Teaching communication skills to medical students, a challenge in the curriculum?

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Abstract

Introduction:

As communication skills become more and more important in medical practice, the new medical curriculum at Ghent University (1999) implemented a communication curriculum.

Method:

Communication training or experiences in ‘real life’ settings are provided every year of the medical curriculum. The training starts with simple basic skills but gradually slips into medical communication or consultation training and results in communication in different contextual situations or with special groups of patients. Rehearsal is important and seen as inevitable. Poorly performing students get extra training.

Several didactical methods are used: the skills are demonstrated by means of videotapes and paper cases of patient stories. Skills are trained in small groups (10–15 students), with focus on role-playing with colleague students or simulated patients (SP). Videotapes of real consultations give an idea of the performance of each student.

Every year the students are assessed by means of an OSCE (objective structured clinical examination).

Conclusion:

After 6 years of experience with the new curriculum, several remarks and questions need to be answered. Small group training gives a huge workload and with different trainers discrepancies between groups can appear. Choosing the most suitable trainer for communication skills is not easy; several options are available: specialists in communication like psychologists with interest in medical practice, GPs with interest in medical communication, medical specialists for communication topics concerning medical problems within their domain. As the most important didactical approach lies in practising the skills, the selection and training of simulated patients remains a challenge.

Practice implication:

A communication continuum during the whole curriculum seems to be worthwhile. Students with specific communicative problems are detected early, remediation is provided. Rehearsal every year seems to lead to better acquisition. The most positive point is that communication is embedded in a global patient-, student- and community-oriented curriculum and that communication skills are seen as core elements of good doctoring.

Introduction

The medical education for future doctors must deal with the relevant themes of our changing society. The WHO defines the ‘five star doctor’ as: a caregiver who assesses and improves the quality of care, who makes optimal use of new technologies, who promotes healthy lifestyles, who reconciles individual and community health requirements and who is able to work efficiently in teams [1]. Good communication is of crucial importance to obtain these aims.

Fortunately during the last decade, much more attention is given to communication training when developing new medical curricula. This is based on the evidence that adequate doctor–patient communication is related to better health outcomes, better compliance and higher satisfaction of both doctor and patient [2], [3]. Although there is no golden standard on ‘good doctor–patient communication’, patient-centred care, characterised by an emphasis on patients’ ideas, concerns and emotions and their need for information, is favoured. Relationship building, negotiating and facilitating patients’ cooperation are core elements of so called good-communication [4], [5].

In literature a wide range of skills can be identified. Letting patients fully express themselves, asking questions about their illness experience and giving support may contribute to promote health outcomes [6].

In order to improve compliance three important skills are needed: information giving, paying attention to emotions and shared decision-making. Clear, concise and explicit instructions in order to assure that the patient understands and remembers what he/she is expected to do, are associated with higher compliance [7]. Emotional support, friendliness, empathy, partnership building and finding common ground for treatment goals and regimens are also associated with increased levels of adherence to treatment [8]. Although the involvement of patients in the decision process has been found essential for compliance, not all the patients want the same share in decisions about treatment. A discussion during the consultation about shared responsibility is positively associated with adherence [9].

The key elements of patient satisfaction include a warm, friendly and understanding attitude of the doctor who must be able to take into account patients’ ideas, concerns and expectations [10]. Doctor's medical competence and his ability to balance between biomedical and psychosocial issues [11] as well as the continuity of care [12] are strongly related to patient satisfaction. Communication skills as giving clear-cut information on diagnosis, causation and treatment of the patient's illness and the use of understandable language increase patient satisfaction [13].

The implementation of communication training in medical schools has focussed on different problems.

Firstly, the training seldom includes training in generic skills, but addresses specific items/topics like breaking bad news, genetic counselling, handling psychosocial problems or stop-smoking advice. Moreover training is mostly limited in time, not integrated in the curriculum and scarcely contextualised.

Secondly, the didactical techniques are often not adapted to the nature of the subject: ex-cathedra lectures on communication can teach the students that communication is useful and necessary but is not solely suited to confront them with their own communicative behaviour or help them to incorporate new communicative techniques in their consultation style.

Finally, students’ communication skills are rarely reinforced when they enter the hospital for clerkships. Hospital care is diagnosis oriented, doctor centred and often related to acute interventions. Students are seldom stimulated to look for patient's ideas, concerns and emotions at the bedside. Outpatient departments and primary care facilities are then mentioned as the best place to train communication skills [14].

In some curricula students have access to simulated patients to exercise with, although sometimes supervision and feedback is lacking [14].

So, communication skills training deals with problems of continuity, number of training hours, theory versus practice, supervision and assessment.

Section snippets

The challenging task of making a communication curriculum

In Belgium medical school lasts 7 years: 3 years to come to the Bachelor degree, 4 to the Master degree. The Master degree does not give any entrance to the medical profession; every student needs vocational training in the speciality chosen. This vocational training lasts from 3 to 5 years.

The reformation of the medical curriculum at Ghent University switched the traditional discipline based curriculum into an integrated approach: patient-centred; student-centred; community oriented; problem

Theory versus practice

The difference between competence and performance is well known. Dealing with theory without practicing is inefficient. Nevertheless some theoretical background is needed. The 1st year starts with a theoretical framework for all the students about general terminology and the evidence underpinning the communication training and the skills they will receive. Communication within the medical education is seen as a core skill equally necessary to clinical skills like measuring blood pressure.

While

Didactical methods

An effective learning process requires a diversity of methods. Millers’ learning pyramid is used as a framework [17]. Miller shows four interrelated stages in the learning process: knowing, knowing how, showing and doing. The didactical methods used in the education are linked to Miller's stages, as shown in Fig. 2.

After the introduction of the theoretical framework, skills are demonstrated by means of videotapes. Communicational principles in medical as well as in non-medical stories are

Assessment

Every year the students are assessed by means of an OSCE. The objectives are specific for every year, but the skills assessed in previous years are still taken into account. The OSCE is conducted with a simulated patient and one student in a room with a one-way screen. Two examiners rate the student and come to a final mark after discussion. The students get their score and feedback after the whole examination period.

After the 1st year Bachelor, the students must demonstrate their ability to

Remedial teaching

For those students who are weak in communication remedial teaching is provided. Three different types can be described.

During the 2nd year of the Bachelor degree, remedial teaching consists of one up to three extra training sessions in a small group.

During the 1st year of the Master education, every student who failed is invited to exercise during 1 h with a simulated patient. The student can formulate his/her own learning objectives. The whole session is videotaped and the taped is reviewed by

Questions and challenges

Small group training is positive but the workload for this kind of education is considerable. For e.g. the 1st year Bachelor counts about 200 students, 18 groups have been formed. This means 64 2 h-training sessions to be organised. More than one trainer is needed and uniformity has to be surveyed. To solve this problem a specific tutor-handbook per training is made. This book includes: the aims of the training, the material, a description of the didactical forms and the scenario for the

Future research plans

Although the performances of the students of this program seem to be promising, at this moment no evidence is shown. Since the new curriculum was entered progressively comparison between the last year of the old curriculum and the 1st year of the new curriculum is possible. The students of both years, at this moment, respectively in the 7th and the 6th year, will fill in a questionnaire about communication intentions (a paper case consultation with multiple choice questions) and perform two

Practice implications

After 6 years of experience, setting up a communication continuum in a ‘line of skills’ during the whole curriculum seems to be worthwhile. Students with specific communicative problems are detected early, remediation is provided. Rehearsal every year seems to lead to better acquisition. Nevertheless objective criteria and comparison with other students groups remain necessary in order to evaluate the added value. But the most positive point is that communication is embedded in a global

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