Reflective writing in the teaching of communication skills for medical students—A systematic review

ObjectiveTo analyse the use, assessment, and measured outcomes of reflective writing (RW) in teaching communication to medical students.MethodsSystematic search of seven electronic databases, focused on using RW in teaching communication skills. Three reviewers selected and prepared the synthesis of the studies. The synthesis was based on thematic analysis using Braun and Clarke’s approach.ResultsWe identified 1325 studies, reviewed 101 full-text articles, and included 12 articles in the analysis. The four themes identified showed that RW is not a stand-alone practice. RW is blended with other teaching strategies. Through RW, students identified structural, emotional, and relational aspects and challenges of communication. Only a few studies found a positive correlation between reflective ability and communication skillsConclusionRW can be integrated with various teaching methods, at all stages of learning, to stimulate discussion of interpersonal and intrapersonal topics. Through RW, students explore theirs and their patient’s emotions, values, behaviours, and needs identifying challenges and practices relevant to communication. Practice implications: RW can address different structural, relational, and emotional issues that are relevant to communication learning. Further educational development and high-quality empirical research on the use of RW and unique outcomes are needed to support communication skills learning.     

Students’ experiences with a longitudinal skills training program on breaking bad news: A follow-up study

Objective

Breaking bad news (BBN) should be trained, preferably early and following a helical model with multiple sessions over time, including feedback on performance. It’s unclear how medical students evaluate such an approach.

The use of simulation in medical student education on the topic of breaking bad news: A systematic review

BackgroundSimulated patients (SPs) are widely used, but the most effective way of utilising them in undergraduate breaking bad news (BBN) medical education is unknown.ObjectivesTo conduct a systematic review into SP’s use in developing BBN skills in medical students.Methods14 databases searched with the terms “Medical education”, “Patient simulation”, “Bad news”. Data was systematically extracted, and thematic analysis undertaken.ResultsOf 2117 articles screened, 29 publications met the inclusion criteria. These demonstrated a variety of SP models, including actors as patients (65.5%), peers (7.0%), and cancer survivors (3.5%). with delivery at varying times in the curricula. SPs are uniformly reported as having positive impact, but there is a lack of high-quality evidence comparing the use of differing forms of training. There was some evidence that virtual SPs were as useful as in-person SPs.ConclusionsSPs allow students to practise vital BBN communication skills without risking detriment to patient care. Despite the heterogeneity of ways in which SPs have been used, the benefits of different approaches and when and how these should be delivered remains unclear.Practice implicationsFurther educational development and research is needed about the use of SPs to support undergraduate BBN communication skills development.     

Breaking bad news: A randomized controlled trial to test a novel interactive course for medical students using blended learning

ObjectiveBreaking bad news (BBN) is challenging for physicians and patients and specific communication strategies aim to improve these situations. This study evaluates whether an E-learning assignment could improve medical students' accurate recognition of BBN communication techniques.MethodsThis randomized controlled trial was conducted at the University of Basel. After a lecture on BBN, 4th year medical students were randomized to an intervention receiving an E-learning assignment on BBN or to a control group. Both groups then worked on an examination video and identified previously taught BBN elements shown in a physician-patient interaction. The number of correctly, misclassified and incorrectly identified BBN communication elements as well as missed opportunities were assessed in the examination video.ResultsWe included 160 medical students (55% female). The number of correctly identified BBN elements did not differ between control and intervention group (mean [SD] 3.51 [2.50] versus 3.72 [2.34], p = 0.58). However, the mean number of inappropriate BBN elements was significantly lower in the intervention than in the control group (2.33 [2.57] versus 3.33 [3.39], p = 0.037).ConclusionsUse of an E-learning tool reduced inappropriate annotations regarding BBN communication techniques.Practice implicationsThis E-learning might help to further advance communication skills in medical students.     

Learning how to break bad news from worked examples: Does the presentation format matter when hints are embedded? Results from randomised and blinded field trials

ObjectivesVideo-based worked examples enable medical students to successfully prepare for breaking-bad-news (BBN) encounters with simulated patients (SPs). This is especially true when examples include hints that signal important content. This paper investigates whether the beneficial effect of hints only applies to video-based worked examples or also text-based examples.MethodsOne-hundred-and-forty-seven fourth-year medical students attending a BBN training participated in either of two equally scaffolded, randomised field trials. Prior to encountering SPs, the students worked through an e-learning module introducing the SPIKES protocol for delivering bad news; it contained the same worked example presented to either of four groups as text or video, with or without additional hints denoting the SPIKES steps being implemented.ResultsOnly a main effect of ‘hints’ was revealed, implying that students in the hints groups delivered the news to an SP significantly more appropriately than those in the without-hints groups.ConclusionsIndependent of their presentation format, worked examples with hints best foster students’ BBN skills learning.Practice implicationsIn addition to video, text-based worked examples can effectively prepare students for BBN simulations if hints are included. This offers an affordable alternative to video examples, as text examples can be generated with less effort.     

The associations between reflective ability and communication skills among medical students

ObjectivesAssess associations between medical students’ reflective ability demonstrated in written narratives, and communication skills demonstrated later in simulated-patient breaking bad news interactions.MethodsWe analyzed 66 medical students’ reflective ability, using ‘REFLECT’ rubric and four newly developed parameters: Noticing Explanations provided to patients, Noticing Emotions, Remoteness/Connectedness in their writing, and mentioning Self-Emotions. ‘BAS’ and ‘SPIKES’ questionnaires measured students’ communication skills. Spearman and Chi-square tests examined correlations among all variables. Multiple regressions examined associations between reflective ability and demographic variables with communication skills.ResultsSignificant positive correlations between students’ reflective ability, measured by REFLECT and three of the new parameters, and global communication skill scores. Reflective ability of Noticing Explanations in writing was associated with ability to tailoring information to patients’ needs and address emotions.ConclusionsHigh reflective ability may improve communication skills. Specifically, ability to notice explanations to patients may enhance later capability to tailor information to patients and address emotions empathically.Practice implicationsEncourage educational interventions enhancing reflective ability; specifically observation and detailed writing about how explanations are given to patients and patients’ reactions to them. This process may help students develop competency to share and tailor difficult information sensitively—a critical skill when communicating bad news.     

Medical student empathy and breaking bad news communication in a simulated consultation

ObjectivesThis study examined the relationship between self-reported empathy and breaking bad news (BBN) communication skills performance in a sample of undergraduate medical students (n = 100) in the clinical years of their program.MethodsCorrelational and regression analysis examined the relationship between Jefferson Scale of Physician Empathy (JSPE-S) and Empathy Quotient (EQ) scores, and communication skills performance based on students’ application of the SPIKES protocol to a BBN scenario in a simulated encounter.ResultsHigher BBN communication skills performance was positively correlated with scores on the “Social Skills” EQ sub-scale (r (99) = 0.31, p = 0.002), which measures spontaneous and context-independent use of social skills. Multiple regression confirmed that “Social Skills” sub-scale variation predicted BBN score variation (B = 2.17, 95% CI = 0.65–3.69, p < 0.01). A weak positive association was also observed between BBN score and the “Standing in Patient’s Shoes” JSPE sub-scale (r (99) = 0.22, p = 0.03).ConclusionsFindings suggest that specific aspects of dispositional empathy may moderate BBN communications skills competence in medical students.Practice implicationsA better understanding of the moderating role of personality may lead to more tailored BBN communications skills training interventions and improved transfer of skills to workplace settings.     

Patient and clinician experiences with cross-border reproductive care: A systematic review

ObjectivesThis review analyzes the experiences of patients and clinicians with regards to international cross-border reproductive care (CBRC) for the purpose of conception.MethodsElectronic databases PubMed, Embase, Web of Science, and Scopus were searched using ‘medical tourism’ AND ‘assisted reproductive technology’ from 1978 to 2020.ResultsPredominant patient motivators for CBRC were cost and legality of assisted reproduction technology (ART) in one's home country, followed by cultural factors like shared language, religion, and cultural familiarity. Clinicians suggested global laws for CBRC would reduce the potential for exploitation of vulnerable populations but believed the enactment of international regulations unlikely and, even if enacted, difficult to enforce.ConclusionsWhile patient and clinician experiences with CBRC varied, patients frequently cited financial and legal reasons for pursuing CBRC, while many providers had concern for the patient’s safety.Clinical practice implicationsThis review recommends clinicians involved in family planning counsel patients seeking treatment abroad by: (i) informing patients of the risks and benefits of treatment abroad, (ii) establishing guidelines and standards for clinicians on resuming patient care post-CBRC, and (iii) creating a directory of reputable CBRC clinicians and experts.     

Exploring student perceptions of empathy development during medical school – A phenomenological study

ObjectiveEmpathy is an essential attribute of a good doctor. There are multiple dimensions to empathy, yet many curricula are limited to empathy display. This study’s aim was to understand the relationship between teaching, learning and development of empathy from the perspective of medical students.MethodsA qualitative approach was used with interpretivist methodology. Ten final year medical students from a single UK University were interviewed. Findings came from inductive thematic analysis.ResultsFive major themes were identified: ‘The Empathic Process’; ‘Self’; ‘Patient’; ‘Teacher/Clinician’; ‘Environment’. Sub-themes included personal qualities, patient factors, role-models and assessment. Students value authentic patient encounters, focused feedback and opportunities for debriefing. Barriers include cognitive load, time-pressures and being observed. Students can maintain empathy through self-checking and addressing biases.ConclusionsStudents are aware of their motivations and barriers towards empathy development and can describe meaningful experiences relating to this during medical school. Students acknowledge controversy surrounding assessment of empathy, but clearly value authentic patient experiences and an environment which is free from scrutiny and distractions.Practice implicationsIn addition to teaching communication skills, undergraduate programmes should focus on students’ inner growth. This may be achieved by guiding students through meaningful reflection and open dialogue with supportive mentors.     

Illness in context and families as teachers: a year-long project for medical students.

The authors describe a program for second-year students in Tel Aviv University's six-year medical school. The program's aim is to teach students the importance of context and interactions in patient care by exposing them to a real patient-family-doctor interaction using narrative-based methods to encourage reflective learning. Each student meets five times a year with a volunteer family, one of whose members suffers from a chronic disease. The program endorses a "patients as teachers" approach, as families are considered to be teachers for the students and not as objects of investigation and assessment. The students receive supervision in small groups, to enhance learning and reflection. To appraise the extent to which students had obtained the required knowledge, skills, and attitudes, the authors extracted reflections regarding the learning experience from students' essays. Major themes identified were becoming "family sensitive," building and improving communication skills, questioning intrusiveness, adopting a nonpatronizing and nonjudgmental attitude, developing reflective skills, creating a future professional model, and experiencing and appreciating continuity of care. The authors argue that learning to listen to patients' narratives, developing a reflective attitude, and being sensitive to patient-family-doctor interactions are of value to all doctors, and therefore programs similar to theirs should be established as part of general medical school education and not just in the context of family medicine.     

Perspectives of Colombian medicine students about their formation on breaking bad news: A cross-sectional study

IntroductionMedical schools are responsible for breaking bad news training, which should be focused on the students; therefore, the purpose of this study is to identify undergraduate medical students’ perceptions regarding the best way to train them.MethodsCross-sectional anonymous survey applied between 438 >18-years-old Colombian medicine students.ResultsThe students feel unprepared to breaking bad news; even without formal training, they believe they are better at breaking bad news as they advance in their training due to their observation of other clinicians and their personal experiences. A higher proportion of male students consider themselves empathetic than female students, but advanced male students report more frequently that their empathic capacity has decreased throughout their career more frequently than female students of the same academic level.DiscussionThis information will allow the medical school to modify the curriculum to offer proper training to its students.ConclusionVery few students have received formal training regarding this topic, and most of them are interested in training.     

Breaking bad news in a cross-language context: A qualitative study to develop a set of culturally and linguistically appropriate phrases and techniques with Zulu speaking cancer patients

ObjectiveBreaking bad news (BBN) in healthcare is common. Guidelines abound but little is documented in an African context. We wanted to describe Zulu speaking patients’ BBN experience and assess their opinions of internationally recommended techniques.MethodsBBN techniques were highlighted from the literature using systematic review methods. Semi-structured focus group interviews with Zulu speaking cancer patients were conducted. Data were analysed using Framework Analysis.ResultsLanguage concordance was central – regardless of whether this necessitated a nurse acting as translator. While non-abandonment, empathy and maintenance of hope was valued by participants, an oft-expressed belief in positive outcomes accounted for mixed responses to phrases implying ambiguity. In contrast, “I wish” phrases were appreciated. Silence received mixed responses with a strong dislike for silence as a front for non-disclosure.ConclusionLanguage-related concerns dictated the bulk of participants BBN perspectives. While cultural and linguistic differences exist, good communication skills, empathy and the maintenance of hope remain central.Practice implicationsBBN in a language in which the patient is fluent, whether mediated or not, should be the standard of care. Cultural and linguistic variance must be born in mind and clinicians should become familiar with the preferences of the communities they serve.     

“A change would do you good”: Training medical students in Motivational Interviewing using a blended-learning approach – A pilot evaluation

Objectives This study aims to assess medical students’ interest in a Motivational Interviewing (MI), the objective need for a special training, and students’ satisfaction with and the effectiveness of such a course.Methods A mandatory MI course was implemented for sixth-semester medical students. Their interest in learning MI was evaluated, along with their satisfaction with the course, which was delivered in a blended-learning teaching approach. Participants’ baseline MI skills and general communication skills were assessed. MI non-adherent behavior, like persuading and confronting patients, was noted. Successful learning was measured with a multiple-choice test administered before and after the course that assessed subjective knowledge and skills.Results Students were highly interested in learning MI. At baseline, they showed good communication skills but moderate MI skills. Satisfaction with the course was high. The course was effective, as subjective and objective knowledge and skills improved significantly.Conclusions This pilot study suggests that basic MI skills can be successfully taught in a blended-learning teaching approach. Further research should investigate sustainability and transfer to clinical practice.Practice implications Medical schools should consider providing students with special training in MI to help students counsel patients towards behavioral changes.     

Using a computer simulation for teaching communication skills: A blinded multisite mixed methods randomized controlled trial

ObjectivesTo assess advanced communication skills among second-year medical students exposed either to a computer simulation (MPathic-VR) featuring virtual humans, or to a multimedia computer-based learning module, and to understand each group’s experiences and learning preferences.MethodsA single-blinded, mixed methods, randomized, multisite trial compared MPathic-VR (N = 210) to computer-based learning (N = 211). Primary outcomes: communication scores during repeat interactions with MPathic-VR’s intercultural and interprofessional communication scenarios and scores on a subsequent advanced communication skills objective structured clinical examination (OSCE). Multivariate analysis of variance was used to compare outcomes. Secondary outcomes: student attitude surveys and qualitative assessments of their experiences with MPathic-VR or computer-based learning.ResultsMPathic-VR-trained students improved their intercultural and interprofessional communication performance between their first and second interactions with each scenario. They also achieved significantly higher composite scores on the OSCE than computer-based learning-trained students. Attitudes and experiences were more positive among students trained with MPathic-VR, who valued its providing immediate feedback, teaching nonverbal communication skills, and preparing them for emotion-charged patient encounters.ConclusionsMPathic-VR was effective in training advanced communication skills and in enabling knowledge transfer into a more realistic clinical situation.Practice implicationsMPathic-VR’s virtual human simulation offers an effective and engaging means of advanced communication training.     

Doctors’ experience of stress during simulated bad news consultations

Objective

Breaking bad news (BBN) is a core component of medicine. Psychophysiological studies confirm the subjective reports of doctors that BBN is a stressful experience. This study investigated doctors’ physiological stress responses prior to and during two simulated bad news consultations.

Methods

Thirty-one doctors participated in a speech-interaction task and two simulated BBN consultations. Heart rate (HR) and skin conductance (SC) were recorded using consecutive 30-s epochs during each of the interactions. The simulations were video recorded.

Results

Most doctors showed an early anticipatory increase in HR and SC that peaked during the reading of the case history prior to the BBN consultations. Most doctors then experienced a brief and relatively small stress response. However, about one-third of the doctors showed a significant and sustained stress response.

Conclusions

The results suggest that most doctors were cognitively engaged with the BBN tasks, however, a small proportion of doctors might have focused more on their own internal feelings and less on these contextual features.

Practice implications

In regards to training medical students and doctors, these results suggest that there is a need to focus more on the impact of these encounters on the doctors, not just their performance during these encounters.     

Effectiveness of a brief training program in relational/communication skills for medical residents

ObjectiveTo assess the effectiveness of a brief training program in relational/communication skills (RCS) for medical residents.MethodsThis longitudinal study enrolled 64 medical residents who participated in a RCS training program in small groups. Teaching was based on interviews with standardized patients and reflective practice. Video-recorded consultations were coded according to the Verona-Coding-Definitions-of-Emotional-Sequences (VR-CoDES) and a coding system developed to assess ten communication skills for breaking bad news. The outcome measures were: independent raters’ score in RCS for breaking bad news and the percentage of providing space and empathic responses, by comparing baseline (T1) skills with those after three-days (T2) and three-months (T3).ResultsAfter the training program residents provided more space for further disclosure of cues and concerns according to VR-CoDES definitions. There were significant improvements in seven of the ten communication skills for breaking bad news. All of these improvements were observed either at T2 or at T3.ConclusionThis study demonstrates the effectiveness of a brief RCS training program designed to improve medical residents’ ability to respond appropriately to patients’ cues and concerns and to conduct a breaking bad news encounter.Practice implicationsBrief RCS training programs adopting multiple approaches, should be offered as mandatory during residency programs.     

An advanced communication skills course for fourth-year, post-clerkship students.

OBJECTIVE: A novel five-module advanced communication skills course entitled "Doctor-Patient Relationships" was planned and implemented in 2000-01 at the University of British Columbia (UBC). The course was part of the final four-month component of the new MD undergraduate program: Effective Skills for Medical Practice. The goals of the communication skills course were to (1) address problems experienced by the students so far; (2) address deficiencies in achieving the UBC exit competencies; (3) help the students pass the Medical Council of Canada examinations, in particular objectives related to the Considerations of the Legal, Ethical, and Organizational aspects of the practice of medicine (CLEO); and (4) help students prepare for their roles beyond undergraduate medicine (residency, independent practice). DESCRIPTION: The course was developed by an interdisciplinary team (family practice, pathology, pediatrics, psychiatry, surgery) with input from students. The broad strengths and weaknesses of their communication skills training were identified by seven third-year medical students who kept logs over the course of their clinical clerkships to document their learning of communication skills. Analysis of these logs plus feedback meetings with the students revealed attitudinal and skills issues that needed to be addressed in the new course. The goals and principles of the course were in part agreed upon by focus groups with students, attended by faculty observers, to ensure their relevance to students. The first module "Beyond the Mask: Surviving and Thriving in Residency Training" is designed to focus students' attention on the personal relevance of developing excellence in communication skills in preparation for residency training. It includes a video of residents talking about their experiences of communication problems to trigger reflection and discussion. In the remaining four modules the students are required to put communication skills together with their medical knowledge. Each module includes pre-readings, video demonstrations (in sessions 4 and 5), practice with standardized patients (total of 14 scenarios) and structured feedback from SPs, students, and tutor. The themes of the sessions are "Dealing with Emotionally Challenging Patient Situations (informing about bad news), "Compliance and Patient Information," "Informed Consent and Shared Decision Making," and "Difficult Physician-Patient Encounters." Each module lasts two hours. The course was implemented for 120 students, facilitated by 14 tutors (seven to eight students per group). DISCUSSION: Student involvement in many different ways provided an important reality check and made us think about how to present the new course so that it was relevant and interesting to students. Attention to student input was a major contributor to the good evaluations given the course. Students rated the course highly: the relevance of the weekly themes was rated 4.21 on a five-point scale; the effectiveness of the SP interviews, 4.10; the effectiveness of the group discussion and feedback, 4.18; and overall course effectiveness in enhancing communication skills, 3.91. The tutors also rated the course highly, and the students rated the tutors highly. Minor changes will be made to the course next year based on the specific suggestions for improvement, which were identified.