How can peer teaching influence the development of medical students? a descriptive, longitudinal interview study.

BACKGROUND: Peer-assisted learning (PAL) - where students take up a teaching role at an early stage of their training-is widely used in medical curricula. Many qualitative studies have investigated the perceptions and benefits of PAL, but no studies have longitudinally explored how peer teachers experienced their development. This could allow for a better understanding of PAL. In this study, we explored the perceived impact of being a peer teacher on the development of personal and professional competencies as a medical student. METHODS: We longitudinally conducted semi-structured interviews with peer teachers, during their 2-year teaching period in the skills lab at the University of Antwerp and applied descriptive thematic analysis. RESULTS: In total we gathered 47 interviews in 13 peer teachers (9 female, 4 male,. 1-7 interviews each). Peer teachers reported an increase in self-confidence, which gradually transformed into self-efficacy in clinical and teaching skills., Participants told us to be inspired by the previous generation of peer teachers. Their motivation shifted from personal benefits to benefiting others while becoming a role model themselves. The peer teachers illustrated how they developed maturity by integrating different CanMEDS roles. They grew in reflection, changed/transformed an initial mark-driven study drive into more patient-centered ambitions, and started developing a personal style. CONCLUSIONS: Our study suggests that being a peer teacher leads to more self-efficacy, in clinical and teaching skills, to become a role model with as motivation to benefit others and to grow towards a good doctor maturity. Although the task is to teach peers, this opportunity nurtures the practice and integration of various CanMEDS roles, not only that of scholar but also communicator, collaborator and leader, thereby positively influencing their personal and professional development and their identity as a doctor (professional role).

Diversity Awareness in Medical Education: An Innovative Training with Visual Reflection Tools.

Dealing with a diverse population is one of the most challenging topics in medicine, with consequences for health disparities as evidenced by poorer health of marginalised groups. An urgent need exists to build a diversity-responsive curriculum in medical education. At the core of such a curriculum are experiential learning and a focus on self-awareness and reflexivity via small group trainings. This Show and Tell paper describes the development and qualitative evaluation of such a training, that was implemented at the University of Antwerp in Belgium, presenting answers to some of the gaps and challenges described in the literature. This training is guided by three visual reflection tools - the kaleidoscope, the iceberg and the communication compass - to inspire learners on how to deal with the diversity of their future patients. The content, method, and educational aim of this hands-on training are described. We discuss some of the challenges the educational methods pose on reflexivity and awareness, looking at the lessons learned based on participants' feedback. While the visual reflection tools offer a dynamic space to broaden the way we look at patients, it remains imperative to create a safe environment for discussing tensions, sharing difficult topics and being aware of different voices. Taking time (space for discussion, small groups, training of faculty) and allowing for continuous reflection of the educators are key in the development of diversity-responsive education.

Learning patient-centredness with simulated/standardized patients: A realist review: BEME Guide No. 68.

BACKGROUND: Given the positive outcomes of patient-centred care on health outcomes, future doctors should learn how to deliver patient-centred care. The literature describes a wide variety of educational interventions with standardized patients (SPs) that focus on learning patient-centredness. However, it is unclear which mechanisms are responsible for learning patient-centredness when applying educational interventions with SPs. OBJECTIVE: This study aims to clarify how healthcare learners and professionals learn patient-centredness through interventions involving SPs in different healthcare educational contexts. METHODS: A realist approach was used to focus on what works, for whom, in what circumstances, in what respect and why. Databases were searched through 2019. Nineteen papers were included for analysis. Through inductive and deductive coding, CIC'MO configurations were identified to build partial program theories. These CIC'MOs describe how Interventions with SPs change the Context (C→C') such that Mechanisms (M) are triggered that are expected to foster patient-centredness as Outcome. RESULTS: Interventions with SPs create three contexts which are 'a safe learning environment,' 'reflective practice,' and 'enabling people to learn together.' These contexts trigger the following seven mechanisms: feeling confident, feeling a sense of comfort, feeling safe, self-reflection, awareness, comparing & contrasting perspectives, combining and broadening perspectives. A tentative final program theory with mechanisms belonging to three main learning components (cognitive, regulative metacognitive and affective) is proposed: Interventions with SPs create a safe learning environment (C') in which learners gain feelings of confidence, comfort and safety (affective M). This safe learning environment enables two other mutual related contexts in which learners learn together (C'), through comparing & contrasting, combining and broadening their perspectives (cognitive M) and in which reflective practice (C') facilitates self-reflection and awareness (metacognitive M) in order to learn patient-centeredness. CONCLUSION: These insights offer educators ways to deliberately use interventions with SPs that trigger the described mechanisms for learning patient-centredness.

The Use of Simulated Patients Is more Effective than Student Role Playing in Fostering Patient-Centred Attitudes during Communication Skills Training: A Mixed Method Study.

Objective: While simulated patients (SPs) are considered a standard tool in communication skills training, there is no evidence thus far of their comparative benefit to the more cost-effective option of student role playing. We compared the effectiveness of both approaches in developing patient-centred attitudes in students. Methods: We retrospectively compared students who participated in the clinical communication course (CCC), based on student role playing (CCCsp-, n = 160), to students who participated in the CCC with SPs (CCCsp+, n = 146), and students with no formal CCC (CCC-, n = 122). We used validated questionnaires to assess patient centredness. We also conducted focus group interviews (FGI) to better understand the impact of CCC with sp. Results: Students after the CCC with simulated patients achieved a significantly higher score in the patient-practitioner orientation scale than other groups (p < 0.001). Conclusions: There is a strong positive correlation between the implementation of simulated patients and patient-centred attitudes among students. Data from the FGI revealed that students perceived training with SP as more realistic, safe, and engaging than student role playing. Practice Implications. Our research provides evidence to justify costs and resources invested in simulated patient programs.

Communication skills training in advance care planning: a survey among medical students at the University of Antwerp.

BACKGROUND: Palliative care (PC) is a strongly emerging discipline worldwide. Despite efforts to integrate this important topic in the medical curriculum in Belgium, still little time is spent on PC and its implementation during theoretical and practical training. MATERIALS & METHODS: We had two cohorts of second master's year MD students at the University of Antwerp complete a survey compromising a custom-built PC knowledge test and a self-confidence assessment of communicative skills used in end-of-life conversations. We evaluated students' self-confidence regarding end-of-life-conversations before and after a PC training program. We also explored whether the PC classes enabled the students to adequately reflect on factors that might influence end-of-life conversations with an open-end question about the potential implications of the COVID-19 pandemic on advance care planning (ACP) conversations. Finally, we compared the results of the respondents having enjoyed face-to-face training (cohort 1) with those having received online training only (cohort 2, COVID-19 pandemic). RESULTS: Although the respondents in both cohorts indicated that the overall curriculum did not pay enough attention to PC training, their average scores on the theoretical questions were good. Feeling confident about their communicative skills in general, they indicated to be less confident when it came to communications concerning PC and ACP in particular. The COVID-19 pandemic was initially equally deemed to impede and facilitate ACP and end-of-life conversations, but after the ACP training class more respondents saw the pandemic as an opportunity to broach end-of-life issues. Finally, we found no differences in scores between online and regular classroom teaching. CONCLUSION: Students experience a lack of confidence in communication skills used in end-of-life conversations and ACP. To help improve skills and competencies in conducting end-of-life conversations, it is recommended to have medical students assess PC/ACP training programs regularly and to modify the curriculum and course content based on these outcomes and current developments.

Does peer teaching improve academic results and competencies during medical school? A mixed methods study.

BACKGROUND: This study investigates the impact of Peer-Assisted Learning (PAL) in clinical skills on peer teachers' academic scores and competencies; however, controversy remains on this topic, and concrete evidence on its impact lacking. METHODS: We performed a mixed methods study combining a retrospective cohort study with a modified Delphi survey. Peer teachers and Skills Lab faculty members participated in this study. A validated questionnaire, the CanMEDS Competency Based Inventory (CCBI), and group interviews were used to assess the outcomes of PAL. Our results were also triangulated with literature data. RESULTS: In 3 consecutive cohorts of medical students (n = 311), 78 participated in PAL. Peer teachers obtained higher scores from the start of the study, at different timepoints in medical school, and on their final scores compared to all other students. Interestingly their progress followed the same path and magnitude as other well-performing students. However, based on our findings from a modified Delphi survey (CCBI interviews) and a literature review, we found further supporting evidence for a positive impact of PAL on the competencies of physical skills (medical expert), teamwork and leadership (collaborator), lifelong learning (scholar), and for admitting uncertainty/limits (professional) within the CanMEDS roles. CONCLUSIONS: We conclude that higher achieving students are more likely to volunteer for a peer tutoring program; however this does not significantly augment their academic scores as compared to above well-performing non-teaching fellow students. Importantly, our modified Delphi survey indicated which CanMEDS roles were positively impacted by PAL: medical expert, collaborator, scholar and professional.

Safety netting advice for respiratory tract infections in out-of-hours primary care: A qualitative analysis of consultation videos.

BACKGROUND: General practitioners (GPs) use safety netting advice to communicate with patients when and how to seek further help when their condition fails to improve or deteriorate. Although many respiratory tract infections (RTI) during out-of-hours (OOH) care are self-limiting, often antibiotics are prescribed. Providing safety netting advice could enable GPs to safely withhold an antibiotic prescription by dealing both with their uncertainty and the patients' concerns. OBJECTIVES: To explore how GPs use safety netting advice during consultations on RTIs in OOH primary care and how this advice is documented in the electronic health record. METHODS: We analysed video observations of 77 consultations on RTIs from 19 GPs during OOH care using qualitative framework analysis and reviewed the medical records. Videos were collected from August until November 2018 at the Antwerp city GP cooperative, Belgium. RESULTS: Safety netting advice on alarm symptoms, expected duration of illness and/or how and when to seek help is often lacking or vague. Communication of safety netting elements is scattered throughout the end phase of the consultation. The advice is seldom recorded in the medical health record. GPs give more safety netting advice when prescribing an antibiotic than when they do not prescribe an antibiotic. CONCLUSION: We provided a better understanding of how safety netting is currently carried out in OOH primary care for RTIs. Safety netting advice during OOH primary care is limited, unspecific and not documented in the medical record.

Antibiotic Prescribing and Doctor-Patient Communication During Consultations for Respiratory Tract Infections: A Video Observation Study in Out-of-Hours Primary Care.

Objective: Communication skills can reduce inappropriate antibiotic prescribing, which could help to tackle antibiotic resistance. General practitioners often overestimate patient expectations for an antibiotic. In this study, we describe how general practitioners and patients with respiratory tract infections (RTI) communicate about their problem, including the reason for encounter and ideas, concerns, and expectations (ICE), and how this relates to (non-)antibiotic prescribing in out-of-hours (OOH) primary care. Methods: A qualitative descriptive framework analysis of video-recorded consultations during OOH primary care focusing on doctor-patient communication. Results: We analyzed 77 videos from 19 general practitioners. General practitioners using patient-centered communication skills received more information on the perspective of the patients on the illness period. For some patients, the reason for the encounter was motivated by their belief that a general practitioner (GP) visit will alter the course of their illness. The ideas, concerns, and expectations often remained implicit, but the concerns were expressed by the choice of words, tone of voice, repetition of words, etc. Delayed prescribing was sometimes used to respond to implicit patient expectations for an antibiotic. Patients accepted a non-antibiotic management plan well. Conclusion: Not addressing the ICE of patients, or their reason to consult the GP OOH, could drive assumptions about patient expectations for antibiotics early on and antibiotic prescribing later in the consultation.

Understanding General Practitioners' Antibiotic Prescribing Decisions in Out-of-Hours Primary Care: A Video-Elicitation Interview Study.

Infections are the most common reason why patients consult out-of-hours (OOH) primary care. Too often there is an overprescribing of antibiotics for self-limiting infections and general practitioners (GPs) do not always choose the guideline recommended antibiotics. To improve antibiotic prescribing quality, a better understanding is needed of the (non) antibiotic prescribing decisions of GPs. This study sets out to unravel GPs' (non) antibiotic prescribing decisions in OOH primary care. We video-recorded 160 consultations on infections during OOH primary care by 21 GPs and performed video-elicitation interviews with each GP. GPs reflected on their decision-making process and communication while watching their consultation. A qualitative thematic analysis was used. GPs found that their (non) antibiotic prescribing decision-making was not only based on objective arguments, but also subconsciously influenced by their own interpretation of information. Often GPs made assumptions (about for example the patients' reason for encounter or expectations for antibiotics) without objectifying or verifying this with the patient. From the beginning of the consultation GPs follow a dichotomous thinking process: urgent versus not urgent, viral versus bacterial, antibiotics versus no antibiotics. Safety-netting is an important but difficult tool in the OOH care context, with no long-term follow-up or relationship with the patient. GPs talk about strategies they use to talk about diagnostic uncertainty, what patients can expect or should do when things do not improve and the difficulties they encounter while doing this. This video- elicitation interview study provides actionable insights in GPs' (non) antibiotic prescribing decisions during OOH consultations on infections.

Learning from patients about patient-centredness: A realist review: BEME Guide No. 60.

Background: Patient-centred work is an essential part of contemporary medicine. Literature shows that educational interventions contribute to developing patient-centredness, but there is a lack of insight into the associated learning processes.Objective: Through reviewing articles about educational interventions involving patients, we aspire to develop a program theory that describes the processes through which the educational interventions are expected to result in change. The processes will clarify contextual elements (called contexts) and mechanisms connected to learning patient-centredness.Methods: In our realist review, an initial, rough program theory was generated during the scoping phase, we searched for relevant articles in PubMed, PsycINFO, ERIC, CINAHL and Embase for all years before and through 2016. We included observational studies, case reports, interviews, and experimental studies in which the participants were students, residents, doctors, nurses or dentists. The relevance and rigour of the studies were taken into account during analysis. With deductive as well as inductive coding, we extended the rough program theory.Results: In our review, we classified five different contexts which affect how upcoming professionals learn patient-centredness. These aspects are influenced through components in the intervention(s) related to the learner, the teacher, and the patient. We placed the mechanisms together in four clusters - comparing and combining as well as broadening perspectives, developing narratives and engagement with patients, self-actualisation, and socialisation - to show how the development of (dimensions of) patient-centredness occurs. Three partial-program-theories (that together constituting a whole program theory) were developed, which show how different components of interventions within certain contexts will evoke mechanisms that contribute to patient-centredness.Translation into daily practice: These theories may help us better understand how the roles of patients, learners and teachers interact with contexts such as the kind of knowledge that is considered legitimate or insight in the whole illness trajectory. Our partial program theories open up potential areas for future research and interventions that may benefit learners, teachers, and patients.

From qualitative data to GP training on CRC screening.

Colorectal cancer (CRC) is the third most common cancer worldwide. In France, although mass screening has been performed using the guaiac fecal occult blood test since 2008, the participation rate remains too low. Previous studies have explored the perspectives of doctors and patients as well as the performance of general practitioners (GPs) by recording and analyzing consultations in which patients came and asked for fecal occult blood test. Results indicated that improvement was needed in patient-centered communication. This research aims to develop educational material and training programs for GPs in order to enhance their communication with patients on CRC screening, based on data from two qualitative studies. Triangulation of all qualitative data was performed and discussed with communication experts in order to develop educational material and training programs based on the patient-centered clinical method. Two different scenarios were developed to improve communication with patients: one for a compliant patient and another for a noncompliant patient. Two videos were made featuring a doctor and a simulated patient. A two-sequence training program was built, including role-playing and presentation of the video followed by a discussion. The qualitative data helped us to produce a useful, relevant training program for GPs on CRC screening.

'More shades of grey in my answers': an interview study revisiting attitude erosion during clerkships.

CONTEXT: Small declines in patient-centred attitudes during medical education have caused great concern. Although some of the self-report scales applied have solid psychometric foundations, validity evidence for the interpretation of attitude erosion during clerkships remains weak. OBJECTIVES: We sought to address this gap in a qualitative study of the relationships between scores on four commonly used attitude scales and participants' experiences and reflections. Our aim was to gain a better understanding of the score changes from the participants' perspectives. METHODS: We conducted semi-structured interviews with 15 junior doctors from a cohort (n = 37) that had previously shown a small decline in patient-centred attitudes during clerkships, measured on four self-report scales. In the interviews, we explored interviewees' experiences of their development of patient-centredness and subsequently discussed their scale scores, particularly for those items that contributed to a rise or decline in scores. We analysed the data using a process of constant comparison among personal experiences, scale scores and participants' explanations of score changes, applying the coding techniques of grounded theory. RESULTS: The analysis revealed important response distortions that might be responsible for small declines in scores during clerkships separately from changes in attitudes. The drastic alterations to the participants' frame of reference, attributable to the transition to clinical practice, represented the most prominent cause of distortion. More nuanced, context-specific, patient-centred reasoning resulted in more neutral responses after clerkships, paradoxically causing a decline in scores. In addition to response distortions, the interviews revealed shortcomings in content validity such as an 'extreme' construct of patient-centredness. CONCLUSIONS: This study calls into question the validity of the interpretation of attitude erosion during clerkships. The findings suggest that small declines in scores on self-report attitude scales are related to a recalibration of trainees' understandings of patient-centredness as they grow more clinically experienced. The evolved construct of patient-centredness and the way attitudes are measured require special attention in the development of future instruments.

Patient-centredness from education to practice: the 'lived' impact of communication skills training.

BACKGROUND: Although communication skills training (CST) enhances patient-centred skills and attitudes, the literature indicates a problematic transfer of these from education into practice. AIM: We explored 'lived' experiences of medical students and doctors to gain a better understanding of the impact of CST on patient-centredness in the transition to real practice. METHODS: From a phenomenological perspective, we conducted 15 interviews and 11 focus groups with 4-9 participants/group (n = 67) at two universities and carried out constant comparative analysis. RESULTS: The gap between education and practice is the central phenomenon. Although CST raises students' communication awareness and self-efficacy in an 'ideal' context, this paradoxically seems to jeopardize their ability to bridge the gulf. In addition, CST does not come to grips with students' attitudes. However, CST appears to be successful in equipping students with long-lasting 'handles'. Yet students need more support to mould the provided 'ideal' models into their own unique style of context-specific patient-centred behaviour. This implies: raising students' awareness of own attitudes and communication styles, offering a more realistic training ground, integrating CST with clinical experience and translating the primary-care-rooted concept of patient-centredness into various specialization contexts. CONCLUSION: CST could raise its impact by supporting students' recycling processes towards a personal style of context-sensitive patient-centredness.

Medical students trained in communication skills show a decline in patient-centred attitudes: an observational study comparing two cohorts during clinical clerkships.

OBJECTIVE: Literature indicates a decline in patient-centredness in medical students, especially during clinical clerkships. We examined the impact of preclinical communication skills training (CST) on students' development of patient-centred attitudes and attitudes toward CST during clerkships. METHODS: We prospectively compared two cohorts before and after clerkships: one cohort (n=48) had not received CST, whereas the other (n=37) had received a five-year CST. We assessed the impact using five validated questionnaires. RESULTS: Communication trained students slightly but significantly declined in patient-centred attitudes (3/4 scales) and attitudes toward CST during clerkships, whereas the scores of the untrained students remained stable (5/5 scales). Both cohorts did not differ in attitudes before clerkships. In the trained cohort, males mostly showed a sharper decline than females. In the total group (n=85), females demonstrated higher attitude scores toward CST, and in 1/4 scales measuring patient-centred attitudes. CONCLUSION: This cohort study suggests that CST might make students more vulnerable to decline in attitude scores during clerkships. PRACTICE IMPLICATIONS: These remarkable findings, contrary to what educators would expect to result from their efforts, challenge medical education to address the new questions that are raised about the validity of the questionnaires, the impact of CST and the learning processes involved in the development of patient-centredness.

Help, I'm losing patient-centredness! Experiences of medical students and their teachers.

OBJECTIVES: Despite all educational efforts, the literature shows an ongoing decline in patient-centredness during medical education. This study explores the experiences of medical students and their teachers and supervisors in relation to patient-centredness in order to gain a better understanding of the factors that determine its development. METHODS: We conducted 11 focus groups on the subject of learning and teaching about patient-centredness. We then carried out a constant comparative analysis of prior theory and the qualitative data collected in the focus groups using the 'sensitising concepts' provided by the Attitude-Social Influence-Self-Efficacy (ASE) model. RESULTS: Although students express positive attitudes towards patient-centredness and acquire patient-centred skills during medical education, this study indicates that these are not sufficient to attain the level of competent behaviour needed in today's challenging hospital environment. Clinical clerkships do provide students with ample opportunity to encounter patients and practise patient-centred skills. However, when students lack self-efficacy, when they face barriers (time pressure, tiredness) or when they are surrounded by non-patient-centred role models and are overwhelmed by powerful experiences, they lose their patient-centred focus. The study suggests that communication skills training protects students from negative social influences. Moreover, personal development, including developing the ability to deal with emotions and personal suffering, self-awareness and self-care are important qualities of the central phenomenon of the 'doctor-as-person', which is identified as a missing concept in the ASE model. The student-supervisor relationship is found to be key to learning patient-centredness and has several functions: it facilitates the direct transmission of patient-centred skills, knowledge and attitudes; it provides social support of students' patient-centred behaviour; it provides support of the 'student-as-person'; it mirrors patient-centredness by being student-centred, and, lastly, it addresses supervisor vulnerability. Finally, participants recommend that student-centred education and guidance be offered, self-awareness be fostered and more opportunities to encounter patients be created, including more time in general practice. CONCLUSIONS: Supportive student-doctor relationships, student-centred education and guidance that addresses the needs of the doctor-as-person are central to the development of patient-centredness. Medical education requires patient-centred, self-caring and self-aware role models.