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Medical Educafiort 1989, 23, 387-394 Communication skills training for medical students: an integrated approach W. G. IRWINt, R. McCLELLANDS & A.H.G. LOVES Departments oftCetiera1 Practice, $Mental Health and §Medicine, The Queen’s University of Belfast Summary. Skills of communication are not epsily taught to medical students. Three main clinical departments (general practice, medicine and mental health) of the Medical Faculty of the Queen’s University, Belfast, introduced an inte- grated course in January 1988 to teach the basic principles. The course is held at the beginning of clinical training and is an integral part of the introductory clinical course. It was introduced in response to the Report of a Working Party of the Education Committee of the General Medical Council (1987) which advocated the need for improved training in history-taking and com- munication. It is a 12-week course and every Monday and Friday afternoon from 1400 to 1700 hours 12 students are seconded from ward work, four to the Department of Medicine, four to the Department of General Practice and four to the Department of Mental Health. Hand-outs about information to be obtained and interview style are standardized and the principles to be followed are clearly defined in an aide-mimoire. Staff from the Departments of General Practice and Mental Health experienced in teaching communication by videotape feedback and analysis of consul- tations prepared 12 tutors for their role and responsibilities. Procedures to be followed were carefully explained to all students beforehand. General practice and psychiatry traditionally have established teaching programmes in com- munication but the inclusion of the Department of Medicine has made a significant impact. Students have come to realize that the taking of a Correspondence: Professor W. G. Irwin, Depart- ment of General Practice, The Queen’s University of Belfast, Dunluce Health Centre, 1 Dunluce Avenue, Belfast BT9 7HR, Northern Ireland. good history demands as much skill as the physical examination of the patient and is an important aspect of any clinical assessment. Key words: *communication; *education, medical, undergraduate; medical history taking; physician-patient relations; interviews; Northern Ireland Introduction ‘I place the interrogation of the patient himself first, since in this way you can learn how far his mind is healthy or otherwise; also his physical strength and weakness, and you can get some idea of the disease and the part affected’. Rufus of Ephesus (ca AD 100) (From MacLeod 1979) From antiquity to the present experienced doctors have stressed the importance of doctor- patient communication and most current text- books on clinical examination lay considerable stress on the skills of patient interviewing. Clinical medicine is above all else about com- munication between two people, it is about establishing an effective working relationship in which there is mutual trust. The history of each patient’s problem is often the most important part of the clinical assessment and the taking of a good history demands as much skill as the physical examination (MacLeod 1979; Ogilvie 1980). In spite of these widely accepted views among the profession recent studies have shown that young doctors are frequently deficient in these very skills (Helfer 1970 Aloia & Jonas 1976; Byrne & Long 1976; Maguire & Rutter 1976a; 387

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Page 1: Communication skills training for medical students: an integrated approach

Medical Educafiort 1989, 23, 387-394

Communication skills training for medical students: an integrated approach

W. G. IRWINt, R. McCLELLANDS & A.H.G. LOVES

Departments of tCet iera1 Practice, $Mental Health and §Medicine, T h e Queen’s University of Belfast

Summary. Skills of communication are not epsily taught to medical students. Three main clinical departments (general practice, medicine and mental health) of the Medical Faculty of the Queen’s University, Belfast, introduced an inte- grated course in January 1988 to teach the basic principles. The course is held at the beginning of clinical training and is an integral part of the introductory clinical course. It was introduced in response to the Report of a Working Party of the Education Committee of the General Medical Council (1987) which advocated the need for improved training in history-taking and com- munication. It is a 12-week course and every Monday and Friday afternoon from 1400 to 1700 hours 12 students are seconded from ward work, four to the Department of Medicine, four to the Department of General Practice and four to the Department of Mental Health. Hand-outs about information to be obtained and interview style are standardized and the principles to be followed are clearly defined in an aide-mimoire. Staff from the Departments of General Practice and Mental Health experienced in teaching communication by videotape feedback and analysis of consul- tations prepared 12 tutors for their role and responsibilities. Procedures to be followed were carefully explained to all students beforehand. General practice and psychiatry traditionally have established teaching programmes in com- munication but the inclusion of the Department of Medicine has made a significant impact. Students have come to realize that the taking of a

Correspondence: Professor W. G. Irwin, Depart- ment of General Practice, The Queen’s University of Belfast, Dunluce Health Centre, 1 Dunluce Avenue, Belfast BT9 7HR, Northern Ireland.

good history demands as much skill as the physical examination of the patient and is an important aspect of any clinical assessment.

Key words: *communication; *education, medical, undergraduate; medical history taking; physician-patient relations; interviews; Northern Ireland

Introduction

‘I place the interrogation of the patient himself first, since in this way you can learn how far his mind is healthy or otherwise; also his physical strength and weakness, and you can get some idea of the disease and the part affected’. Rufus of Ephesus (ca AD 100)

(From MacLeod 1979) From antiquity to the present experienced

doctors have stressed the importance of doctor- patient communication and most current text- books on clinical examination lay considerable stress on the skills of patient interviewing. Clinical medicine is above all else about com- munication between two people, it is about establishing an effective working relationship in which there is mutual trust. The history of each patient’s problem is often the most important part of the clinical assessment and the taking of a good history demands as much skill as the physical examination (MacLeod 1979; Ogilvie 1980).

In spite of these widely accepted views among the profession recent studies have shown that young doctors are frequently deficient in these very skills (Helfer 1970 Aloia & Jonas 1976; Byrne & Long 1976; Maguire & Rutter 1976a;

387

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388 W. G. Irwin et al.

Korsch et a\. 1986). The recent report of a working party of the Education Committee of the General Medical Council (1987) stresses the need for improvements in the teaching of com- munication skills within the undergraduate cur- riculum. In addition to such professional evaluation there has been a growing public demand for improvements in doctor-patient communication (Hodgkinson 1987). Patient dis- satisfaction appears to fall into two major domains: lack of empathy and lack of informa- tion (Sanson-Fisher & Poole 1979; Fitzpatrick & Hopkins 1981).

In response to the growing awareness of these difficulties clinical teachers in several UK medical schools have established teaching pro- grammes in history-taking and communication skills training. Present evidence suggests that the apprenticeship method of teaching these skills is less effective than the use of feedback methods, particularly videotape feedback (Maguire et al . 1978).

At Queen’s University the Department of General Practice has for many years been con- cerned with the teaching and assessing of com- munication skills during the undergraduate teaching programme in general practice (Irwin & Perrott 1981; Irwin & Bamber 1984). In the autumn of 1987, in the wake of the above report, senior clinical academics from the Departments of General Practice, Medicine, Surgery and Mental Health met to consider the introduction of an integrated programme of communication skills training in the undergraduate curriculum. There was full agreement for the proposal, which had several novel features. It was to be intro- duced at the beginning of clinical training as an integral part of the clinical introductory pro- gramme; the tutors would be recruited from the main clinical specialties; in addition to didactic teaching on communication skills, students would receive small-group experiential teaching using videotape feedback; student assessment of the new programme would be carefully moni- tored. The integrated approach from several departments ensured adequate tutor resourcing for the labour-intensive small-group teaching. The new programme was based on that presently used in the Department of General Practice and borrows from the published work of Maguire & Rutter (Maguire & Rutter 1976b).

Preparation of tutors

A total of 12 tutors were involved with the small-group skills teaching programme. Several staff were experienced in the use of videotape feedback while others attended communication skills workshops by Creed & Maguire. A prepar- atory seminar was held for all tutors a t which the objectives of the small-group teaching were carefully outlined and their relationship to the rest of the clinical introductory programme explained. Arrangements for recording of inter- views and the role and responsibilities oftutors in the video feedback sessions were discussed at length and illustrated using videotape examples. Furthermore, guidelines for tutors were planned as follows.

Preparation of students

Outline the ultimate goals, namely the development of self-assurance, warmth and empathy together with competence in the inter- view process. Specific goals for the training session must be appropriate to the student’s level of experience. Students should be encouraged to recognize that there is no single correct way to good interviewing. Optimal methods should be considered for the specific task in hand. The procedure involving videotape feedback should then be carefully explained. Clear instructions must be given, e.g. ‘only take the history of presenting condition’. Procedures for time allo- cation must be clearly indicated, e.g. when and how will the interview be stopped during the recording sessions.

Video feedback session

Feedback procedure has two major foci - information gathered and the skills of inter- viewing.

Three learning processes are available during the feedback session:

(1) natural learning, from the student’s own

(2) peer comments; (3) tutor opinion, comment and encourage-

ment - faults should not be overempha- sized as natural learning will take care of many of them.

review of performance on tape;

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Cornrritrriiratiori skills training 389

The procedure should be explained, including stopping the rape and putting questions. The students should then be invited to give a brief review embracing:

(1) summary of clinical presentation; and (2) assessment of interview: how trainee felt,

Some suggestions should be made with regard

(1) Stopping the tape:

how did the patient fare.

to improving tutor performance.

I t is perhaps best if a group member rather than the tutor puts a question, and helpful to stop on a positive point and put a question to the group - what was observed, why was the tape stopped, how would the other members proceed?

(2) Encourage and reinforce natural learning: (3) Choice of issues:

One should commence with basic issues- seating, explaining aims, taking notes; take only one issue at a time - if several in current sequence, replay the tape sequence; and don’t overpoint faults as natural learn- ing from video feedback will take care of many.

(4) Finding alternative interview approaches: Always consider suggestions from the group - peer comments are valued. The use of role-play should always be carefully appraised to supplement real patient interviews.

(5) Use of ‘talking through’ an interview sequence - especially where problems experienced or change of tack or where solutions are uncovered during an inter- view sequence.

There is a need to be aware of threat and avoidance of the ‘hot seat’; to encourage positive aspects first; to acknowledge feel- ings and encourage group participation. I t is helpful to make use of personal experi- ence and humour. When pointing to alter- natives emphasize that there is no single right way. Point out the acceptability of ‘error’, that it is necessary for learning. Wait for a safe time and optimal time to comment on ‘errors’. Finally, avoid group scapegoating of a difficult patient - again the need for appropriate skills should be developed.

(6) Coping with anxiety:

(7) Group work: One should encourage the group to put questions - e.g. stopping the tape, why was the tape stopped, finding alternatives, proposing the next step, etc. Also encour- age the group to focus on one point at a time and avoid diffuse discussion. The tutor has a key role in coordinating, con- trolling and focusing discussion. It is essential to deal with disagreements over the trainer’s leadership and guidance - alternatively rewind and review and use follow-on as a test.

(8) Tutor comments should be useful. One should realize the importance of tutor empathy, encouragement and positive regard for the student and patient.

(9) Use of summaries - in the form of questions to the group, ‘what was in the introduction’. It may be necessary to recapitulate to reinforce.

(10) Reinforcement of key principles. Review and evaluation:

One could consider the use of a check-list of items of behaviour to evaluate com- munication skills in an interview, and ask what were the most helpful and least helpful aspects of the whole procedure.

The introductory clinical course

In the second year of the 5-year medical curricu- lum in the Queen’s University, Belfast, a 3- month introductory clinical course is organized, which is mandatory for all students. It forms the first in-depth clinical exposure to real patients in hospital and general practice. The overall objectives of the course are to give students a sound grasp of clinical skills and an ability to relate to and understand their patients. We begin therefore with an emphasis on communication skills as a basis for subsequent clinical instruction in history-taking and later in methods of physical examination. Students receive as an introduction several lectures on the characteristics of the doctor-patient relationship and the means of achieving effective doctor-patient communica- tion. These lectures are shared between the three departments concerned. They present the theory and techniques of good interviewing and the dificulies likely to be experienced. Regrettably,

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390 W . G. l w i n et al

surgery is not currently involved in instructing about communication and history-taking at this stage of the second-year course.

New 12-week course in history-taking and communication

Every Monday and Friday afternoon from 1400 to 1700 hours 12 students are seconded from ward work to a new course in history-taking and communication - four to the Department of Medicine, four to the Department of General Practice and four to the Department of Mental Health. These are videorecording sessions of students in role-play and real interviews with patients. Each student is given two sessions.

Discussion and hand-outs about communi- cation and clinical interviewing skills are stand- ardized as far as possible and emphasize the following principles:

(1) Diagnosis and treatment begin with the interview. Communication is about gathering information as efficiently as possible in the time available and learning to define as precisely as possible the patient’s problems and why he or she may have chosen to come to the doctor.

(2) Knowledge and experience of communi- cation must be blended with knowledge of medicine and clinical reasoning to produce an effective interview process. Medical students must become skilled in conduct- ing patient interviews.

(3) The interview process is a key component of all medical consultations. History- taking notes commonly list specific ques- tions to be asked to identify common symptom patterns and characteristics. It is important to become familiar with these questions.

(4) However, a clinical interview is not the administration of a questionnaire. There are basic skills which have applicability to all types of interviews and are important irrespective of the nature of the patient’s complaints, whether physical or psycho- logical, and irrespective of the discipline of the interviewer, whether social worker, general practitioner, psychiatrist, surgeon or physician.

Difficulties in interviewing are commonly

(1) Lack of a systematic interview procedure including the manner of beginning and terminating interviews.

(2) Failure to seek clarification of the patient’s problems and the need to check the accu- racy of the patient’s story.

(3) Difficulty controlling the interview and providing clear time-limits. Students are often afraid that any attempts to interrupt and redirect the conversation may make patients uncooperative and resentful.

(4) Premature and restricted focus for the interview and in particular failure to attend to problems and issues in the psychological and social dimensions.

(5) An insensitivity or lack of responsiveness to verbal and non-verbal cues.

(6) Deficiencies in the questioning style with the use of leading questions or multiple questions.

(7) Lack of self-awareness, including manner- isms which hamper the process of com- munication with the patient.

(8) Difficulties with taking notes and main- taining eye contact.

An aide mimoire setting out the information to be obtained and main elements ofinterview style has been prepared; it is pocket sized and is of firm plastic material. Its content is as follows:

‘The main aim is to find out what has brought the patient to see you at this point in time. There may be several problems so prioritization will also need to be established. Details of the main problems should therefore be sought as follows:-

experienced in the following areas:

(1) The nature of the problems - characteristics - onset - course of the illness - precipitating factors - help so far and support available.

- on work life - on key relationships - on social life - on mood.

condition - the nature of the illness - the future.

(2) The impact on daily life

(3) The patient’s perception of their own

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Communication skills training 39 1

Other vulnerability and precipitating factors (personal history)

- positive family history - relevant social personal history - similar illness in the past - premorbid personality.’

Next the aide mimoire presents a suitable interview style and procedures:

Interviewing style

Beginning the interview (a) Introduce yourself, put the patient a t

ease, state who you are and the pur- pose of the interview

(b) The seating arrangments - ensure privacy, chairs at a comfortable dis- tance and angle

(c) Time-limits - it is advisable to inform the patient of the amount of time available for the interview

(d) Notes - explain and ask permission to take notes. Most patients readily agree.

Interview procedures

Appropriate use of the following: (a) Listen carefully to the patient (b) Facilitate using both verbal and non-

verbal responses (c) Attend to both verbal and non-verbal

cues (d) Clarify by appropriate use of quest-

ions, repetition, summarizing. Avoid jargon

(e) Avoid premature focus on the initial problem

(0 Control the interview by encouraging the patient to keep to the point

(g) Appropriate use of questions - use open questions before going

- use single questions - avoid leading questions

(h) A positive and supportive atmosphere can be enhanced by informality of style, a pleasant and warm manner, good eye contact, avoidance of physi- cal barriers, proximity.

on to ask specific questions

(3) Ending the interview (a) Summarize the problem (b) Ask if there is anything else troubling

the patient (c) Would he/she like to ask any

questions. During each session students are introduced to

the kind of questions and questioning style required of an effective interview as illustrated below (from the Professional Communication Unit, University of Capetown).

Direct: Directly involve patient Open: Opportunity for lengthy answer.

Broad or general information. Few restrictions on how patient might answer

Advantages: Encourage catharsis Reveal emotional state Easy to answer

Interview is more difficult to control Recording answers is more difficult

Controlling: Change direction of the conver- sation and introduce a new subject

Closed: Yes/No option. Produces only short answers

Advantages: Saves time and money

Disadvantages: Consume time and energy

Maximize control of the interview Use when you know what information you want When patient is shy and reluc- tant to talk

Thwarts patients who feel they need to explain Falsification is easy

Disadvantages: Information is limited

Probing: Extend enquiry and build upon an answer already given

Reflecting back: Used by doctor to test his understanding of patient’s message Patient produces the answer he thinks the doctor might like to hear

Indirect: Doctor makes the question a generalized non-personal one.

The procedure for the training sessions embracing role-play, patient interviewing and

Leading:

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392 W. G. Irwin et al.

video are explained by the tutor. We have generally found the most cost-effective arrange- ment to be two students separately interviewing one patient. The first student tries to elicit as fully as possible the nature of the patient’s presenting problems and the impact on hidher life within the allotted time of 10 minutes. The task of the second student is to establish the patient’s per- ception of the problems and then to discover the past medical, family and social histories, again within a 10-minute interval. The interview is observed with a video monitor or one-way screen by the other students. Following this the procedure is repeated with the second patient/ role-play and second pair ofstudents. The second half of the training session consists of a 60-90- minute video review of each student’s interview. All members of the group are encouraged to participate - to ask questions, to comment on style, to suggest alternatives and to assess the quality of the interview process. The week following each group of four students is given a second training session at the end of which they are invited to complete written anonymous assessment of the training exercise.

Introductory clinical course 1988

Rating of interview skills training

Figure 1 illustrates the format of the course evaluation form completed by each student. Overall scores were positive and very supportive of the whole concept of an integrated learning approach by the three departments. The students enjoyed being videorecorded, videotape analysis of the interview and feedback of per- formance.

Reinforcement of learning

All three departments in their different specialist ways try to reinforce strongly basic knowledge of interviewing skills in their later fourth- and fifth-year clinical clerkships.

Department of General Practice

The systematic use of closed circuit television in the Department of General Practice and its

clinical base in Dunluce Health Centre to teach communication and the primary diagnostic pro- cess in medical care has been described (Irwin & Perrot 1981). A later paper from the Department discusses an evaluation of fourth-year medical student behaviours in consultations with real patients in general practice (Irwin & Bamber 1984). The methodology of teaching communi- cation and its assessment by direct observation are fundamental to the evaluation of history- taking in clinical cases from general practice in the Final MB Part I1 Examination, the Queen’s University, Belfast (Irwin 1987).

Department of Mental Health

The Department of Mental Health also uses videotape feedback to develop further student interviewing during the first week of the psy- chiatry clerkship. To this is added training in the specialist skills of psychiatric interviewing and assessment, also evaluated in the final qualifying examination.

Department of Medicine

The Department of Medicine seeks to enhance and mature communication skills throughout the subsequent three clinical years. Immediately following the introductory course, junior clerkships (12 weeks) in the major teaching hospitals concentrate upon history-taking and elicitation of physical signs. Fourth-year attach- ment (6 weeks) is to more peripheral medical units. Their associated teaching staff pay particu- lar attention to case contact and problem defi- nition by the students. Attachments to rheumatology in association with the Depart- ment of Community Medicine help to develop skills in the recognition of disability and social handicap. Final year with its senior medical clerkship (4 weeks) leads to the Final MB clinical examination where all students are observed by the examiners during the history-taking part of their long case. This has been particulary helpful in assessing abilities in patient contact.

In summary we believe that by the end of training the young graduate should have learned to communicate easily, be readily understood, inspire trust and involve the patient in advice,

Page 7: Communication skills training for medical students: an integrated approach

Communicat ion skills training

Figure 1. Interview skills training (small-group video feedback)

Please indicate where your training sessions were held:

393

General practice Medicine Mental health

What is your opinion of:

(1) The length of each session? Too long About right Too short

R (2) The number of sessions? Too long About right Too many

PLEASE MARK THE APPROPRIATE COLUMN TO GIVE YOUR OPINION:

Very good = 1; Good = 2; Average = 3; Poor = 4; Bad = 5.

1 2 3 4 5 (3) The quality of teaching overall? (4) The overall content of learning? (5) The format of each session - introduction? (6) Being videorecorded? (7) Video analysis and feedback of

(8) Use of role-play, not real patients? 19) Use of video case examples involving staff

pe rfo r m a nce?

to identify communication skills?

Other comments:

planning and treatment. It is to be hoped that our integrated approach to teaching communication in the second-year course will ensure that each student understands that there is more to history- taking than simply asking questions and learns how to establish effective working relationships with patients.

References

Aloia J.F. &Jonas E. (1976) Skills in history-taking and physical examination. Medical Education 51, 410-15.

Byrne P.S. & Long B.E.L. (1976) Doctors Talking to Patients. HMSO, London.

Fitzpatrick R. & Hopkins A. (1981). Patient’s satis- faction with communication in neurological out- patients’ clinics. Journal of Psychosomatic Research 25,32’+34.

General Medical Council (1987) Report of a working party of the Educarion Committee on the tearhing of behauioural sciences, community medicine and general practice in basic medical education. General Medical Council, London.

Helfer R.E. (1970) An objective comparison of the paediatric interviewing skills of Freshmen and Senior Medical Students. Paediatrics 45. 623-70.

Hodgkinson N. (1987) Doctors go to class for bedside manner. The Sunday Times, 4 October, p. 13.

Irwin W.G. (1987) Current involvement of university departments of general practice in the final qualify- ing examination of medical schools in the UK. Journal ofthe Royal College ofCeneral Practitioners 36.

Irwin W.G. & Bamber J.H. (1984). An evaluation of medical students’ behaviour in communication. Medical Education 18, 9C5.

iiwin W.G. & Perrott J.S. (1981) Medical education: systematic use of closed circuit television in a general practice teaching unit. journal of the Royal Colfege of Generat Practitioners 31, 557-60.

21-3.

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394 W. G. I r w i n et al.

Korsch B., Gozzi E. & Francis C. (1986) Gaps in doctor-patient communication. Paediatria 62, 855-71.

MacLeod J. (1979) The history and the general prin- ciples governing the physical examination. In: Clinical Examination. Churchill Livingstone, Edinburgh.

Maguire G.P. & Rutter D.R. (1976a) History-taking for medical students. Lancet ii, 556-8.

Maguire G.P. & Rutter D.R. (1976b) Training medical students to communicate. In: Communication between Doctors and Patients fed. by A.E. Bennett.) Oxford University Press, London.

Maguire P., Roe P., Goldberg D., Jones S., Hyde C. & O’Dowd T. (1978) The value of feedback in

teaching interviewing skills to medical students. Psychological Medicine 8,695-704.

Ogilvie C. (1980) The history and general principles of examination. In: Chamberlain’s Symptoms and Signs in Clinical Medicine. John Wright & Sons, Ltd, Bristol.

Sanson-Fisher R. & Poole A. (1979) Teaching medical students communication skills. in: Research in Psy- chology and Medicine. Academic Press, London.

Received 17 October 1988; editorial comments to alrthors 22 December 1988; acceptedforpublicatioti 20 January 1989