Teaching communication skills to clinical students

Transitioning from pre-clinical to clinical dental radiology, a pilot study: Student perceived influences on confidence

INTRODUCTION

Producing radiographic images requires the use of ionizing radiation, which has been well documented for its potentially detrimental effects on human tissues. Therefore, dental hygiene students begin their radiographic training by practicing on manikins in a pre-clinical environment. Use of manikins does not allow for patient interaction factors. No published dental studies have examined factors important in helping dental hygiene students develop confidence during the transition from manikins to working with live patients in a clinical radiology setting.

PURPOSE/OBJECTIVES

The purpose of this study was to identify students' perceived influences on confidence and ultimately on performance when transitioning from a pre-clinical radiology setting to working with live patients. Specific research questions that were answered by this qualitative study were (1) What pre-clinical radiographic experiences did students feel were beneficial for transitioning from manikins to live patients? (2) What were the primary factors that students felt they struggled with when initially taking radiographs on patients?

METHODS

A qualitative study design was implemented in 2017. Data were obtained from students in a 2-year dental hygiene program. Survey responses, focus group feedback, and observation data were used to identify common themes. Emergent themes were reported using frequencies, emic and etic expressions.

RESULTS

Four themes surfaced surrounding patient management, communication, appointment mechanics, and infection control.

CONCLUSION

The use of standardized simulated patients may enhance clinical preparedness and confidence.

The impact of expert- and peer feedback on communication skills of undergraduate dental students - a single-blinded, randomized, controlled clinical trial

OBJECTIVE

To evaluate the effect of peer- and expert feedback on communication skills of undergraduate dental students.

METHODS

All students of the first clinical treatment course (n=46) were randomly assigned into two groups. For three times a medical-dental interview/consultation of each student with a real patient was videotaped. After every consultation the videos were assessed either by a person experienced in communication (expert group) or by a fellow student (peer group), giving the students feedback regarding their chairside performed communication skills. Before and after the feedback-interventions all students conducted an interview with simulated patients, which was rated using a validated global rating and analyzed statistically.

RESULTS

Global ratings mean scores after feedback-intervention were significantly improved (p<0.05). Thereby, no significant differences in the overall assessment could be observed between expert and peer feedback (p>0.05).

CONCLUSION

During this study students improved their communication skills in dentist-patient interactions. The communication experience of the feedback provider seems not to have any impact on the communication skills in undergraduate dental students.

PRACTICE IMPLICATIONS

The clinical courses in dentistry offer the opportunity to implement peer-feedback interventions in real treatment situation as part of communication training to longitudinally improve communication skills.

Narrative medicine as a means of training medical students toward residency competencies

OBJECTIVE

This study sought to explore the perceived influence of narrative medicine training on clinical skill development of fourth-year medical students, focusing on competencies mandated by ACGME and the RCPSC in areas of communication, collaboration, and professionalism.

METHODS

Using grounded-theory, three methods of data collection were used to query twelve medical students participating in a one-month narrative medicine elective regarding the process of training and the influence on clinical skills. Iterative thematic analysis and data triangulation occurred.

RESULTS

Response rate was 91% (survey), 50% (focus group) and 25% (follow-up). Five major findings emerged. Students perceive that they: develop and improve specific communication skills; enhance their capacity to collaborate, empathize, and be patient-centered; develop personally and professionally through reflection. They report that the pedagogical approach used in narrative training is critical to its dividends but misunderstood and perceived as counter-culture. CONCLUSION/PRACTICE IMPLICATIONS: Participating medical students reported that they perceived narrative medicine to be an important, effective, but counter-culture means of enhancing communication, collaboration, and professional development. The authors contend that these skills are integral to medical practice, consistent with core competencies mandated by the ACGME/RCPSC, and difficult to teach. Future research must explore sequelae of training on actual clinical performance.

How we teach ethics and communication during a Canadian neonatal perinatal medicine residency: an interactive experience

BACKGROUND

Ethically challenging clinical situations frequently confront health care professionals in neonatology. These situations require neonatologists to exercise professionalism by communicating effectively throughout evolving physician-parent relationships in order to arrive at shared decisions for care that are in the best interest of the neonate and grounded solidly in ethical precepts.

AIM

This article describes the process by which a well-delineated, interactive program to teach ethical reasoning and skillful communication with parents was implemented at the University of Ottawa, Canada.

METHODS

A revised ethics program implemented in 2009 identified competencies that should be demonstrated at the end of the Neonatal-Perinatal Medicine (NPM) residency. Several seminars were refined while new workshops, problem-based learning in ethics, and a personal portfolio were added.

RESULTS

All teaching strategies were well received based on the average level of satisfaction (5.8 out of 7, SD 0.4). We are now moving forward by formally assessing our program including the impact on knowledge acquisition and behavior.

CONCLUSION

A dedicated, interactive competency-based neonatal ethics teaching program is vital to support NPM trainees in learning how to integrate ethical thinking with competencies in communication.

Interventions for providers to promote a patient-centred approach in clinical consultations

BACKGROUND

Communication problems in health care may arise as a result of healthcare providers focusing on diseases and their management, rather than people, their lives and their health problems. Patient-centred approaches to care delivery in the patient encounter are increasingly advocated by consumers and clinicians and incorporated into training for healthcare providers. However, the impact of these interventions directly on clinical encounters and indirectly on patient satisfaction, healthcare behaviour and health status has not been adequately evaluated.

OBJECTIVES

To assess the effects of interventions for healthcare providers that aim to promote patient-centred care (PCC) approaches in clinical consultations.

SEARCH METHODS

For this update, we searched: MEDLINE (OvidSP), EMBASE (OvidSP), PsycINFO (OvidSP), and CINAHL (EbscoHOST) from January 2000 to June 2010. The earlier version of this review searched MEDLINE (1966 to December 1999), EMBASE (1985 to December 1999), PsycLIT (1987 to December 1999), CINAHL (1982 to December 1999) and HEALTH STAR (1975 to December 1999). We searched the bibliographies of studies assessed for inclusion and contacted study authors to identify other relevant studies. Any study authors who were contacted for further information on their studies were also asked if they were aware of any other published or ongoing studies that would meet our inclusion criteria.

SELECTION CRITERIA

In the original review, study designs included randomized controlled trials, controlled clinical trials, controlled before and after studies, and interrupted time series studies of interventions for healthcare providers that promote patient-centred care in clinical consultations. In the present update, we were able to limit the studies to randomized controlled trials, thus limiting the likelihood of sampling error. This is especially important because the providers who volunteer for studies of PCC methods are likely to be different from the general population of providers. Patient-centred care was defined as a philosophy of care that encourages: (a) shared control of the consultation, decisions about interventions or management of the health problems with the patient, and/or (b) a focus in the consultation on the patient as a whole person who has individual preferences situated within social contexts (in contrast to a focus in the consultation on a body part or disease). Within our definition, shared treatment decision-making was a sufficient indicator of PCC. The participants were healthcare providers, including those in training.

DATA COLLECTION AND ANALYSIS

We classified interventions by whether they focused only on training providers or on training providers and patients, with and without condition-specific educational materials. We grouped outcome data from the studies to evaluate both direct effects on patient encounters (consultation process variables) and effects on patient outcomes (satisfaction, healthcare behaviour change, health status). We pooled results of RCTs using standardized mean difference (SMD) and relative risks (RR) applying a fixed-effect model.

MAIN RESULTS

Forty-three randomized trials met the inclusion criteria, of which 29 are new in this update. In most of the studies, training interventions were directed at primary care physicians (general practitioners, internists, paediatricians or family doctors) or nurses practising in community or hospital outpatient settings. Some studies trained specialists. Patients were predominantly adults with general medical problems, though two studies included children with asthma. Descriptive and pooled analyses showed generally positive effects on consultation processes on a range of measures relating to clarifying patients' concerns and beliefs; communicating about treatment options; levels of empathy; and patients' perception of providers' attentiveness to them and their concerns as well as their diseases. A new finding for this update is that short-term training (less than 10 hours) is as successful as longer training.The analyses showed mixed results on satisfaction, behaviour and health status. Studies using complex interventions that focused on providers and patients with condition-specific materials generally showed benefit in health behaviour and satisfaction, as well as consultation processes, with mixed effects on health status. Pooled analysis of the fewer than half of included studies with adequate data suggests moderate beneficial effects from interventions on the consultation process; and mixed effects on behaviour and patient satisfaction, with small positive effects on health status. Risk of bias varied across studies. Studies that focused only on provider behaviour frequently did not collect data on patient outcomes, limiting the conclusions that can be drawn about the relative effect of intervention focus on providers compared with providers and patients.

AUTHORS' CONCLUSIONS

Interventions to promote patient-centred care within clinical consultations are effective across studies in transferring patient-centred skills to providers. However the effects on patient satisfaction, health behaviour and health status are mixed. There is some indication that complex interventions directed at providers and patients that include condition-specific educational materials have beneficial effects on health behaviour and health status, outcomes not assessed in studies reviewed previously. The latter conclusion is tentative at this time and requires more data. The heterogeneity of outcomes, and the use of single item consultation and health behaviour measures limit the strength of the conclusions.

Is video review of patient encounters an effective tool for medical student learning? A review of the literature

PURPOSE

To determine if video review of student performance during patient encounters is an effective tool for medical student learning.

METHODS

MULTIPLE BIBLIOGRAPHIC DATABASES THAT INCLUDE MEDICAL, GENERAL HEALTH CARE, EDUCATION, PSYCHOLOGY, AND BEHAVIORAL SCIENCE LITERATURE WERE SEARCHED FOR THE FOLLOWING TERMS: medical students, medical education, undergraduate medical education, education, self-assessment, self-evaluation, self-appraisal, feedback, videotape, video recording, televised, and DVD. The authors examined all abstracts resulting from this search and reviewed the full text of the relevant articles as well as additional articles identified in the reference lists of the relevant articles. Studies were classified by year of student (preclinical or clinical) and study design (controlled or non-controlled).

RESULTS

A total of 67 articles met the final search criteria and were fully reviewed. Most studies were non-controlled and performed in the clinical years. Although the studies were quite variable in quality, design, and outcomes, in general video recording of performance and subsequent review by students with expert feedback had positive outcomes in improving feedback and ultimate performance. Video review with self-assessment alone was not found to be generally effective, but when linked with expert feedback it was superior to traditional feedback alone.

CONCLUSION

There are many methods for integrating effective use of video-captured performance into a program of learning. We recommend combining student self-assessment with feedback from faculty or other trained individuals for maximum effectiveness. We also recommend additional research in this area.

How Italian students learn to become physicians: a qualitative study of the hidden curriculum

BACKGROUND

A great deal of what medical students learn in terms of behaviors, values, and attitudes related to their profession is conveyed by the hidden curriculum.

AIM

To explore the messages conveyed by the hidden curriculum as perceived by third-year students of the Milan School of Medicine, Italy, following their first clinical internship.

METHOD

Three group interviews were conducted. Students were asked to reflect on values, attitudes, and implicit rules they noticed during their internship experiences. Verbatim transcripts of the group interviews were analyzed through content analysis using Nvivo8.

RESULTS

Of the 81 students, 57 (70%) participated in the group interviews. Six themes were identified within the hidden curriculum: Physicians reassure and protect patients; power differential between physicians and patients; variable respect for patients; disease-centered medicine; respect for hierarchies; and delegation of patients' emotional needs to nurses.

CONCLUSIONS

Our findings suggest that the hidden curriculum has a strong cultural component. In our students' experience, the hidden curriculum conveyed a paternalistic model of physician-patient relationships. Some of the messages conveyed by the actual hidden curriculum may compromise the standards formally taught in medical schools about doctor-patient relationships. Organizational culture change and student empowerment could be fostered to counteract the negative effects of the hidden curriculum.

Effective consulting and history-taking skills for prescribing practice

There is increasing emphasis on the need for nurses to develop history-taking and consultation skills for prescribing and advanced clinical practice roles. This article discusses both theoretical and practical aspects that could facilitate the development of these skills using safe and structured approaches. It explores some of the origins of consultation theory, and the challenge that nurses face in integrating new consultation skills with existing nursing assessment practice. This article outlines practical generic approaches to history taking in the clinical consultation and considers the main areas that need to be covered to support safe prescribing decisions.

Feedback by simulated patients in undergraduate medical education: a systematic review of the literature

OBJECTIVES

Although the importance of feedback by simulated patients (SPs) is generally recognised, knowledge is scarce about the most effective ways in which SPs can provide feedback. In addition, little is known about how SPs are trained to provide feedback. This study aimed to provide a systematic overview of the ways in which SPs provide feedback to undergraduate medical students, the domains in which SPs provide feedback and the ways in which SPs are trained to provide feedback.

METHODS

We performed a systematic search of the literature using PubMed, PsychINFO and ERIC and searched for additional papers cited in reference lists. Papers were selected on the basis of pre-established inclusion and exclusion criteria and were classified, using a pre-established form, according to three aspects of SP feedback: training in giving feedback; the process of delivering feedback, and the domain(s) in which feedback is given.

RESULTS

A total of 49 studies were included and described in detail on the basis of the three aspects of SP feedback described above. The ways in which SPs were trained to give feedback were largely heterogeneous, as were the processes by which feedback was provided by SPs. Only a few studies described feedback processes that were in accordance with general recommendations for the delivery of effective feedback. Although feedback from the patient's perspective is generally recommended, most SPs provided feedback on clinical skills and communication skills.

DISCUSSION

There appear to be no clear standards with regard to effective feedback training for SPs. Furthermore, the processes by which feedback is provided by SPs and the selection of domain(s) in which SPs give feedback often seem to lack a solid scientific basis. Suggestions for further research are provided.

Viewpoint: power and communication: why simulation training ought to be complemented by experiential and humanist learning

The authors present an analysis of communication training for medical students using simulation patients, and its possible influence on later doctor-patient relationships. Many empirical studies have shown the various benefits of using simulation patients to teach communication skills, but theoretical sociology and humanistic reflection shed light on some fundamental differences between the student-doctor/actor-patient interactions practiced in simulation encounters and real doctor-patient relationships. In contrast to the usual power dynamics of a doctor-patient relation, those of simulation encounters are inverted and overwritten by an entirely different set of power relations, namely, those of the evaluator-student relationship. Since the power dynamics of real doctor-patient relations are generally overlooked, the altered dynamics of the simulation encounter are not readily perceived, and simulation encounters are thus often mistaken as accurate representations of clinical reality. Exclusive reliance on this pedagogic approach of simulation training may be encouraging students to become "simulation doctors" who act out a good relationship to their patients but have no authentic connection with them. The authors propose that liberal-arts learning and encounters with real patients should be used to cultivate students' abilities to create good doctor-patient relationships, as a compliment to the pedagogic benefits of simulation encounters.

Evaluation by dental students of a communication skills course using professional role-players in a UK school of dentistry

This paper reports student (n = 180) feedback on the role-play teaching methodology used in behavioural sciences teaching at The School of Dentistry in Birmingham (UK). The feedback received on this well-established (since 1995) educational programme was collected via questionnaire (100% response rate), requiring Likert scale and free text responses. Generally students reported that they had enjoyed and valued the session. Over two-thirds (69.7%) of students rated the role-players as 'very real' and over three-quarters (78.9%) rated their feedback as 'very fair'. The data collected from this study will inform future curriculum development. Student feedback was very positive and demonstrated that the cohort (86% of all students studying in years 1, 2 and 3) found the use of professional role-players involved in behavioural sciences teaching to be both acceptable and valuable.

A relação assimétrica médico-paciente: repensando o vínculo terapêutico

A relação médico-paciente é uma temática que hoje encontra um renovado interesse na produção cientifica, na formação e prática clínica com a aplicação de técnicas comunicacionais que podem proporcionar uma melhor qualidade na relação. O presente artigo, por meio de uma revisão da literatura e da apresentação dos resultados de uma pesquisa que realizamos sobre a relação entre médicos e pacientes no Programa de Saúde da Família no Estado do Ceará, se propõe a refletir sobre quais os fatores que estão na raiz desta problemática. Uma melhor relação médico-paciente não tem somente efeitos positivos na satisfação dos usuários e na qualidade dos serviços de saúde, mas exerce também uma influência direta sobre o estado de saúde dos pacientes. Esta demanda exige a implementação de mudanças visando à aquisição de competências na formação dos médicos.

Physicians of the future: Renaissance of polymaths?

Science and technology are crucial in modern medicine; societies devote enormous amounts of time, money and effort to developing new diagnostic and therapeutic procedures. However, the fact that people now report higher rates of disability, symptoms and general dissatisfaction with their health and well-being calls us to rethink the functions of health care and medical education. There is a need for a new medical paradigm, which should involve and reconcile the natural and the social scientific paradigms ('two cultures'). Medicine should be viewed as an integrative, biopsychosocial science. Therefore, medical education must involve the study of the biological structures and psychosocial functioning of human beings not as separate systems, but as interactive ones. This mandate suggests that the physician needs to become a sort of 'neo-polymath' in a 'new Renaissance'. The new paradigm, however, should not demand the acquisition of more and more information. Instead, the crucial principle would focus on the appropriate selection of information.

Using simulated consultations to develop communications skills for neurology trainees

Communication skills are essential for clinical medicine yet, unlike in general practice, trainees in specialist and general medicine are not formally trained in them. We have used videotaped recording of simulated consultations to evaluate their acceptability and usefulness for training neurology specialist registrars. Twelve specialist registrars in neurology participated; their perceptions of the method were assessed using quantified scales and focus groups. All but one of the 12 trainees found the exercise useful both for improving clinical skills and for the imparting of information. The median visual analogue scores (0=useless, 100=very useful) for history taking and for imparting information were 91 and 90%, respectively. The median scores [and interquartile range (IQR)] of perceived usefulness for communication skills increased before to after (for use of video) from 68 (58-78) to 88 (80-92)% (P < 0.02), and (for use of simulated patients) from 51 (40-71) to 86 (79-89)% (P < 0.02). The focus groups provided additional qualitative data supporting the technique. We conclude that videotaped consultations with simulated patients are valued by most neurology trainees, both for improving their history-taking skills and for imparting information. The technique could be used more widely in neurology training, and may have a role in assessment.

[Direct supervision. Perceptions of ex-residents in family medicine]

OBJECTIVE

To explore former residents' perceptions of their experience of direct supervision.

DESIGN

Qualitative study using in-depth semistructured interviews.

SETTING

Family practice unit (FPU) at Hôpital Laval in Quebec city, Que.

PARTICIPANTS

Twelve physicians who had been practising for 2 to 5 years and who did their family medicine residency in the FPU at Hôpital Laval.

METHOD

Twelve interviews lasting 1 to 2 hours conducted by someone with no connection to the teaching centre. Interviews were taped and transcribed in full. Results were analyzed using L'Ecuyer's developmental method.

MAIN FINDINGS

The former residents thought direct supervision had helped them in relationships with patients and in getting to know themselves, and was still doing them good several years later. It was also a difficult and disturbing experience; it created performance anxiety, forcing residents into self-examination and allowing others to see them as they really are. Three things made the direct supervision process easier: a preparatory activity, a focus on learning rather than evaluation, and their supervisors' ability to adapt to their learning styles.

CONCLUSION

The former residents appreciated direct supervision; in spite of the difficulties, it was worthwhile. This conclusion will encourage teachers to continue to be involved in direct supervision.

The Structured Clinical Operative Test (SCOT) in dental competency assessment

INTRODUCTION

This paper describes a method of assessment of invasive clinical procedures which are currently being devised, and which are perceived to be a method that may be used to complement OSCEs in overall clinical skills assessment.

OBJECTIVE

The objective of the Structured Clinical Operative Tests (SCOT) is to introduce a greater level of objectivity to the assessment of operative clinical skills. Invasive or irreversible clinical operative procedures from a large part of dental undergraduate training and are by their very nature precluded from OSCE scenarios. It is also important to test intraoperative skills, communication skills and contingency management, and performance of these with awareness of the psychosocial context and ethical framework. The paper describes the use of checklists in the monitoring of clinical operative skills in a more authentic clinical situation using the SCOT. FORMATIVE ASSESSMENT: Continuous assessment should a) record achievement of competency in as objective a manner as possible and b) should encourage continuous self-evaluation. In the SCOT the students reflect on their clinical performance and in consultation with their supervisors record their plans to improve their competence in that skill or procedure in the future. This is done immediately on completion of a clinical task while the experience is still fresh in the mind. This encourages deep reflective learning as opposed to superficial factual learning which is characteristic of the more traditional curriculum, and is described as supervisor validated self-assessment.

DISCUSSION

The discussion outlines how SCOTs can be practically implemented and integrated into the undergraduate curriculum and an example of a SCOT is appended to the paper. The scope for using SCOTs in postgraduate assessment such as in VT/GPT is also described.

Training physicians in communication skills with adolescents using teenage actors as simulated patients

Role-play exercises with simulated patients may serve the purpose of training professionals to develop appropriate communication skills with adolescents. Authentic adolescent responses toward the physicians may be achieved by actors who themselves are in their teenage years. We describe our experience in continuing medical education programmes for primary care physicians aimed at improving their skills in communicating with adolescents, using simulation methodology with teenage actors. Eight 16-17-year-old actors from the drama department of a high school for the arts were trained to simulate 20 cases with characteristic adolescent medical problems, as well as confidentiality issues and home and school problems. The actors performed in front of large groups of 20-30 paediatricians, family practitioners, or gynaecologists in continuing medical education. Diagnostic issues as well as therapeutic and management approaches were discussed, while the actors provided feedback to the trainees about their understanding and their feeling regarding the issues raised during the exercises. Normally, smaller learning groups are more suitable for such training purposes; nevertheless the participants could appreciate learning the principles of careful listening, a non-judgmental approach and assuring confidentiality. A collaboration of medical schools and postgraduate programmes with high schools which have drama departments may be fruitful in the teaching of adolescent medicine with special emphasis on communication skills with teenagers.

Interventions for providers to promote a patient-centred approach in clinical consultations

BACKGROUND

Communication problems in health care may arise as a result of health care providers focusing on diseases and their management, rather than people, their lives and their health problems. Patient-centred approaches to care are increasingly advocated by consumers and clinicians and incorporated into training for health care providers. The effects of interventions that aim to promote patient-centred care need to be evaluated.

OBJECTIVES

To assess the effects of interventions for health care providers that aim to promote patient-centred approaches in clinical consultations.

SEARCH STRATEGY

We searched Medline (1966 - Dec 1999); Health Star (1975 - Dec 1999); PsycLit (1887- Dec 1999); Cinahl (1982 - Dec 1999); Embase (1985-Dec 1999) and the bibliographies of studies assessed for inclusion.

SELECTION CRITERIA

Randomised controlled trials, controlled clinical trials, controlled before and after studies, and interrupted time series studies of interventions for health care providers that promote patient-centred care in clinical consultations. Patient-centred care was defined as a philosophy of care that encourages: (a) shared control of the consultation, decisions about interventions or management of the health problems with the patient, and/or (b) a focus in the consultation on the patient as a whole person who has individual preferences situated within social contexts (in contrast to a focus in the consultation on a body part or disease). The participants were health care providers, including those in training.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data onto a standard form and assessed study quality for each study. We extracted all outcomes other than health care providers' knowledge, attitudes and intentions.

MAIN RESULTS

17 studies met the inclusion criteria. These studies display considerable heterogeneity in terms of the interventions themselves, the health problems or health concerns on which the interventions focused, the comparisons made and the outcomes assessed. All included studies used training for health care providers as an element of the intervention. Ten studies evaluated training for providers only, while the remaining studies utilised multi-faceted interventions where training for providers was one of several components. The health care providers were mainly primary care physicians (general practitioners or family doctors) practising in community or hospital outpatient settings. In two studies, the providers also included nurses. There is fairly strong evidence to suggest that some interventions to promote patient-centred care in clinical consultations may lead to significant increases in the patient centredness of consultation processes. 12 of the 14 studies that assessed consultation processes showed improvements in some of these outcomes. There is also some evidence that training health care providers in patient-centred approaches may impact positively on patient satisfaction with care. Of the eleven studies that assessed patient satisfaction, six demonstrated significant differences in favour of the intervention group on one or more measures. Few studies examined health care behaviour or health status outcomes.

REVIEWER'S CONCLUSIONS

Interventions to promote patient-centred care within clinical consultations may significantly increase the patient centredness of care. However, there is limited and mixed evidence on the effects of such interventions on patient health care behaviours or health status; or on whether these interventions might be applicable to providers other than physicians. Further research is needed in these areas.

Using a Lego-based communications simulation to introduce medical students to patient-centered interviewing

PURPOSE

Teaching patient-centered interviewing skills to medical students can be challenging. We have observed that 1st-year medical students, in particular, do not feel free to concentrate on the interviewing skills because they are preoccupied with complicated technical medical knowledge. The Lego simulation we use with our 1st-year students as part of a professional-skills course overcomes that difficulty.

SUMMARY

The Lego activity is a role play analogous to a doctor-patient interview that uses identical sets of Legos for the "doctor" and for the "patients" and a small construction that represents a patient history.

CONCLUSIONS

With a simple questionnaire, data were collected from students at different points during instruction. Results indicate that the Lego activity was very effective in helping students learn the importance of open-ended questioning. It also was rated as highly as the very dynamic interactive part of the instructional session. The effectiveness of the Lego activity may be due to the properties of analogies.

A survey of physician training programs in risk management and communication skills for malpractice prevention

Malpractice lawsuits serve as a great source of pain, consternation and loss for physicians and patients alike, usually leaving all parties involved in the process with a sense of betrayal. A significant number of physicians will be sued at least once in their career, especially if they practice in some of the more vulnerable specialties. In addition, there is some evidence that the threat of malpractice lawsuits changes the practice style of many physicians, leading to the practice of “defensive medicine” and raises the total cost of health care. Clearly, the prevention of medical malpractice is an issue that deserves considerable attention from physicians and from those who train them.

Empirical evidence suggests that medical negligence may play a relatively minor role in malpractice lawsuits. As demonstrated by Localio, et al., one in thirty-five cases of negligence or incompetence actually results in a lawsuit.

Recording skills practice on videotape can enhance learning - a comparative study between nurse lecturers and nursing students

Video recording techniques have been used in educational settings for a number of years. They have included viewing video taped lessons, using whole videos or clips of tapes as a trigger for discussion, viewing video recordings to observe role models for practice, and being video recorded in order to receive feedback on performance from peers and tutors. Although this last application has been in use since the 1960s, it has only been evaluated as a teaching method with health care professionals in the past 10 years and mostly in the areas of medical and counsellor education. In nurse education, however, use of video recording techniques has been advocated without any empirical evidence on its efficacy. This study has used nursing degree students and nurse educationalists to categorize statements from four cohorts of students who took part in a 12-day clinical supervision course during which their interpersonal skills were recorded on videotape. There were two categories: positive and negative/neutral. Analysis of the data showed that between 61% and 72% of the subjects gave an overall positive categorization to the statements in the questionnaire. Chi-square tests were significant for all groups in both categories. This suggests that both nursing students and nurse lecturers thought that course participants' statements expressed a positive belief that video tape recording is useful in enhancing students' ability to learn effective interpersonal skills in clinical supervision.

A preliminary exploration of the interactional skills of trainee surgeons

BACKGROUND

The interactional skills of 21 surgical trainees were studied in the areas of breaking bad news to patients and preparing patients for potentially threatening medical procedures. When compared to the established guidelines for dealing with these issues, the trainees performed poorly.

METHODS

Trainees were videotaped using clinical histories delivered by simulated patients in simulated consulting rooms. All videos were scored on standard rating scales where the criteria for rating the specific interactional skills were adopted from existing guidelines.

RESULTS

The proportion of trainees who could meet the guidelines when breaking bad news was low. The proportion of trainees who met the guidelines were: closing the the consultation (0%), provided patient information about prognosis (43%) and treatment (38%) and when they gave support (10%). There were also low numbers of trainees who could meet the guidelines when they prepared patients for potentially threatening procedures. Ten per cent of trainees followed the guidelines when providing information, 25% could establish treatment goals, 35% could give a prognosis and 0% could deal appropriately with psychosocial issues or close the consultation appropriately.

CONCLUSIONS

It is concluded that there is a need for further formal training in interactional skills as part of surgical training.

Evaluation of two videotape instruction programmes on how to break bad news--for Cantonese-speaking medical students in Hong Kong

OBJECTIVES

To evaluate a culture-specific videotape on how to 'break bad news' and another videotape produced by a western university, and to determine if the language of presentation influenced the students' perceived abilities to execute basic skills.

SUBJECTS

Third year medical students at the Faculty of Medicine, the University of Hong Kong.

DESIGN

Longitudinal study with experimental design.

INTERVENTION

Two instructional tapes on breaking bad news; one using Chinese speaking role models and one using English.

RESULTS

In both groups, self-efficacy summed scores increased from 26.8 (95% CI = 25.9-27.7) at the pre-test to 29.0 (95% CI = 28.4-29.6). The biggest changes occurred in perceived self-efficacy regarding specific skills. However, students using the Chinese tape rated skills as more useful than those using the English tape.

CONCLUSION

The videotapes were useful in teaching communication skills. Culturally relevant audiovisual materials were more effective.

Communication skills and psychological training in oncology

Preserving the best possible quality of life for cancer patients and their families has become a major goal in cancer care. However, the cumulative effect of stressors related to cancer care, many of which involve communicating with patients and relatives, may lead to the development of burnout in staff. Many health care professionals lack the psychosocial knowledge and communications skills needed to identify patients' problems because general professional training focuses on technical care. Teaching strategies known as psychological training programs (PTP) are therefore being developed to help improve health care professionals' sensitivity to communication problems with patients and relatives. Cognitive (e.g. theoretical information), experiential (e.g. case-history discussions), behavioural (e.g. role-playing exercise) and supportive (e.g. stressor identification) training techniques are used to teach the essential skills of good communication, i.e. listening, empathy, response to cues and appropriate use of reassurance. PTP range from one-day courses and residential workshops to full-time 1- or 2-year curricula. However, one of the main obstacles to implementing PTP is scepticism among health care professionals about its usefulness. Research on training effectiveness should therefore be developed to assess the impact of communication skills on quality of care and patients' quality of life.

Interviewing skills: self-evaluation by medical students

In an independent learning project, 52 third-year medical students carried out a structured self-assessment of two videotaped psycho-social interviews they had conducted with volunteer clients 1 year earlier, as part of a previous course. The interviews had been conducted in small tutorials with feedback from their clients, fellow students and tutors, facilitated by videotape playback. During the sequence of 16 tutorials each student had carried out an early and a late interview and had observed and participated in the discussion of the interviews of 14 peers. Students were asked to tally the frequencies of various interview behaviours, to evaluate the quality of their behaviours, and to establish priorities for future learning. The videotapes were also reliably rated by an independent observer. Students' overall self-assessments correlated 0.46 with those of the independent observer. This correlation was higher than is typically reported in studies of the validity of self-assessment. In absolute terms, the students' mean rating of interviewing performance was 3.2 (adequate plus) which was significantly lower than the observer's mean of 3.6 (adequate to good). Results are discussed in terms of Gordon's (1992) two recommendations for improving the validity of self-assessments and two further suggestions, for paired comparisons and low-threat learning environments, are added.

Videotaped interviewing of non-English speakers: training for medical students with volunteer clients

In a multicultural society such as Australia, with over 20% of its population born overseas, interpreters are often required to facilitate medical interviews. However, where a patient has some proficiency in English, medical interviews are sometimes conducted across the boundaries of culture and language. This is a report of an educational innovation to teach interviewing skills to pre-clinical medical students with the assistance of volunteers of non-English-speaking backgrounds. Pre-clinical students interviewed community volunteers on topics of general life history in a sequence of 16 tutorials. Each student conducted two interviews. Teaching methods included feedback from the volunteers, tutorial discussion facilitated by playback of videotapes, and modelling of skills by the teachers. Evaluations by volunteers and students indicated high satisfaction with the teaching methods and outcomes. Students gained confidence in interviewing people from different cultures. Evaluation of students' pairs of videotapes by an independent rater achieved satisfactory reliabilities and indicated significant gains in inquiry skills and the communication of positive attitudes. Skills in communicating empathy and in using simple language did not improve measurably.

Impact of litigation on senior clinicians: implications for risk management

OBJECTIVES

To investigate the impact of litigation on consultants and senior registrars and to establish their views on methods of reducing adverse events and litigation.

DESIGN

Postal survey.

SETTING

Acute hospitals in the North Thames (West) Regional Health Authority.

SUBJECTS

1011 consultants and senior registrars in acute hospitals.

MAIN MEASURES

Perceived causes and effects of adverse events; views on methods of reducing litigation and adverse events.

RESULTS

769 (76%) doctors responded. 288 (37%) had been involved in litigation at some point during their career; 213 surgeons (49%) and 75 (23%) doctors in the medical specialties. Anger, distress, and feeling personally attacked were common responses to litigation. Clinicians' views on reducing litigation emphasised the need for change at the clinical level. Supervision of junior staff, workload, and training in communication skills were to the fore.

CONCLUSIONS

The high frequency of doctors who have experienced litigation and the emotional responses described indicate that clinicians require support at several levels. At a personal level, support can be offered to clinicians going through the litigation process or after an adverse event. Also, managerial support is needed by offering financial and practical help in correcting the factors that have been consistently identified as producing high risk situations to minimise the possibility of a reoccurrence. Accidents in medicine are, by their very nature, costly in human and financial terms and the root causes must be tackled. Recommendations are made for clinicians and risk management teams.

Patient comprehension of doctor-patient communication on discharge from the emergency department

An exit interview was conducted during March, 1994 on 314 patients treated and released from the Emergency Department at Kern Medical Center in Bakersfield, California. The questionnaire was designed to assess understanding of diagnosis, prescribed medications, additional instructions, and plans for follow-up care. The patients' own perceptions of the adequacy of communication and whom they considered the most important source of information were also determined. Overall, patients correctly identified 59% of their instructions. The performance of the English speaking and the Spanish speaking patients was compared. Spanish speaking patients scored significantly lower on all questions. The physician was identified by most patients (63.8%) as the source of the most information.

Organ donation in the accident and emergency department: a study of relatives' views

OBJECTIVE

To determine whether recently bereaved people would object to being asked about organ donation immediately after the death of their relative.

METHODS

A telephone interview of 78 recently bereaved relatives of people who had died in an inner city accident and emergency (A&E) department; 68 (87%) agreed to participate in the study and were sent a questionnaire. Outcome measures were views on being asked about organ donation in the A&E department immediately after the death of a relative and knowledge of the possibility for organ donation in A&E after a sudden death.

RESULTS

37 questionnaires were returned: 27 (72.9%) of those who responded would not have minded being asked, five would have minded, and five did not know or did not fill in the questionnaire; 29 were aware that organs could be donated following a death in A&E. Only six people had discussed organ donation before the bereavement. Only two of the people who died and seven of their relatives carried a donor card. Sixteen had heard about the NHS donor register.

CONCLUSIONS

Most those responding would not have minded being asked about organ donation following a sudden death. More education is needed in two main areas: (1) to raise public awareness about the shortage of donor organs; (2) to improve the medical and nursing confidence in discussing these difficult issues sensitively but more openly and frequently.

How can clinical supervision become a real vision for the future?

Clinical supervision is increasingly cited as being a necessary part of the work and development of all nurses. This paper discusses an educational programme offered to nurses in one particular Trust and outlines the course philosophy, content, organization and background to this development. Emphasis is placed on the importance of clinical supervision, the student-centred approach to course delivery, and the need to recognize the importance of adequate training and education of all nurses in this area.

Discussing the diagnosis and prognosis with cancer patients

Effective doctor-patient communication is an integral part of good clinical care. Telling a patient that he/she has cancer can be a daunting task. If done with empathy and sensitivity it can create an important bond between the doctor and patient. If done brusquely and without tact it can create barriers and lasting hostility. Several key steps help make the breaking of bad news easier for doctors and patients. There is not one 'right formula' but appreciation of and responsiveness to the patient's verbal and non-verbal signals are core skills which can be developed.

Telling parents their child has severe congenital anomalies

A large number of potential malformations exist, but the key skills in communicating with the parents of a malformed baby are the same. Dissatisfaction is common in this situation and has prompted a national initiative in improving standards of disclosure of disability and malformation--the Right from the start strategy (see appendix). Key skills include keeping the family together, ie, not removing the baby unnecessarily, knowing how parents like to be informed, listening, checking that parents have understood, being nonderogatory and, most importantly, emphasizing the positive side of their newborn child.

Patients' assessment of trainee general practitioners

To determine patients' attitudes to their involvement in assessment of trainee and qualified general practitioners, and their preferences for the methods currently used, a closed-question questionnaire was distributed for self- completion to 300 patients, randomly selected from the waiting areas of three training practices and one non-training practice in the West of Scotland. Most (208) of the 266 patients who responded were comfortable with the idea of being involved in the training and assessment of general practitioners. Patients have clear views and preferences, and it would be wrong to disregard them.

Using simulators to aid the teaching of communication skills in cancer and palliative care

The involvement of simulators for training health professionals to improve their interactive skills appears to be successful. They allow health professionals to practice in a relatively safe environment and to have useful feedback based on a positive approach and constructive suggestion. The simulators appear to find the experience very rewarding. The costs are small and can be built into course fees.

Evaluation of patients' knowledge about anticoagulant treatment

OBJECTIVE

To develop a questionnaire to evaluate patients' knowledge of anticoagulation.

DESIGN

Anonymous self completed questionnaire study based on hospital anticoagulant guidelines.

SETTING

Anticoagulant clinic in a 580 bed district general hospital in London.

SUBJECTS

70 consecutive patients newly referred to the anticoagulant clinic over six months.

MAIN MEASURES

Information received by patients on six items of anticoagulation counselling (mode of action of warfarin, adverse effects of over or under anticoagulation, drugs to avoid, action if bleeding or bruising occurs, and alcohol consumption), the source of such information, and patients' knowledge about anticoagulation.

RESULTS

Of the recruits, 36 (51%) were male; 38(54%) were aged below 46 years, 22(31%) 46-60, and 10(14%) over 75. 50 (71%) questionnaires were returned. In all, 40 respondents spoke English at home and six another language. Most patients reported being clearly advised on five of the six items, but knowledge about anticoagulation was poor. Few patients could correctly identify adverse conditions associated with poor control of anticoagulation: bleeding was identified by only 30(60%), bruising by 23(56%), and thrombosis by 18(36%). Only 26(52%) patients could identify an excessive level of alcohol consumption, and only seven (14%) could identify three or more self prescribed agents which may interfere with warfarin.

CONCLUSION

The questionnaire provided a simple method of determining patients' knowledge of anticoagulation, and its results indicated that this requires improvement.

IMPLICATIONS

Patients' responses suggested that advice was not always given by medical staff, and use of counselling checklists is recommended. Reinforcement of advice by non-medical counsellors and with educational guides such as posters or leaflets should be considered. Such initiatives are currently being evaluated in a repeat survey.