From threat to challenge-Improving medical students' stress response and communication skills performance through the combination of stress arousal reappraisal and preparatory worked example-based learning when breaking bad news to simulated patients: study protocol for a randomized controlled trial.

BACKGROUND: Breaking bad news (BBN; e.g., delivering a cancer diagnosis) is perceived as one of the most demanding communication tasks in the medical field and associated with high levels of stress. Physicians' increased stress in BBN encounters can negatively impact their communication performance, and in the long term, patient-related health outcomes. Although a growing body of literature acknowledges the stressful nature of BBN, little has been done to address this issue. Therefore, there is a need for appropriate tools to help physicians cope with their stress response, so that they can perform BBN at their best. In the present study, we implement the biopsychosocial model of challenge and threat as theoretical framework. According to this model, the balance between perceived situational demands and perceived coping resources determines whether a stressful performance situation, such as BBN, is experienced as challenge (resources > demands) or threat (resources < demands). Using two interventions, we aim to support medical students in shifting towards challenge-oriented stress responses and improved communication performance: (1) stress arousal reappraisal (SAR), which guides individuals to reinterpret their stress arousal as an adaptive and beneficial response for task performance; (2) worked examples (WE), which demonstrate how to BBN in a step-by-step manner, offering structure and promoting skill acquisition. METHODS: In a randomized controlled trial with a 2 (SAR vs. control) x 2 (WE vs. control) between-subjects design, we will determine the effects of both interventions on stress response and BBN skills performance in N = 200 third-year medical students during a simulated BBN encounter. To identify students' stress responses, we will assess their perceived coping resources and task demands, record their cardiovascular activity, and measure salivary parameters before, during, and after BBN encounters. Three trained raters will independently score students' BBN skills performances. DISCUSSION: Findings will provide unique insights into the psychophysiology of medical students who are tasked with BBN. Parameters can be understood more comprehensively from the challenge and threat perspective and linked to performance outcomes. If proven effective, the evaluated interventions could be incorporated into the curriculum of medical students and facilitate BBN skills acquisition. TRIAL REGISTRATION: ClinicalTrials.gov (NCT05037318), September 8, 2021.

Investigating acceptability of a training programme in precision medicine for frontline healthcare professionals: a mixed methods study.

BACKGROUND: Precision Medicine offers tailored prevention, diagnosis, treatment and management to patients that considers genomics, lifestyle and environmental factors. If implementation of Precision Medicine is to advance, effective, focused upskilling of frontline healthcare professionals through quality continuing professional development is needed. This study reports on an evidence-based approach to needs assessment to investigate the current level of knowledge of Precision Medicine, acceptable content for training, the perceived potential of a more precision approach to patient care and motivation to participate in a training programme among pharmacists, advanced practice nurses and general practitioners. Investigating perceived needs can avoid a top-down approach and support a design that is fit for purpose to targeted professions. METHODS: This study reports on 2 focus groups (n = 12) delivered in French and German with equal professional participation of the targeted professions. The research objectives were investigated in two phases. During the first phase, a literature review and expert consultations were conducted to develop a definition of PM, patient cases and content for training. In a second phase, these investigations were further explored using focus groups to investigate acceptable learning objectives, the potential of PM to relevant professions and motivation of participants. Quantitative investigations using rating scales and visual analogues were incorporated. The focus groups were audio recorded, transcribed by intelligent verbatim and translated to English. NVivo was used for data analysis and interpretation following a hybrid approach using the Framework Method and thematic analysis. The analytical framework, Implementation Science, was applied to organise and present research data. RESULTS: Precision Medicine is considered a new topic area, largely unfamiliar to frontline healthcare professionals.. There was acceptance of a more precision approach to care among all participants with perceived positive implications for patients. Valuable insight was gathered on acceptable content and form for training. All participants expressed concerns on readiness within their professions which included an insufficient system infrastructure, a lack of time to attend needed training, a lack of clarity for use in practice and the time needed to build a support network. CONCLUSIONS: A precision approach to patient care is on the horizon for health care professionals not only in hospital settings but also at the community level. Our results conclude that an adaptable and flexible training programme in PM is timely, contextually relevant and conducive to the needs of targeted health professions for successful implementation. A training programme in PM will require support across sectors and stakeholders, supporting insurance models, educated patients and integrated care supported by innovative technology. Implementation Science outcomes are a useful strategy towards design of an effective training programme that can have measurable impact in practice.

An overview of and approach to selecting appropriate patient representations in teaching and summative assessment in medical education.

Medical education has a long tradition of using various patient representations in teaching and assessment. With this literature review we aim, first, to provide an overview of the most important patient representations used to teach and assess clinical skills, considering in particular “summative exams” that have a pass or fail outcome; second, to provide arguments for choosing certain patient representations; and third, to show the advantages and limitations of different patient representations, especially simulated patients (SPs) and real patients (RPs). Typical patient representations include case narratives, anatomical models, simulators and mannequins, as well as SPs and RPs. The literature indicates that there are multiple ways of using various patient representations in teaching and that the intended didactical purpose informs the choice of representation. Early in the educational programme, even low-fidelity patient representations can be a good fit for assessment purposes if chosen to match the educational level. The use of RPs in summative, high-stakes assessments (exams with particularly important consequences for the examinee) is limited for methodological and ethical reasons. The methodological implementation of summative exams also entails specific challenges, such as ensuring measurement reliability and fairness towards the examinees. Carefully prepared, SPs can perform their roles with a sufficient degree of authenticity, making summative exams more manageable, and imposing no strain or risk on RPs. The ongoing debate concerning the use of SPs and RPs in summative assessment highlights perceived limitations of SPs in relation to RPs that are often not supported by research. Evidence shows that SPs, in combination with additional simulation modalities as needed, represent the first choice for summative clinical assessment. We also consider the strengths and limitations of this review and reflect on the applicability of our findings. We conclude that in order to select the right patient representations in clinical teaching and/or assessment, a number of perspectives must be considered: (i) the learning goals, aligned with the stage of study, (ii) the corresponding requirements of the clinical task itself (e.g., performing a phlebotomy or a communication task), (iii) the level of authenticity required and (iv) the resources needed, taking patient safety and feasibility into consideration.

Learning how to break bad news from worked examples: Does the presentation format matter when hints are embedded? Results from randomised and blinded field trials.

OBJECTIVES: Video-based worked examples enable medical students to successfully prepare for breaking-bad-news (BBN) encounters with simulated patients (SPs). This is especially true when examples include hints that signal important content. This paper investigates whether the beneficial effect of hints only applies to video-based worked examples or also text-based examples. METHODS: One-hundred-and-forty-seven fourth-year medical students attending a BBN training participated in either of two equally scaffolded, randomised field trials. Prior to encountering SPs, the students worked through an e-learning module introducing the SPIKES protocol for delivering bad news; it contained the same worked example presented to either of four groups as text or video, with or without additional hints denoting the SPIKES steps being implemented. RESULTS: Only a main effect of 'hints' was revealed, implying that students in the hints groups delivered the news to an SP significantly more appropriately than those in the without-hints groups. CONCLUSIONS: Independent of their presentation format, worked examples with hints best foster students' BBN skills learning. PRACTICE IMPLICATIONS: In addition to video, text-based worked examples can effectively prepare students for BBN simulations if hints are included. This offers an affordable alternative to video examples, as text examples can be generated with less effort.

The learning effects of different presentations of worked examples on medical students' breaking-bad-news skills: A randomized and blinded field trial.

OBJECTIVES: Effective instructional approaches are needed to enable undergraduates to optimally prepare for the limited training time they receive with simulated patients (SPs). This study examines the learning effects of different presentation formats of a worked example on student SP communication. METHODS: Sixty-seven fourth-year medical students attending a mandatory communication course participated in this randomized field trial. Prior to the course, they worked through an e-learning module that introduced the SPIKES protocol for delivering bad news to patients. In this module, a single worked example was presented to one group of students in a text version, to a second group in a video version, and to a third group in a video version enriched with text hints denoting the SPIKES steps. RESULTS: The video-with-hints group broke bad news to SPs significantly more appropriately than either of the other groups. Although no further condition-related effects were revealed, students who learned from the text version most frequently (although non-significantly) ignored unpleasant emotions (standardised emotional cues and concerns) expressed by the SPs. CONCLUSIONS: The learning effect was strongest when the video-based worked example was accompanied by hints. PRACTICE IMPLICATIONS: Video-related learning approaches that embed attention-guiding hints can effectively prepare undergraduates for SP encounters.

Learning communication from erroneous video-based examples: A double-blind randomised controlled trial.

OBJECTIVE: Appropriate training strategies are required to equip undergraduate healthcare students to benefit from communication training with simulated patients. This study examines the learning effects of different formats of video-based worked examples on initial communication skills. METHODS: First-year nursing students (N=36) were randomly assigned to one of two experimental groups (correct v. erroneous examples) or to the control group (no examples). All the groups were provided an identical introduction to learning materials on breaking bad news; the experimental groups also received a set of video-based worked examples. Each example was accompanied by a self-explanation prompt (considering the example's correctness) and elaborated feedback (the true explanation). RESULTS: Participants presented with erroneous examples broke bad news to a simulated patient significantly more appropriately than students in the control group. Additionally, they tended to outperform participants who had correct examples, while participants presented with correct examples tended to outperform the control group. CONCLUSION: The worked example effect was successfully adapted for learning in the provider-patient communication domain. PRACTICE IMPLICATIONS: Implementing video-based worked examples with self-explanation prompts and feedback can be an effective strategy to prepare students for their training with simulated patients, especially when examples are erroneous.