Attitude of Medical Students - Dr. Zita

8/12/2019 Attitude of Medical Students - Dr. Zita

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Med Educ Online [serial online] 2006;11:18Available from http://www.med-ed-online.org

Wrght, KB, Bylumd C, Ware J, Parker P, Query JL, Baile W. Medicalstudent attitudes toward communication skills training and knowledgeof appropriate provider-patient communication skills: A comparison of

rst-year and fourth-year medical students.

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Medical Student Attitudes Toward Communication Skills Training andKnowledge of Appropriate Provider-Patient Communication: A Comparison

of First-Year and Fourth-Year Medical Students

Kevin B. Wright, PhD *, Carma Bylund, PhD , Jennifer Ware, MA , Patricia Parker,

PhD

, Jim L. Query, Jr, PhD||

, Walter Baile, MD

*Department of Communication, University of OklahomaDepartment of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center Department of Communication, University of MemphisDepartment of Psychiatry, M. D. Anderson Cancer Research Center ||School of Communication, University of Houston

Abstract - Drawing upon Blooms taxonomy of educational objectives as a theoretical framework,this study examines attitudes toward communication skills training, knowledge of appropriate pro-vider-patient communication, and con dence communicating with patients between rst-year andfourth-year medical students at a large medical school in the southern United States. The study

ndings indicate that fourth-year medical students do not differ from rst-year medical students

in terms of attitudes towards communication skills training or knowledge of appropriate provider- patient communication, but they have signi cantly higher con dence scores about communicatingwith patients. In addition, positive attitudes towards communication skills training are signi cantlyrelated to perceived importance of communication skills and con dence when communicating with

patients. Finally, female medical students have more positive attitudes towards communication skillstraining than male medical students. The implications of the study ndings and directions for futureresearch are also discussed.

Over the last 30 years, communication skills in themedical school curriculum have received a considerableamount of attention among scholars in a variety of dis-ciplines, including communication. 1-5 Research on com-munication skills training suggests good communicationskills may improve the physician-patient relationship andare related to positive health outcomes for patients, suchas improved compliance, satisfaction with care, and ben-e ts to physical and psychological health. 6- 8 In addition,good provider communication skills have been linkedto more ef cient health care organizations and effectivehealth care delivery, provider and patient satisfaction, andfewer incidents of malpractice. 9,3,10,11

Based upon the ndings of this body of research,many medical schools across the country and nationalmedical organizations, such as the Association of Ameri -can Medical Colleges (AAMC), have recently supportedan increased emphasis on communication skills as animportant part of medical education. 12 Despite the in-terest in communication skills training for medical stu-dents, most communication skills training studies haveinvolved more experienced providers such as residents,fellows and attendings. 13 However, medical school typi-cally exposes future physicians to medical communica-tion through coursework. Their experiences with commu-nication skills training in medical school is likely to shape

their perceptions of communication issues and how theyinteract with patients throughout their career. 2

While a variety of communication skills training programs have been found to improve providers knowl-edge, attitudes, and skills, 14-16 there are a number of issuesthat may impede the success of communication skillstraining, especially among medical students. 2 Previousresearch suggests that variables such as attitudes towardscommunications skills training, attitudes towards thevalue of medical communication skills, medical studentexperience within the clinical setting, and demographicvariables may all in uence the success of a communica -tion skills training program. 17-19

The relationship between attitudes toward com-munication skills training and the effective learning ofthese skills is consistent with several models of learning,most notably Blooms (1956) taxonomy of educationalobjectives. While there has been some interest in apply-ing Blooms taxonomy to medical student education, 20, 21 these studies have primarily focused on the cognitive and

psychomotor dimensions of Blooms taxonomy as opposed to the affective domain. Moreover, these studieshave not speci cally explored the relationships betweenaffective aspects of the taxonomy, such as medical studentattitudes toward communication skills training, on learn-


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ing outcomes such as knowledge of appropriate medicalcommunication behavior, perceived importance of com-munication skills, or self-assessments of con dence incommunicating with patients.

Accordingly, the purpose of this study is to explore

the relationships among medical student attitudes towardcommunication skills training, perceptions of the impor-tance of medical communication, knowledge of appro-

priate medical communication skills, and their perceivedcon dence in their ability to communicate effectivelywith patients. In addition, the study explores differencesin these perceptions between rst and fourth-year medicalstudents and between male and female medical students.

Blooms Taxonomy of Educational Objectives

Notwithstanding its limitations, Blooms 22 taxonomyof educational objectives serves as a useful theoretical

framework for studying medical student attitudes to-wards communication skills training (see also Bloom andcolleagues 23 for an extension of this taxonomy). The tax-onomy is useful in explicating the hierarchical nature oflearning, and it contains three domains of learning: cogni-tive, affective, and psychomotor.

The focus of this study is on measuring aspects ofthe affective domain. This domain consists of attitudes,values, motivation, and feelings toward the information a

person is learning. As with the other domains, the affec-tive domain is hierarchical. For example, the lowest levelof the affective domain hierarchy includes behaviors suchas awareness of a phenomena and willingness to pay at-tention to it. At the next level of the affective domain hier-archy, people attend and react to a particular phenomenonor piece of information. In addition, there is some level ofsatisfaction associated with reacting to it. The next levelof the affective domain hierarchy is known as valuing, orthe worth or value a person attaches to a particular object,

phenomenon, or behavior . In other words, at this stagean individual begins to associated feelings of worth orvalue to what they are learning. Next in the hierarchy,

people organize values into priorities by contrasting dif -ferent values, resolving con icts between them, and cre -ating a unique value system. Finally, at the top of the af-fective domain hierarchy, individuals internalize valuesabout what they are learning, and they tend to behave inways that are consistent with these values. For example, amedical student who has internalized positive values as -sociated with communication skills training would likely

behave in ways that are consistent with those values,such as listening to patients more, explaining treatmentsin ways that the patient will understand, and attending tothe physical, psychological, and social needs of patients

when constructing messages.

Perceptions of Communication Skills Training andMedical Communication

Several researchers have found that attitudes toward

communication skills training are an important anteced-ent to acquiring communication skills. Medical studentsattitudes toward communication skills training may beimportant indicators of the importance they place uponthem, and they may eventually in uence communication

behaviors in clinical settings. 18 However, previous studieshave also found that courses dealing with communicationskills training often have mixed results in terms of theirin uence on the attitudes of medical students. 24-26

Rees and colleagues, 27 in a qualitative study of medi-cal students, found that students held both positive andnegative attitudes towards different aspects of communi-

cation skills learning. Negative attitudes were related tothe perception that communication skills training coursesare subjective and take a soft social science approach,and that many of the behaviors emphasized in communi -cation skills training courses are basically common senseor too easy. Many of the students with negative attitudestoward learning communication skills believed them-selves to be good communicators. In other words, indi-viduals who perceived themselves as being able to con-

dently communicate with patients tended to have nega -tive attitudes towards communication skills training.

There is some evidence that suggests medical stu-dents attitudes toward communication skills are in u -enced by taking courses that emphasize communicationskills training. 28 In a study that examined attitudes to-wards communication skills before and after a communi-cation skills course, investigators found that the studentsrated their communication skills signi cantly lower at theend of the course than before the start of the course. Posi-tive attitudes towards communication skills learning also

became signi cantly lower by the end of the course com - pared with the start. These researchers believe that themedical students in this study might have been overcon-

dent about their abilities to communicate with patientsinitially, and that the communication issues they learnduring communication skills training might have reducedtheir overcon dence to more realistic levels.

The reviewed literature suggests that medical studentattitudes toward communication skills training likely in-

uences perceptions of the importance of these skills, andthey may eventually in uence the learning and adoptionof communication skills in the clinical setting. In addi-tion, attitudes toward communication skills training are

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also likely to be related to medical student assessmentsof their ability to communicate effectively with patients.However, much of the previous work in this area hasinferred these relationships among variables rather thanspeci cally testing them.

RQ1: Medical students attitudes towardcommunication skills training will berelated to their perceptions of the im-

portance of medical communication,con dence about communicating with

patients, and knowledge about appropri-ate provider communication.

Experience Communicating with Patients and Per-ceptions of Communication Skills

According to Humphris and Kaney, 2 many coursesdo not introduce teaching of communication skills until

midway into the medical curriculum, to coincide withthe traditional starting point of the clinical component oftraining. Third and fourth-year medical student trainingis much more focused on actual clinical work than thetraining of rst and second-year students, who primarilydeal with classroom lecture about communication or sim-ulated training with standardized patients. Since third andfourth-year medical students spend more time interactingwith actual patients and dealing with real, as opposed tosimulated, health issues, it is reasonable to assume thatthese differences in experiences would affect perceptionsof both communication skills training and the importanceof medical communication skills.

There is some evidence that beginning medical stu-dents may differ from more experienced medical studentsin terms of their perceptions of communication skillstraining as well as their perceptions of the importance ofmedical communication skills. 4,15, 17 Studies comparingcommunication skills between more experienced medi-cal students and beginning medical students have demon-strated mixed results. Some studies have shown that theexperience third and fourth-year medical students gain byactually communicating with patients tends to improvetheir communication skills. For example, Kaufman 17 found that experience with patients in clinical settingstended to promote the acquisition of communicationskills that were often learned at earlier points in the medi-cal school curriculum. In addition, Kaufman 17 suggestedthat medical students who had performed basic commu-nication skills with patients in a clinical setting may bemore con dent in their ability to communicate with pa -tients than medical students who lacked this experience.However, Roter and Hall 29 report that since communica-tion skills are often emphasized in coursework taken ear -

lier in the medical school curriculum, beginning medicalstudents are often more knowledgeable about communi-cation skills than more advanced medical students, andthat knowledge of communication skills may deteriorateover time.

Kaufman17

also found that while medical studentsexperience communicating with patients increased theircon dence about performing basic communication skills,these experiences did not necessarily increase con denceabout their ability to perform more complex communica-tion skills (such as discussing sensitive issues with pa-tients or breaking bad news). It is possible knowledgeof more complicated communication situations, such asdiscussing dif cult topics with patients, coupled with arelatively small number of experiences of actual commu-nication with patients, might actually raise apprehensionamong more advanced medical students and underminecon dence about their abilities to communicate effective -

ly in these types of situations. By comparison, beginningmedical students exposure to dif cult medical communi -cation situations is often limited to textbook descriptions,and this may lead them to be more con dent about theirabilities to handle them effectively.

Given the ndings of these studies, it appears thatrst-year and fourth-year medical students likely differ in

terms of their perceptions of communication skills train-ing, con dence in communicating well with patients, andknowledge about appropriate provider communication.Yet few studies have examined how attitudes towardscommunication skills training may differ between begin-ning and advanced medical students. Although it is likelythat more experience with patients in clinical settingsaffects attitudes towards communication skills. Whilecon dence about communicating with patients shouldincrease as a medical student gains experience with pa-tients, self-perceptions of con dence could possibly beundermined if actual communication experiences with

patients raise doubts about the ability to communicateeffectively. Finally, since some studies have found thatknowledge of communication skills deteriorates as medi-cal students advance into later stages of the curriculumand others have found that experience with patients fos-ters the development of communication skills, it is impor-tant to compare how knowledge of good communicationskills may change over time.

RQ2: Are there differences between rst-year and fourth-year medical students interms of their attitudes toward commu-nication skills training, perceptions ofthe importance of medical communica-tion, con dence about communicating

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with patients, and knowledge about appropriate provider communication?

Gender Differences in Communication Skills AmongMedical Students

There is some evidence that attitudes toward com-munication skills training may also be associated withdemographic variables, such as gender 4. While few stud-ies have explored the relationship between gender and

perceptions of medical communication skills, some smallgender differences might be expected. A recent meta-analysis 19 indicated that female physicians are more likelyto perform more patient-centered communication behav-iors such as collaborative communication, empathic com-munication and giving psychosocial information. Otherresearchers have found that male medical students wereslower at learning communication skills than females. 30

RQ3: Are there gender differences interms of medical students attitudes ofcommunication skills training, percep-tions of the importance of medical com-munication, con dence about commu -nicating effectively with patients, andknowledge about appropriate providercommunication?

Methods

Sample Characteristics - Medical students wererecruited for the survey by the rst author at a large met -ropolitan medical school in the southern United States.There were 118 rst-year and fourth-year medical stu -dents respondents to the survey (N = 118). Of these indi-viduals, 71 were rst-year and 47 were fourth-year medi -cal students. The gender of respondents was 68 male and50 female. The ethnicity of respondents was 96 white,nine African-American, three Asian-American, and theremainder were classi ed as other. The majority of thesample (113) indicated that English was their rst lan -guage while ve indicated that English was their secondlanguage. The average age for the sample was 25.17 ( SD = 3.41). The medical students had taken an average of1.35 ( SD = 1.87) courses that emphasized communicationskills training.

Medical Communication Curriculum for the Par-ticipants - Medical students at the institution where thestudy took place are required to take a four-year interdisci-

plinary course with an emphasis on communication skillstraining. In addition to communication and clinical skills,such as physical examination and patient interviewing,other topics presented in this course include prevention,

epidemiology, behavioral development, nutrition, medi-cal ethics, culture and professionalism.

The rst two years of this course are taught throughsmall group discussions and role play with faculty, di-dactic sessions, working with a community preceptor

physician to examine and interview patients under the physicians supervision, and practical sessions where stu-dents learn and practice communication and other clinicalskills such as techniques of physical examination and pa-tient interviewing. During the last two years, students ro-tate through clinical clerkships and attend workshops onspecial topics throughout the year such as palliative care,complimentary and alternative medicine, HIV/AIDS, andgiving bad news. The participants in this study included

both rst- and fourth-year medical students. The surveywas administered at the end of the academic year. Thus, atthe time of participation in the study both had completedthe same curriculum in the rst year, while the fourth year

students had also completed the curriculum in the second,third, and fourth years. Both the rst and fourth year stu -dents were exposed to identical content and instructorsduring their rst year.

Medical students graduating from this institution in2005 and after will be required to take and pass a nationaltest using standardized patients (SPs), a process that testsstudents communication and interpersonal skills as wellas clinical skills. This is mandatory for certi cation andlicensure, and many medical schools in the United Statesmay require passing this test as a requirement for gradua-tion.

Survey Instrument Measures - The survey ques-tionnaire used four established measures, and demo-graphic questions. The reliability of each instrument wasassessed using Cronbachs alpha. The instruments usedwere Communication Skills Attitude Scale (CSAS) 31,Perceived Importance of Medical Communication 18, Per-ceived Con dence about Communicating with Patients, 32 Appropriate Provider Communication Knowledge. 32

The researchers measured the medical students at-titudes toward communication skills learning using Com-munication Skills Attitude Scale (CSAS). 31 This 26-itemmeasure uses a ve-point Likert-type scale, and it in -cludes positive and negative statements about communi-cation skills training. Examples of positive CSAS itemsincluded, Learning communication skills will help merespect patients, and In order to be a good doctor I musthave good communication skills. Examples of negativeCSAS items included, I cant see the point in learningcommunication skills, and Communication skills learn-ing should be left to psychology students, not medical stu-

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dents. All negative CSAS items were reverse coded foranalysis, so that higher scores on all items indicated more

positive attitudes toward communication skills training.The reliability coef cient for all CSAS items was 0.87.

Perceptions of the importance of medical commu-nication were assessed using an instrument developed

by Languille and colleagues.18

This measure contains12 items and uses a ve-point Likert type scale to as -sess various attitudes towards the importance of com-munication in a variety of medical situations, including

patient-provider interactions and communication amonghealth care workers. Examples of items included, Gooddoctor-patient communication improves patients healthoutcomes, and Giving information about lifestyle isimportant in medical practice. The reliability coef cientfor this measure was 0.79.

The researchers assessed perceptions of con denceabout communication with patients using an instrument

developed by Parker, Baile, Lenzi and Cohen.32, 33

Medi-cal students were asked to rate, on a seven-point semanticdifferential scale with not con dent at all and totallycon dent as bi-polar descriptors, how con dent theycurrently felt about their ability to successfully performeight communication behaviors. Sample items included,Initiate a discussion with a patient about his/her illnessand concerns, and Ask questions that will increase

patients disclosure of their feelings and concerns abouttheir illness and treatment. Scores on the eight itemsfor this scale were summed to create a composite score(minimum score=8; maximum score =56). The reliabilitycoef cient for this instrument was 0.90.

The medical students were also tested about theirknowledge of appropriate provider communication be-havior in a variety of provider-patient situations. Theresearchers used a measure of knowledge of appropri-ate provider communication behaviors. 32,33 The measureconsisted of 15 true/false items regarding appropriate

provider communication behaviors (minimum score=0;maximum score=15). Sample items included, Open-ended questions encourage patients to give more irrel-evant details, and A family mem-

ber should always be present whenyou break bad news. The reliabil-ity coef cient for this measure was0.76.

Data Analysis - The rst re -search question was assessed byconducting correlations betweenattitudes toward communicationskills training scores, perceptionsof the importance of medical com-

munication scores, con dence about communicating with patients scores, and knowledge about appropriate pro-vider communication scores. The researchers analyzedthe second research question concerning differences be-tween rst- and fourth-year medical students in terms ofthese variables by conducting a series of t-tests. Finally,

the third research question was assessed by conductingt-tests for these variables between male and female medi-cal students. Given that the state-of-the-art meta-analysisconducted by Roter, Hall, and Aoki 19 emphasized that thedifferences between male and female physicians, thoughsigni cant, are generally small, for this questions we ex -

pected that an educationally signi cant difference would be any difference, no matter how small.

Results

The rst research question asked whether there arerelationships among medical students attitudes toward

communication skills training, perceptions of the importance of medical communication, con dence aboutcommunicating with patients, and knowledge about ap-

propriate provider communication. Table 1 shows the bivariate correlations for each of these variables. The

ndings indicate a small positive relationship between positive attitudes toward communication skills trainingand perceived of importance of medical communica-tion. Moreover, there was a small positive relationship

between positive attitudes toward communication skillstraining and knowledge of appropriate provider commu-nication. Finally, while there was no direct relationship

between attitudes toward communication skills trainingand con dence communicating with patients, there wasa small positive relationship between perceptions of theimportance of medical communication and con denceabout communicating with patients.

The second research question was concerned withwhether there were differences between rst-year andfourth-year medical students in terms of their attitudestoward communication skills training, perceptions of theimportance of medical communication, con dence about

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Table 1: Correlations among Attitudes toward Communication SkillsTraining, Perceptions of the Importance of Medical Communication,

Confdence about Communicating with Patients, and Knowledge aboutAppropriate Provider Communication

CSAS Importance Confdence Knowledge

CSAS 0.45** 0.03 0.19*Importance 0.27** 0.09Confdence 0.08Knowledge

* p < 0.05, ** p < 0.01, 2-tailed



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communicating with patients, and knowledge about appropriate provider communication. A series of t-tests re-vealed that fourth-year medical students had signi cantlyhigher positive attitude toward communication skill train-ing scores ( M = 90.15 SD = 5.84) than rst-year medicalstudents ( M = 86.98; SD = 6.65, t (116) = -2.628, p< 0.01,

eta2

=0.06), and that fourth-year medical students hadsigni cantly higher perceived con dence scores aboutcommunicating with patients than rst-year medical stu -dents (( M = 44.73; SD = 13.17), t (116) = - 4.756, p

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Attitude of Medical Students - Dr. Zita