Medical Education
Reflective teaching of medical communication skills with DiViDU: Assessing the level of student reflection on recorded consultations with simulated patients

https://doi.org/10.1016/j.pec.2008.10.009Get rights and content

Abstract

Objective

Acquisition of effective, goal-oriented communication skills requires both practicing skills and reflective thinking. Reflection is a cyclic process of perceiving and analysing communication behaviour in terms of goals and effects and designing improved actions. Based on Korthagen's ALACT reflection model, communication training on history taking was designed. Objectives were to develop rating criteria for assessment of the students’ level of reflection and to collect student evaluations of the reflective cycle components in the communication training.

Methods

All second year medical students recorded a consultation with a simulated patient. In DiViDU, a web-based ICT program, students reviewed the video, identified and marked three key events, attached written reflections and provided peer-feedback. Students’ written reflections were rated on four reflection categories. A reflection-level score was based on a frequency count of the number of categories used over three reflections. Students filled out an evaluation questionnaire on components of the communication training.

Results

Data were analyzed of 304 (90.6%) students. The four reflection categories Observations, Motives, Effects and Goals of behaviour were used in 7–38%. Most students phrased undirected questions for improvement (93%). The average reflection score was 2.1 (S.D. 2.0). All training components were considered instructive. Acting was preferred most. Reviewing video was considered instructive. Self-reflection was considered more difficult than providing written feedback to the reflections of peers.

Conclusion

Reflection on communication behaviour can be systematically implemented and measured in a structured way. Reflection levels were low, probably indicating a limited notion of goal-oriented attributes of communication skills.

Practice Implications

Early introduction of critical self-reflection facilitates acceptance of an important ability for physicians for continued life-long learning and becoming mindful practitioners.

Introduction

Medical communication is a core competency as defined by accrediting and policy-making bodies like the Accreditation Council for Graduate Medical Education (ACGME) and the Royal College of Physicians and Surgeons of Canada (RCPSC) [1], [2]. Medical communication can be regarded as a complex task consisting of constantly appraising goals, information, responses, effects in the interaction and making decisions about responses and solutions [3], [4]. Competent practitioners are able to use communication skills at the right time in the right way to reach goals and sub-goals in their dialogues with patients. Examples of goals and sub-goals are history taking, breaking bad news, counselling and decision making, rapport building, agenda setting, exchanging information, responding to psychosocial cues and emotions, and reaching common ground [5], [6], [7]. Effective communication trainings should equip (future) physicians with fundamental abilities for life-long professional development that help them in dealing with a diversity of patients having a wide range and constantly changing set of communicative needs. Reflection is such an ability.

Constructivists regard learning as an active process where learners discover principles, concepts and facts for themselves. Beside active involvement in their own learning, constructivist models also stress the need for collaboration among learners [8]. According to the constructivistic learning approach, acquiring communication skills is not only a matter of practicing skills, but also of reflective thinking [8]. Reflection is an essential activity in developing the cognitive schemata or scripts for problem solving and decision making in medical communication. These cognitive scripts facilitate the process of appraisal of goals and efficient selection of behavioural alternatives [3], [9].

Reflection helps learners better understand the complexity of how one acts in a specific practice situation and should act in a future situation. It is the ability to step back from an experience and consider it critically, in an analytical, non-subjective manner [10]. Reflection helps in understanding relatively complex and sometimes troubling experiences for which there is no obvious solution and transform these into new knowledge and action [11].

Reflective learning is often modelled as a cyclical process. The ALACT model of Korthagen et al. describes a reflective sequence of five stages: Acting, Looking back on the action, Awareness of essential aspects, Creating alternative methods of action, and Trial, testing the newly designed strategies [12]. The fifth stage is the first (Action) phase of the next cycle.

Video is a powerful tool for looking back on one's own performance in an unbiased manner, taking the reflective process away from purely introspective explanations of our behaviours which are often unreliable [13], [14]. Video reviews allow trainees to base their judgments of their own abilities on the same standards used to judge others. Still, critical self-evaluation, necessary to identify key events in one's own performance for creating alternative solutions, is a difficult task. Reflective self-evaluation is often avoided and vulnerable to selective attention and several kinds of cognitive bias [14], [15].

To develop a more accurate impression of oneself, the meta-cognitive judgements of one's own performance should be accompanied with systematic and intentional elicitations of the views of others [14]. Peer-review may be helpful to ensure essential feedback on areas of strength and weakness not always gleaned from self-assessment or even assessment by instructors [16]. Furthermore, self- and peer-assessment help students to get a better understanding of the quality criteria for performance and to make a critical appraisal of their own conduct [17]. Decisions about responses in specific moments in the flow of the medical encounter are to be made in split-seconds. Peers dealing with the same problems can help each other in finding viable solutions.

A training was designed based on the ALACT reflection cycle that invited students explicitly to reflect on their own communication behaviour, to identify personal key issues that are meaningful to them, and to provide feedback on the reflections of peers. The primary aim of this paper was to develop rating criteria for assessment of the students’ level of reflection. Because of the difficulties of the meta-cognitive processes involved in reflection, students may find it difficult to provide a detailed analysis of their own behaviour, which may result in superficial levels of reflection. Availability of specific criteria may be helpful in providing students feedback to enhance the quality of their reflective process. The secondary aim of the study was to collect student evaluations, perceived learning effects, and motivation related to the different stages of the reflection cycle in the training program.

Section snippets

The reflective communication training program

In 2006 we developed a new communication skills training based on the ALACT reflection model for second year undergraduate students, featuring: use of simulated patients; self-directed reflective learning; collaborative learning and peer-feedback; and use of Information and Communication Technology (ICT). The training consisted of seven small group sessions on history taking. Three main goals of medical communication in history taking were trained: (1) gathering reliable diagnostic information

Participants

Of all 331 students; 328 (99.1%) recorded a consultation and 319 (96.4%) students returned the evaluation questionnaire. In this paper data are presented of 304 (90.6%) students, aged 20.6 (S.D. 2.0), 201 (70.1%) women, whose questionnaires could be matched to their work in DiViDU. Consultations of 111 students were recorded in Cycle 1, 101 students were recorded in Cycle 2 and 92 students were recorded in Cycle 3 of the training program.

Rating the students’ reflections in DiViDU

Most students (297; 97.7%) identified in DiViDU three key

Discussion

A reflective communication training program on history taking was designed for second year medical students. With DiViDU students reflected in a systematic way following the ALACT reflection cycle [12] on their video recording of a consultation with a simulated patient. Our first aim was to develop a method for rating the students’ written reflections on their own communication behaviour. Four reflection categories emerged from the data. A full reflection includes describing and explaining

Conflicts of interest

All authors have no conflicts of interest including any financial, personal or other relationships with other people or organizations within 3 years of beginning the submitted work that could inappropriately influence, or be perceived to influence, their work.

Acknowledgements

The authors thank Noelle de Graaf, Educational Science student at the Utrecht University, for developing a preliminary edition of the evaluation questionnaire. Judith Janssen and Anne-Martine Gielis from the Graduate School of Teaching and Learning of the University of Amsterdam were helpful in their advice on setting up the training using DiViDU.

Role of funding: Financial support for the conduct of the research was obtained from The SURF Foundation, the Dutch higher education and research

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