Developing a digital training tool to support oncologists in the skill of information-provision: a user centred approach.

BACKGROUND: For patients with cancer, being well informed by their oncologist about treatment options and the implications thereof is highly relevant. Communication skills training (CST) programs have shown to be effective in improving clinicians' communication skills, yet CSTs are time-consuming, inconvenient to schedule, and costly. Online education enables new ways of accessible learning in a safe and personalised environment. AIM AND METHODS: We describe the design of a digital CST-tool for information provision skills that meets oncologists' learning needs. We used the CeHRes Roadmap for user-centred design as a guiding framework. Phase 1 (Contextual Inquiry) involved consultation of the literature and a focus group interview study to uncover the learning needs and training preferences of clinicians' regarding a digital training for the skill of information-provision. In phase 2 (Value Specification), two multidisciplinary expert panels specified the learning content and format of a digital training. Phase 3 (Design) encompassed an iterative development process, including two user group assessment sessions and 5 individual user sessions in which prototypes were tested. All sessions were recorded and independently analyzed by two researchers. RESULTS: Based on literature and consultation of the users in the inquiry phase of the development process, and on expert opinion in the value specification phase, relevant (sub) skills and user requirements were defined to consider for the digital training format. It was decided to develop a conventional e-learning and a chatbot. Personalization and interactivity were integrated in the prototypes by including features that allow for e.g., choosing text, video or animation; to upload video-recorded consultations to receive peer-feedback; and to consult a communication expert. Results revealed that, overall, participants expressed a willingness to use a digital training tool to acquire information-provision skills. Individual user testing (including junior clinicians), indicated a preference for the chatbot over the e-learning. CONCLUSION: We offer a description of extensive development work which was conducted in collaboration with multiple health care professionals to iteratively develop two innovative prototypes of digital tools that would appropriately engage oncologists in learning effective information giving skills. The resulting prototypes were well appreciated and thus provide a solid basis for further development and testing.

Terminal Bleeding in Angiosarcoma.

Introduction: Terminal bleeding, a distressing symptom experience for patients, caregivers, and health professionals, occurs in a subset of patients in the palliative care setting. Terminal bleeding is often thought of as a large-volume catastrophically fatal event, but it can also occur for a longer period of time and still be the precipitating event for a patient's death. Case Report: We present the case of terminal bleeding in an 87-year-old patient with angiosarcoma, a rare aggressive vascular neoplasm that can occur anywhere in the body but tend to occur more frequently in the head and neck. Discussion: The patient's advanced age and aggressive disease presented challenges in managing the symptoms and precluded many of the conventional recommended interventions to manage bleeding. Conclusion: This case report speaks to the need for multidisciplinary planning that takes prognosis, performance status, previous therapies, and patient preferences into account when caring for patients with advanced cancer.

Developing a digital communication training tool on information-provision in oncology: uncovering learning needs and training preferences.

BACKGROUND: Adequate information-provision forms a crucial component of optimal cancer care. However, information-provision is particularly challenging in an oncology setting. It is therefore imperative to help oncological health care practitioners (HCP) optimise their information-giving skills. New forms of online education, i.e. e-learning, enable safe and time and location independent ways of learning, enhancing access to continuous learning for HCP. As part of a user-centred approach to developing an e-learning to improve information-giving skills, this study aims to: 1) uncover the learning needs of oncological healthcare providers related to information- provision, and 2) explore their training preferences in the context of clinical practice. METHODS: Focus groups and interviews were organised with oncological HCP (medical specialists and clinical nurse specialists) addressing participants' learning needs concerning information- provision and their training preferences with respect to a new digital training tool on this issue. All sessions were audiorecorded and transcribed verbatim. Using an inductive approach, transcripts were independently coded by three researchers and discussed to reach consensus. Main themes were summarised and discussed. RESULTS: Four focus group sessions (total n = 13) and three interviews were conducted. The first theme concerned the patient outcomes HCP try to achieve with their information. We found HCP to mainly strive to promote patients' understanding of information. The second theme concerned HCP reported strategies and challenges when trying to inform their patients. These entailed tailoring of information to patient characteristics, structuring of information, and dealing with patients' emotions. Regarding HCP training preferences, an e-learning should be neatly connected to clinical practice. Moreover, participants desired a digital training to allow for feedback on their own (videotaped) information-giving skills from peers, communication experts, and/or patients; to monitor their progress and to tailored the training to individual learning needs. CONCLUSIONS: An e-learning for improvement of information-giving skills of oncological HCP should be aimed at the transfer of skills to clinical practice, rather than at enhancing knowledge. Moreover, an e-learning is probably most effective when the facilitates individual learning needs, supports feedback on competence level and improvement, and allows input from significant others (experts, peers, or patients).

Students' approaches to medical school choice: relationship with students' characteristics and motivation.

OBJECTIVES: The aim was to examine main reasons for students' medical school choice and their relationship with students' characteristics and motivation during the students' medical study. METHODS: In this multisite cross-sectional study, all Year-1 and Year-4 students who had participated in a selection procedure in one of the three Dutch medical schools included in the study were invited to complete an online survey comprising personal data, their main reason for medical school choice and standard, validated questionnaires to measure their strength of motivation (Strength of Motivation for Medical School-Revised) and autonomous and controlled type of motivation (Academic Self-regulation Questionnaire). Four hundred seventy-eight students participated. We performed frequency analyses on the reasons for medical school choice and regression analyses and ANCOVAs to study their associations with students' characteristics and motivation during their medical study. RESULTS: Students indicated 'city' (Year-1: 24.7%, n=75 and Year-4: 36.0%, n=52) and 'selection procedure' (Year-1: 56.9%, n=173 and Year-4: 46.9%, n=68) as the main reasons for their medical school choice. The main reasons were associated with gender, age, being a first-generation university student, ethnic background and medical school, and no significant associations were found between the main reasons and the strength and type of motivation during the students' medical study. CONCLUSIONS: Most students had based their medical school choice on the selection procedure. If medical schools desire to achieve a good student-curriculum fit and attract a diverse student population aligning the selection procedure with the curriculum and taking into account various students' different approaches is important.

Self-evaluation and peer-feedback of medical students' communication skills using a web-based video annotation system. Exploring content and specificity.

OBJECTIVE: Self-evaluation and peer-feedback are important strategies within the reflective practice paradigm for the development and maintenance of professional competencies like medical communication. Characteristics of the self-evaluation and peer-feedback annotations of medical students' video recorded communication skills were analyzed. METHOD: Twenty-five year 4 medical students recorded history-taking consultations with a simulated patient, uploaded the video to a web-based platform, marked and annotated positive and negative events. Peers reviewed the video and self-evaluations and provided feedback. Analyzed were the number of marked positive and negative annotations and the amount of text entered. Topics and specificity of the annotations were coded and analyzed qualitatively. RESULTS: Students annotated on average more negative than positive events. Additional peer-feedback was more often positive. Topics most often related to structuring the consultation. Students were most critical about their biomedical topics. Negative annotations were more specific than positive annotations. Self-evaluations were more specific than peer-feedback and both show a significant correlation. Four response patterns were detected that negatively bias specificity assessment ratings. CONCLUSION: Teaching students to be more specific in their self-evaluations may be effective for receiving more specific peer-feedback. PRACTICE IMPLICATIONS: Videofragmentrating is a convenient tool to implement reflective practice activities like self-evaluation and peer-feedback to the classroom in the teaching of clinical skills.

Peer-assessment of medical communication skills: the impact of students' personality, academic and social reputation on behavioural assessment.

OBJECTIVE: Peer-assessment of communication skills may contribute to mastery of assessment criteria. When students develop the capacity to judge their peers' performance, they might improve their capacity to examine their own clinical performance. In this study peer-assessment ratings are compared to teacher-assessment ratings. The aim of this paper is to explore the impact of personality and social reputation as source of bias in assessment of communication skills. METHODS: Second year students were trained and assessed history taking communication skills. Peers rated the students' personality and academic and social reputation. RESULTS: Peer-assessment ratings were significantly correlated with teacher-ratings in a summative assessment of medical communication. Peers did not provide negative ratings on final scales but did provide negative ratings on subcategories. Peer- and teacher-assessments were both related to the students' personality and academic reputation. CONCLUSION: Peer-assessment cannot replace teacher-assessment if the assessment should result in high-stake decisions about students. Our data do not confirm the hypothesis that peers are overly biased by personality and reputation characteristics in peer-assessment of performance. PRACTICE IMPLICATIONS: Early introduction of peer-assessment in medical education would facilitate early acceptance of this mode of evaluation and would promote early on the habit of critical evaluation of professional clinical performance and acceptance of being evaluated critically by peers.

The psychophysiology of medical communication. Linking two worlds of research.

OBJECTIVE: Medical communication is goal oriented behavior. As such, it can be modeled as a chain of decisions, resulting from cognitive and emotional processes each potentially associated with psychophysiological reactions. Psychophysiological may be helpful to detect small changes in affect or arousal in the course of a consultation that would be difficult to detect by other evaluations of the process, like self-reports. The question is how psychophysiological communication research should be modeled for unraveling in more detail the cognitive, emotional and interpersonal processes which underlie physician and patient behavior. METHODS: In the world of medical communication research the six-function model of medical communication reveals a number of fundamental perceptual, cognitive and emotional processes which may evoke psychophysiological responses. The world of psychophysiological research encompasses domains of perception, mental imagery, anticipation and action which all have close connections with fundamental tasks in communication. CONCLUSION: This paper discusses ten methodological issues in linking continuous psychophysiological data to verbal and nonverbal events in a medical consultation observed with the Verona coding system. PRACTICE IMPLICATIONS: When linking the two worlds of research, the methodological challenges discussed need to be solved to obtain a valid and reliable application of psychophysiological measures in medical communication research.

How stressful is doctor-patient communication? Physiological and psychological stress of medical students in simulated history taking and bad-news consultations.

INTRODUCTION: Medical communication can be a stressful experience for both doctors and patients. In particular, inexperienced doctors facing the demanding task of a bad news consultation may experience high levels of distress. The aim of this exploratory study is to test students' differential cardiovascular reactivity to history taking and bad news consultations with a simulated patient, and to test the relation between the students' self-reported stressfulness of the consultation and their cardiovascular response. METHODS: Fourth and fifth year medical students (n=20) conducted a history taking (HT) and a bad news (BN) consultation in a randomized order with a standardized patient. Heart rate (HR), mean arterial pressure (MAP), cardiac output (CO) and systemic vascular resistance (SVR) were assessed by way of the Finapres-technique in four conditions: rest, reading aloud, and during both consultations. Self-reported stress was assessed before and after each interview using the State and Trait Anxiety Inventory (STAI), and a visual analogue scale (VAS). RESULTS: Both HT and BN provoked more cardiovascular stress than reading. Bad-news provoked the highest HR and CO responses compared to all other conditions, and had a greater impact when it was the student's first consultation. The STAI and VAS data showed some correlations with the cardiovascular stress measures and a comparable but less significant pattern in stress response. DISCUSSION: The effect of order of the HT and BN consultations on the students' stress levels suggests an additional impact of novelty and habituation. Unfamiliarity with the patient may enhance the stressfulness of the task of breaking bad news.

Shifting goals in medical communication. Determinants of goal detection and response formation.

OBJECTIVES: Research and education of medical communication different perspective, making the extraction of clear recommendations from research that can be applied in education not always possible. In education, medical communication is encountered from a goal-oriented perspective, which is often lacking in quantitative research where the relationship between process variables and the content of medical practice is often ignored. The aim of this paper is to bring the worlds of research and education together by presenting a comprehensive model of determinants explaining the behavior of physicians in daily practice. A basic notion in this model is that medical communication is goal-oriented, problem-solving behavior. Goals in communication are not fixed, but permanently changing over time. Hence, communication abilities do not rely on behavioral skills only but also on perceptual skills in identifying goals. A number of determinants affect the cognitive processes of goal appraisal and response formation: knowledge, attitudes, social norms, self-efficacy, stressors and interfering goals. CONCLUSION: Modeling medical communication as goal-oriented problem-solving behavior, and recognizing the complexity of goal appraisal and other key determinants of response formation may provide a common focus for both research and education in measuring, explaining and improving the HCP's behavior. PRACTICE IMPLICATIONS: In education not only skill practicing but also reflection on the process and outcomes is important to understand how one acts in practice situations and should act in future situations. In research measurements should be expanded to take contextual and goal-oriented dimensions of the process of communication into account to make findings more relevant for education and practice.

Effectiveness of selection in medical school admissions: evaluation of the outcomes among freshmen.

CONTEXT: In 2000 our medical school introduced a selection procedure (SP) for 10% of the otherwise randomly selected (RS) applicants. Students with excellent high school grade point averages (GPAs) were allowed direct access (DA) to our medical school. The selection procedure focused on medical comprehension, social and ethical understanding of health care, and communication and interpersonal skills. Objectives We aimed to establish how SP students compared with RS and DA students on motivation, academic achievement, study behaviour and extracurricular activities, and how these variables were interrelated within these groups. METHODS: In 2003, all Year 1 and 2 students were given a questionnaire on motivation, study behaviour and extra-curricular activities. Primary year GPAs were obtained from our administration department. Student groups were compared using descriptive statistics. The interrelationship between outcomes was tested using structural equation modelling. RESULTS: The questionnaire was returned by 418 students (76%). Selection procedure students were significantly more highly motivated (59.4) than RS students (56.6) and DA students (52.1). This was not reflected in academic achievement (6.7), which was highest among DA students (7.2). Selection procedure students carried out more extra-curricular activities, often health care-related, and displayed more study behaviour. Academic achievement could not be explained by motivation and study behaviour but motivation affected study behaviour and health care-related extra-curricular activities. CONCLUSIONS: The more profound commitment of selected students to health care is not primarily reflected in academic achievement but in motivation, extra-curricular activities and study behaviour. Follow-up research including all pre-clinical and clinical years should demonstrate the stability of these characteristics and their effects on graduates' post-qualification clinical performance as practising doctors.

Communication patterns of primary care physicians in the United States and the Netherlands.

BACKGROUND: While international comparisons of medical practice have noted differences in length of visit, few studies have addressed the dynamics of visit exchange. OBJECTIVES: To compare the communication of Dutch and U.S. hypertensive patients and their physicians in routine medical visits. DESIGN: Secondary analysis of visit audio/video tapes contrasting a Dutch sample of 102 visits with 27 general practitioners and a U.S. sample of 98 visits with 52 primary care physicians. MEASUREMENTS: The Roter Interaction Analysis System applied to visit audiotapes. Total visit length and duration of the physical exam were measured directly. MAIN RESULTS: U.S. visits were 6 minutes longer than comparable Dutch visits (15.4 vs 9.5 min, respectively), but the proportion of visits devoted to the physical examination was the same (24%). American doctors asked more questions and provided more information of both a biomedical and psychosocial nature, but were less patient-centered in their visit communication than were Dutch physicians. Cluster analysis revealed similar proportions of exam-centered (with especially long physical exam segments) and biopsychosocial visits in the 2 countries; however, 48% of the U.S. visits were biomedically intensive, while only 18% of the Dutch visits were of this type. Fifty percent of the Dutch visits were socioemotional, while this was true for only 10% of the U.S. visits. CONCLUSIONS: U.S. and Dutch primary care visits showed substantial differences in communication patterns and visit length. These differences may reflect country distinctions in medical training and philosophy, health care system characteristics, and cultural values and expectations relevant to the delivery and receipt of medical services.

The effectiveness of a computer-assisted instruction programme on communication skills of medical specialists in oncology.

BACKGROUND: Although doctor--patient communication is important in health care, medical specialists are generally not well trained in communication skills. Conventional training programmes are generally time consuming and hard to fit into busy working schedules of medical specialists. A computer-assisted instruction (CAI) programme was developed -- 'Interact-Cancer' -- which is a time-efficient learning method and easily accessible at the workplace. OBJECTIVE: To investigate the effect of the CAI training, 'Interact-Cancer', on the communication behaviour of medical specialists, and on satisfaction of patients about their physician interaction. DESIGN: Consultations of medical specialists with cancer outpatients were videotaped at 4 specific stages, 2 before and 2 after Interact-Cancer, with intervals of 4 weeks. PATIENTS/PARTICIPANTS: Participants were 21 medical specialists, mainly internists, working in 7 hospitals, and 385 cancer outpatients. METHODS: Communication behaviour was assessed on 23 observation categories derived from the course content. Frequencies were rated as well as judgements about the quality of the performance of each target skill. Satisfaction was measured by the Medical Interview Satisfaction Scale. Data were analyzed by means of multilevel statistical methods. RESULTS: The behavioural assessment showed course effects on ratings of the physicians' quality of performance. No course effects were found on the frequencies of physicians' behaviours and on the patient satisfaction ratings. CONCLUSIONS: CAI is a promising method to supply medical specialists with postgraduate training of communication skills. The application of judgement ratings of communication behaviour proved to be valuable to evaluate course effects in real-life patient encounters.