The study was carried out at FMH College of Medicine and Dentistry, a private medical college in Lahore, Pakistan. The college admits an average of 75 students in every class and follows the typical five year curriculum as determined by the Pakistan Medical and Dental Council (PMDC), and the University of Health Sciences (UHS). The first two years are devoted entirely to Basic Health Sciences while clinical rotations are part of the curriculum for the next three years. This study involved fourth year medical students during the session 2006-07.
Before the intervention, students had not received any formal training in communication skills in the medical college. The curriculum did not provide a designated slot for a rotation in Community Medicine as well. Our intervention included a two-week rotation with the Community Medicine Department and four video-recorded scenarios depicting an ideal doctor-patient encounter. Four instructors of the department were trained to counsel for vaccination of infants, diarrhea management, breast feeding and antenatal care. The same instructors were also trained to act as patients. The instructors alternated between acting as patients and physicians to produce videos on these four topics of counseling, each lasting about 15 minutes. The same facilitators also observed and evaluated the students later on, in test as well as real clinical settings.
The videos covered the essential elements of physician-patient communication including the ways to open a consultation, use of open and close ended questions, clarifications, facilitation, reflection and assessment of patient understanding [12]. The videos were prepared completely in Urdu (the national language of Pakistan) since the local community in Pakistan mostly does not understand English. To the best of our knowledge, these are the first such video scenarios recorded in Urdu for the undergraduate level. All videos were reviewed by a family physician and a psychologist for adequacy of content.
Students inclusive in the study were evaluated for communication and interpersonal skills (CIS), pre- and post intervention based on a structured checklist. The assessment checklists had been prepared using the Education Commission for Foreign Medical Graduates (ECFMG) scoring criteria for interpersonal skills in clinical skills examination and the Robert Wood Johnson College of Medicine, New Jersey assessment list for OSCEs (Objective Structured Clinical Examinations) in consultation with a family physician and a psychologist [13, 14]. All contained a common section on communication skills in addition to a variable number of specific clinical counseling points that the students were supposed to address. One mark was awarded for correctly performing each item on the checklist. There were only two categories, 'done' and 'not done', for each item (Figure 1) To minimize inter-rater disparity each instructor was given one specific category to grade, before and after intervention as well as in real clinical setting for one set of rotation. Additionally, the percentage of items checked by an assessor in different categories was compared periodically. The study question was not revealed to the observers to ensure unbiased assessment.
The checklists used had been pretested on students passing through fourth year in the previous year, to ascertain the feasibility of the study design. This group of students on an average scored similar to the pre-intervention group of the study. They were subsequently utilized in the actual study without any change.
Each participant of the trial underwent an initial assessment at the beginning of the two week rotation in the four selected categories through role playing by trained instructors. Students were made to practice these counseling skills on real patients encountered during their visits to community clinics. These encounters were observed by the same facilitators using guidelines similar to the items inclusive in the assessment checklists. On-the-spot feedback was provided to the students. The post-intervention OSCE was repeated after six months and the results of the two were compared in order to objectively document the effect of the intervention provided [15]. Moreover, one actual real-time student-patient interaction in a clinical or community setting was randomly selected out of the post intervention group for each counseling topic and graded with the same checklist that had been used earlier in the OSCEs (Direct Observation through structured checklist DOS).
Data was entered and analyzed using SPSS 12.0. Paired t-test was performed with the one-tailed probability set at 0.05.
The project was approved by the Institutional Review Board and Ethical committee of FMH College of Medicine & Dentistry, Lahore. The study was in compliance with the 'Ethical Principles for Medical Research Involving Human Subjects' as laid down in the Helsinki Declaration [16]. Since the rotation was part of their curriculum and approved by the academic council of the college, individual informed consent was not required from every student.
