157.11, P < 0.001). Factor analysis yielded a single dimensional structure of physician empathy with all factor loadings exceeding 0.80 and showing excellent goodness of fit.

CONCLUSION

This study supports the reliability and validity of the Korean CARE measure in a university hospital setting in Korea.

The use of simulation in medical student education on the topic of breaking bad news: A systematic review

BACKGROUND

Simulated patients (SPs) are widely used, but the most effective way of utilising them in undergraduate breaking bad news (BBN) medical education is unknown.

OBJECTIVES

To conduct a systematic review into SP's use in developing BBN skills in medical students.

METHODS

14 databases searched with the terms "Medical education", "Patient simulation", "Bad news". Data was systematically extracted, and thematic analysis undertaken.

RESULTS

Of 2117 articles screened, 29 publications met the inclusion criteria. These demonstrated a variety of SP models, including actors as patients (65.5%), peers (7.0%), and cancer survivors (3.5%). with delivery at varying times in the curricula. SPs are uniformly reported as having positive impact, but there is a lack of high-quality evidence comparing the use of differing forms of training. There was some evidence that virtual SPs were as useful as in-person SPs.

CONCLUSIONS

SPs allow students to practise vital BBN communication skills without risking detriment to patient care. Despite the heterogeneity of ways in which SPs have been used, the benefits of different approaches and when and how these should be delivered remains unclear.

PRACTICE IMPLICATIONS

Further educational development and research is needed about the use of SPs to support undergraduate BBN communication skills development.

Improved detection of patient centeredness in objective structured clinical examinations through authentic scenario design

OBJECTIVE

In current objective structured clinical examinations (OSCEs), simulated encounters lacking realism reduce authenticity of assessment as students can take the OSCEs with a search-and-scan approach and trained empathy. Accordingly, patient-centeredness, the fundamental goal of OSCE, is not well assessed. This study evaluated the effect of a change in the OSCE scenario and checklist with respect to detecting students' patient-centeredness.

METHODS

A scenario script for valid representation of a real clinical encounter was developed and defined as authenticated scenario. The OSCE scores and the measure of patient-centered communication (MPCC) scores of 79 medical students were compared between the two OSCE stations, one using the traditional scenario and another using the authenticated scenario.

RESULTS

The MPCC total score was higher in the OSCE station using the authenticated scenario than that of the traditional scenario (p < 0.001). For the OSCE scores, the patient satisfaction score and the patient-physician interaction score were higher in the station using the authenticated scenario than the traditional one (p < 0.001).

CONCLUSION

The OSCE station using the authenticated scenario better detected medical student level of patient-centeredness.

PRACTICE IMPLICATIONS

Strengthening the authenticity of the OSCE scenario is critical for detecting the medical students' levels of patient-centeredness.

When Doctor Means Teacher: An Interactive Workshop on Patient-Centered Education

INTRODUCTION

Increasingly, health care is delivered through a patient-centered model, and patients engage in shared decision-making with their medical providers. As a result, medical educators are placing more emphasis on patient-centered communication skills. However, few published curricula currently offer a comprehensive discussion of skills for providing patient-centered education (PCE), a key component of shared decision-making. We developed an interactive, two-session workshop aiming to improve students' abilities to provide PCE.

METHODS

Our workshop included didactic instruction, group discussion, and interactive simulations. The workshop was delivered to 50 clinical clerkship medical students. The first session concentrated on educating patients about their diagnoses, while the second session focused on providing patients with information about medications and other treatments. We used detailed and realistic role-play exercises as a core tool for student practice and demonstration of confidence. To evaluate the workshop, we used pre- and postsurveys.

RESULTS

The sessions were well received by students, who strongly agreed both before and after the workshop that PCE was an important skill. Students also strongly agreed that the role-play exercises were an effective tool for learning PCE. They demonstrated significant improvements in their confidence to name important elements of PCE and to deliver PCE in the future.

DISCUSSION

This workshop fills a curricular gap in offering a comprehensive and interactive curriculum for improving students' abilities to provide critical PCE. The format and content should be easily adaptable to various disciplines, learners, and teaching modalities.

Twelve tips for running an effective session with standardized patients

The incorporation of actors as standardized patients (SPs) to help students achieve learning goals across a range of topics has become widespread in medical education. SPs are integrated into formative and summative objective structured clinical examinations by medical educators and by licensing boards for assessment of competence. While SPs are useful for assessment of dynamic skills, they also have significant utility as an engaging instructional method. Few tools in teaching allow for the breadth of instruction, practice, and assessment offered by workshops involving SPs. A simulated encounter with an SP may be a trainee's only opportunity to experience working through a particular clinical scenario in an environment that carries no risk of significant harm. Thus, there is immense potential for educational innovation with SPs. The following Twelve Tips piece provides suggestions for harnessing this potential based on available literature and educational experiences of the authors.

Reliability of scores obtained from standardized patient and instructor assessments

INTRODUCTION

To obtain more reliable results from observation-based assessments, high-quality raters are key. Although this quality can be obtained by using instructors, extra workload can be a burden on them. To overcome this problem, one alternative to instructor raters can be standardized patients (SPs).

METHOD

In this study, the students carried out an SP interview related to communication with an applicant/patient in the context of clinical skills training course. SPs rated student interviews just after interview and after watching a recording. Instructors rated students just by watching the recordings. To determine the appropriateness of use of SPs as raters, ratings of SPs and instructors were compared by using mean scores given to the interview performances of students' communication skills. Moreover, G theory was used to determine the reliability of scores.

RESULTS

Standardized patients' ratings immediately after the interviews showed the highest scores, and these ratings were statistically different from the SPs' and instructors' ratings done while watching recordings. Besides, the G coefficient for the 4 instructors was 0.71, while that for the 12 SPs was estimated as 0.73. However, even when using 12 SPs, the obtained reliability coefficient of 0.73 brings into question the reliability of their ratings. Moreover, it was found that the one who contributed the most to reliability among instructors was the most experienced person in subject area.

CONCLUSIONS

If SPs are to be used as raters, they will need more comprehensive training. More importantly, regardless of who the rater is, rater training is one of the most important factors in achieving more reliable and valid results. Moreover, having experience and knowledge about assessed topic is another crucial point of performance assessment by means of obtaining reliable results.

Specific feedback makes medical students better communicators

BACKGROUND

Feedback is regarded a key element in teaching communication skills. However, specific aspects of feedback have not been systematically investigated in this context. Therefore, the aim of this study was to investigate the effectiveness of communication skills training (CST) integrating specific, structured and behavioral feedback.

METHODS

We condensed best practice recommendations for feedback in a CST for undergraduate medical students and compared the effect of specific, structured and behavior-orientated feedback (intervention group CST-behav) to general, experience-orientated feedback (CST- exp. as our control group) in a randomized controlled trial (RCT). We investigated changes on communication skills evaluated by independent raters, and evaluated by standardized patients (SP). To do that, every student was video-recorded in a pre and post assessment.

RESULTS

Sixty-six undergraduate medical students participated voluntarily in our study. Randomization did not result in equally skilled groups at baseline, so valid inter-group comparisons were not possible. Therefore, we analyzed the results of 34 students of our intervention group (CST-behav). Five out of seven domains in communication skills as evaluated by independent raters improved significantly, and there was a significant change in the global evaluation by SP.

CONCLUSIONS

Although we were unable to make between-group comparisons, the results of the within group pre-post evaluation suggest that specific feedback helps improve communication skills.

Understanding the impact of simulated patients on health care learners' communication skills: a systematic review

CONTEXT

Effective communication skills are at the core of good health care. Simulated patients (SPs) are increasingly engaged as an interactive means of teaching, applying and practising communication skills with immediate feedback. There is a large body of research into the use of manikin-based simulation but a gap exists in the body of research on the effectiveness of SP-based education to teach communication skills that impact patient outcomes. The aim of this systematic review was to critically analyse the existing research, investigating whether SP-based communication skills training improves learner-patient communication, how communication skill improvement is measured, and who measures these improvements.

METHODS

The databases Medline, ProQuest (Health & Medical Complete, Nursing and Allied Health Source) and CINAHL (EBSCOhost) Education Resources Information Centre (ERIC) were searched for articles that investigated the effects of SP-based education on the communication skills of medical, nursing and allied health learners.

RESULTS

There were 60 studies included in the review. Only two studies reported direct patient outcomes, one reporting some negative impact, and no studies included an economic analysis. Many studies reported statistically significant third-party ratings of improved communication effectiveness following SP-based education; however, studies were unable to be pooled for meta-analysis because of the outcome collection methods. There were a small number of studies comparing SP with no training at all and there were no differences between communication skills, contradicting the results from studies reporting benefits. Of the 60 studies included for analysis, 54 (90%) met the minimum quality score of 7/11, with four articles (7%) scoring 11/11.

CONCLUSION

SP-based education is widely accepted as a valuable and effective means of teaching communication skills but there is limited evidence of how this translates to patient outcomes and no indication of economic benefit for this type of training over another method.

Effect of individualized communication skills training on physicians' discussion of clinical trials in oncology: results from a randomized controlled trial

Background

Discussing randomized clinical trials (RCTs) with cancer patients is one of the most challenging communication tasks a physician faces. Only two prior Communication Skills Trainings (CSTs) focused on RCTs in oncology have been reported. Their results demonstrated the need for further improvement. We developed and evaluated an enhanced, individually-tailored CST focused on improving physicians’ communication during discussions of RCTs.

Methods

The CST focused on personal learning goals derived from video pre-assessment that were addressed in a 1.5-day group workshop and one-on-one coaching sessions. Forty physicians were recruited and randomly assigned to intervention and control groups. Video-recorded standardized consultations with actor-patients were utilized. As a primary outcome (1), training success was evaluated by blinded raters using a previously developed checklist. Change in checklist items was evaluated between pre- and post-training assessment and compared against control group results. As a secondary outcome (2), the physicians’ feeling of confidence was assessed by a questionnaire.

Results

(1) Significant improvements in the intervention group were observed for the score on all items (p = 0.03), for the subgroup of content-specific items (p = 0.02), and for the global rating of communication competence (p = 0.04). The improvement observed for the subgroup of general communication skill items did not achieve significance (p = 0.20). (2) The feeling of confidence improved in nine out of ten domains.

Conclusion

While the individually-tailored CST program significantly improved the physicians’ discussions of RCTs, specifically related to discussion content, what remains unknown is the influence of such programs in practice on participant recruitment rates.

The study was registered retrospectively in 2010/07/22 under DRKS-ID: DRKS00000492.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-017-3238-0) contains supplementary material, which is available to authorized users.

Competence of medical students in communicating drug therapy: Value of role-play demonstrations

Objectives:

This study used role-play demonstrations to train medical students to communicate drug therapy and evaluated the perceptions on this instructional approach.

Materials and Methods:

The second-year medical students who attended a prescription writing session (n = 133), participated in this study. Prescription communication was introduced by using role-play demonstrations. Participant's perceptions were explored by a self-administered questionnaire and focus group discussion. The academic achievement of attendees and nonattendees was compared with an objective structured performance evaluation (OSPE) station that tested students’ competence in this skill.

Results:

Most attendees responded to the questionnaire (81.2%). Almost all respondents expressed their desire to have similar demonstrations in other units. A large proportion of participants reported that role-play demonstrations helped them develop their communication skills, in general, confidence to communicate drug-related information in a prescription, and the ability to explain the aim of drug therapy to patients. Most trainees thought also that they developed skills to communicate instructions on drug use including drug dose, frequency of administration, duration of therapy, adverse drug reactions, and warnings. During the focus group interviews, students thought that role-play was useful but would be more beneficial if conducted frequently in small group as part of the curriculum implementation. The majority of students also reported improved competence in writing a complete prescription. Analysis of attendees and nonattendees grades in the OSPE showed that the former scored higher than the latter group (P = 0.016).

Conclusions:

Role-play demonstrations were well accepted by medical students and led to the development of their competence in communicating drug therapy to patients.

How to assess communication skills? Development of the rating scale ComOn Check

BACKGROUND

Good communication is a core competency for all physicians. Thus, medical students require adequate preparation in communication skills. For research purposes, as well as for evaluation in teaching, there is a clear need for reliable assessment tools. We analyzed the shortcomings of existing instruments and saw a need for a new rating scale. The aim of this publication is to describe the development process for, and evaluation of, a new rating scale.

METHODS

First, we developed the rating scale in 10 steps. Then, two raters evaluated the newly developed rating scale by rating 135 videotaped consultations of medical students with standardized patients. Additionally, standardized patients evaluated students' performance, which was used as an outside criterion to validate ratings.

RESULTS

Our rating scale comprises six domains with 13 specific items evaluated on a five-point Likert scale: initiating conversation, patient's perception, structure of conversation, patient's emotions, end of conversation, and general communication skills. Item-total correlation coefficients between the checklist items ranged from 0.15 to 0.78. Subscale consistency was calculated for domains comprised of more than one item and Cronbach's α ≥ 0.77, indicating acceptable consistency. Standardized patients' global evaluation correlated moderately with overall expert ratings (Spearman's ρ = .40, p < .001).

CONCLUSION

Our rating scale is a reliable and applicable assessment tool. The rating scale focuses on the evaluation of general communication skills and can be applied in research as well as in evaluations, such as objective structured clinical examinations (OSCE).

ABBREVIATIONS

CST: Communication skills training; ICC: Intra-class correlation coefficient; OSCE: Objective structured clinical examination; SP: Standardized patients; SD: Standard deviation; M: Mean.

Implementing and Evaluating a Four-Year Integrated End-of-Life Care Curriculum for Medical Students

PROBLEM

Meeting the needs of patients with life-limiting and terminal illness requires effectively trained physicians in all specialties to provide skillful and compassionate care. Despite mandates for end-of-life (EoL) care education, graduating medical students do not consistently feel prepared to provide this care.

INTERVENTION

We have developed a longitudinal, integrated, and developmental 4-year curriculum in EoL care. The curriculum's purpose is to teach basic competencies in EoL care. A variety of teaching strategies emphasize experiential, skill-building activities with special attention to student self-reflection. In addition, we have incorporated interprofessional learning and education on the spiritual and cultural aspects of care. We created blended learning strategies combining interactive online modules with live workshops that promote flexibility, adaptability, and interprofessional learning opportunities.

CONTEXT

The curriculum was implemented and evaluated in the 4-year program of studies at Yale School of Medicine.

OUTCOME

A mixed-method evaluation of the curriculum included reviews of student written reflections and questionnaires, graduating student surveys, and demonstration of 4th-year students' competency in palliative care with an observed structured clinical examination (OSCE). These evaluations demonstrate significant improvements in students' self-reported preparedness in EoL care and perceptions of the adequacy in their instruction in EoL and palliative care, as well as competency in primary palliative care in a newly developed OSCE.

LESSONS LEARNED

A 4-year longitudinal integrated curriculum enhances students' skills and preparedness in important aspects of EoL care. As faculty resources, clinical sites, and curricular structure vary by institution, proven and adaptable educational strategies as described in this article may be useful to address the mandate to improve EoL care education. Teaching strategies and curricular components and design as just described can be adapted to other programs.

Teaching history taking to medical students: a systematic review

BACKGROUND

This paper is an up-to-date systematic review on educational interventions addressing history taking. The authors noted that despite the plethora of specialized training programs designed to enhance students' interviewing skills there had not been a review of the literature to assess the quality of each published method of teaching history taking in undergraduate medical education based on the evidence of the program's efficacy.

METHODS

The databases PubMed, PsycINFO, Google Scholar, opengrey, opendoar and SSRN were searched using key words related to medical education and history taking. Articles that described an educational intervention to improve medical students' history-taking skills were selected and reviewed. Included studies had to evaluate learning progress. Study quality was assessed using the Medical Education Research Study Quality Instrument (MERSQI).

RESULTS

Seventy-eight full-text articles were identified and reviewed; of these, 23 studies met the final inclusion criteria. Three studies applied an instructional approach using scripts, lectures, demonstrations and an online course. Seventeen studies applied a more experiential approach by implementing small group workshops including role-play, interviews with patients and feedback. Three studies applied a creative approach. Two of these studies made use of improvisational theatre and one introduced a simulation using Lego® building blocks. Twenty-two studies reported an improvement in students' history taking skills. Mean MERSQI score was 10.4 (range 6.5 to 14; SD = 2.65).

CONCLUSIONS

These findings suggest that several different educational interventions are effective in teaching history taking skills to medical students. Small group workshops including role-play and interviews with real patients, followed by feedback and discussion, are widespread and best investigated. Feedback using videotape review was also reported as particularly instructive. Students in the early preclinical state might profit from approaches helping them to focus on interview skills and not being distracted by thinking about differential diagnoses or clinical management. The heterogeneity of outcome data and the varied ways of assessment strongly suggest the need for further research as many studies did not meet basic methodological criteria. Randomized controlled trials using external assessment methods, standardized measurement tools and reporting long-term data are recommended to evaluate the efficacy of courses on history taking.

Teaching patient-centered communication skills: a telephone follow-up curriculum for medical students

BACKGROUND

To encourage medical students' use of patient-centered skills in core clerkships, we implemented and evaluated a Telephone Follow-up Curriculum focusing on three communication behaviors: tailoring education to patients' level of understanding, promoting adherence by anticipating obstacles, and ensuring comprehension by having patients repeat the plans.

METHODS

The intervention group consisted of two different cohorts of third-year medical students in longitudinal clerkships (n=41); traditional clerkship students comprised the comparison group (n = 185). Intervention students telephoned one to four patients 1 week after seeing them in outpatient clinics or inpatient care to follow up on recommendations. We used surveys, focus groups, and clinical performance examinations to assess student perception, knowledge and skills, and behavior change.

RESULTS

Students found that the curriculum had a positive impact on patient care, although some found the number of calls excessive. Students and faculty reported improvement in students' understanding of patients' health behaviors, knowledge of patient education, and attitudes toward telephone follow-up. Few students changed patient education behaviors or called additional patients. Intervention students scored higher in some communication skills on objective assessments.

CONCLUSION

A patient-centered communication curriculum can improve student knowledge and skills. While some intervention students perceived that they made too many calls, our data suggest that more calls, an increased sense of patient ownership, and role modeling by clerkship faculty may ensure incorporation and application of skills.

Improving the standardized patient experience

BACKGROUND

As the facilitator of the standardized patient rotation at the Ohio College of Podiatric Medicine (now Kent State University College of Podiatric Medicine [KSUCPM]) for the past 4 years, I have felt that there is underused time in the program. Therefore, I sought the views of podiatric medical students at KSUCPM who have completed the standardized patient rotation to see how they felt their time in the course was used and whether they felt that the course was useful to them in terms of advancing their podiatric medical education.

METHODS

A survey was administered to 105 third-year podiatric medical students. These students had already completed the standardized patient rotation, which at KSUCPM is in the second year.

RESULTS

Seventy-seven students completed the survey. Most of these students felt that there was improperly used time in the course, and many recommended ways of improving the course organization.

CONCLUSIONS

The students answered positively that the standardized patient rotation was important in terms of improving interviewing skills and worthwhile for future professional development. The students agreed that there likely was underused time in the course and even suggested ways in which they would make the course run more efficiently.

Benefits of teaching medical students how to communicate with patients having serious illness: comparison of two approaches to experiential, skill-based, and self-reflective learning

Innovative approaches are needed to teach medical students effective and compassionate communication with seriously ill patients. We describe two such educational experiences in the Yale Medical School curriculum for third-year medical students: 1) Communicating Difficult News Workshop and 2) Ward-Based End-of-Life Care Assignment. These two programs address educational needs to teach important clinical communication and assessment skills to medical students that previously were not consistently or explicitly addressed in the curriculum. The two learning programs share a number of educational approaches driven by the learning objectives, the students' development, and clinical realities. Common educational features include: experiential learning, the Biopsychosocial Model, patient-centered communication, integration into clinical clerkships, structured skill-based learning, self-reflection, and self-care. These shared features - as well as some differences - are explored in this paper in order to illustrate key issues in designing and implementing medical student education in these areas.

Assessment of a motivational interviewing curriculum for year 3 medical students using a standardized patient case

OBJECTIVE

We sought to evaluate a year 3 motivational interviewing (MI) curriculum using a standardized patient case.

METHODS

The 2-h small group MI curriculum included a didactic presentation followed by interactive role plays. During a clinical skills assessment at the end of year 3 the MI skills of 80 students who had participated in the curriculum were compared with those of 19 students who had not participated.

RESULTS

The standardized patient reliably rated the students on their performance of 8 items. Students who had participated in the MI curriculum were significantly more proficient than nonparticipating students in the performance of 2 strategic MI skills, importance and confidence rulers (ps<.006). The groups did not differ in their use of patient-centered counseling skills or collaborative change planning commonly used in MI.

CONCLUSIONS

Third year medical students can learn to use MI skills that specifically aim to enhance patients' motivations for change.

PRACTICE IMPLICATIONS

Medical schools should consider providing students with MI training and MI skill assessments using standardized patient cases to help students prepare to counsel patients for behavior change.

Moral imagination in simulation-based communication skills training

Clinical simulation is used in nursing education and in other health professional programs to prepare students for future clinical practice. Simulation can be used to teach students communication skills and how to deliver bad news to patients and families. However, skilled communication in clinical practice requires students to move beyond simply learning superficial communication techniques and behaviors. This article presents an unexplored concept in the simulation literature: the exercise of moral imagination by the health professional student. Drawing from the works of Hume, Aristotle and Gadamer, a conceptualization of moral imagination is first provided. Next, this article argues that students must exercise moral imagination on two levels: towards the direct communication exchange before them; and to the representative nature of simulation encounters. Last, the limits of moral imagination in simulation-based education are discussed.

Students' views on the use of real patients and simulated patients in undergraduate medical education

PURPOSE

To determine students' views about the strengths and weaknesses of real patient interactions as opposed to simulated patient (SP) interactions in the undergraduate medical curriculum in order to evaluate how their strengths can be optimally used and weaknesses remedied.

METHOD

Five focus-group interviews were conducted among fourth- and fifth-year medical students at Maastricht University in 2007, using a preestablished interview guide. The interviews were recorded, transcribed, and analyzed using qualitative methods.

RESULTS

In general, the 38 participants considered real patient encounters more instructive and more authentic than SP encounters. However, students identified several strengths of SP encounters compared with real patient encounters. For example, SP interactions were helpful in preparing students for real patient interactions (particularly with regard to communication skills and self-confidence), in the teaching of "intimate" physical examination skills, such as gynecological examination skills, and in giving constructive feedback on communication skills. In contrast to what we had anticipated, taking a time-out was considered easier in real patient interactions.

CONCLUSIONS

Both real patient interactions and SP interactions are considered indispensable to undergraduate medical education. Each encounter has unique strengths and weaknesses from the perspectives of students. On the basis of strengths and weaknesses that were identified, suggestions were made for the use of real patients and SPs in undergraduate medical education.

Patient-centered interviewing and student performance in a comprehensive clinical skills examination: is there an association?

OBJECTIVE

Communication skills, including patient-centered interviewing (PCI), have become a major priority for educational and licensing organizations in the United States. While patient-centered interviewing is associated with positive patient outcomes and improved diagnostic accuracy, it is unknown if an association exists between patient-centered interviewing and student performance in high-stakes clinical skills assessment (CSA) examinations. The purpose of this study was to determine if generic communication skills and patient-centered interviewing skills were associated with students' overall student performance on a multi-station clinical skills assessment (CSA) examination.

METHODS

This was a cross-sectional study to assess student performance with standardized patients (SPs). We conducted a retrospective review of 30 videotaped SP encounters of Third year medical students (class of 2006) at the University of Kansas School of Medicine. We measured correlations between observed PCI scores, overall CSA scores and CSA interpersonal and communication (ICS) skills scores of student-SP encounters.

RESULTS

PCI scores, as measured with the Four Habits Coding Scheme, a measurement tool of patient-centered communication, were not correlated with either overall CSA scores or ICS scores. Students' PCI scores were lower than the ICS scores (57% vs. 85% of correct items). The students performed poorly (30% mean score of correct items) in eliciting patient perspectives, compared to three other domains (Invest in the beginning, Demonstrate empathy, and Invest in end) of patient-centered interviewing.

CONCLUSIONS

Our study failed to demonstrate any association between student performance and patient-centered interviewing skills (PCI) in the setting of a comprehensive in-house CSA examination. Third-year medical students in our study did not practice some elements of patient-centered interviewing.

PRACTICE IMPLICATIONS

Given the increasing importance of patient-centered communication, the high-stakes in-house clinical skills examinations may consider assessing patient-centered interviewing using a more comprehensive and valid checklist.

Strengths and weaknesses of simulated and real patients in the teaching of skills to medical students: a review

The aim of this review was to identify the strengths and weaknesses of the roles of real and simulated patients in undergraduate medical education. The literature was reviewed in relation to four patient roles: real patients as educational "resource" (passive role), real patients as teachers (active role), and simulated patients as educational resource and teachers. Each of the four patient roles was found to have specific advantages and disadvantages from the perspectives of teachers, students, and patients. For example, advantages of real patients as educational resource were patient-centered learning and high patient satisfaction. Disadvantages were their limited availability and the variability in learning experiences among students. Despite the considerable amount of literature we found, many gaps in knowledge about patient roles in medical education remain and should be addressed by future studies.

Teaching medical students how to break bad news: a Turkish experience

BACKGROUND

To assess the effect of teaching breaking bad news.

METHODS

The session incorporated brainstorming, presentation, discussion, small-group exercises using standardized patients. Course was evaluated through a pre-objective structured clinical examination (OSCE), first post-OSCE (post-OSCE1), second post-OSCE (post-OSCE2) (6th month), and questionnaires.

RESULTS

Pre-OSCE, post-OSCE1, post-OSCE2 scores: preparing the environment 5.83 +/- 0.23, 7.93 +/- 0.19, 9.78 +/- 0.07; understanding what patient knows and wants to learn 1.83 +/- 0.33, 6.47 +/- 0.27, 9.68 +/- 0.11; giving information 3.25 +/- 0.34, 7.43 +/- 0.19, 9.67 +/- 0.10; developing empathy 2.50 +/- 0.32, 6.92 +/- 0.28, 9.87 +/- 0.06; closing the interview 2.28 +/- 0.28, 6.98 +/- 0.25, 9.83 +/- 0.07. The differences between OSCEs were significant. In the questionnaire, 54.1% of 146 students perceived more competent.

CONCLUSIONS

Course seems beneficial.

Using simulated interviews to teach junior medical students to disclose the diagnosis of cancer

BACKGROUND

Disclosing cancer is a difficult task for junior doctors.

METHODS

We conducted a survey of 4th-year (of 6 years) medical students' (N = 50) expectations of training in breaking bad news and then designed a course for students in their 5th-year oncology clerkship. The course comprised (a) a group discussion that taught a 6-point protocol for delivering a diagnosis (N = 40), (b) a videotaped simulated interview with actors to assess protocol implementation and communication skills (N = 18), and (c) feedback from a senior physician. The impact of the course was assessed during the end-of-year faculty examination (N = 55).

RESULTS

Most students considered breaking bad news most difficult for the diagnosis of cancer or neurodegenerative disease and desired appropriate training. Their primary concerns were attitude and choice of words. During the interview, their greatest difficulty was asking patients what they want to know. In the end-of-year examination, students who took part in both the group discussion and a simulated interview did significantly better in remembering items of the 6-point protocol than those who had only taken part in the group discussion.

CONCLUSION

This pilot study shows that our course improves students' knowledge in breaking bad news such as cancer. However, its effectiveness after graduation still needs to be determined. Assessing knowledge is feasible using interviews with simulated patients in France.

Community-based collaboration with high school theater students as standardized patients

OBJECTIVES

To describe a collaborative undertaking between a private school of pharmacy (Bernard J. Dunn School of Pharmacy) and a public high school (John Handley High School) in the development, and implementation of a partnership utilizing high school theater students as standardized patients.

METHODS

High school theater students were trained to portray patients within the Standardized Patient Assessment Laboratory. The patient encounters were videotaped and evaluated by both peer and faculty members. Quantitative and qualitative analyses of semi-structured interviews, focus groups, post-encounter surveys of students and faculty members, and encounter grades were used to evaluate the outcomes.

RESULTS

Pharmacy students exhibited competence in clinical assessment skills as evidenced by high encounter grades (91.5% +/- 6.8%) and 100% positive faculty feedback. The high school theater students self-reported that their improvisational skills improved through learning patient conditions and behaviors. Both schools met their mission statement and accreditation goals, including increased collaboration with the community.

CONCLUSION

This model for collaboration between a school of pharmacy and a high school using adolescents as simulated patients was successful in creating a beneficial learning experience for both the theater and pharmacy students.

Managerial Culture, Workplace Culture and Situated Curricula in Organizational Learning

Seen from a perspective of symbolic interaction and social constructivism, organizational learning is a practical accomplishment that takes place among and through other organizational members. This study sets out to explore the social construction of organizational learning by examining the responses of members to a management-imposed teaching curriculum that contradicted basic assumptions regarding professional identity. We build on the results of recent ethnographic fieldwork which has investigated the incorporation of communication skills training in an Israeli medical school. This professional socialization is examined in terms of its theoretization by the management, its implementation in the curriculum, and its interpretation by supervising physicians and medical students. These various facets of meaning and their mismatches provide a concrete example for the study of situated learning in organizations. We conclude by exploring the meaning and interplay of managerial ideology, workplace culture and situated curricula in organizational learning.

Teaching personal awareness

Educators rarely consider the attitudes that determine whether a learner will use the clinical skills we teach. Nevertheless, many learners and practitioners exhibit negative attitudes that can impede the use of patient-centered skills, leading to an isolated focus upon disease and impairing the provider-patient relationship. The problem is compounded because these attitudes often are incompletely recognized by learners and therefore are difficult to change without help. We present a research-based method for teaching personal awareness of unrecognized and often harmful attitudes. We propose that primary care clinicians without mental health training can follow this method to teach students, residents, faculty, and practitioners. Such teachers/mentors need to possess an abiding interest in the personal dimension, patience with a slowly evolving process of awareness, and the ability to establish strong, ongoing relationships with learners. Personal awareness teaching may occur during instruction in basic interviewing skills but works best if systematically incorporated throughout training.

Invite, listen, and summarize: a patient-centered communication technique

The need for physicians to have patient-centered communication skills is reflected in the educational objectives of numerous medical schools' curricula and in the competencies required by groups such as the Accreditation Council for Graduate Medical Education. An innovative method for teaching communications skills has been developed at the University of Colorado School of Medicine as part of its three-year, longitudinal course focusing on basic clinical skills required of all physicians. The method emphasizes techniques of open-ended inquiry, empathy, and engagement to gather data. Students refer to the method as ILS, or Invite, Listen, and Summarize. ILS was developed to combat the high-physician-control interview techniques, characterized by a series of "yes" or "no" questions. The authors began teaching the ILS approach in 2001 as one basic exercise and have since developed a two-year longitudinal communications curriculum. ILS is easy to use and remember, and it emphasizes techniques that have been shown in other studies to achieve the three basic functions of the medical interview: creating rapport, collecting good data, and improving compliance. The skills are taught using standardized patients in a series of four small-group exercises. Videotaped standardized patient encounters are used to evaluate the students. Tutors come from a variety of disciplines and receive standardized training. The curriculum has been well received. Despite the fact that the formal curriculum only occurs in the first two years, there is some evidence that it is improving students' interviewing skills at the end of their third year.

Teaching medical students and residents skills for delivering bad news: a review of strategies

Although delivering bad news is something that occurs daily in most medical practices, the majority of clinicians have not received formal training in this essential and important communication task. A variety of models are currently being used in medical education to teach skills for delivering bad news. The goals of this article are (1) to describe these available models, including their advantages and disadvantages and evaluations of their effectiveness; and (2) to serve as a guide to medical educators who are initiating or refining curriculum for medical students and residents. Based on a review of the literature and the authors' own experiences, they conclude that curricular efforts to teach these skills should include multiple sessions and opportunities for demonstration, reflection, discussion, practice, and feedback.