Communication Skills for Medical Students

Teaching and Learning Methods in Communication Training

Research on the effectiveness of medical students’ communication training has shown that the best results are achieved when communication training incorporates the use of learner-centered, experiential learning methods and feedback (Aspegren, 1999; Berkhof, van Rijssen, Schellart, Anema, & van der Beek, 2011). Moreover, the effectiveness of the communication skills training may be improved when combined with the theoretical knowledge of doctor-patient interactions (Gysels, Richardson, & Higginson, 2005). Nowadays, SPs and role-play are widely used in medical students’ communication training during the Observed Structured Clinical Examinations (OSCE; C. Lane & Rollnick, 2007; May, Park, & Lee, 2009; Wallace, 2007). More theater-based learning methods such as theater performance (Shapiro & Hunt, 2003), lectures supported by theater performance (Ünalan et al., 2009), improvisation (Hoffman, Utley, & Ciccarone, 2008), and devised theater (McCullough, 2012) have been used to teach interpersonal communication skills, history-taking skills, empathy, and compassion to medical students. However, few studies (C. Lane, Hood, & Rollnick, 2008; Mounsey, Bovbjerg, White, & Gazewood, 2006; Papadakis, Croughan-Minihane, Fromm, Wilkie, & Ernster, 1997) have compared the use and the effect of different experiential learning methods in medical students’ communication training. A comparison is needed because each experiential learning method may offer the learner a unique set of experiences and opportunities for learning.

For example, role-play enables the simulation of social settings (Mariais, Michau, & Pernin, 2012), and practicing communication skills in the role of both patient and doctor. An interchange of roles is supposed to promote empathy toward patients (J. L. Lane et al., 2001). Alternatively, the SP method provides a learning experience where medical students are in the doctor’s role and they must meet a patient regarding a specific case (a trained actor who simulates the patient’s illness or a real patient trained to perform his or her own illness; Barrows, 1993). The experience is thought to be more realistic than the one gained through role-play (Kurtz, Silverman, & Draper, 2005). In both the role-play and the SP method, some students practice communication skills while others may observe the encounter. Therefore, the focus is on the learner who is practicing a professional role. This is thought to arouse anxiety in medical students (Hoffman et al., 2008). Therefore, an experiential learning method based more on drama education, such as Theatre in Education (TIE), could offer students a supportive learning experience based more on group work. TIE differs from SPs and role-play because a theater group first performs a short performance entailing doctor-patient interaction and the group of students then reflects on the play through drama exercises (Jackson, 1993). The whole group of students is actively involved throughout the TIE workshop.

On the basis of comprehensive reflection of the previous literature, we propose novel conceptual models which show that TIE, SPs, and role-play enable somewhat different participation levels for learning ICC. The extent of participation increases as the students shift from one participation level to another. Moreover, the participation levels include reflective thinking and debriefing. We argue that the participation levels for learning ICC are to described as (a) observing and analyzing doctor-patient interaction individually (TIE, SPs, role-play), (b) debriefing during the exercise (TIE, SPs) and after the exercise (SPs and role-play), and (c) training communication skills in a doctor’s role individually in a social context (TIE, SPs, role-play). In addition, creating a psychologically safe learning environment is vital when learning ICC through these experiential methods. The participation levels and their differences in each method are illustrated in Figures 1 to 3.

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Figure 1.

Participation levels for learning ICC in the Theatre in Education method.

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Figure 2.

Participation levels for learning ICC in the simulated patient method.

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Figure 3.

Participation levels for learning ICC in the role-play method.

To conclude, TIE has rarely been applied to medical students’ communication training, whereas role-play and SPs are widely used. Because methods differ and they offer students different participation levels and learning opportunities, we were interested in comparing SPs, role-play, and TIE in our study.

Theoretical Background of the Communication Course

Medical students’ communication training may be organized as a separate communication course or it may be integrated into medical studies (communication in the disciplines [CID]; Dannels, 2001). The theoretical framework of CID is grounded on principles of disciplinary knowledge construction, the social construction of knowledge, and situated learning, when learning to communicate is seen as a context-driven activity (Dannels & Housley Gaffney, 2009). So far, studies using the CID theoretical framework have explored discipline-specific contexts and communication education in the technical sciences (Dannels, 2002; Darling, 2005), business studies (Cyphert, 2002), design (Dannels, 2005), dietetics (Vrchota, 2011), pharmacy (Hyvärinen, 2011), and medicine (Haber & Lingard, 2001; Lingard, Garwood, Schryer, & Spafford, 2003). Studies on the discipline-specific communication education in medicine have explored public speaking (Haber & Lingard, 2001) and case reports as a speaking context (Lingard et al., 2003). However, these studies have not explored the use and the effect of experiential learning methods in teaching ICC to medical students.

In this study, we developed a course in communication based on the CID theoretical framework. Therefore, we chose a specific context relevant to medical students’ future careers, namely, patient consultation practiced using three experiential learning methods. Although the CID theoretical framework sees learning as a context-driven activity and social phenomenon (Dannels, 2001), it does not explain how learning through experience and reflection occurs. Therefore, we expanded the theoretical framework of the CID with the idea of drama education, and learning through experience and reflection.

As experiential learning methods, TIE, SPs, and role-play have a link to drama education because in all these methods the setting can be seen to resemble theater: Some students engage in a fiction while others watch the fiction (Jacobsen, Baerheim, Lepp, & Schei, 2006). Drama education is playful; however, we do not play only for fun, but in order to learn. Learning in drama is seen as a creative, communal, and active process, and the concepts of learning are based on constructivism and experiential learning (Østern & Heikkinen, 2001).

Both experiential learning theories and constructivism are based on the assumption that learners construct knowledge when they attempt to make sense of their experiences (Yardley, Teunissen, & Dornan, 2012). We need to reflect on our experiences in order to convert the experience into learning through both the reflection-in-action and reflection-on-action processes that correspond with the learning event (Schön, 1983). In this study, we used the reflection-on-action process referred to as debriefing (Crookall, 2010). Crookall (2010) emphasizes the importance of debriefing in order to learn from simulations and games. Participating in a role-play does not automatically guarantee learning, but debriefing is needed in order to reflect on the experience and turn it into learning (Crookall, 2010; Lederman, 1992).

This article describes a course in communication for second-year medical students, which was based on the communication in the disciplines (CID) theoretical framework and principles of experiential learning and reflection. We explain how we used TIE, SPs, and the role-play method during the course. Then we describe our methods to explore students’ perceptions of the three methods, their attitudes to learning communication skills, and their self-reported learning outcomes in three groups using SPs, role-play, and TIE. We summarize the results of our sub-studies (Koponen, Pyörälä, & Isotalus, 2011a, 2011b, 2012), and focus on profound reflection of the results.

Method

In 2006, we developed a course in communication for second-year medical students in cooperation with a speech communication lecturer and seven clinical lecturers. No specific communication curriculum for medical students existed in our university, and therefore, we needed to select and train a group of eight facilitators to design and implement the course. Clinical lecturers received 3 hours of speech communication preparation to facilitate the training. The first author of this article was one of the facilitators selected for this task.

The objectives of the course were to (a) encourage the students to analyze doctor-patient communication, (b) practice interpersonal communication skills, and (c) enhance students’ understanding and appreciation of the importance of communication and interpersonal communication skills in the doctor-patient relationship. The course emphasized history-taking skills (especially building a relationship with the patient, asking questions, listening skills, nonverbal communication skills, and providing structure for the consultation). These skills were selected on the basis of the enhanced Calgary-Cambridge Observation Guide (Kurtz et al., 2005). A 2-hour lesson in doctor-patient communication was provided with opportunities for the learners to analyze the doctor-patient interaction shown on a DVD with specific debriefing cards. The students were divided into three groups to practice the communication skills through the TIE, SPs, or role-play methods (2 × 2 hours) and allow for opportunities to reflect on their experiences. The debriefing process in each method is described in the appendix. The patient scenarios used in each group were based on real patient cases in primary health care. Patient scenarios were written by clinical lecturers to make sure that they were suitable for second-year medical students. Three experiential learning methods were compared.

Following their participation in one of the three methods, all students spent 2 days in public health centers observing and analyzing real doctor-patient encounters. Finally, the students discussed their different learning experiences in small groups. The study period was 3 months and student grading was either pass/fail, based on active participation and a written report. Ethical approval to conduct the study was obtained from our university and all participating students gave their informed consent to participate in the study.

Results

The results from the questionnaire showed that most of the medical students (84%) in each group found TIE, SPs, and role-play as suitable learning methods for acquiring interpersonal communication competence. We found no statistically significant differences (Kruskal-Wallis test, χ² = 4.418; df = 2; p = .110) in students’ perceptions in the three groups (Koponen et al., 2011a).

The results of the cross-case analysis (containing data from open-ended questions and focus group interviews) showed that these three methods had five special elements in common: (a) the doctor’s role, (b) the patient’s role, (c) reflective participation, (d) emotional reactions, and (e) facilitators’ actions. Within these five themes, medical students indicated helpful and unhelpful aspects. First, practicing communication skills in a doctor’s role, scripts of patient roles felt to be realistic, observing the interaction, positive emotional reactions, and positively experienced facilitators’ actions were considered helpful elements in these learning methods. In addition, reflecting on the problematic situation together with peers in the modified forum theater stage in the TIE method and the multifaceted feedback discussion in the other two methods were reportedly helpful. Second, the unhelpful elements were avoiding being in a doctor’s role or having a negative experience of being in a doctor’s role, lack of medical knowledge, experiencing stress during the rehearsal, unrealistic scripts, patient cases or peer student performances, negative experience of facilitators’ actions, and, in TIE, lack of motivation and avoiding taking part (Koponen et al., 2011a).

The results of the cross-case analysis (data obtained from the open-ended questions of the questionnaire) showed that the medical students’ self-assessed learning outcomes can be summarized as following themes. The students learned (a) interpersonal communication skills, (b) awareness of one’s own and doctor’s interpersonal communication competence, (c) knowledge of doctor-patient communication and understanding the meaning of communication and interpersonal communication skills in the doctor-patient relationship, and (d) patient-centeredness. Three students reported that they did not learn anything new (Koponen et al., 2011b). The students’ self-reported learning outcomes were very similar in each of the three groups. However, students practicing communication skills through the TIE method reported learning more patient-centeredness than did the other two groups.

The results of the non-parametrical statistical tests (data obtained from the CSAS) revealed that medical students’ (n = 129) positive attitudes to learning communication skills improved significantly (Wilcoxon’s test, z = −3.932, p = .000), and their negative attitudes diminished significantly (Wilcoxon’s test, z = −3.677, p = .000) between the beginning and end of the communication course (Koponen et al., 2012). We found no significant differences between the three groups in the mean scores for positive attitude scale (PAS) measured before (Kruskal-Wallis test, χ² = 1.570; df = 2; p = .456) or after the course (Kruskal-Wallis test, χ² = 4.333; df = 2; p = .115). In addition, we found no significant differences between the three groups in the mean scores for negative attitude scale (NAS) measured before (Kruskal-Wallis test, χ² = 1.906; df = 2; p = .386) or after the course (Kruskal-Wallis test, χ² = 4.097; df = 2; p = .129). According to Mann-Whitney U test, female and male students’ scores on PAS differed significantly measured before (U = 1,176, z = −2.968, p = .003) and after (U = 1,308.5, z = −2.794, p = .005) the communication course. These results show that female students had more positive attitudes to learning communication skills at the beginning and at the end of the course. Furthermore, Mann-Whitney U test showed that female and male students’ scores on NAS differed significantly measured before (U = 1,375, z = −2.111, p = .035) and after (U = 1,302.5, z = −2.824, p = .005) the communication course. These results indicate that female students had less negative attitudes to learning communication skills than males before and after the communication course. In summary, female students had more positive attitudes to learning communication skills than males (Koponen et al., 2012).

Discussion

First, medical students perceived all three methods favorably. We found no statistically significant differences in students’ perceptions, and the methods had five similar elements (Koponen et al., 2011a). The results are supported by earlier findings of medical students’ positive views on learning communication skills through SPs (Eagles, Calder, Nicoll, & Walker, 2001; Mönkkönen, Pyörälä, & Isotalus, 2007; Rees, Sheard, & McPherson, 2004) and role-play (Nestel & Tierney, 2007). Second, the medical students’ self-assessed learning outcomes were very similar in the three groups using TIE, SPs, and role-play (Koponen et al., 2011b) and the students’ attitudes to learning communication skills became more positive during the course in communication (Koponen et al., 2012). If we look at the learning outcomes achieved and compare them to the aims of the course in communication, we claim that the aims of the course were well achieved.

TIE, SPs, and role-play have not previously been compared. However, in a few studies, SPs and role-play have been found to be equally effective when teaching motivational interviewing to health care professionals (C. Lane et al., 2008) or third-year medical students (Mounsey et al., 2006), and when first-year medical students practiced smoking-cessation techniques (Papadakis et al., 1997). In light of the results, we argue that TIE, SPs, and role-play seem equally suitable for learning ICC.

The positive change in the students’ attitudes found in this sample of students differs from the work described by other researchers who have measured medical students’ attitudes to learning communication skills with the CSAS (Bombeke et al., 2011; Harlak et al., 2008; Rees & Sheard, 2003). None of the studies exploring medical students’ attitudes before and after communication training with CSAS (Harlak et al., 2008; Rees & Sheard, 2003) describe integrating visits to public health centers with communication training or using mainly experiential learning methods during training, as was done in this study. One of the reasons behind the positive results of this communication course may be that it was integrated into a clinical context where students were able to observe and analyze real doctor-patient consultations, affecting transfer and making the instruction more meaningful for the students. The results showed that female medical students had more positive attitudes to learning communication skills than males. This finding is consistent with previous studies (Bombeke et al., 2011; Cleland et al., 2005; Harlak et al., 2008; Rees & Sheard, 2003). One of the reasons for this difference might be that male medical students have been shown to be slower at learning communication skills than females (Aspegren, 1999; Rees & Sheard, 2003). Therefore, more attention should be paid to support males in learning communication skills.

On the basis of comprehensive reflection of the results, we argue that in all three methods at the first participation level (see Figures 1-3), learning ICC was based on students’ active observations and their own reflections about doctor-patient interactions shown either in the TIE play or in live interactions with simulated patients or peers (role-play). At the second participation level (see Figures 1-3), learning ICC was based on social interaction and debriefing together with other students because the students were able to discuss and reflect on problematic doctor-patient interaction with peers during and after the exercise. This active debriefing process enhances learning and these observations support the idea that learning occurs through constructing knowledge and meaning from experience through reflection (Boud, Cohen, & Walker, 1993; Yardley et al., 2012).

At the third participation level (see Figures 1-3), learning was based on having an experience of being in a doctor’s role. This was an individual experience for the students, although the exercise took place in a social context. Practicing communication skills in a doctor’s role is common in medical students’ communication skills training (Craig & Cosgrove, 2010; Hargie et al., 2010). However, according to our results, the experience was at the same time rewarding and unproductive: The students thought that the experience was realistic, challenging, interesting, supported self-confidence, and was good preparation for the doctor’s profession. In contrast, the experience was felt to be unrealistic, too difficult due to lack of medical knowledge, and stressful. Therefore, the experience of being in the doctor’s role could be described as a meaningful, but stressful at the same time.

All in all, learning ICC through TIE, SPs, and role-play can be described as an individual and a social process at the same time. In addition, social interaction can be seen as fundamental to experiential learning. The idea of learning through experiential methods in a specific context with others concurs with the ideas of the CID theoretical framework (Dannels, 2001) because learning takes place in a specific context and is social in nature. Communication education requires learning settings and situations that are as authentic as possible, and stimulate social processing and co-construction of knowledge (Lave & Wenger, 1991). All the learning methods studied provide such learning opportunities for students. In addition, the communication skills studies were immediately followed by observations in authentic health care settings in primary health care. This instructional design fostered further reflection on doctors’ communication skills after the different types of simulated patient scenarios used in this study, and therefore the instructional design may have had a positive effect on creating situational interest in medical students (Clapper, 2014).

Figure 4 describes the learning process of ICC through experiential learning methods and illustrates the instructional design used in this study. This model can be used in designing specialty-specific communication training in other disciplines than medicine. When implementing this model, the facilitator needs to decide in which specialty-specific context learning communication may take place. Then this context can be simulated through experiential learning methods. For example, TIE, SPs, and role-play could be applied to teaching communication in those disciplines where building a relationship with a patient/client is crucial in order to achieve the goals of the professional work. Finally, simulation-based training should be followed by observations in authentic communication context.

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Figure 4.

Instructional design for specialty-specific communication training.