Experiences of simulated patients in providing feedback in communication skills teaching for undergraduate medical students.

BACKGROUND: Simulated Patients (SPs) are commonplace in the teaching of communication skills in medical education and can provide immediate feedback to students from the patient's perspective. The experiences of SPs and their perspective on providing feedback is an under-studied area. This study aims to explore SP experiences and views on feedback, factors influencing their feedback and implications for training. METHODS: Using a constructivist grounded theory approach, we conducted six focus groups with 30 SPs. Participants included experienced simulated patients from a London-based actor agency, used in undergraduate teaching programmes of communication skills. Consistent with the principles of grounded theory, data was collected and analysed in an iterative process to identify themes. RESULTS: Five over-arching themes were identified: 1.) Feedback processes, 2.) Challenges in providing feedback, 3.) Cumulative experiences, 4.) Web of interpersonal relationships and dynamics and 5.) Portraying the character and patient representations. DISCUSSION: These SPs regarded the sharing of the emotions they experienced during the consultation as the focus of their feedback. Their preference was for giving a 'sandwich style' of feedback and 'out-of-role' approach. The relationship with facilitators and students and politeness conventions emerged as significant factors when providing feedback. Sensitivity to the social dynamics of groups and implicit facilitator expectations were challenges they experienced as was divergence in views of student performance. CONCLUSION: This study explored SP experiences and perspectives on providing feedback. Findings reveal complex social and structural dynamics at play in providing feedback which have not been reported so far in the literature. It is recommended that these issues should be addressed in training of both SPs and facilitators, in addition to feedback guidelines.

Training to enhance psychiatrist communication with patients with psychosis (TEMPO): cluster randomised controlled trial.

BACKGROUND: A better therapeutic relationship predicts better outcomes. However, there is no trial-based evidence on how to improve therapeutic relationships in psychosis. AIMS: To test the effectiveness of communication training for psychiatrists on improving shared understanding and the therapeutic relationship (trial registration: ISRCTN94846422). METHOD: In a cluster randomised controlled trial in the UK, 21 psychiatrists were randomised. Ninety-seven (51% of those approached) out-patients with schizophrenia/schizoaffective disorder were recruited, and 64 (66% of the sample recruited at baseline) were followed up after 5 months. The intervention group received four group and one individualised session. The primary outcome, rated blind, was psychiatrist effort in establishing shared understanding (self-repair). Secondary outcome was the therapeutic relationship. RESULTS: Psychiatrists receiving the intervention used 44% more self-repair than the control group (adjusted difference in means 6.4, 95% CI 1.46-11.33, P<0.011, a large effect) adjusting for baseline self-repair. Psychiatrists rated the therapeutic relationship more positively (adjusted difference in means 0.20, 95% CI 0.03-0.37, P = 0.022, a medium effect), as did patients (adjusted difference in means 0.21, 95% CI 0.01-0.41, P = 0.043, a medium effect). CONCLUSIONS: Shared understanding can be successfully targeted in training and improves relationships in treating psychosis.

Learning patient-centred communication: The journey and the territory.

OBJECTIVE: The student entering medical school is about to undergo a socialisation process that profoundly shapes their development as a professional. A central feature is the formal and informal curriculum on the doctor-patient relationship and patient-centred communication. In this paper I will chart some of the features of the student journey which might impact on learning and practice. KEY FEATURES: The medical undergraduate's role is largely that of observer and learner, rather than a provider of care, so much of the formal teaching on patient-centred communication is within simulated practice. Clinical practice environments are the most powerful influences on learning about professional behaviour. Challenges for educational practitioners include how to support authenticity in learners, respond to their agendas, and foster insight to enable flexibility about communication in different contexts. Parallels between the doctor-patient relationship and the student-tutor relationship are explored for their relevance. A number of educational theories can inform curriculum design and educational practice, notably Vygotsky's Zone of Proximal Development. CONCLUSION: Application of this and other social learning theories, together with students' reflections can enrich our planning of educational interventions and understanding of their impact.

Patient safety and communication: a new assessment for doctors trained in countries where language differs from that of the host country: results of a pilot using a domain-based assessment.

OBJECTIVE: Global migration of healthcare workers places responsibility on employers to comply with legal employment rights whilst ensuring patient safety remains the central goal. We describe the pilot of a communication assessment designed for doctors who trained and communicated with patients and colleagues in a different language from that of the host country. It is unique in assessing clinical communication without assessing knowledge. METHODS: A 14-station OSCE was developed using a domain-based marking scheme, covering professional communication and English language skills (speaking, listening, reading and writing) in routine, acute and emotionally challenging contexts, with patients, carers and healthcare teams. Candidates (n=43), non-UK trained volunteers applying to the UK Foundation Programme, were provided with relevant station information prior to the exam. RESULTS: The criteria for passing the test included achieving the pass score and passing 10 or more of the 14 stations. Of the 43 candidates, nine failed on the station criteria. Two failed the pass score and also the station criteria. The Cronbach's alpha coefficient was 0.866. CONCLUSION: This pilot tested 'proof of concept' of a new domain-based communication assessment for non-UK trained doctors. PRACTICE IMPLICATIONS: The test would enable employers and regulators to verify communication competence and safety in clinical contexts, independent of clinical knowledge, for doctors who trained in a language different from that of the host country.

Improving health care professionals' feedback on communication skills: development of an on-line resource.

OBJECTIVE: This project aimed to develop an open-access on-line resource to assist health care professionals in providing effective feedback on patient-centered clinical and communication skills. The collaborative nature of the development of this learning resource is outlined and evaluation of its use is discussed. METHODS: An inter-professional team of teaching staff from two London Universities employed a researcher to interview experienced clinical and academic health care professionals and gather examples of difficult feedback situations. Material was used to develop short video clips illustrating some common challenges in giving feedback on clinical and communication skills. Initial evaluation following use of the scenarios in workshops was undertaken by means of a "talking wall" technique. RESULTS: Evaluation indicated that the resource enhanced the learning experience by providing realistic and challenging scenarios to focus discussion. CONCLUSION: Inter-professional working and piloting the use of the video scenarios in workshops enabled the improvement and refinement of an on-line staff development resource on feedback. PRACTICAL IMPLICATIONS: The on-line resource is now available as an open access learning tool, with eight scenarios and guidelines for providing effective feedback in the academic or clinical setting. It can be used for self-study or as part of a group training session.

Peer feedback as an aid to learning--what do we want? Feedback. When do we want it? Now!

BACKGROUND: With 360° appraisals integral to professional life, learning how to give constructive feedback is an essential generic skill. AIM: To use a formative objective structured clinical examination (OSCE) for skills acquisition and development in giving feedback, whilst facilitating awareness of the importance of communication skills in clinical practice. METHODS: Medical and nursing students took part in a formative OSCE. Using actors as simulated patients, a three-station OSCE circuit was repeated three times so that students could rotate through the roles as 'candidate', 'examiner' and 'observer'. As 'candidates', they received immediate feedback on their consultation from the 'examiner'/'observer'. The events were evaluated using a questionnaire and focus groups. RESULTS: Students immensely valued this learning event for considering expectations for a performance (91-100%). Concerns around giving peers feedback were acknowledged, and they were divided on preference for feedback from peers or tutors (48% versus 52%). But training in providing feedback and criteria for assessment were considered helpful, as was instruction by faculty to give corrective feedback to peers. CONCLUSIONS: Peer observation and professional accountability for giving constructive feedback enhanced awareness of their skills education and training needs. It also opened the dialogue for identifying opportunities for peer assessment and feedback to support work-based education and skills development.

UK consensus statement on the content of communication curricula in undergraduate medical education.

CONTEXT: The teaching and assessment of clinical communication have become central components of undergraduate medical education in the UK. This paper recommends the key content for an undergraduate communication curriculum. Designed by UK educationalists with UK schools in mind, the recommendations are equally applicable to communication curricula throughout the world. OBJECTIVES: This paper is intended to assist curriculum planners in the design, implementation and review of medical communication curricula. The document will also be useful in the education of other health care professionals. Designed for undergraduate education, the consensus statement also provides a baseline for further professional development. METHODS: The consensus statement, based on strong theoretical and research evidence, was developed by an iterative process of discussion between communication skills leads from all 33 UK medical schools conducted under the auspices of the UK Council of Clinical Communication Skills Teaching in Undergraduate Medical Education. DISCUSSION: How this framework is used will inevitably be at the discretion of each medical school and its implementation will be determined by different course designs. Although we believe students should be exposed to all the areas described, it would be impractical to set inflexible competency levels as these may be attained at different stages which are highly school-dependent. However, the framework will enable all schools to consider where different elements are addressed, where gaps exist and how to generate novel combinations of domains within the communication curriculum. It is hoped that this consensus statement will support the development and integration of teaching, learning and assessment of clinical communication.

Optimizing medicines management: From compliance to concordance.

Medication prescribed but not consumed represents a huge loss in drug and prescribing costs and an enormous waste of expensive medical time. In this article we discuss what is known about compliance and adherence, explore the concept of concordance and demonstrate its fundamental difference from both. Not all patients are ready or suitable for shared decision making in management of their condition, some still preferring a doctor-led decision but an increasing number want a partnership approach. By opening up and rebalancing the discussion about medication, we can expect a consultation which is more satisfying for both parties and flowing from this, more effective, focused prescribing of medication which is more likely to be adhered to by the patient. We examine the extent to which doctor and patient behaviors are currently compatible with this change of concept and practice, look at available consultation models which might be useful to the reflective practitioner and consider what actions on the part of the doctor and the healthcare system could promote medicine prescription and utilization in line with this new approach based on partnership.

Patients' attitudes towards the presence of medical students during consultations.

This study analyses the attitudes of patients towards the presence of medical students during consultations. It was conducted in a very culturally and ethnically diverse part of London. The study aimed to investigate the factors, particularly ethnicity, which influence patients' attitudes towards medical students. A total of 422 patients participated in the study, which was conducted in general practice and hospital outpatient waiting areas in the London Boroughs of Tower Hamlets and Hackney. In general, the results demonstrate that patients are positive towards medical student participation during consultations. In particular, older patients, patients born in the UK and patients with prior experience of medical students seem to be particularly favourable towards students. However, compared with the White-British population, the non-White-British population appears to be more negative towards medical student participation. This study highlights the need for patient education regarding the importance, for the training of future doctors, of medical student involvement in consultations.

Informed consent in clinical practice: pre-registration house officers' knowledge, difficulties and the need for postgraduate training.

In clinical practice consent is often obtained by junior doctors. This study investigates the involvement of pre-registration house officers (PRHOs) in the process of obtaining consent, the supervision they receive and their knowledge on the subject. Some 74% of the PRHOs in post completed the questionnaire; 68% had often or sometimes obtained consent during their year as PRHO; 18% stated that on the occasions when they had obtained consent they were always the only person eliciting consent; 62% of the doctors perceived some lack of knowledge with regard to the nature of the procedure as a difficulty. Despite a comprehensive undergraduate programme in ethics, law and communication there is a need for applied education regarding the clinical procedures for which PRHOs are obtaining consent.

Medical students' attitudes and behaviour towards sexual health interviewing: short- and long-term evaluation of designated workshops.

Workshops aimed at promoting fourth-year medical students' attitudes towards and subsequent behaviour in talking to patients about sexual health are reported on. Improvements in attitudes are reported following the workshops in 1999-2000 with students being more likely to see the relevance of sexual health enquiry, feeling more confident and competent about broaching the subject and expressing greater intention to do so. One year on, comparison of the intervention and non-intervention group for attendance at the workshop showed no difference in the proportion who had subsequently asked patients questions about sex. The proportion of students asking patients rose from 47% in the fourth year to 92% by the fifth year. Issues of long-term evaluation and the importance of the informal relative to the formal curriculum are discussed.

Breaking bad news: experiences, views and difficulties of pre-registration house officers.

OBJECTIVES: To obtain information regarding the involvement of pre-registration house officers (PRHOs) in the discussions on bad news, and the competency and difficulties they perceive in clinical practice. DESIGN: Structured telephone interviews. PARTICIPANTS: 104 PRHOs. MAIN OUTCOME MEASURES: Information about frequency and quality of involvement of PRHOs in discussions on bad news with patients and relatives, perceived competency and difficulties related to this task as well as ethical views concerning the disclosure of bad news. RESULTS: 82 PRHOs (78.9%) had initiated the breaking of bad news to a patient at least once, whilst patients themselves had initiated discussions of bad news by asking the doctors questions (92.3%). Almost all (96.2%), indicated that they had broken bad news to relatives of a patient. The majority of the junior doctors participating in our study felt fairly or very confident (90.4%) to break bad news. 'Often' quoted difficulties for over a fifth of the sample included 'Thinking I was not the appropriate person to discuss the bad news', 'Having all the relevant information available', 'Dealing with emotions of patient/relative', 'Lack of privacy' and 'Patients/relatives do not speak English'. Although 99 PRHOs (95.2%) believed that patients should be informed about a serious life threatening illness, 30.8% of the participants stated that doctors need to judge whether or not to tell a patient bad news. Factors most frequently selected by the PRHOs from a given list of possible factors contributing to a gap between theory and practice included problems with the organization of clinics (73.1%), insufficient postgraduate training (63.5%) and lack of staff (54.8%). CONCLUSIONS: The results indicate that PRHOs are frequently involved in the breaking of bad news. Whilst no claims can be made for their,actual performance in practice, their perceptions of competency would indicate that the extensive and compulsory undergraduate teaching they had received on this subject has served to prepare them for this difficult task. Organizational and structural aspects need to be taken into account as factors assisting or undermining doctors in their efforts to put into practice ethically sound and skilled communication when disclosing bad news.