Jan van Dalen

Assessing simulated patients in an educational setting: the MaSP (Maastricht Assessment of Simulated Patients)

Context  For more than two decades the Medical School in Maastricht, the Netherlands, has used simulated patients (SPs) to provide students with opportunities to practise their skills in communication and physical examination. In this educational setting a student meets a SP in a videotaped session. Feedback by the SP to the student at the end of the session is considered an important educational feature. We found no instruments to assess individual SP performance during those sessions.

Verbal and non-verbal behavior of doctors and patients in primary care consultations - how this relates to patient enablement.

OBJECTIVE To assess the relationship between observable patient and doctor verbal and non-verbal behaviors and the degree of enablement in consultations according to the Patient Enablement Instrument (PEI) (a patient-reported consultation outcome measure). METHODS We analyzed 88 recorded routine primary care consultations. Verbal and non-verbal communications were analyzed using the Roter Interaction Analysis System (RIAS) and the Medical Interaction Process System, respectively. Consultations were categorized as patient- or doctor-centered and by whether the patient or doctor was verbally dominant using the RIAS categorizations. RESULTS Consultations that were regarded as patient-centered or verbally dominated by the patient on RIAS coding were considered enabling. Socio-emotional interchange (agreements, approvals, laughter, legitimization) was associated with enablement. These features, together with task-related behavior explain up to 33% of the variance of enablement, leaving 67% unexplained. Thus, enablement appears to include aspects beyond those expressed as observable behavior. CONCLUSION For enablement consultations should be patient-centered and doctors should facilitate socio-emotional interchange. Observable behavior included in communication skills training probably contributes to only about a third of the factors that engender enablement in consultations. PRACTICE IMPLICATIONS To support patient enablement in consultations, clinicians should focus on agreements, approvals and legitimization whilst attending to patient agendas.

Doctor–patient communication in a Southeast Asian setting: the conflict between ideal and reality

Doctor–patient communication has been extensively studied in non-Western contexts and in relation to patients’ cultural and education backgrounds. This study explores the perceived ideal communication style for doctor–patient consultations and the reality of actual practice in a Southeast Asian context. We conducted the study in a teaching hospital in Indonesia, using a qualitative and a quantitative design. In-depth interviews were conducted with ten internal medicine specialists, ten internal medicine residents, 16 patients in two groups based on education level and ten most senior medical students. The contributions of doctors and patients to the communication during consultations were observed and rated quantitatively by thirty internal medicine residents, 393 patients with different educational backgrounds and ten senior medical students. The ‘informed and shared decision making’ is the central observation in this quantitative study. The results of the interviews showed that Southeast Asian stakeholders are in favor of a partnership style of communication and revealed barriers to achieving this: doctors and patients are not prepared for a participatory style and high patient load due to an inefficient health care system does not allow sufficient time for this type of communication. The results of the quantitative study showed a sharp contrast between observed and ideal communication styles. A paternalistic style seems to prevail, irrespective of patients’ educational background. We found a sharp conflict between ideal and reality concerning doctor–patient communication in a Southeast Asian context. Further studies should examine ways to change the prevailing communication style in the desired direction.

Learning in context: Identifying gaps in research on the transfer of medical communication skills to the clinical workplace

OBJECTIVE In order to reduce the inconsistencies of findings and the apparent low transfer of communication skills from training to medical practice, this narrative review identifies some main gaps in research on medical communication skills training and presents insights from theories on learning and transfer to broaden the view for future research. METHODS Relevant literature was identified using Pubmed, GoogleScholar, Cochrane database, and Web of Science; and analyzed using an iterative procedure. RESULTS Research findings on the effectiveness of medical communication training still show inconsistencies and variability. Contemporary theories on learning based on a constructivist paradigm offer the following insights: acquisition of knowledge and skills should be viewed as an ongoing process of exchange between the learner and his environment, so called lifelong learning. This process can neither be atomized nor separated from the context in which it occurs. Four contemporary approaches are presented as examples. CONCLUSION The following shift in focus for future research is proposed: beyond isolated single factor effectiveness studies toward constructivist, non-reductionistic studies integrating the context. PRACTICE IMPLICATIONS Future research should investigate how constructivist approaches can be used in the medical context to increase effective learning and transition of communication skills.

Performance-related stress symptoms in simulated patients

Introduction  During the first 4 years of the 6‐year undergraduate medical curriculum at Maastricht University, the Netherlands, students practise clinical skills in simulated patient (SP) encounters at the Skillslab. Generally, these encounters are instructive and enjoyable for both students and SPs. However, in conversations with SP trainers, some SPs have mentioned experiencing adverse symptoms due to performing a patient role. Some published studies have reported similar findings in SPs. We explored the seriousness of this problem by surveying SPs on the occurrence and severity of stress symptoms related to performing patient roles. We also examined by which variables the symptoms were influenced.

The impact of simulation on people who act as simulated patients: a focus group study

Objective  Previous studies have shown that people who act as simulated patients (SPs) experience negative effects caused by performing patient roles. This study was performed to further explore the impact of simulation and the factors that might affect this impact. The aim was to find ways of preventing negative effects of simulation impacting on our SPs.

Student views on the effective teaching of physical examination skills: a qualitative study

Objectives  The lack of published studies into effective skills teaching in clinical skills centres inspired this study of student views of the teaching behaviours of skills teachers.

Communication skills in context: trends and perspectives.

OBJECTIVE Doctor-patient communication has been well researched. Less is known about the educational background of communication skills training. Do we aim for optimal performance of skills, or rather attempt to help students become skilled communicators? METHODS An overview is given of the current view on optimal doctor-patient communication. Next we focus on recent literature on how people acquire skills. These two topics are integrated in the next chapter, in which we discuss the optimal training conditions. RESULTS A longitudinal training design has more lasting results than incidental training. Assessment must be in line with the intended learning outcomes. For transfer, doctor-patient communication must be addressed in all stages of health professions training. CONCLUSION Elementary insights from medical education are far from realised in many medical schools. Doctor-patient communication would benefit strongly from more continuity in training and imbedding in the daily working contexts of doctors. PRACTICE IMPLICATIONS When an educational continuum is realised and attention for doctor-patient communication is embedded in the working context of doctors in training the benefits will be strong. Training is only a part of the solution. In view of the current dissatisfaction with doctor-patient communication a change in attitude of course directors is strongly called for.

Nurses’ roles in informed consent in a hierarchical and communal context

Although the main responsibility for informed consent of medical procedures rests with doctors, nurses’ roles are also important, especially as patient advocates. Nurses’ preparation for this role in settings with a hierarchical and communal culture has received little attention. We explored the views of hospital managers and nurses regarding the roles of nurses in informed consent and factors influencing these roles. We conducted a qualitative study in a private, multispecialty hospital in Indonesia. Semi-structured interviews were conducted with seven managers. Two rounds of focus group discussions with nurses (n = 27) were conducted. Constant comparative approach was used in the analysis. Nurses can act as manager, witness, information giver, and advocate in the informed consent process. These roles are influenced by nurses’ preparedness, hospital culture and policy, patients’ understanding, family involvement, and cost-related issues. In preparation for these tasks, nurses should acquire communication skills, clinical knowledge, and legal and ethical knowledge.

Exploring Residents' Communication Learning Process in the Workplace: A Five-Phase Model

Context Competency-based education is a resurgent paradigm in professional medical education. However, more specific knowledge is needed about the learning process of such competencies, since they consist of complex skills. We chose to focus on the competency of skilled communication and want to further explore its learning process, since it is regarded as a main competency in medical education. Objective This study aims to explore in more detail the learning process that residents in general practice go through during workplace-based learning in order to become skilled communicators. Methods A qualitative study was conducted in which twelve GP residents were observed during their regular consultations, and were interviewed in-depth afterwards. Results Analysis of the data resulted in the construction of five phases and two overall conditions to describe the development towards becoming a skilled communicator: Confrontation with (un)desired behaviour or clinical outcomes was the first phase. Becoming conscious of one’s own behaviour and changing the underlying frame of reference formed the second phase. The third phase consisted of the search for alternative behaviour. In the fourth phase, personalization of the alternative behaviour had to occur, this was perceived as difficult and required much time. Finally, the fifth phase concerned full internalization of the new behaviour, which by then had become an integrated part of the residents’ clinical repertoire. Safety and cognitive & emotional space were labelled as overall conditions influencing this learning process. Conclusions Knowledge and awareness of these five phases can be used to adjust medical working and learning environments in such a way that development of skilled medical communication can come to full fruition and its benefits are more fully reaped.