Have medical students' attitudes towards clinical communication skills changed over a 12- year period? A comparative long-term study.

BACKGROUND: Attitudes towards learning clinical communication skills at the end of medical school are likely to reflect the students' training and motivation for the continued development of their skills as doctors. Students from two Norwegian medical schools, one with a traditional, and the other with an integrated curriculum, were approached in 2003 and 2015; with regard to changes in students' attitudes towards acquiring communication skills in two diverse learning environments. This comparison might reveal the effects of the training programs from a long-term perspective, as neither of the medical schools made any major curriculum changes within the study period. METHODS: The samples comprised final-year medical students. Two separate cross-sectional surveys performed 12 years apart (2003 and 2015) used items from the Communication Skills Attitude Scale in addition to age and gender. The traditional curriculum included only theoretical teaching and no contact with patients was made during the first 2 to 2.5 years of medical school. However, the integrated curriculum combined training in theoretical and clinical communication skills with early patient contact from the beginning. RESULTS: Attitudes improved from the first to the second survey at both schools, however, students from the integrated school reported more positive attitudes than those from the traditional school. Female students from the integrated school contributed the most to the difference in attitudes in both surveys. CONCLUSIONS: Students in both traditional and integrated curricula improved their attitudes from the first to the second assessment. However, compared with the traditional curriculum, the integrated one fostered even higher levels of positive attitudes towards acquiring communication skills, and a pronounced influence was observed on female students. These findings suggest that an educational program with greater emphasis on improving attitudes among male students may be required.

Do medical students and young physicians assess reliably their self-efficacy regarding communication skills? A prospective study from end of medical school until end of internship.

BACKGROUND: This prospective study from end of medical school through internship investigates the course and possible change of self- reported self-efficacy in communication skills compared with observers' ratings of such skills in consultations with simulated patients. METHODS: Sixty-two medical students (43 females) from four Norwegian universities performed a videotaped consultation with a simulated patient immediately before medical school graduation (T1) and after internship (internal medicine, surgery and family medicine, half a year each - T2). Before each consultation, the participants assessed their general self-efficacy in communication skills. Trained observers scored the videos and applied a well-validated instrument to rate the communication behaviour. Results from the two assessment methods were correlated at both time points and possible differences from T1 to T2 were explored. RESULTS: A close to zero correlation between self-efficacy and observed communication skills were found at T1. At T2, participants' self-efficacy scores were inversely correlated with levels of observed skills, demonstrating a lack of concordance between young physicians' own assessment of self-efficacy and observers' assessment. When dividing the sample in three groups based on the observers' scores (low <1/3-, medium 1/3 to 2/3-, high competence >2/3), the group of male physicians showed higher levels of self-efficacy than females in all the three performance groups at T1. At T2, those having a high performance score yielded a low self-efficacy, regardless of gender. CONCLUSIONS: The lack of positive correlations between self-efficacy assessment and expert ratings points to limitations in the applicability of self-assessment measures of communication skills. Due to gender differences, groups of female and male physicians should be investigated separately. Those obtaining high-performance ratings from observers, through the period of internship, may become more conscious of how demanding clinical communication with patients may be. This insight may represent a potential for growth, but could in some physicians represent too much of a self-critical attitude. Active supervision of young physicians throughout internship is important in order to help physicians to be more aware of their strengths and weaknesses, in order to gain increased mastery in the art of doctoring.

General principles to consider when designing a clinical communication assessment program.

OBJECTIVES: Assessment of clinical communication helps teachers in healthcare education determine whether their learners have acquired sufficient skills to meet the demands of clinical practice. The aim of this paper is to give input to educators when planning how to incorporate assessment into clinical communication teaching by building on the authors' experience and current literature. METHODS: A summary of the relevant literature within healthcare education is discussed, focusing on what and where to assess, how to implement assessment and how to choose appropriate methodology. RESULTS: Establishing a coherent approach to teaching, training, and assessment, including assessing communication in the clinical context, is discussed. Key features of how to implement assessment are presented including: establishing a system with both formative and summative approaches, providing feedback that enhances learning and establishing a multi-source and longitudinal assessment program. CONCLUSIONS: The implementation of a reliable, valid, credible, feasible assessment method with specific educational relevance is essential for clinical communication teaching. PRACTICE IMPLICATIONS: All assessment methods have strengths and limitations. Since assessment drives learning, assessment should be aligned with the purpose of the teaching program. Combining the use of different assessment formats, multiple observations, and independent measurements in different settings is advised.

A few more minutes make a difference? The relationship between content and length of GP consultations.

OBJECTIVES: To investigate the relationship between the length of a medical consultation in a general practice setting and the biopsychosocial information obtained by the physician, and to explore the characteristics of young physicians obtaining comprehensive, especially psychosocial information. DESIGN: A prospective, longitudinal follow-up study. SETTING: Videotaped consultations with standardized patients on two occasions were scored for the amount of biopsychosocial information obtained. Consultation length was recorded in minutes. Subjects. Final-year (T-1) medical school students (n = 111) participated in the project. On completion of their internship one and a half years later (T-2), 62 attended a second time, as young physicians. MAIN OUTCOME MEASURES: Content lists. RESULTS: Pearson's r correlations between content and length at T-1 and T-2 were 0.27 and 0.66, respectively (non-overlapping confidence intervals). Psychosocial content increased significantly when consultations exceeded 13 minutes (15 minutes scheduled). Physicians using more than 13 minutes had previously, as hospital interns, perceived more stress in the emergency room and had worked in local hospitals. CONCLUSIONS: A strong association was found between consultation length and information, especially psychosocial information, obtained by the physicians at internship completion. This finding should be considered by faculty members and organizers of the internship period. Further research is needed to detect when, during the educational process, increased emphasis on communication skills training would be most beneficial for students/residents, and how the medical curriculum and internship period should be designed to optimize young physicians' use of time in consultations.

Do physicians improve their communication skills between finishing medical school and completing internship? A nationwide prospective observational cohort study.

OBJECTIVE: To test whether young physicians improve their communication skills between graduating from medical school and completing clinical internship, and to explore contributing background and/or internship factors. METHODS: Norwegian medical students graduating June 2004 were invited to take part in a videotaped standardized patient interview February 2004. Of the 111 students who originally participated, 62 completed a second interview February 2006. Observed communication skills were assessed with the Arizona Communication Interview Rating Scale (ACIR). RESULTS: The level of communication skills increased significantly during the period for participants overall; and for females but not males. General social skills reached significantly higher levels than specific professional skills, both types of skill improving during the study. Independent predictors were working in local hospitals, learning atmosphere and low stress. At school completion, 50% reached a level defined as 'advanced beginner'. Towards the end of the internship, 58% reached 'capable' and 27% 'competent' levels of communication skills. CONCLUSIONS: Female physicians improved most in communication skills, the gender difference being multivariate mediated through low stress levels and learning atmosphere. The findings support the division of communication skills into general social and specific professional skills. PRACTICE IMPLICATIONS: The relatively low proportion of young physicians, especially males, developing the capability to practise independently at internship completion indicates a need for more effective training in communication skills, during both medical school and internship.

Medical students' cognitive and affective attitudes towards learning and using communication skills--a nationwide cross-sectional study.

AIMS: We wanted to explore cognitive and affective attitudes towards communication skills among students in Norwegian medical schools. METHOD: 1833 (60% response rate) medical students at the four medical schools in Norway filled in questionnaires by the end of term in May 2003. The Communication Skills Attitudes Scale (CSAS) was used for assessing affective and cognitive attitudes separately. RESULTS AND CONCLUSIONS: Medical students have positive attitudes towards learning and using communication skills. Cognitive and affective attitudes displayed different patterns. Being female and having worked in the health services before admission to the medical school predicted more positive scores both towards cognitive and affective attitudes. Having worked as a junior doctor during medical school predicted more positive cognitive attitudes. Cognitive attitudes towards communication skills did not vary significantly between year groups in any of the medical schools. Scores reflecting affective attitudes gradually fell for each year in all schools, but rose again in the final year in two of them. Implications for curriculum design are discussed.

Observed communication skills: how do they relate to the consultation content? A nation-wide study of graduate medical students seeing a standardized patient for a first-time consultation in a general practice setting.

BACKGROUND: In this study, we wanted to investigate the relationship between background variables, communication skills, and the bio-psychosocial content of a medical consultation in a general practice setting with a standardized patient. METHODS: Final-year medical school students (N = 111) carried out a consultation with an actor playing the role of a patient with a specific somatic complaint, psychosocial stressors, and concerns about cancer. Based on videotapes, communication skills and consultation content were scored separately. RESULTS: The mean level of overall communication skills had a significant impact upon the counts of psychosocial issues, the patient's concerns about cancer, and the information and planning parts of the consultation content being addressed. Gender and age had no influence upon the relationship between communication skills and consultation content. CONCLUSION: Communication skills seem to be important for final-year students' competence in addressing sensitive psychosocial issues and patients' concerns as well as informing and planning with patients being representative for a fairly complex case in general practice. This result should be considered in the design and incorporation of communication skills training as part of the curriculum of medical schools.

Curriculum factors influencing knowledge of communication skills among medical students.

BACKGROUND: Communication training builds on the assumption that understanding of the concepts related to professional communication facilitates the training. We know little about whether students' knowledge of clinical communication skills is affected by their attendance of communication training courses, or to what degree other elements of the clinical training or curriculum design also play a role. The aim of this study was to determine which elements of the curriculum influence acquisition of knowledge regarding clinical communication skills by medical students. METHODS: The study design was a cross-sectional survey performed in the four Norwegian medical schools with different curricula, spring 2003. A self-administered questionnaire regarding knowledge of communication skills (an abridged version of van Dalen's paper-and-pencil test) was sent to all students attending the four medical schools. A total of 1801 (59%) students responded with complete questionnaires. RESULTS: At the end of the 1st year of study, the score on the knowledge test was higher in students at the two schools running communication courses and providing early patient contact (mean 81%) than in the other two medical schools (mean 69-75%, P < or = 0.001), with students studying a traditional curriculum scoring the lowest. Their scores increased sharply towards the end of the 3rd year, during which they had been subjected to extensive patient contact and had participated in an intensive communication course (77% vs. 72% the previous year, P

Examination of final-year medical students in general practice.

With general practice recognized as one of three major subjects in the Tromsø medical school curriculum, a matching examination counterpart was needed. The aim was to develop and implement an examination in an authentic general practice setting for final-year medical students. In a general practice surgery, observed by two examiners and one fellow student, the student performs a consultation with a consenting patient who would otherwise have consulted his/her general practitioner (GP). An oral examination follows. It deals with the consultation process, the observed communication between "doctor" and patient, and with clinical problem-solving, taking today's patient as a starting point. The session is closed by discussion of a public-health-related question. Since 2004 the model has been evaluated through questionnaires to students, examiners, and patients, and through a series of review meetings among examiners and students. Examination in general practice using unselected, consenting patients mimics real life to a high degree. It constitutes one important element in a comprehensive assessment process. This is considered to be an acceptable and appropriate way of testing the students before graduation.

Assessing medical students' attitudes towards learning communication skills--which components of attitudes do we measure?

BACKGROUND: The Communication Skills Attitudes Scale (CSAS) created by Rees, Sheard and Davies and published in 2002 has been a widely used instrument for measuring medical students' attitudes towards learning communication skills. Earlier studies have shown that the CSAS mainly tests two dimensions of attitudes towards communication; positive attitudes (PAS) and negative attitudes (NAS). The objectives of our study are to explore the attitudes of Norwegian medical students towards learning communication skills, and to compare our findings with reports from other countries. METHODS: The CSAS questionnaire was mailed simultaneously to all students (n = 3055) of the four medical schools in Norway in the spring of 2003. Response from 1833 students (60.0%) were analysed by use of SPSS ver.12. RESULTS: A Principal component analysis yielded findings that differ in many respects from those of earlier papers. We found the CSAS to measure three factors. The first factor describes students' feelings about the way communication skills are taught, whereas the second factor describes more fundamental attitudes and values connected to the importance of having communication skills for doctors. The third factor explores whether students feel that good communication skills may help them respecting patients and colleagues. CONCLUSION: Our findings indicate that in this sample the CSAS measures broader aspects of attitudes towards learning communication skills than the formerly described two-factor model with PAS and NAS. This may turn out to be helpful for monitoring the effect of different teaching strategies on students' attitudes during medical school.

"When patients have cancer, they stop seeing me"--the role of the general practitioner in early follow-up of patients with cancer--a qualitative study.

BACKGROUND: The role of the general practitioner (GP) in cancer follow-up is poorly defined. We wanted to describe and analyse the role of the GP during initial follow-up of patients with recently treated cancer, from the perspective of patients, their relatives and their GPs. METHODS: One focus group interview with six GPs from the city of Bodø and individual interviews with 17 GPs from the city of Tromsø in North Norway. Text analysis of the transcribed interviews and of free text comments in two questionnaires from 91 patients with cancer diagnosed between October 1999 and September 2000 and their relatives from Tromsø. RESULTS: The role of the GP in follow-up of patients with recently treated cancer is discussed under five main headings: patient involvement, treating the cancer and treating the patient, time and accessibility, limits to competence, and the GP and the hospital should work together. CONCLUSION: The GP has a place in the follow-up of many patients with cancer, also in the initial phase after treatment. Patients trust their GP to provide competent care, especially when they have more complex health care needs on top of their cancer. GPs agree to take a more prominent role for cancer patients, provided there is good access to specialist advice. Plans for follow-up of individual patients could in many cases improve care and cooperation. Such plans could be made preferably before discharge from in-patient care by a team consisting of the patient, a carer, a hospital specialist and a general practitioner. Patients and GPs call on hospital doctors to initiate such collaboration.

Comparing self-reported communication skills of medical students in traditional and integrated curricula: a nationwide study.

OBJECTIVES: To investigate medical students' self-assessments of their communication skills through medical school related to background factors, curriculum design and perceived medical school stress. METHODS: Medical students at all year levels attending Norwegian universities in the spring of 2003 were mailed the Oslo Inventory of Self-reported Communication Skills (OSISCS) developed by the authors. Of the total number of students (N=3055), 60% responded. One school had a traditional curriculum, the other three ran integrated models. RESULTS: Students assessed their instrumental communication skills to increase linearly year by year, while the relational skills showed a curve-linear trajectory reaching the optimum level half-way into the curriculum. Students attending the traditional school reported lower levels of instrumental skills compared to the students from the integrated schools. In relational skills, a similar difference was maintained half-way into the curriculum, but disappeared towards the end. Perceived medical school stress correlated to the self-reported end point levels of the two types of communication skills. DISCUSSION: The trajectories of self-reported instrumental and relational skills indicate significant variations in facilitating mechanisms between curricula, cognitive processing and perceived medical school stress. CONCLUSIONS: Self-reported instrumental and relational communication skills develop differently in medical students over the years according to the type of curriculum. PRACTICE IMPLICATIONS: Curricula should be evaluated for improvement implementations.

Do cancer patients benefit from short-term contact with a general practitioner following cancer treatment? A randomised, controlled study.

GOALS OF WORK: To investigate whether increased contact with the patient's general practitioner (GP) soon after cancer treatment can increase patient quality of life (QoL) and satisfaction with follow-up. PATIENTS AND METHODS: A randomised controlled study with 91 patients from one Norwegian municipality. The intervention group got a 30-min invited consultation with the patient's GP and an invitation to further GP follow-up. Quality of life and patient satisfaction with diagnosis, treatment and overall care were measured with validated instruments. MAIN RESULTS: Relatives' satisfaction with care increased over 6 months in the intervention group (P = 0.018), but otherwise, there was no difference between the intervention and control groups concerning QoL, satisfaction with care or number of consultations. Patient satisfaction with care showed a tendency to increase when treatment intent was curative. Some functional QoL measures and satisfaction tended to increase during the first 6 months after treatment. Free text comments suggested that some patients appreciated the contact with their GP. CONCLUSION: Some cancer patients benefit from follow-up by their GP. The way to perform this kind of follow-up in primary care, and who these cancer patients are, should be further studied. Short follow-up time and an urban setting may have contributed to the lack of group differences in our study, but patients treated for cancer may have limited need for follow-up as long as they feel well and the situation remains stable.

Does change from a traditional to a new medical curriculum reduce negative attitudes among students? A quasi-experimental study.

The authors investigated whether a new type of medical school curriculum-with problem-based learning, integrated preclinical and clinical phases, and increased levels of contact between students, patients and teachers--is associated with lower levels of students' negative attitudes towards medical training than is a traditional medical school curriculum. This association was found, and was confirmed by a comparison between students in a university that had changed from a traditional curriculum to a new curriculum. Curriculum design may explain differences in students' attitudes towards medical school.

[Teaching clinical communication to medical students in Norway]. / Undervisning i klinisk kommunikasjon for medisinstudenter i Norge.

BACKGROUND: Clinical communication as part of the doctor-patient relationship has gained increased attention in the undergraduate medical education in Norway. Such teaching programmes require considerable resources, as much of the instruction has to be carried out in small groups, and they should be subjected to a thorough assessment from a cost-benefit perspective. MATERIALS AND METHODS: A working group representing the four medical faculties in Norway initiated EKKO, a project designed as a quality assurance of the instruction in clinical communication. In this paper comparable data are presented relating to the extent, form and content of the instruction. RESULTS AND INTERPRETATION: There are great variations as to what part of the curriculum the instruction is placed in, the extent of faculty-based teaching, training periods in general practice and hospital settings with feed-back on communication skills, as well as in faculty development. To what degree these variations influence doctors' communication skills when fully qualified could be assessed in a further stage of this project, which could also provide an empirical basis for improvements in the instruction given.