'Making room for student autonomy' - an ethnographic study of student participation in clinical work.

Participation in clinical work is important for medical students' professional development. However, students often report that they experience a passive observer role, and further research on contextual factors that influence student participation is needed. The theory of practice architectures contributes a new perspective to this challenge by elucidating how cultural-discursive, material-economic, and social-political arrangements enable and constrain student participation in clinical work. The aim of this study was to explore how practice architectures in clinical learning environments enable and constrain medical students' participation. The study was designed as an ethnographic field study in three student clinics: 106 h of observation. Analysis comprised ethnographic analysis followed by application of the theory of practice architectures. The ethnographic analysis resulted in six themes: setting the scene, when to call for help, my room - my patient, getting in a routine, I know something you don't, and my work is needed. Applying the theory of practice architectures showed that material-economic arrangements, such as control of the consultation room and essential artefacts, were crucial to student participation and position in the clinical workplace. Furthermore, co-production of a student mandate to independently perform certain parts of a consultation enabled a co-productive student position in the hierarchy of care-producers. The findings offer a conceptually generalisable model for the study of material and social dimensions of clinical learning environments. Although not all clinical learning environments may wish to or have the resources to implement a student clinic, the findings offer insights into general issues about the arrangements of student participation relevant to most clinical teaching contexts.

Consensus on communication curriculum content in Danish undergraduate medical education: A Delphi study.

BACKGROUND: The acquisition of skills in patient-centered communication is a critical aspect of medical education which demands both resource-intensive instruction and longitudinal opportunities for learning. Significant variation currently exists in the content and timing of communication education. The aim of this study was to establish consensus regarding communication curriculum content for undergraduate medical education (UME) within the country of Denmark. METHODS: This study employed a Delphi process which is a widely accepted method for establishing consensus among experts and can be utilized to guide planning and decision-making in education. For this study, consensus was based on greater than 60% agreement between participants. Diverse stakeholders, representing all four universities with medical schools in Denmark, participated in an iterative three-round Delphi process which involved: (1) identifying key curricular elements for medical student education, (2) rating the importance of each item, and (3) prioritizing items relative to one another and rating each item based on the level of mastery that was expected for each skill (i.e. knowledge, performance with supervision, or performance independently). RESULTS: A national sample of 149 stakeholders participated with a 70% response rate for round 1, 81% for round 2, and 86% for round 3. The completed Delphi process yielded 56 content items which were prioritized in rank order lists within five categories: (1) establishing rapport, engaging patient perspectives and responding to needs; (2) basic communication skills and techniques; (3) phases and structure of the encounter; (4) personal characteristics and skills of the student; (5) specific challenging patient groups and context-dependent situations. DISCUSSION: Using a Delphi process, it was possible to achieve consensus regarding communication curriculum content for UME. These findings provide an important foundation for ensuring greater uniformity in UME, as well as supporting the important longitudinal goals of communication skill development across medical training.

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.

The self-efficacy in patient-centeredness questionnaire - a new measure of medical student and physician confidence in exhibiting patient-centered behaviors.

BACKGROUND: Patient-centered communication is a core competency in modern health care and associated with higher levels of patient satisfaction, improved patient health outcomes, and lower levels of burnout among physicians. The objective of the present study was to develop a questionnaire assessing medical student and physician self-efficacy in patient-centeredness (SEPCQ) and explore its psychometric properties. METHODS: A preliminary 88-item questionnaire (SEPCQ-88) was developed based on a review of the literature and medical student portfolios and completed by 448 medical students from Aarhus University. Exploratory Principal Component analysis resulted in a 27-item version (SEPCQ-27) with three underlying self-efficacy factors: 1) Exploring the patient perspective, 2) Sharing information and power, and 3) Dealing with communicative challenges. The SEPCQ-27 was completed by an independent sample of 291 medical students from 2 medical schools and 101 hospital physicians. RESULTS: Internal consistencies of total and subscales were acceptable for both students and physicians (Cronbach's alpha (range): 0.74-0.95). There were no overall indications of gender-related differential item function (DIF), and a Confirmatory Factor Analysis (CFA) indicated good fit (CFI = 0.98; NNFI = 0.98; RMSEA = 0.05; SRMR = 0.07). Responsiveness was indicated by increases in SEPCQ scores after a course in communication and peer-supervision (Cohen's d (range): 0.21 to 0.73; p: 0.053 to 0.001). Furthermore, positive associations were found between increases in SEPCQ-scores and course-related motivation to learn (medical students) and between SEPCQ scores and years of clinical experience (physicians). CONCLUSIONS: The final SEPCQ-27 showed satisfactory psychometric properties, and preliminary support was found for its construct validity, indicating that the SEPCQ-27 may be a valuable measure in future patient centered communication training and research.

Patient-centred learning in practice. A mixed methods study of supervision and learning in student clinics.

OBJECTIVE: Patient-centred learning (PCL) allows medical students to practice a patient-centred approach; however, didactic characteristics of PCL have yet to be fully elucidated. Clinical placements structured as a student clinic (SC) enable authentic student-patient learning relations through enhanced student responsibility and can serve as examples of PCL. We explored the didactic characteristics of supervision and learning in SCs to provide recommendations for PCL-oriented medical education. METHODS: Triangulation mixed methods study based on qualitative data collected from in-depth interviews with clinical teachers and quantitative data collected from student evaluations of supervision and learning in the SCs. RESULTS: Supervision and learning in SCs were characterized by 1) a focus on student-patient compatibility and patient needs and resources, which indicated PCL, 2) person-centred explorative supervision to adjust challenges to students' needs and resources, and 3) support of student autonomy to take responsibility for patient treatment. CONCLUSION: PCL was facilitated by clinical teachers through a dual person-centred didactic approach combined with autonomy-supportive didactic practice. This enabled the integration of patients' and students' needs and resources in clinical teaching. PRACTICE IMPLICATIONS: Clinical teachers can stimulate student-patient learning relations by selecting patients, exploring students' needs and resources, and supporting student autonomy through reflective practice and backup.

Exploring patient experiences in the student outpatient clinic - A contribution to learning.

OBJECTIVE: To understand how patients experience participation in student encounters. METHODS: Qualitative semi-structured telephone interviews with ten cardiac surgery patients who had attended voluntary postoperative consultations in a student outpatient clinic. The interview guide included questions about reasons for and experiences of being part of a teaching situation. Interviews were analysed through inductive thematic analysis where pieces of text in each interview were assigned different codes and condensed into themes. RESULTS: The patients expressed a duality in their reasons for participating in student consultations: (1) a personal need for assurance (safety) and (2) a wish to help students (altruism). Students were perceived as professional and sometimes insecure. Being part of an educational situation was meaningful to the patients because they did not feel objectified. Knowing that there was a backup supervisor made the patients feel safe even though the supervisor was not present during all parts of the consultation. CONCLUSIONS: Patients experienced safety, understood their role in all parts of the consultation, and shared a wish to help students learn. PRACTICE IMPLICATIONS: A sequential consultation model alternating between student- and supervisor-driven supervision can balance student autonomy and patient safety. This knowledge could guide future patient-centred medical education in student clinics.

[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.