Nationwide survey of patients’ and doctors’ perceptions of what is needed in doctor - patient communication in a Southeast Asian context

Background

Asian countries are making efforts to apply the partnership model in doctor-patient communication that has been used effectively in Western countries. However, notable differences between Western and Asian cultures, especially the acceptance of a hierarchical order and little attention to individuality in Asian cultures, could mean that the application of the partnership model in Vietnam requires adaptation.

The study aimed to investigate whether communication models used in the Western world are appropriate in Southeast Asia, and to identify key items in doctor-patient communication that should be included in a doctor-patient communication model for training in Vietnam.

Methods

In six provinces, collaborating medical schools collected data from 480 patients using face-to-face surveys with a structured guideline following a consultation session, and from 473 doctors using a cross-sectional survey on how they usually conduct consultation sessions with patients. Data collection tools covered a list of communication skills based on Western models, adapted to fit with local legislation.

Using logistic regression, we examined whether doctor patient communication items and other factors were predictors of patient satisfaction.

Results

Both patients and doctors considered most elements in the list necessary for good doctor-patient communication. Both also felt that while actual communication was generally good, there was also room for improvement. Furthermore, the doctors had higher expectations than did the patients. Four items in the Western model for doctor-patient communication, all promoting the partnership relation between them, appeared to have lower priority for both patients and doctors in Vietnam.

Conclusion

The communication model used in the Western world could be applied in Vietnam with minor adaptations. Increasing patients’ understanding of their partner role needs to be considered. The implications for medical training in universities are to focus first on the key skills perceived as needing to be strengthened by both doctors and patients. In the longer term, all of these items should be included in the training to prepare for the future.

True communication skills assessment in interdepartmental OSCE stations: Standard setting using the MAAS-Global and EduG

BACKGROUND

Comparing outcome of clinical skills assessment is challenging. This study proposes reliable and valid comparison of communication skills (1) assessment as practiced in Objective Structured Clinical Examinations (2). The aim of the present study is to compare CS assessment, as standardized according to the MAAS Global, between stations in a single undergraduate medical year.

METHODS

An OSCE delivered in an Irish undergraduate curriculum was studied. We chose the MAAS-Global as an internationally recognized and validated instrument to calibrate the OSCE station items. The MAAS-Global proportion is the percentage of station checklist items that can be considered as 'true' CS. The reliability of the OSCE was calculated with G-Theory analysis and nested ANOVA was used to compare mean scores of all years.

RESULTS

MAAS-Global scores in psychiatry stations were significantly higher than those in other disciplines (p<0.03) and above the initial pass mark of 50%. The higher students' scores in psychiatry stations were related to higher MAAS-Global proportions when compared to the general practice stations.

CONCLUSION

Comparison of outcome measurements, using the MAAS Global as a standardization instrument, between interdisciplinary station checklists was valid and reliable.

PRACTICE IMPLICATIONS

The MAAS-Global was used as a single validated instrument and is suggested as gold standard.

Calibration of communication skills items in OSCE checklists according to the MAAS-Global

BACKGROUND

Communication skills (CS) are commonly assessed using 'communication items' in Objective Structured Clinical Examination (OSCE) station checklists. Our aim is to calibrate the communication component of OSCE station checklists according to the MAAS-Global which is a valid and reliable standard to assess CS in undergraduate medical education.

METHOD

Three raters independently compared 280 checklists from 4 disciplines contributing to the undergraduate year 4 OSCE against the 17 items of the MAAS-Global standard. G-theory was used to analyze the reliability of this calibration procedure.

RESULTS

G-Kappa was 0.8. For two raters G-Kappa is 0.72 and it fell to 0.57 for one rater. 46% of the checklist items corresponded to section three of the MAAS-Global (i.e. medical content of the consultation), whilst 12% corresponded to section two (i.e. general CS), and 8.2% to section one (i.e. CS for each separate phase of the consultation). 34% of the items were not considered to be CS.

CONCLUSION

A G-Kappa of 0.8 confirms a reliable and valid procedure for calibrating OSCE CS checklist items using the MAAS-Global. We strongly suggest that such a procedure is more widely employed to arrive at a stable (valid and reliable) judgment of the communication component in existing checklists for medical students' communication behaviours.

PRACTICE IMPLICATIONS

It is possible to measure the 'true' caliber of CS in OSCE stations. Students' results are thereby comparable between and across stations, students and institutions. A reliable calibration procedure requires only two raters.

Optimum number of procedures required to achieve procedural skills competency in internal medicine residents

BACKGROUND

Procedural skills training forms an essential, yet difficult to assess, component of an Internal Medicine Residency Program. We report the development of process of documentation and assessment of procedural skills training.

METHOD

An explanatory sequential mixed methods design was adopted where both quantitative and qualitative information was collected sequentially. A survey was conducted within the Department of Internal Medicine at The Aga Khan University Hospital, Karachi, Pakistan to determine the optimum number of procedures needed to be performed by residents at each year of residency. Respondents included both faculty and the residents in the Department. Thereafter, all responses were compiled and later scrutinized by a focus group comprising of a mix of faculty from various subspecialties and resident representatives.

RESULTS

A total of 64 responses were obtained. A significant difference was found in eight procedural skills' status between residents and faculty, though none of these were significant after accounting for multiple consecutive testing. However, the results were reviewed and a consensus for the procedures needed was developed through a focus group. A finalized procedural list was generated to determine: (a) the minimum number of times each procedure needed to be performed by the resident before deemed competent; (b) the level of competency for each procedure for respective year of residency.

CONCLUSION

We conclude that the opinion of both the residents and the faculty as key stakeholders is vital to determine the number of procedures to be performed during an Internal Medicine Residency. Documentation of procedural competency development during the training would make the system more objective and hence reproducible. A log book was designed consisting of minimum number of procedures to be performed before attaining competency.

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

Context

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

Objective

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

Methods

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

Results

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

Conclusions

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

Implementing a skillslab training program in a developing country

BACKGROUND

Eight skills laboratories (skillslabs) were established by consensus of Vietnamese medical universities, with international support. A national list of basic skills needed for medical practice and suitable for skillslab training was developed; models, medical and teaching equipment were supplied; learning material was developed and core staff and teachers were trained. This study was designed to assess how closely eight schools in Vietnam came to implementing all recommended skills on list developed by educators of that country, and identify the facilitating factors and barriers to skillslab use within the country's largest school.

METHODS

Data were collected from reports from the eight skillslabs. Students and trainers from the largest university were surveyed for their perceptions of the quality of training on eight selected skills. Results of students' skill assessments were gathered, and focus group discussions with trainers were conducted. SPSS 16 was used to analyze the quantitative data and cluster analysis was used to test for differences.

RESULTS

Only one medical school was able to train all 56 basic skills proposed by consensus among the eight Vietnamese medical universities. Deeper exploration within the largest school revealed that its skillslab training was successful for most skills, according to students' postprogram skills assessment and to students' and trainers' perceptions. However, through focus group discussions we learned that the quantity of training aids was perceived to be insufficient; some models/manikins were inappropriate for training; more consideration was needed in framing the expected requirements of students within each skill; too little time was allocated for the training of one of the eight skills investigated; and further curriculum development is needed to better integrate the skills training program into the broader curriculum.

DISCUSSION

The fact that one medical school could teach all skills recommended for skillslab training demonstrates that all Vietnamese schools may be similarly able to teach the basic skills of the national consensus list. But as of now, it remains challenging for most schools in this developing country to fully implement a national skillslab training program.

Informed consent and nurses' roles: a survey of Indonesian practitioners

BACKGROUND

In Southeast Asia, the process of obtaining informed consent is influenced by both culture and policy at the hospital and national level. Both physicians and nurses play vital roles in this process, but physicians influence the roles of nurses.

OBJECTIVES

Since the physicians and nurses often have different perspectives, it is important to investigate their views about the informed consent process and nurses' roles therein and whether there is a difference between ideal and experienced practice (reality), and whether this differs across hospitals.

METHODS

A questionnaire was developed and a survey was conducted among physicians and nurses. Using exploratory factor analysis a three factor structure was determined: 'nurses' roles', 'barriers in informed consent', and 'adequacy of information'. Non-parametric tests were applied to compare nurses and physicians, and hospital setting.

PARTICIPANTS AND RESEARCH CONTEXT

Responses were obtained from 129 physicians and 616 nurses from two Indonesian hospitals. Those hospitals differ in ownership, location, and size.

ETHICAL CONSIDERATION

The study was reviewed by the hospital ethical committee. Participation was voluntary and confidentiality was ensured by keeping the responses anonymous.

FINDINGS

Physicians and nurses differ significantly on all three factors. The scores reflecting disparity between ideal and reality regarding nurses' roles varied across professions, while barriers in informed consent differed between hospitals.

DISCUSSION

The differences between ideal and reality indicated that improvement in the informed consent process and nurses' roles therein is called for. Varying views between physicians and nurses on nurses' roles may hinder collaboration. The differences between hospital settings showed interventions may have to be customized for different settings.

CONCLUSION

Views on nurses' roles vary across professions. Views on barriers in informed consent vary across hospitals. Therefore interprofessional education is needed to promote interprofessional collaboration and intervention to improve informed consent practice should be tailored to the hospital context.

Residents' perceived barriers to communication skills learning: comparing two medical working contexts in postgraduate training

OBJECTIVE

Contextual factors are known to influence the acquisition and application of communication skills in clinical settings. Little is known about residents' perceptions of these factors. This article aims to explore residents' perceptions of contextual factors affecting the acquisition and application of communication skills in the medical workplace.

METHOD

We conducted an exploratory study comprising seven focus groups with residents in two different specialities: general practice (n=23) and surgery (n=18).

RESULTS

Residents perceive the use of summative assessment checklists that reduce communication skills to behavioural components as impeding the learning of their communication skills. Residents perceive encouragement to deliberately practise in an environment in which the value of communication skills is recognised and support is institutionalised with appropriate feedback from role models as the most important enhancing factors in communication skills learning.

CONCLUSION

To gradually realise a clinical working environment in which the above results are incorporated, we propose to use transformative learning theory to guide further studies.

PRACTICAL IMPLICATIONS

Provided it is used continuously, an approach that combines self-directed learning with observation and discussion of resident-patient consultations seems an effective method for transformative learning of communication skills.

Play the Music, not the Instrument

None

Influence of the workplace on learning physical examination skills

BACKGROUND

Hospital clerkships are considered crucial for acquiring competencies such as diagnostic reasoning and clinical skills. The actual learning process in the hospital remains poorly understood. This study investigates how students learn clinical skills in workplaces and factors affecting this.

METHODS

Six focus group sessions with 32 students in Internal Medicine rotation (4-9 students per group; sessions 80-90 minutes). Verbatim transcripts were analysed by emerging themes and coded independently by three researchers followed by constant comparison and axial coding.

RESULTS

Students report to learn the systematics of the physical examination, gain agility and become able to recognise pathological signs. The learning process combines working alongside others and working independently with increasing responsibility for patient care. Helpful behaviour includes making findings explicit through patient files or during observation, feedback by abnormal findings and taking initiative. Factors affecting the process negatively include lack of supervision, uncertainty about tasks and expectations, and social context such as hierarchy of learners and perceived learning environment.

CONCLUSION

Although individual student experiences vary greatly between different hospitals, it seems that proactivity and participation are central drivers for learning. These results can improve the quality of existing programmes and help design new ways to learn physical examination skills.

Communication in the initial paediatric consultation

The first time a paediatrician meets with a patient, either with or without parents or caretakers, there are generally two aims with this consultation. Aside from exchanging relevant information for diagnosis, a relationship develops. This relationship is an important factor in the encounter: it can facilitate or impede collaboration between the partners in the consultation. The paediatrician can influence this relationship so that it becomes beneficial in the diagnostic process and in creating a collaborative atmosphere in the consultation, which in turn will prove useful for adherence. This paper addresses this second aim: how can we use the relationship between the patients (with or without parents) and their doctors to enhance the quality and effectiveness of the encounter. Below we will first address why investing in a relationship is beneficial. Next we will describe how this can be done. The review will continue with a discussion of three important pitfalls and how to avoid them, and a small epilogue will provide a brief summary.

Introducing a partnership doctor-patient communication guide for teachers in the culturally hierarchical context of Indonesia

INTRODUCTION

A guide for a partnership style of doctor-patient communication tailored to a Southeast Asian culture was previously developed and validated. We introduced the guide to clinical teachers in Indonesia through a participatory approach. Evaluation was based on teachers' demonstrated comprehension and ability to teach the guide.

METHODS

Three junior researchers invited twelve senior clinical teachers to learn about the guide by writing a chapter on doctor-patient communication using their clinical expertise, reflections on the guide, and the international literature. A participatory study comprised of two cycles (producing first and second drafts of the chapters) was conducted over 18 months with guidance from researchers and written feedback from an expert in communication skills. Qualitative content-analysis was used to assess the content of the submitted chapters.

RESULTS

The clinical teachers understood the concept of partnership style doctor-patient communication but demonstrated limited reflection on the Southeast Asian culture. Teachers had difficulty translating the guide into a written learning guide. However, teachers proposed an adapted guide with a simpler structure, tailored to their clinical environment characterized by high patient load and limited time for doctor-patient communications.

DISCUSSION

The adapted guide was proof of the teachers' willingness to learn about a partnership style of doctor-patient communications. However, the process of introducing the guide was hindered by the wide power distance between participants throughout all aspects of the study, including communication between senior teachers and more junior researchers.

Communication skills in context: trends and perspectives

OBJECTIVE

Doctor-patient communication has been well researched. Less is known about the educational background of communication skills training. Do we aim for optimal performance of skills, or rather attempt to help students become skilled communicators?

METHODS

An overview is given of the current view on optimal doctor-patient communication. Next we focus on recent literature on how people acquire skills. These two topics are integrated in the next chapter, in which we discuss the optimal training conditions.

RESULTS

A longitudinal training design has more lasting results than incidental training. Assessment must be in line with the intended learning outcomes. For transfer, doctor-patient communication must be addressed in all stages of health professions training.

CONCLUSION

Elementary insights from medical education are far from realised in many medical schools. Doctor-patient communication would benefit strongly from more continuity in training and imbedding in the daily working contexts of doctors.

PRACTICE IMPLICATIONS

When an educational continuum is realised and attention for doctor-patient communication is embedded in the working context of doctors in training the benefits will be strong. Training is only a part of the solution. In view of the current dissatisfaction with doctor-patient communication a change in attitude of course directors is strongly called for.

From lecture to learning tasks: use of the 4C/ID model in a communication skills course in a continuing professional education context

This article describes the use of four-component instructional design (4C/ID), a model to plan educational interventions for complex learning. This model was used to design a continuing education course on communication skills for health professionals in a context that is hierarchical and communal. The authors describe the 4C/ID model and provide an example of its application in designing the course. In the 4C/ID model, learning tasks serve as the backbone of the course, with lectures and other supportive information organized around them. The 4C/ID model is different from traditional models that base the course on lectures on different topics and connect part-task assignments to these topics. The use of the 4C/ID model to develop the educational intervention moves the paradigm from lectures to learning tasks to better prepare learners for real practice.

Doctor-patient communication in Southeast Asia: a different culture?

Studies of doctor-patient communication generally advocate a partnership communication style. However, in Southeast Asian settings, we often see a more one-way style with little input from the patient. We investigated factors underlying the use of a one-way consultation style by doctors in a Southeast Asian setting. We conducted a qualitative study based on principles of grounded theory. Twenty residents and specialists and 20 patients of a low or high educational level were interviewed in internal medicine outpatient clinics of an Indonesian teaching hospital and two affiliated hospitals. During 26 weeks we engaged in an iterative interview and coding process to identify emergent factors. Patients were generally dissatisfied with doctors' communication style. The doctors indicated that they did not deliberately use a one-way style. Communication style appeared to be associated with characteristics of Southeast Asian culture, the health care setting and medical education. Doctor-patient communication appeared to be affected by cultural characteristics which fell into two broad categories representing key features of Southeast Asian culture, "social distance" and "closeness of relationships", and to characteristics categorized as "specific clinical context". Consideration of these characteristics could be helpful in promoting the use of a partnership communication style.

Learning in context: identifying gaps in research on the transfer of medical communication skills to the clinical workplace

OBJECTIVE

In order to reduce the inconsistencies of findings and the apparent low transfer of communication skills from training to medical practice, this narrative review identifies some main gaps in research on medical communication skills training and presents insights from theories on learning and transfer to broaden the view for future research.

METHODS

Relevant literature was identified using Pubmed, GoogleScholar, Cochrane database, and Web of Science; and analyzed using an iterative procedure.

RESULTS

Research findings on the effectiveness of medical communication training still show inconsistencies and variability. Contemporary theories on learning based on a constructivist paradigm offer the following insights: acquisition of knowledge and skills should be viewed as an ongoing process of exchange between the learner and his environment, so called lifelong learning. This process can neither be atomized nor separated from the context in which it occurs. Four contemporary approaches are presented as examples.

CONCLUSION

The following shift in focus for future research is proposed: beyond isolated single factor effectiveness studies toward constructivist, non-reductionistic studies integrating the context.

PRACTICE IMPLICATIONS

Future research should investigate how constructivist approaches can be used in the medical context to increase effective learning and transition of communication skills.

Medical students' and residents' conceptual structure of empathy: a qualitative study

BACKGROUND

Empathy is a crucial component of medicine. However, many studies that have used quantitative methods have revealed decline of learners' empathy during undergraduate and postgraduate medical education. We identified medical students' and residents' conceptual structures of empathy in medicine to examine possible differences between the groups in how they conceive empathy.

METHODS

We conducted a qualitative study with two focus group discussions in which six medical students and seven residents participated separately. The transcripts of the focus group discussions were analysed combining qualitative data analysis and theoretical coding.

RESULTS

Medical students and residents had different conceptual structures of empathy. While medical students thought that sharing emotions with patients was essential to showing empathy, residents expressed empathy according to their evaluation of patients' physical and mental health status. If the residents thought that showing empathy was necessary for the care of patients, they could show it, regardless of whether they shared the patients' emotions or not.

CONCLUSIONS

The comparison of medical students' and residents' conceptual structures of empathy reveals a qualitative difference. Residents show more empathy to their patients by a cognitive decision as clinicians than medical students do. Communication skills training should consider the qualitative change of students' and residents' empathy with clinical experience. We should consider the change when we evaluate learners' empathy and introduce methods that cover the qualitative range of empathy.

Leary's Rose to improve negotiation skills among health professionals: experiences from a Southeast Asian culture

CONTEXT

Although inter-professional collaboration is important for patient safety, effective collaboration can be difficult to achieve, especially in settings with a strong hierarchical or blame culture.

EDUCATIONAL MODEL

Leary's Rose is a model that gives insight into the hierarchical positions people take during a negotiation process. The assumption behind this tool is that the default reaction we intuitively choose is not always the most effective. Becoming aware of this default reaction makes it possible to choose to behave differently, in a more effective way. We propose to use this model to make health professionals more aware of their attitudes and communication styles when negotiating and provide them with a tool to improve communication by modifying their natural responses.

APPLICATION

Leary's Rose can be used in simulated and authentic work-based educational settings. To train the communication skills of nurses to be the patients' advocates, for example Leary's Rose was used in role plays in which nurses have to negotiate in the patients' interest with the doctor while they have to maintain partnership relationship and avoid opposition with the doctor.

All of this and he can cook, too…

Professor Cees van der Vleuten has been awarded the 2012 Karolinska Insitutet Prize for Research in Medical Education for his research in evaluation and assessment of medical competences.

Learning physical examination skills outside timetabled training sessions: what happens and why?

Lack of published studies on students' practice behaviour of physical examination skills outside timetabled training sessions inspired this study into what activities medical students undertake to improve their skills and factors influencing this. Six focus groups of a total of 52 students from Years 1-3 using a pre-established interview guide. Interviews were recorded, transcribed and analyzed using qualitative methods. The interview guide was based on questionnaire results; overall response rate for Years 1-3 was 90% (n = 875). Students report a variety of activities to improve their physical examination skills. On average, students devote 20% of self-study time to skill training with Year 1 students practising significantly more than Year 3 students. Practice patterns shift from just-in-time learning to a longitudinal selfdirected approach. Factors influencing this change are assessment methods and simulated/real patients. Learning resources used include textbooks, examination guidelines, scientific articles, the Internet, videos/DVDs and scoring forms from previous OSCEs. Practising skills on fellow students happens at university rooms or at home. Also family and friends were mentioned to help. Simulated/real patients stimulated students to practise of physical examination skills, initially causing confusion and anxiety about skill performance but leading to increased feelings of competence. Difficult or enjoyable skills stimulate students to practise. The strategies students adopt to master physical examination skills outside timetabled training sessions are self-directed. OSCE assessment does have influence, but learning takes place also when there is no upcoming assessment. Simulated and real patients provide strong incentives to work on skills. Early patient contacts make students feel more prepared for clinical practice.

Verbal and non-verbal behavior of doctors and patients in primary care consultations - how this relates to patient enablement

OBJECTIVE

To assess the relationship between observable patient and doctor verbal and non-verbal behaviors and the degree of enablement in consultations according to the Patient Enablement Instrument (PEI) (a patient-reported consultation outcome measure).

METHODS

We analyzed 88 recorded routine primary care consultations. Verbal and non-verbal communications were analyzed using the Roter Interaction Analysis System (RIAS) and the Medical Interaction Process System, respectively. Consultations were categorized as patient- or doctor-centered and by whether the patient or doctor was verbally dominant using the RIAS categorizations.

RESULTS

Consultations that were regarded as patient-centered or verbally dominated by the patient on RIAS coding were considered enabling. Socio-emotional interchange (agreements, approvals, laughter, legitimization) was associated with enablement. These features, together with task-related behavior explain up to 33% of the variance of enablement, leaving 67% unexplained. Thus, enablement appears to include aspects beyond those expressed as observable behavior.

CONCLUSION

For enablement consultations should be patient-centered and doctors should facilitate socio-emotional interchange. Observable behavior included in communication skills training probably contributes to only about a third of the factors that engender enablement in consultations.

PRACTICE IMPLICATIONS

To support patient enablement in consultations, clinicians should focus on agreements, approvals and legitimization whilst attending to patient agendas.

The role of deliberate practice in the acquisition of clinical skills

BACKGROUND

The role of deliberate practice in medical students' development from novice to expert was examined for preclinical skill training.

METHODS

Students in years 1-3 completed 34 Likert type items, adapted from a questionnaire about the use of deliberate practice in cognitive learning. Exploratory factor analysis and reliability analysis were used to validate the questionnaire. Analysis of variance examined differences between years and regression analysis the relationship between deliberate practice and skill test results.

RESULTS

875 students participated (90%). Factor analysis yielded four factors: planning, concentration/dedication, repetition/revision, study style/self reflection. Student scores on 'Planning' increased over time, score on sub-scale 'repetition/revision' decreased. Student results on the clinical skill test correlated positively with scores on subscales 'planning' and 'concentration/dedication' in years 1 and 3, and with scores on subscale 'repetition/revision' in year 1.

CONCLUSIONS

The positive effects on test results suggest that the role of deliberate practice in medical education merits further study. The cross-sectional design is a limitation, the large representative sample a strength of the study. The vanishing effect of repetition/revision may be attributable to inadequate feedback. Deliberate practice advocates sustained practice to address weaknesses, identified by (self-)assessment and stimulated by feedback. Further studies should use a longitudinal prospective design and extend the scope to expertise development during residency and beyond.

Frozen section analysis of sentinel lymph nodes in patients with breast cancer does not impair the probability to detect lymph node metastases

Intra-operative frozen section analysis (FS analysis) of sentinel lymph nodes (SLNs) in patients with breast cancer can prevent a second operation for axillary lymph node dissection. In contrast, loss of tissue during FS analysis may impair the probability to detect lymph node metastases. To determine the effect of tissue loss on the probability of detection of metastases, dimensions and tissue loss resulting from intra-operative frozen section analysis were measured for 21 SLNs. In a mathematical model, the influence of tissue loss on the probability to detect metastases was calculated in relation to SLN size for various pathology protocols: an American, a widely used European, the extensive ‘Milan’ and the Dutch protocol. For median-sized SLN 11 × 8 × 5 mm (length × width × height), FS analysis led to a median loss of 680 μm (13.6%) of the height of the SLN. Irrespective of SLN size or used pathology protocol, the probability of detecting 2 mm metastases remained unchanged or even increased (0–12.8%). Moreover, the probability to detect 0.2 mm metastases increased for the majority of tested combinations of SLN size, tissue loss and used protocol. Only when combining maximum tissue loss and smallest SLN size in the Dutch protocol, or when applying the extensive Milan protocol on a median-sized SLN, the probability to detect 0.2 mm metastases decreased by 2.7% and 14.3%, respectively. Contrary to ‘common knowledge’, doing FS analysis of SLNs does not impair the probability to detect lymph node metastases.

A qualitative study of caregivers' expectations and communication desires during medical consultation for sick children in Uganda

OBJECTIVE

Little data exist on patients' expectations and communication desires during medical consultation in Non-Western settings. We conducted a qualitative study to compare expectations and communication desires of sick children's caregivers at Mulago Hospital, Uganda, to those of patients in Western countries.

METHODS

Three Focus Group Interviews and three Key Informant Interviews were conducted with 24 caregivers of sick children in Mulago Hospital Kampala, Uganda. An interview guide adapted from the Calgary-Cambridge Guide was used to conduct focus group and Key Informant Interviews. Two investigators worked independently to review transcripts and analyse them for content and emerging themes.

RESULTS

Caregivers of sick children in Mulago Hospital expect attending doctors to build a relationship with them, by demonstrating the verbal and nonverbal skills outlined in the CCG including maintaining eye contact, using appropriate gestures and voice during communication, and being nonjudgmental.

CONCLUSION

The communication needs and expectations of caregivers of sick children in Mulago Hospital are similar to those of patients and caregivers in Western countries.

PRACTICE IMPLICATIONS

The CCG can be used as a training guide to enhance the communication skills of current and future doctors in Mulago Hospital.

Student views on the effective teaching of physical examination skills: a qualitative study

OBJECTIVES

The lack of published studies into effective skills teaching in clinical skills centres inspired this study of student views of the teaching behaviours of skills teachers.

METHODS

We organised focus group discussions with students from Years 1-3 of a 6-year undergraduate medical curriculum. A total of 30 randomly selected students, divided into three groups, took part in two sessions. They discussed what teaching skills helped them to acquire physical examination skills.

RESULTS

Students' opinions related to didactic skills, interpersonal and communication skills and preconditions. Students appreciated didactic skills that stimulate deep and active learning. Another significant set of findings referred to teachers' attitudes towards students. Students wanted teachers to be considerate and to take them seriously. This was reflected in student descriptions of positive behaviours, such as: 'responding to students' questions'; 'not exposing students' weaknesses in front of the group', and '[not] putting students in an embarrassing position in skill demonstrations'. They also appreciated enthusiasm in teachers. Important preconditions included: the integration of skills training with basic science teaching; linking of skills training to clinical practice; the presence of clear goals and well-structured sessions; good time management; consistency of teaching, and the appropriate personal appearance of teachers and students.

CONCLUSIONS

The teaching skills and behaviours that most facilitate student acquisition of physical examination skills are interpersonal and communication skills, followed by a number of didactic interventions, embedded in several preconditions. Findings related to interpersonal and communication skills are comparable with findings pertaining to the teaching roles of tutors and clinical teachers; however, the didactic skills merit separate attention as teaching skills for use in skills laboratories. The results of this study should be complemented by a study performed in a larger population and a study exploring teachers' views.

Factors determining students' global satisfaction with clerkships: an analysis of a two year students' ratings database

Clerkships would benefit from teachers' improved understanding of the didactic aspects of their task. The purpose of this study is to identify factors that determine the teaching quality of clerkships and to examine the predictive value of these factors for students' global satisfaction. Thus, results would be further reflected to clinical teachers' tasks. These factors could then be taken into account in future clinical teaching. In this paper, a medical faculty's 2 year data set of student feedback from a systematic programme evaluation project was used. A factor analysis was performed on 11,780 student questionnaires. Factor loads, and the Cronbach's alpha coefficients of the questionnaire and factors were calculated. In order to examine the contributions of the factors to the students' global satisfaction, the study included a multivariate stepwise regression analysis. The analysis revealed four factors, which together explained 60.24% of the variance: Structure & Process (44.66%); Time (5.8 %); Outcome (5.35%) and Input (4.39%). The Structure & Process factor was found to be the best predictor of students' global satisfaction (R2 =( ).537). Our conclusion is that "efforts to improve clerkship quality should focus on students' learning processes and clerkship structure".

Strategies for optimizing pathologic staging of sentinel lymph nodes in breast cancer patients

Due to the extensive pathologic evaluation of the sentinel lymph node (SLN), micrometastases are frequently observed. If micrometastases are clinically relevant, the histopathologic examination of SLNs should be sensitive enough to detect them. The probability of detecting micrometastases was calculated when examining the SLN according to the current Dutch pathology protocol and strategies evaluated to optimize the chance of detection. The dimensions of 20 consecutive axillary SLNs in patients with cT1-2N0 breast cancer were measured. In a mathematical model, the probability of detecting micrometastases in a SLN was calculated. Similarly, strategies to optimize the probability of detecting micrometastases were explored. When applying the pathology guidelines, the calculated probability to detect a micrometastasis was 18% for a 200-microm micrometastasis and 69% for a 2.0-mm metastasis in a median sized SLN. To detect the smallest micrometastasis in a median-sized SLN with a 95% probability, the interval between the sections must be decreased to 200 microm, and 20 levels from both halves must be examined. Given a prognostic significance of micrometastases, our current pathology guidelines are not sensitive enough. The number of sections should be increased, while the interval between cuts should be no more than 200 microm.

Simulating the longitudinal doctor-patient relationship: experiences of simulated patients in successive consultations

CONTEXT

The use of simulated patients (SPs) in teaching communication and practical skills at medical schools is mostly limited to single-case use: a student has 1 consultation with an SP and receives feedback afterwards. Very little literature is available that describes consecutive consultations between the same student and SP. In this study, we explored the experiences of SPs in a new, longitudinal SP programme in which SPs met the same Year 3 students ('GP') in 4 consecutive consultations during the year. The SPs suffered from a chronic disease in their patient roles.

METHODS

Four focus group discussions were conducted with 23 SPs (8 men, 15 women; average age 60.9 years) who had performed in the new programme. Discussions were semi-structured and followed a pre-established interview guide. Data were categorised by 3 independent raters.

RESULTS

The SPs described the development of a more familiar relationship with students under the new programme, compared with single-case consultations. They developed specific expectations of students' performances. The SPs enjoyed participating in the programme and felt it was more realistic than single-case consultations. Feedback changed and became more detailed as SPs were able to compare consultations; students' response to feedback could be experienced during the next consultation.

DISCUSSION

Practising the development of a realistic, longitudinal doctor-patient relationship may help prepare students for real practice. Longitudinal feedback is now possible; it may be of higher quality and of benefit to SPs as well. These findings suggest new possibilities for SP-based education and research. Future studies should focus on quantitative analysis and students' perspectives.

The impact of simulation on people who act as simulated patients: a focus group study

OBJECTIVE

Previous studies have shown that people who act as simulated patients (SPs) experience negative effects caused by performing patient roles. This study was performed to further explore the impact of simulation and the factors that might affect this impact. The aim was to find ways of preventing negative effects of simulation impacting on our SPs.

METHODS

Focus groups interviews were conducted among 35 SPs at Skillslab, University of Maastricht. The discussion was guided by 6 pre-established items.

RESULTS

The majority of the SPs appeared to experience negative effects of performing a patient role. The effects were considered as inherent to acting as an SP or due to simulation being a strenuous activity. The impact was short-lived and did not affect SPs' enjoyment of their work. Factors that appeared to affect the impact of performing included: the type of role (whether it is emotionally complex or not); the number of consecutive performances; the length of time between performances; the giving of feedback; the amount of experience, and students.

DISCUSSION

Although the SPs were found to experience negative effects caused by playing patient roles, the frequency and intensity of the negative effects were minor. The focus group discussions led to various suggestions for measures to reduce the impact of simulation.

Basic life support skills training in a first year medical curriculum: six years' experience with two cognitive-constructivist designs

RATIONALE

Although the Basic Life Support (BLS) ability of a medical student is a crucial competence, poor BLS training programs have been documented worldwide. Better training designs are needed. This study aims to share detailed descriptions and the test results of two cognitive-constructivist training models for the BLS skills in the first year of medical curriculum.

METHOD

A BLS skills training module was implemented in the first year curriculum in the course of 6 years (1997-2003). The content was derived from the European Resuscitation Council Guidelines. Initially, a competence-based model was used and was upgraded to a cognitive apprenticeship model in 2000. The main performance-content type that was expected at the end of the course was: competent application of BLS procedures on manikins and peers at an OSCE as well as 60% achievement in a test consisting of 25 MCQ items. A retrospective cohort survey design using exam results and a self-completed anonymous student ratings' questionnaire were used in order to test models.

RESULTS

Training time for individual students varied from 21 to 29 hours. One thousand seven hundred and sixty students were trained. Fail rates were very low (1.0-2.2%). The students were highly satisfied with the module during the 6 years.

CONCLUSION

In the first year of the medical curriculum, a competence-based or cognitive apprenticeship model using cognitive-constructivist designs of skills training with 9 hours theoretical and 12-20 hours long practical sessions took place in groups of 12-17 students; medical students reached a degree of competence to sufficiently perform BLS skills on the manikins and their peers. The cognitive-constructivist designs for skills training are associated with high student satisfaction. However, the lack of controls limits the extrapolation of this conclusion.

Performance-related stress symptoms in simulated patients

INTRODUCTION

During the first 4 years of the 6-year undergraduate medical curriculum at Maastricht University, the Netherlands, students practise clinical skills in simulated patient (SP) encounters at the Skillslab. Generally, these encounters are instructive and enjoyable for both students and SPs. However, in conversations with SP trainers, some SPs have mentioned experiencing adverse symptoms due to performing a patient role. Some published studies have reported similar findings in SPs. We explored the seriousness of this problem by surveying SPs on the occurrence and severity of stress symptoms related to performing patient roles. We also examined by which variables the symptoms were influenced.

METHODS

An anonymous questionnaire was developed to investigate factors related to stress symptoms and the frequency and severity of stress symptoms. A burnout scale was also included in the questionnaire. All SPs who had performed between March 2000 and March 2001 were asked to participate.

RESULTS

The response rate was 84%. Of the SPs, 73% were found to have experienced stress symptoms, with a mean of 4 symptoms per SP. No significant correlations were found between the occurrence of symptoms on the one hand and factors that might influence symptoms or the burnout scale on the other hand.

DISCUSSION

An unexpectedly high number of SPs reported symptoms. Fortunately, the symptoms were relatively mild (2.2 on a 5-point scale). Future studies should address the connection between work as an SP and symptoms, and measures should be taken to prevent and treat the symptoms. Debriefing sessions might play a role in this respect.