"Bring your worst": Residents' perspectives on video review of challenging patient communication as a learning tool.

Objective: To investigate residents' experiences recording and receiving feedback on a challenging video of a patient encounter. Methods: We used a qualitative design with first year residents who took part in a mandatory communication skills course in which all participants were asked to bring a challenging video of a patient encounter. The methods consisted of brief reflection texts and focus groups related to their perspectives on the use of challenging videos. Results: 106 residents wrote brief reflection texts, and 13 residents participated in four focus groups. Residents mainly expressed positive experiences with the challenging video exercise. Residents reported that the pressure to perform was felt to be less than on previous teaching sessions because the focus was on choosing an encounter which was less than perfect. They also reported that they appreciated the opportunity to see that other doctors were not performing optimally. Conclusion: The use of challenging videos as a teaching method for communication skills was experienced as encouraging by residents and facilitated enhanced learning. Innovation: We recommend adding more focus on challenging situations in video review. This could support learning by providing what our participants found to be a less daunting learning environment.

End-of-life care for cancer patients with pre-existing severe mental disorders-a systematic review.

BACKGROUND: Cancer patients with pre-existing severe mental disorders (SMDs) less frequently receive guideline recommended cancer treatment and have a higher cancer mortality. However, knowledge is needed concerning end-of-life care in this patient group. The aim of this systematic review was to provide an overview of the literature concerning end-of-life care in cancer patients with pre-existing SMD. METHODS: A systematic search was conducted in the following databases: PubMed, Embase and Science Direct and all results were downloaded to Endnote on 1st of September 2023. The review was registered on International Prospective Register of Systematic Reviews (PROSPERO) (ID: CRD42023468571). The quality of the studies was assessed according to the Newcastle-Ottawa Scale. RESULTS: Ten studies fulfilling the inclusion criteria were included. There was a recurring pattern indicating a difference between the end-of-life care received by cancer patients with SMD, compared to those without. Cancer patients with pre-existing SMD received more palliative end-of-life care but less high-intensive-end-of-life (HIEOL) care, e.g., less hospitalisations and chemotherapy at the end of life, and died less frequently at hospital. CONCLUSIONS: The study indicates that patients with pre-existing SMD and cancer more often received palliative end-of-life care and less HIEOL care compared to controls. Further research regarding the difference in end-of-life care is lacking, including the consequences of less intense HIEOL care for this patient group. Thus, further studies are needed to identify reasons for less intense HIEOL among cancer patients with pre-existing SMD.

Exploring formal and informal learning opportunities during morning report: a qualitative study.

BACKGROUND: Morning reports are an essential component of physicians' daily work. Attending morning reports is prioritized by junior doctors as it provides them with an opportunity to learn diagnostic reasoning through discussion of cases. While teaching formats during morning reports have previously been reported, an in-depth analysis of what learning opportunities exist, e.g., how teaching is enacted during morning reports, is lacking. This qualitative study explores learning opportunities during morning reports. METHODS: We used an explorative design based on video-recordings of 23 morning reports from two surgical departments, an internal medicine department and an emergency department. We used thematic analysis combined with and inspired by Eraut's theoretical framework of workplace learning. RESULTS: Both formal and informal learning opportunities were identified. Formal learning opportunities had the character of planned teaching activities, and we identified four themes: (1) modes of teaching, (2) structure, (3) presenter role, and (4) participant involvement. Informal learning, on the other hand, was often implicit and reactive, while deliberate learning opportunities were rare. The data showed many missed opportunities for learning. CONCLUSION: Both formal and informal learning opportunities are present during morning reports. However, a prevalent focus on medical topics exists, leaving other important aspects of the medical role under-discussed. Pedagogical methods could be employed more optimally, and harnessing the potential of missed opportunities should be encouraged.

How doctors build community and socialize into a clinical department through morning reports. A positioning theory study.

PHENOMENON: The morning report is one of the longest surviving hospital practices. Most studies of the morning report focus on the effectiveness of formal medical training, while focus on social and communicative aspects is rarer. This study explores the social interactions and communication in morning reports, examining the ways in which they contribute to the construction of professional identity and socialization into the community of the clinical department. APPROACH: We used a qualitative explorative design with video observations of morning reports. Our data consisted of 43 video-recorded observations (in all, 15.5 hours) from four different hospital departments in Denmark. These were analyzed using the theoretical framework of positioning theory. FINDINGS: A key finding was that each department followed its own individual structure. This order was not articulated as such but played out implictly. Two alternative storylines unfolded in the elements of the morning report: 1) being equal members of the specialty and department, and 2) preserving the hierarchical community and its inherent positions. INSIGHTS: The morning report can be seen as playing an important role in community making. It unfolds as a "dance" of repeated elements in a complex collegial space. Within this complexity, the morning report is a space for positioning oneself and others as a collegial "we", i.e., equal members of a department and specialty, at the same time as "having a place" in a hierarchal community. Thus, morning reports contribute to developing professional identity and socialization into the medical community.

"I Surrendered": Metaphors in Residents' Stories about Communication Challenges.

It is well-known that communication with patients can be challenging for residents. Although some studies have focused on residents' experiences of communication challenges, few, if any, have investigated the language residents use when describing such challenges. In this study, we explore the metaphors residents use when asked to share stories about challenging communication situations. Metaphor has been the focus of research in a variety of health-related disciplines; here, we use it to gain an understanding of why these situations are seen as challenging. Methodologically, we draw on metaphor-led discourse analysis, which facilitates a systematic approach to the identification and analysis of metaphors. The empirical material consists of 138 Danish residents' 259 narratives about communication challenges. We identified more than 700 metaphors used in connection with accounting for communication challenges with patients. The metaphors are primarily driven by vehicles belonging to four groups, namely: "Location," "Movement," "Games and play," and "Battle and warfare." We discuss the implications of these metaphors in relation to residents' conceptualizations of communication and challenges.

Doctors' experiences of earlier mandatory postgraduate communication skills training: a qualitative study.

OBJECTIVES: This study explored the question: what are doctors' perspectives on and experiences with their earlier mandatory postgraduate communication skills training? METHODS: The study used a qualitative, exploratory design. We used purposeful sampling based on the principle of maximal variation to ensure different clinical perspectives. Thus, three focus groups were formed with 12 doctors who had attended mandatory postgraduate communication skills training within 1-9 years prior to the study. The doctors were from three specialties: internal medicine, oncology, and general practice. We used a semi-structured interview guide, and the focus groups were video-recorded. Thematic analysis was used to analyze the data material. Through an iterative process, we identified main and sub-themes. RESULTS: The first-year residency mandatory postgraduate communication skills training provided all participants with skills that had helped them in their ongoing clinical work. In addition, five dominant themes were observed: modes of use, the timing of course, experience with experiential methods, sharing challenges with peers, and need for continuous feedback and follow-up. CONCLUSIONS: Doctors value early mandatory postgraduate communication skills training even years after attending the course and request similar ongoing initiatives. Their experiences are positive, they found the timing relevant, and they used the learned skills in their ongoing clinical work, even years after the initial course. Our study indicates that more attention should be given to 'early career' postgraduate communication skills training that is tailored to specific clinical contexts, including hospital settings.

Transfer of communication teaching skills from university to the clinical workplace - does it happen? A mixed methods study.

BACKGROUND: Communication skills learned in the classroom do not transfer easily into clinical practice because they are not reinforced by teachers in the workplace setting and because lack of faculty training restricts the transfer of communication skills in real patient encounters. Trained university-based communication skills teachers often work simultaneously as doctors in clinics. This study explored if and how the skills of these teachers play a role in communication skills training in the clinical workplace. METHODS: We used an exploratory sequential design: a mixed method approach that combined a survey with communication skills teachers, and qualitative individual interviews with these teachers and their educational leaders in clinical departments. The questionnaire was analysed using descriptive statistics. The interviews were analysed using content analysis. RESULTS: The response rate was 34 %. A majority (93 %) used their communication skills when communicating with patients and relatives. Less than half taught communication in clinical departments. Approximately half of the respondents stated that encouragement from their leaders or colleagues would inspire them to use their teaching skills in the workplace. However, only 20 % had told their leaders about their competencies in teaching communication. One third thought that they needed further teacher training to teach in the clinical workplace. Qualitative analysis showed that teaching opportunities existed but mainly consisted of random, one-off sessions that came about through the initiative of the communication skills teachers themselves. The teachers described several barriers, such as the challenge of teaching colleagues, as communication relates to identity and hierarchical structures, as well as a lack of requests from colleagues or management, and department culture prioritizing topics relating to medical expertise. None of the educational leaders made use of the teachers' specific communication skills in a structured way: some saw it as unimportant, while others saw it as a potential resource. CONCLUSION: Transfer of the teaching skills of communication skills teachers trained for university-based clinical communication training happened, but to a limited degree. Although both opportunities and barriers for transferring communication skills existed, barriers seemed to dominate, and opportunities for communication skills training in the workplace setting were not used to their full potential.

Multilevel structures and human agency in relation to email consultations: A strong structuration theory analysis of the Danish general practice setting.

In recent years and throughout the developed world, policymakers have encouraged the implementation of digital patient-clinician interaction. Our focus is on the Danish general practice setting where email consultations were implemented as a mandatory service in 2009 and now constitute 21% of all consultations in general practice. Drawing upon strong structuration theory (SST), our analysis sets out to explore how email consultations are represented in structures on macro, meso and micro-levels and how the interplay between structures and agents plays out with respect to possible alignments, tensions and adjustments. We analyze data from policy documents on the macro and meso-levels, data from clinics' websites (meso-level) and data from interviews with GPs and patients (micro-level) (n = 53). Our findings show that the introduction of email consultation as a new health technology is a key site for development in email consultation practice, professional boundary setting and adjustments within the doctor-patient relationship. Our findings thus demonstrate that email consultation can be considered a dynamic component of a socio-technical network rather than a static medium for simple health transactions or information delivery. Based on these findings, we recommend that, for future implementation of patient-clinician digital communication it is important to investigate the multiple sources of influence on telecare practices and to see its intended users as agents who actively shape their own care motivated by opinions, relationships and values.

I am not a doctor, but A reflection on training doctors in communication skills without being one.

Over the last 15-20 years, the scope of medical education has broadened to include disciplines other than the biomedical. Many educators from the humanities and social sciences are thus currently teaching in the faculty of medicine. But how should we understand and communicate the position from which we - as 'non-doctors' - teach in this field? This article provides a reflection on how both doctors and 'non-doctors' in medical education seem to confirm and reproduce an underlying norm, namely that doctors are the most suitable teachers in medical education. I argue that these norms could and should be challenged. I provide examples of how a 'gaze from the outside' is fruitful and may be necessary in medical education, and highlight the potential strength of cross-disciplinary teaching that involves medical educators 'within and outside' medicine.

Dilemmas in delivering health promotion activities: findings from a qualitative study of mental health nurses in Denmark.

OBJECTIVE: Recent studies have shown that people with mental illnesses have higher mortality and morbidity rates due to long-term conditions and lifestyle diseases. This knowledge has led to health promotion initiatives in mental health care to improve the physical health of people with mental illness. This article explores how mental health nurses experience working with health promotion activities in mental healthcare practices. DESIGN: We adopted a qualitative research design using an interactive approach. Qualitative content analysis was used to develop the analytical framework. PARTICIPANTS: Focus groups (n=7; n=5) were conducted with two groups of mental health nurses who attended health specialist training sessions in Denmark in the spring and fall of 2018. RESULTS: The findings showed that working with health promotion activities in mental health care created two dilemmas for the mental health nurses: (1) dilemmas related to health promotion that involved discrepancies between the health promotion activities that were offered and patients' autonomy and wishes, and (2) system-related dilemmas stemming from working with screening for risk factors and documentation programmes. The mental health nurses developed different strategies to navigate these dilemmas, such as devising interview techniques for the screening questions and bending guidelines. CONCLUSIONS: Mental health nurses found it challenging to implement health promotion activities in mental health care, although they generally found these activities meaningful. The findings show that new health promotion activities need to be adapted to nurses' existing mental healthcare practices; however, this may require some adaptation of existing nursing practices.

Medical students' perspectives on the ethics of clinical reality.

INTRODUCTION: Medical ethicists have pointed out that a gap exists between classroom teaching of bioethical theory and the ethics of clinical reality. Studies recommend that the teaching of bioethics should focus on everyday dilemmas in the clinical setting instead of only dramatic dilemmas and have expressed the need for more studies of how medical students perceive ethical problems in the clinical setting. This study explored themes in and types of ethical dilemmas in medical students' reflective writing in their clinical rotations. METHODS: The study was a qualitative explorative analysis of group reflection texts from fourth-year medical students at Aarhus University, Denmark. RESULTS: The thematic analysis of 51 group reflection texts (n = 396) revealed four key themes in the material: 1) confidentiality issues, 2) treatment options and side effects, 3) the students' role and responsibility and 4) information-giving and communication. The majority of the ethical dilemmas that the students identified were everyday dilemmas. Dramatic dilemmas were represented to a limited degree. CONCLUSIONS: Students' perspectives on ethical dilemmas in the clinical setting provide a unique opportunity to integrate a variety of ethical dimensions into bioethical education and draw attention to overlooked everyday ethical dilemmas. Thus, involving the students' perspectives may be a way to bridge the gap between bioethical theory and the ethics of clinical reality. FUNDING: none. TRIAL REGISTRATION: not relevant.

How do residents perceive and narrate stories about communication challenges in patient encounters? A narrative study.

OBJECTIVE: This article investigated residents' narratives to gain their understandings of which patterns are challenging in doctor-patient conversations. DESIGN: Qualitative narratological framework. PARTICIPANTS: We analysed 259 narratives from 138 residents' oral recounts of communication with patients in which they had felt challenged. RESULTS: The analysis identified an ideal narrative for the doctor-patient encounter with the resident as protagonist pursuing the object of helping the patient with his health problem. Disruptions of this ideal narrative were at play when challenges occurred. Regardless of medical setting, challenges were often related to the establishment of a common object, and the communication actants had to go through negotiations, disagreements or even battles when trying to reach a common object. Challenges also occurred when actants which in the ideal narrative should act as helpers become opponents. We find narratives where patients, relatives and colleagues become opponents. CONCLUSIONS: Our study showed that communication challenges were the result of disruptions of the perceived ideal narrative. Residents found it especially challenging to establish a common object, and dealing with helpers turned opponents. Patient communication is thus a challenge in the transition phase from student to doctor, and doctor-patient communication is complex in nature and continuously perceived to be so by residents, despite pregraduate training.

Workplace-based communication skills training in clinical departments: Examining the role of collegial relations through positioning theory.

INTRODUCTION: Studies suggest that the workplace is a key to understanding how clinical communication skills learning takes place and that medical communication skills need to be reinforced over time in order not to deteriorate. This study explored the perceptions of doctors in four hospital departments who participated in a workplace-based communication training project. Its specific focus was the relationship between collegial relations and learning communication skills. METHODS: The study applied a qualitative design using an ethnographic methodology, i.e. interviews and observations. Positioning theory was used as the theoretical framework. RESULTS: Training communication skills with colleagues in the actual workplace setting was valued by the participants who experienced more sharing of communication challenges, previously understood as something private one would not share with colleagues. However, collegial relations were also barriers for providing critical feedback, especially from junior doctors to their seniors. CONCLUSION: The position as "colleague" both reinforced the communication skills training and hindered it. The communication skills educational model had a flat, non-hierarchical structure which disturbed the hierarchical structure of the workplace, and its related positions.

Cross cultural training in primary mental health care consultations in Moldova - The tEACH perspective.

OBJECTIVE: This article reports experiences and challenges encountered in a cross-cultural training project in Moldova that was undertaken by tEACH, the teaching subcommittee of EACH: International Association for Communication in Healthcare, in cooperation with local and international stakeholders. As part of a major health policy reform, the aim was to equip a group of trainers with the skills to train Moldovan professionals in skills for primary mental health care, including communication skills. METHODS: The project consisted of 3 weeks of training using mainly experiential teaching methods to allow participants to practice content and methods, including interactive lecturing, roleplay, feedback and video. RESULTS: A majority of the participants reported that they acquired key facilitation skills. They valued the opportunity to practice and receive feedback. However, some reported that there was too much focus on communication skills, which was thought to be less relevant in a Moldovan context. Furthermore our learner-centered approach was occasionally experienced as a lack of structure CONCLUSION: The tEACH expertise plays an important role in supporting trainers in cross-cultural contexts with effective communication skills methods. PRACTICE IMPLICATIONS: Teaching in a cross-cultural context is only successful through continuous dialogue with stakeholders and demands attention to cultural differences.

[Communication skills training in Denmark has come a long way]. / Kommunikationsundervisningen i Danmark er nået langt.

In this paper we describe and discuss communication skills training in Denmark - it has come a long way. After a short review of current research we outline the history of communication training in Denmark and describe the case of communication training at Aarhus University, which illustrates how the Danish universities have radically changed their communication training in the last decade. Finally, we discuss communication models and teaching methods and recommend an attempt to reach a national consensus on communication training.

[Clinical communication skills training is an educational challenge]. / Klinisk kommunikationstræning er en uddannelsesmæssig udfordring.

This qualitative study presents results from a development project of clinical communication skills training for physicians in a paediatric ward. Overall, the doctors express that the training positively supports their clinical work and that it provides a model for discussing communication challenges with colleagues. Challenges, however, are time constraints and overcoming conventional hierarchical structures. Prerequisites for ward-based communication training thus are: a suitable timeframe, use of a structured feedback model, managerial backup, and support from external expertise.

[Clinical communication skills training is an educational challenge]. / Klinisk kommunikationstræning er en uddannelsesmæssig udfordring.

This qualitative study presents results from a development project of clinical communication skills training for physicians in a paediatric ward. Overall, the doctors express that the training positively supports their clinical work and that it provides a model for discussing communication challenges with colleagues. Challenges, however, are time constraints and overcoming conventional hierarchical structures. Prerequisites for ward-based communication training thus are: a suitable timeframe, use of a structured feedback model, managerial backup, and support from external expertise.