|Year : 2016 | Volume
| Issue : 5 | Page : 579-584
Structured communicative skills training for medical interns improves history taking skills on sensitive issues: An interventional study
Anupama Sukhlecha1, Radha Dass2, Deepak S Tiwari3, Nalini I Anand4, Hemal J Dholakia5
1 Department of Pharmacology, M.P. Shah Medical College, Jamnagar, Gujarat, India
2 Department of Opthalmology, M.P. Shah Medical College, Jamnagar, Gujarat, India
3 Department of Psychiatry, M.P. Shah Medical College, Jamnagar, Gujarat, India
4 Department of Obstetrics and Gynecology, M.P. Shah Medical College, Jamnagar, Gujarat, India
5 Private Medical Practitioner, Bhuj, Gujarat, India
|Date of Web Publication||13-Oct-2016|
Department of Pharmacology, M.P. Shah Medical College, Jamnagar, Gujarat
Source of Support: None, Conflict of Interest: None
Background: Communication is a process that allows us to interact with other people. Medical professionals need to possess good communication skills for history taking, diagnosis, and treatment. Communicative skills are hardly taught in medical schools of India. The students are expected to learn them on their own. To address this issue, we introduced communicative skills training (CST) for medical interns. Objective: Primary – To determine the effectiveness of CST in improving history taking on sensitive issues by medical interns. Secondary – To improve patients' satisfaction through improved communicative skills. Materials and Methods: This was a randomized control study carried out on medical interns at Jamnagar. The interns were randomized to either Group A or Group B. Intervention in the form of CST was given to Group A while Group B was control. The topic of CST was “eliciting sexual history.” Assessment of participants was done by pre- and post-intervention objective structured clinical examination. For ethical reasons, Group B was also given CST by experts after completion of our study but their results were not included for analysis. Results: Although mean scores increased in both the groups, (from 6.4 to 13.4 in the intervention group and from 6.5 to 7.5 in controls), the percent increase was much larger in the intervention group than controls (109% vs. 15%). Students gave a positive feedback to CST. Opinion of teachers was favoring CST. Among the patients allotted to intervention group, 83% were satisfied. Conclusion: CST imparted to medical interns helps in improving doctor–patient relationship.
Keywords: Communication skills, doctor–patient relationship, objective structured clinical examination, training, assessment
|How to cite this article:|
Sukhlecha A, Dass R, Tiwari DS, Anand NI, Dholakia HJ. Structured communicative skills training for medical interns improves history taking skills on sensitive issues: An interventional study. Med J DY Patil Univ 2016;9:579-84
|How to cite this URL:|
Sukhlecha A, Dass R, Tiwari DS, Anand NI, Dholakia HJ. Structured communicative skills training for medical interns improves history taking skills on sensitive issues: An interventional study. Med J DY Patil Univ [serial online] 2016 [cited 2020 Jun 2];9:579-84. Available from: http://www.mjdrdypu.org/text.asp?2016/9/5/579/192167
| Introduction|| |
Communication includes listening and understanding with passion and respect as well as expressing views and ideas and passing information to others in a clear manner. Communication skill is the ability to communicate effectively is important in improving health outcomes. Good doctor–patient relationship is a felt need of novel medical profession. A good doctor–patient relationship should result in patient satisfaction. Communication failure within health care teams can lead to errors and threaten patient safety. In clinics, there are various areas where communicative skills are needed. It could be for eliciting sexual history, counseling a patient of HIV, breaking bad news, taking consent for surgery, for conflict resolution or taking a history from a patient of different language, culture, etc.
Sexual problems invariably have an impact on other relationships. Special skills should be learned which can help in counseling patients about sexual matters which bear a lot on their management. This is particularly relevant where sexual history taking and human immunodeficiency virus (HIV) counseling require the sensitive application of these skills. During the course of history taking doctors should try to develop a continuing supportive environment and collaborative relationship. There are personnel, professional, and social reasons why giving bad news to the patient is difficult. Giving bad news requires time, a setting free from distractions or interruptions, empathy, active listening, and humility to say that one may not have an answer to certain questions. The patients' own resources should be elicited for copying and installing realistic hope. It is also important to ensure that colleagues know what the patient has been told. Support needs to be provided to the patients' relatives and professional colleagues., Studies have documented the lack of interactions among differentially cultured students that may weaken the learning process and eventually the health care system. Communication within health care teams usually is learned through a hidden curriculum of on-the-job training or not at all.,
Medical Council of India in “Vision 2015” has highlighted on competency based training, one component of which is learning communication skills. At present, communication skills are rarely taught in medical education and it is left to students to learn it by themselves. This leads to a communication gap between doctors and patients. To address this issue, we introduced training in communication skills for medical interns in our institute and assessed by objective structured clinical examination (OSCE).
| Materials and Methods|| |
This prospective randomized control study was conducted on interns posted at Obstetrics and Gynaecology Department and HIV Clinic of M.P. Shah Medical College and G.G. Hospital, Jamnagar. The study was carried out in March 2015 after approval by the Institutional Ethics Committee. The study participants were medical interns and patients. The participation was voluntary. A written informed consent of participation was obtained from interns and patients. The interns were assured that scores obtained by them in this study would not be counted for awarding internship completion certificates. Inclusion criteria were those interns who were in the age group of 22-25 years, with at least 80% attendance (in the preceding 2 months) in clinics during internship and had no previous formal training in communication skills. Interns who had passed with more than two attempts in final university exam were excluded from the study.
A sample size analysis was done at the initiation of the study. The standard deviation of marks was estimated to be approximately 1.12. Based on a two-tailed α of 0.05 and power of 80%, it was determined that twenty interns per group were required to detect a 1° of difference in the outcome variable. On the assumption of an overall rate of loss to follow-up of about 20-25%, 25 subjects per group were enrolled for communicative skills training (CST) or controls who did skill learning by self (SLS). Coding of interns was done by a senior technician who was not involved in the study. Randomization was done through random number tables to assign interns to either Group A (CST) or Group B (controls). Decoding of interns was done after scores in postintervention test were recorded. The topic allotted for CST was “eliciting sexual history.”
Objective structured clinical examination stations
The stations for OSCE were designed by investigators of the study. There were six OSCE stations, three on either side of a hall. All the stations were for topic “eliciting sexual history.” There were screens around the station to provide privacy to patients. Stations were adequately distanced to prevent interview being heard by others, who were outside the station. Test objectives were identified for the OSCE stations and examiners used a checklist with twenty items to score interns. The OSCE checklist is shown in [Table 1]. Examiners were teachers or senior resident doctors who were previously trained in OSCE. There was one examiner per station. The patients interviewed at OSCE stations were both real and simulated of either sex. The examiners included ten simulated and fifteen real patients for the interview. Each intern had to take up an interview only at one station out six and it was chosen by lots. A patient was interviewed by two interns, in turns. The time duration to complete the OSCE was 10 min.
|Table 1: Objective structured clinical examination checklist for eliciting sexual history (time allotted: 10 min)|
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Interns were briefed on OSCE procedure. A preintervention test was taken for interns. The scores were recorded. Following preintervention test, Group A interns were allotted CST and were posted in morning clinics. Group B interns were controls (SLS) and were posted in evening clinics.
Group A (intervention group) was briefed on why communication skills are required for eliciting sexual history. The reasons mentioned were that it may be embarrassing for the patient and doctor or that the patients may misinterpret the purpose of the discussion and feel that their lifestyle is being judged or condemned.
The teaching room of ward was made ready for a role play. A rehearsal of role play was done by acting experts to further refine the methodology. Problems in the script and acting in were resolved by consensus. Video recording of role play was also kept ready; in case, the acting experts did not turn up on the planned day. A role play of about 10 min was enacted on allotted topic in front of Group A. Acting experts performed the role of doctors and simulated patients. Interviewing skills such as greeting, assuring confidentiality and privacy to patients, and use of nonverbal clues such as body language, gestures, and eye contact (within limits) were enacted. Open-ended questions were asked first followed by closed-ended. Patient's queries were addressed and treatment options were also explained. The doctor also confirmed from the patient whether he/she understood all that was explained.
After the completion of the role play, each intern of Group A was given a chance to practice communication skills on simulated patients under the observation of experts. If the experts were satisfied with interns' performance on the 1st day, they were permitted to proceed to the next step. In the next step, interns could practice the skills on real patients under observation. This went on for 2-3 days.
The interns of Group B were posted in evening clinics. They were instructed to “elicit sexual history” of allotted patients in clinics. There was no trainer for Group B. They had to learn it on their own in 2-3 days' time. For these 2-3 days, attempts were made to isolate Group A and B during their common free time. This was done by engaging Group A in fun games and Group B in the creative art so that they did not intermingle and discuss on this topic.
After 3 days, Group A and Group B were assessed through a surprise OSCE on “eliciting sexual history” to know the skills gained on the topic. Twenty-four patients (real or simulated) were randomized for allotment to either Group A or group B. The setting of OSCE station was similar to preintervention test. The Group A interns had OSCE on the left side of the hall and Group B on the right side. Scores of Group A and B were recorded. Perception and satisfaction of patients were also recorded on a 0-5 scale.
Feedback on interns' experience of eliciting sexual history was taken on a 5-point Likert scale (from score 1 for strongly disagree to 5 for strongly agree). Opinion of the faculty was also taken through focused group discussion. Patient satisfaction was recorded on a scale of 0 to 5 (from score 0 for highly dissatisfied to 5 for highly satisfied). The scores obtained by the Group A and B interns in OSCE were compared using Student's t-test. Paired t-test was used to compare pre- and post-intervention scores while unpaired t-test was used for comparing differences between Group A and B. Chi-square test was used for categorical variables. GraphPad Prism 5.0, Publisher: GraphPad Software, Inc., San Diego, California, USA was used for statistical analysis.
Interns and students should not be deprived of the benefits of a successful intervention. Hence, for ethical reasons, Group B was also given CST by experts after completion of our study. However, their results were not included for analysis.
| Results|| |
The flow of participants during the study is shown in [Figure 1]. There were 23 interns who were imparted CST (Group A) and 24 interns who were controls and did SLS (Group B). There were no significant age differences between Group A and Group B (23.4 ± 1.12 vs. 23.5 ± 1.14, P = 0.84, unpaired t-test). The results and analyses of the OSCE results of both groups are shown in [Table 2]. There was no significant difference in preintervention scores in Group A and B (6.4 ± 1.12 vs. 6.5 ± 1.14, P = 0.43, unpaired t-test). The mean marks obtained by Group A were higher than those obtained by Group B in postintervention test (13.4 ± 1.16 vs. 7.5 ± 1.21, P< 0.0001, unpaired t-test).
|Figure 1: Flow of participants during the study. Group A: Communicative skill training given to interns following preintervention test. Group B: Controls (skill learning by self)|
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Following the intervention, there were 96% interns of Group A (CST) who felt that intervention improved their communicative skills. Interns found CST clinically relevant, satisfying, and enjoyable [Table 3]. The opinion and views expressed by the experts and faculty who conducted CST and assessed the interns are shown in [Table 4]. They reported that this format could train students on communication skills in a better manner. Among the limitations reported were difficulties in structuring and preparing checklists in OSCE, time-consuming, monotonous, and shortage of staff (to train about two hundred students per batch). Among the patients allotted to Group A (CST), 83% of patients were satisfied [Table 5].
| Discussion|| |
In the present study, efforts were made to understand gaps in communication skills among interns. Training was provided through role play. OSCE was used as an assessment tool. This study demonstrates that role play with structured feedback is an effective method of training interns to apply knowledge and skills in similar clinical settings. It is a relatively new method of learning in India, which has several advantages over traditional teaching methods. It teaches communication skills by repeatedly practicing skills on simulated patients. When they are confident of skills gained, they can go to real patients.
Interview with a patient needs to be taken methodical and tactful manner. The interview should be patient-centric rather than disease-centric. The patient's interview should achieve three essential goals: gathering of information, building a healthy doctor–patient relationship, and education of the patient. Greeting the patient initially is important, particularly for eliciting sexual history. The doctor should be aware of the signs of patient's anxiety and distress. He should be able to recognize nonverbal cues from the patient and also be alert about his own nonverbal clues such as body language, gestures, and eye contact (if culturally acceptable). Consultation should begin with open questions leading to closed questions later. Rationale for questions asked should be explained. Sexually explicit language should be used within the sexual history consultations. Language used should be clear, comprehensible, and comfortable to both the clinician and patient. The use of medical jargon and abbreviations should be avoided. Description of the disease, investigations, and treatment options should be discussed in detail. The patient should be involved in decision-making. The treatment plan must conform to the patient's understanding, beliefs, cultural values, and concerns. The patients need to be motivated regarding adherence to lifestyle modifications.,,,
Cutoff (not ≥3 attempts) was fixed for results in the final year university exam because there was a chance that chronic repeaters (who usually happen to be low scorers) could give skewed results in our study. Cutoff for attendance (minimum 80%) was also fixed because unless interns attended and interacted with patients regularly, they would not have been able to develop a good doctor-patient relationship.
In our study, we found that scoring in CST (intervention) group was 67%. In a study in London, it was 73.1% in CST which is more than our study. In our study, the percentage increase in OSCE in scores following intervention in our study was 109%. In a study at Loni, the percent increase following intervention was 117% which is more than our study. This shows that our study is at par with other studies. The performance in controls also improved in our study, but the percent increase was only 15%. It could be because of self-learning skills of students and intermingling with intervention group in hostels.
Opinion of interns who were given CST (intervention) in our study was positive (96%). They agreed that the training helped them in improving communication skills and improve doctor-patient relationship. The feedback from control (SLS) group was not encouraging. A study on the 1st year medical students had shown an increased level of confidence among students who underwent training in communication skill and they were more productive during their clinical postings. CST enhances retention of knowledge because it is clinically relevant and develops learning skills that are sustainable throughout professional life. Opinion of teachers in our study was encouraging. However, they said that preparation for this method consumes a lot of time. In a study in London, the teachers gave a constructive feedback on training students through video role play and assessing them through OSCE.
In our study, among the patients allotted to CST (intervention), 83% were satisfied. Patient satisfaction improved after communication skills training to doctors, as reported in yet another other study. Patient satisfaction is an important criterion to decide the quality of care given to the patient. Doctors with good communication skills identify patients' problems more accurately. Their patients adjust better psychologically and are more satisfied with their care. Patient's compliance with their treatment plan and patient's satisfaction with the care they receive also bears a direct relationship with good communication, so it is imperative that medical professionals possess good communication skills to deliver their professional duties to the fullest extent.,,
In our study, use of simulated patients for role play was found to provide a safe, low anxiety learning experience which could help interns in building competence and confidence. Real patients were beneficial as they are seen as more authentic and could present actual abnormal physical findings. Interaction with real patients during the early years can help medical students and interns learn and develop appropriate attitudes toward their studies and future practice. However, there is a need for these experiences to be supported by a range of other teaching methods in an integrated approach.,
The strength of the study was training a batch on communication skills and assessing it through OSCE. Feedback was taken not just from students and teachers but also from patients. The limitation of the present study is that it involved a single batch of interns who were trained on communication skills. It was difficult to prevent interaction between the intervention and control group, in spite of our best efforts. Some discrepancies in scoring were beyond our control.
| Conclusion|| |
CST-improved communication skills among interns and is acceptable to students and teachers. It also improves patient satisfaction. However, its conduct is a resource-intensive exercise and requires preplanning. Assessment by OSCE is valid because of grading or scoring system. There is a need for training of teachers before CST can be introduced in the undergraduate curriculum. Training can be given by organizing workshops and developing orientation manuals. Gradual changes in policies to introduce CST will bring a welcome change in the attitude of medical graduates and improve doctor-patient relationship.
We thank the hospital staff for helping and supporting us during the study. We also thank the patients for cooperating with us during the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Maguire P, Pitceathly C. Key communication skills and how to acquire them. BMJ 2002;325:697-700.
Brook G, Bacon L, Evans C, McClean H, Roberts C, Tipple C, et al.
2013 UK national guideline for consultations requiring sexual history taking. Clinical Effectiveness Group British Association for Sexual Health and HIV. Int J STD AIDS 2014;25:391-404.
Schildmann J, Kampmann M, Schwantes U. Teaching courses on aspects of medical history taking and communication skills in Germany: A survey among students of 12 medical faculties. Z Arztl Fortbild Qualitatssich 2004;98:287-92.
Zaidi H. Breaking bad news. Ann R Coll Surg Engl 2006;88:507.
Buckman R. Breaking bad news: Why is it still so difficult? Br Med J (Clin Res Ed) 1984;288:1597-9.
Kripalani S, Bussey-Jones J, Katz MG, Genao I. A prescription for cultural competence in medical education. J Gen Intern Med 2006;21:1116-20.
Merrill JM, Laux LF, Thornby JI. Why doctors have difficulty with sex histories. South Med J 1990;83:613-7.
O'Flynn N, Spencer J, Jones R. Consent and confidentiality in teaching in general practice: Survey of patients' views on presence of students. BMJ 1997;315:1142.
Zayyan M. Objective structured clinical examination: The assessment of choice. Oman Med J 2011;26:219-22.
Barrier PA, Li JT, Jensen NM. Two words to improve physician-patient communication: What else? Mayo Clin Proc 2003;78:211-4.
Tsimtsiou Z, Hatzimouratidis K, Nakopoulou E, Kyrana E, Salpigidis G, Hatzichristou D. Predictors of physicians' involvement in addressing sexual health issues. J Sex Med 2006; 3:583-8.
Ramasamy R, Murugaiyan SB, Rachel S, Vengadapathy KV, Gopal N. Communication skills for medical students: An overview. J Contemp Med Educ 2014;2:134-40.
Ranjan P, Kumari A, Chakrawarty A. How can doctors improve their communication skills? J Clin Diagn Res 2015;9:JE01-4.
Knowles C, Kinchington F, Erwin J, Peters B. A randomised controlled trial of the effectiveness of combining video role play with traditional methods of delivering undergraduate medical education. Sex Transm Infect 2001;77:376-80.
Jorwekar GJ, Apturkar DK, Baviskar PK, Shaikh MH. Training of intern doctors with interpersonal communication [IPC]: A step towards better doctor patient relationship. Int J Biomed Adv Res 2015;6:422-6.
Marteau TM, Humphrey C, Matoon G, Kidd J, Lloyd M, Horder J. Factors influencing the communication skills of first-year clinical medical students. Med Educ 1991;25:127-34.
Roter D, Rosenbaum J, de Negri B, Renaud D, DiPrete-Brown L, Hernandez O. The effects of a continuing medical education programme in interpersonal communication skills on doctor practice and patient satisfaction in Trinidad and Tobago. Med Educ 1998;32:181-9.
Hausberg MC, Hergert A, Kröger C, Bullinger M, Rose M, Andreas S. Enhancing medical students' communication skills: Development and evaluation of an undergraduate training program. BMC Med Educ 2012;12:16.
Wu RC, Lo V, Morra D, Wong BM, Sargeant R, Locke K, et al.
The intended and unintended consequences of communication systems on general internal medicine inpatient care delivery: A prospective observational case study of five teaching hospitals. J Am Med Inform Assoc 2013;20:766-77.
Wong SY, Cheung AK, Lee A, Cheung N, Leung A, Wong W, et al.
Improving general practitioners' interviewing skills in managing patients with depression and anxiety: A randomized controlled clinical trial. Med Teach 2007;29:e175-83.
Shendurnikar N, Thakkar PA. Communication skills to ensure patient satisfaction. Indian J Pediatr 2013;80:938-43.
Richard S, Pardoen D, Piquard D, Fostier P, Thomas JM, Vervier JF, et al.
Perception of training in doctor-patient communication for students at faculty of medicine. Rev Med Brux 2012;33:525-30.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]