gms | German Medical Science

Instilling communication competences is an essential part of a practice-orientied medical teaching curriculum [1], [2]. In German speaking regions there is room for improvement [3] in this area. In many medical faculties, including for example the University Düsseldorf, communication learning in the first three academic years focuses on exercises in medical history and general conversation techniques [4], [5], [6]. However, more complex communication areas,for example ’How to handle difficult emotions’, ’Conducting patient briefings‘ and target-oriented conversations, are relevant for all medical students toward the later stages of their training [4], [5].

Our tuition fee-funded project Teaching and Assessing Communicative Competence (CoMeD = Communication in Medical Education Düsseldorf) was initiated by the Department of General Practice, the Clinical Institute of Psychosomatic Medicine and Psychotherapy, and the Study Deanery. It is aimed at the teaching of challenging conversational issues that are not (yet) part of the curriculum, and to make competent communication under such challenges subject to examination. In particular, we are working on how best to establish communication training for complex doctor-patient interactions as an integral part of clinical education with the help of simulated patients (SP) [6].

The first phase of the project ran from October 2008 to March 2011 and was dedicated to reforming tuition within the fourth academic year. At the same time this phase constituted the first stage in the establishment of a longitudinal curriculum for the training of communication skills at the University Hospital Düsseldorf http://www.comed-duesseldorf.de. This article provides a description of the development and implementation of this concept, the results of student evaluation tests and a discussion about the lessons learned, with a view to the general transferability of this training to other medical faculties.

The concept development of our teaching project CoMeD followed the recommended steps for curriculum development suggested by Kern et al. [7]. In the first step, an actual state analysis of current tuition methods within the clinical study period was carried out. Focus group discussions and interviews with lecturers and students also formed part of the analysis [8]. Structured communication training at the University Hospital Düsseldorf begins with taking the medical history as part of the basic ’medical skills‘ course at the beginning of the third academic year and concludes with an OSCE (objective structured clinical examination). Within the Department of General Practice, communication issues used only to be taught selectively through role plays during the fourth academic year. Video analyses were used for the same purpose in the Department of Psychosomatic Medicine.

In summary, the analysis revealed a deficit in the teaching of communication skills, particularly with regard to more senior students in the fourth and fifth academic years. The analysis also showed an insufficient integration of learning targets in terms of a longitudinal curriculum covering communication training across the whole duration of pre-clinical and clinical studies.

As a secondary step, a needs assessment was carried out. The most significant finding was that students, particularly those in the latter stages of their training, and lecturers consider communication training relevant and advantageous only if it has an immediate relevance to clinical contexts [8].

As a result we decided it would be best to integrate communication skills into the symptom- and disease-based instruction of clinical teaching rather than as a separate training course. We had to bear in mind that communication learning targets are only accepted and taken seriously if those targets play a role in compulsory curriculum exams [9]. Given the importance of exams in the management of learning - ‘assessment drives learning‘ [10] - we decided to establish an OSCE exam to test communication skills within our project. Furthermore, we identified a need for the improvement of training opportunities for lecturers.

In the third step we developed the main features of the general learning objectives for any future curriculum teaching “Communicative Competence”. The first challenge was to select from the learning objectives outlined in the Basler Consensus Statement (2), and to make them intelligible for lecturers and students. We identfified six domains of competences from which six general learning objectives were established (see figure 1 [Fig. 1]).

In interviews with lecturers and students 16 communication areas were considered relevant. Those which were considered appropriate as key aspects in the implementation of learning targets were assigned to the six general learning targets. For example, the subjects ‘Dealing with aggressively demanding patients‘ and ’Dealing with one’s own guilt or shame‘ were assigned to the competence domain ’Emotion‘ (cf. figure 1 [Fig. 1]).

The project groups were comprised of students and representatives from the Departments of General Practice, Psychosomatic Medicine and Internal Medicine. In the fourth step, these groups came up with specific operational learning objectives for each of the 16 subject areas, originating from the general learning targets. Before establishing new CoMeD courses the specific learning targets were clearly stipulated to the departments involved. These specific learning targets were based upon the traditional assessment areas of knowledge, attitude and skills.

In the first stage of the project CoMeD (October 2008 to March 2011) the course of tuition in the fourth academic year was to be reformed.

Each particular communication study area was combined with an appropriate clinical subject in that year’s curriculum. For example, "shared decision-making" was combined with "Cardiovascular prevention" from General Practice or "Dealing with guilt and shame" was taught in combination with "Domestic violence" – an area of Psychosomatic and Forensic Medicine.

Following completion of the pilot phase, four CoMeD courses were established in the fourth academic year in the winter semester of 2009/2010. The courses were integrated into the interdisciplinary clinical lessons as part of symptom-oriented weekly modules like "Abdominal pain" and carried out across various surgical and non-surgical subject areas .

Two other CoMeD courses were added in the following semesters and further courses are being prepared. An overview of the CoMeD courses with their respective assignments to clinical subject areas can be found in figure 2 [Fig. 2].

Each CoMeD course provides a preliminary teaching unit in which the requisite specialist medical knowledge is taught. Some courses take place through e-learning units via computer-based preparatory tasks. Other courses take place in classroom seminars where clinicians teach the clinical context while stressing the importance of communication learning targets.

Communication lessons are conducted within small groups of 5-7 students over a session of 60-100 minutes and always involves a simulated patient (SP). At the outset of each course any important technical contents relating to the topic and any relevant conversation guidelines are reiterated if necessary, for example, the SPIKES model for conveying bad news [11]. After the SP exercise, the feedback round follows in this order: Physician’s role, simulated patient (SP), observers.

Since the summer of 2009 the training of lecturers in the relevant disciplines has been conducted on a quarterly and later biannual basis. In terms of contents, the key aspects are: learning objective communication, feedback training, and the use of simulated during lessons.

In addition, all lecturers involved in their first teaching units are assessed by project staff and receive detailed feedback. There is opportunity for lecturers to sit in on each other’s presentations and regular interchange within interdisciplinary lecturer meetings.

During the course of this project a simulated patient programme was launched at the University Hospital. Approximately 30 actors (mostly professional) were recruited and trained to take on the roles of patients (SP). Basic training was conducted in order to adapt and develop preordained roles – at first on the basis of impromptu exercises but later within the context of a doctor-patient conversation. The actors were prepared for the the standarized settings of the OSCE via video-based repeat exercises. The SPs received regular feedback from project staff who attended their lessons, and in addition they completed trainings in how to provide feedbackto medical students.

Since the winter semester of 2009/10 and following completion of the pilot phase, an OSCE (objective structured clinical examination) [12] - designed to assess communicative competences - has been put in place for all students in the fourth academic year. The CoMeD-OSCE exam comprises four scenarios: ’breaking bad news‘, ’guilt and shame‘, ’aggressively demanding patient‘, and ’shared decision-making‘. Each OSCE station lasts 8 minutes, there are 2-minute breaks between each scenario. Students are given the opportunity to have their performance in the OSCE filmed in order to receive individual feedback subsequent to the exam. Only a few students used this opportunity.

In its present format our OSCE is rather a formative exam than a summative one. There is no minimum score to achieve. Following the exam the students receive their overall score. To obtain their credits in Psychosomatic Medicine and in General Practice, it is obligatory for students to attend the OSCE.

In order to evaluate clinical and communication skills within an OSCE, so-called checklists are available like the Calgary Cambridge Observation Guide [5] and global assessment instruments [13]. However, we opted for a global rating instrument to measure communication competences in complex doctor-patient interactions. Some authors favour this because competences like empathy and other relevant non-verbal communication may be more validly measurable via the general impressions of the examiner [14], [15].

We chose the Berlin Global Rating Scale (BGR) as a rating instrument. This is a validated translation of an English language instrument developed by Hodges and McIlroy [16]. The BGR is based upon four areas of assessment: ’empathy‘, ’structuring conversations‘, ’verbal expression‘, and ’non-verbal expression’. These categories are evaluated by means of a five-level Likert scale [17]. The examiners receive half a day’s training on rating before each OSCE in which they use examples to compare their judgment with that of other examiners.

The CoMeD OSCE proved viable and was generally welcomed by students and examiners. After the OSCE many students even expressed their desire for more practical exam preparations in the free-text part of the evaluation. Only a few students demanded a longer duration of the single OSCE station beyond the scheduled 8 minutes. Detailed results from the OSCE outcomes and the student feedback are under evaluation and will be published.

The teaching project runs parallel to two teaching research projects. Firstly, in a qualitative study students were interviewed both prior to and following the teaching reforms about their opinions concerning doctor-patient communication, and how they perceived their own competences and their learning experiences [8].

Secondly, the controlled experimental connected study CoMeD-Eva compares the improvement in communication skills between those students who received the regular tuition and those who received the reformed tuition. For this study, videotaped SP conversations, carried out at the beginning and the end of the semester [18], are subjected to a RIAS-analysis by blinded observers. This evaluation of potential changes in the students’ actual behaviour is an important addition to the evaluation of “learning satisfaction” and “examinable training success” [19].

Students were asked for an evaluation subsequent to each tuition unit of the CoMeD course. Using the five-level Likert-scale students provided an approval rating, from “I fully agree” to “I do not agree”, for the following five propositions: 1 The tuition unit provided a steep learning curve, 2 The tuition unit had substantial practical relevance, 3 The tuition unit had a level of ambition that suited my needs, 4 The tuition unit motivated me, and 5 Overall assessment; cf. figure 3 [Fig. 3] for the results from the overall assessment of the CoMeD courses using simulated patients in the winter semester of 2010/2011.

The discrepancy in the number of valid questionnaires between the single tution units can mainly be attributed to the fact that a number of lecturers failed to carry out the evaluation at various occasions. Reasons provided for this failure ranged from a lack of time to students feeling emotially upset after the lessons which rendered a written evaluation unfeasible.

The CoMeD courses received some of the highest ratings from students in the overall evaluation. The single items referred to above received similarly positive results http://www.comed-duesseldorf.de. Thus, it seems that students broadly accepted the curriculum reforms. This impression is supported by the feedback from the lecturers, obtained during lecturer meetings. As the project progresses we will also evaluate whether differences in approval ratings within the CoMeD courses were influenced by the popularity of respective subjects or, for instance, by the varying teaching styles of lecturers.

The CoMeD project developed and established a curriculum for training fourth-year students at the University Düsseldorf in communication skills, including an OSCE to evaluate their perfomance. As the evaluation shows, the new CoMeD courses, with the use of simulated patients, achieve high approval ratings from the students.

In the literature on this subject it is often suggested that students find it hard to accept communication training programmes partly because these so-called soft skills are taught in separate sessions rather than as an integral part of clinical tuition. As a consequence, medical students are believed to often experience “two different worlds”: On the one hand they experience the “psycho subjects” where communication skills are taught; and on the other hand, “the clinic”, where ’real physicians‘ take histories and perform medical rounds on their own terms. While teaching communication in compact workshops separate from clinical teaching may offer certain organizational advantages [20], we believe that the approach taken in our project to integrate communication training into clinical contexts proved highly successful. To achieve this, a serious commitment to the training of clinical lecturers who are not primarily skilled for teaching communication competences is mandatory.

One particular challenge was the training of external lecturers in the Department of General Practice. In their weekly tutorial groups, they cover a variety of clinical topics, two of which will be linked to communication modules using simulated patients, i.e. CoMeD courses. The advantage of this setup is that the lecturer can accompany “his group” through the entire semester, so that continuity - a core issue in General Practice – is warranted even in the organization of tuition. On the other hand, lecturers in General Practice had less opportunities to be in practice concerning the topic and didactic of particular courses compared to lecturers in Psychosomatic Medicine, Urology and Surgery, who were allocated to a single specific course (CoMeD or other) for the entire semester. Of the 20 lecturers who had up to then been accompanied by our communication experts during their CoMeD courses, 5 claimed after two semesters they still did not feel confident to teach the communication training on their own. Thus, the project illustrates the importance of allowing for learning curves and how other organizational structures should be considered which enable the lecturer to teach the same course at least 3-4 times in a semester under supervision so as to gain sufficient confidence.

Another challenge within the curriculum was how to integrate the respective learning objectives of clinical medicine and communication. On the one hand, a communication exercise using a simulated patient is only viable if the student is not inhibited by subject-specific insecurities in addition to communication issues. The subject framework for the conversations was carefully selected so that the medical facts were unambiguous and specific. Nevertheless, according to the lecturers the SP exercises seemed the more effective the better the students had mastered clinical tasks in preparatory lessons (e-learning or small-group seminars).

Moreover, in the course ’shared decision-making‘ for instance, we observed that when talking with simulated patients about cardiovascular risk factors, the communication strategy of the students was directly linked to their personal understanding of the cardiovascular risk concept. This is why the discussions subsequent to SP training sessions not only focused on communication issues, but also regularly covered the respective specific subject theme (here: concept of cardiovascular risk). Here it became apparent that communication competences should not be taught separately from clinical tuition and clinical contexts. Therefore we believe that teaching communication skills is more likely to be successful if clinical lecturers are also involved in the training, and able to deal with the medical questions after an SP exercise. We interpret the high approval ratings of the CoMeD courses within the student evaluation as an acknowledgement of our concept.

The overall communication competence of students was measured in the OSCE using the BGR rating instrument. The accuracy of clinical information given by the students to the SPs was partially registered but did not influence the overall evaluation. The exclusive focus on communication skills in the OSCE evaluation followed didactic considerations and was welcomed by students and examiners. However, although not formally evaluated we did notice in the OSCE’s that insecurities regarding clinical issues could represent a barrier to appropriate doctor-patient communication. The advancement of suitable evaluation instruments to measure the integration of clinical and communication competences remains an important challenge in the future.

The integration of communication training into clinical tuition in the fourth academic year and the implementation of an OSCE proved viable and a relevant improvement of the curriculum. In conclusion, we recommend combining complex communication learning targets - like “Dealing with difficult emotions” or “Conducting patient briefings and target-oriented conversations” - with clinical tuition for fourth and / or fifth year students to obtain a high clinical relevance as well as a high acceptance rate among students. The involvement of clinical lecturers, who are active in the care of patients, requires serious investment in training, yet this is feasible and according to this concept necessary.

The CoMeD project was funded by tuition fees. We are grateful to our medical students and the Deanery of Student Affairs of the Faculty of Medicine, Heinrich-Heine University of Düsseldorf (Prof. Stefanie Ritz-Timme, Prof. Ulrich Decking und Prof. Matthias Schneider) for facilitating and supporting our project. We thank Dr. Götz Fabry (University of Freiburg, Medical Faculty, Department of Medical Psychology and Sociology) and Dr. Matthias Hofer (University Düsseldorf, Medical Faculty, AG Medizindidaktik) for collaboration. Our special thanks go to Nikolas Frey for his dedication in project organisation.

The authors declare that they have no competing interests.