Curriculum factors influencing knowledge of communication skills among medical students

Differences in curricula

The four medical schools follow different curricula. Two employ problem-based learning (PBL) and involve early patient contact. These two schools are denoted 'Early/PBL A' and 'Early/PBL B'; both run a doctor-patient course during the 1st year of study (the first 2 years for school A). In this course, students are allocated to family doctors, with training twice monthly to learn how to interview patients about their background, medical history, expectations regarding the consultation, understanding of their symptoms and their emotions.

The third school follows an integrated curriculum with parallel preclinical and clinical training, but does not use PBL and does not run an extensive doctor-patient course during the 1st years of study. This school is denoted as 'Integrated'.

The fourth school is traditional, with a sharp division between preclinical and clinical training after 2.25 years. This school is denoted as 'Traditional'. The two PBL-based schools and the Integrated school provide clinical teaching during all 6 years of study, while students at the Traditional school experience their first patient contact at the beginning of the 3rd year.

All schools have a common, national admittance system. About 10% of applicants are admitted annually. The criteria for admittance are identical in the four schools. Students are selected based on study points from previous studies, range 58.9–61.8 points in 2003 [10]. All schools provide a 6-year curriculum.

Intensified clinical training in primary care preceptorship and hospital-based preceptorship (mainly in smaller hospitals) takes place in the 5th year in the Integrated school (8 weeks in a primary-care setting vs. 16 weeks in a hospital) and in school Early/PBL B (6 weeks vs. 6 weeks), and in the 5th and 6th years in school Early/PBL A (6 weeks vs. 16 weeks). Similar teaching is spread through years 4–6 at the Traditional school (4 weeks vs. 15 weeks) [11]. The master-apprentice approach is the main didactic element in preceptorship-based training, whether it takes place in primary care or in smaller hospitals. Students learn by observing, performing and reflecting, all as a part of clinical work. In primary care, each student is allocated to one general practitioner, and in the smaller hospitals, limited groups of students (5–10 students per group) enter the different departments.

Instrument

The main instrument used in this study is based on the paper-and-pencil test as described by van Dalen et al [7]. Originally, this questionnaire comprised 78 items addressing theoretical and conceptual knowledge regarding communication skills. The aim of the questionnaire is to establish whether students can identify the communication interventions that are most effective in certain situations [7]. Items are formed as either short, context-based questions, or they are in the format of a short vignette followed by one or more statements. Students mark each statement as true or false. The sum of the test score is presented as a percentage [7].

Examples of questions are:

The questionnaire was translated from Dutch to Norwegian by a bilingual Dutch psychologist and a bilingual Norwegian medical communication trainer. The questionnaire was tested on ten medical communication teachers. Of a total of 78 items, 34 were selected because they produced the most consistent scoring. On further analysis of the abridged questionnaire, four more items were deleted because they were deemed not relevant to our study. The final result was a 30-item questionnaire covering communicative microskills, clinical interaction, patient-centred style, the provision of information and the breaking of bad news.

Data on the students' exposure to communication training or preceptorship in general practice or local hospitals were extracted from the curricula of the four medical schools. Background variables comprised gender, previous health-related education, and work experiences in the health services undertaken prior to medical school (yes/no).

Ethical approval was not deemed necessary.

Discussion of results

The four medical schools in Norway – one Traditional, one Integrated and two based on PBL – may together represent the contemporary varieties of medical schools in the Western world. Due to the common admittance system in Norway, 1st-year students at the four schools are comparable at the time of admittance. The similarities between the students' background variables reinforce this view.

Early communication training and extensive patient contact during the 1st year of medical school increased the scores on knowledge of communication skills to an extent unparalleled later in the curricula by any of the four schools, even though the quantity of later training in the same curricular elements is far greater. These results should be interpreted with some caution, since for the Early/PBL schools, PBL pedagogy may in itself account for some of our findings; PBL activity may be a confounder.

Early communication training has been advocated by, among others, Deveugele et al [14]. Fineberg reports that early intervention increases the proficiency and skills needed to conduct family conferences and advances communication in palliative care [15]. For acquisition of knowledge of communication skills, our results indicate that early extensive supervised patient contact combined with smaller amounts of communication training is more effective than more extensive communication training later in the curriculum.

Maguire and Pitceathly have shown that successful training in communication skills depends partly on the training itself and partly on its contextual relevance (i.e. adequate patient exposure) [16]. Our results indicate that knowledge of communication skills is best attained by attendance of communication courses in combination with clinical training. First-year students at the Early/PBL schools may be an example of this. Another example is the substantial increase in scores from the end of the 2nd year to the end of the 3rd year in the Traditional school. Students at this school start their clinical training during the 3rd year of study, which is also when they have their first communication course.

Furthermore, at the two Early/PBL schools, there is no communication training in year 4, although clinical teaching involving patients is maintained. Students from these schools scored lower at the end of year 4 compared to year 3, and also to year 5, in which they are exposed to extensive preceptorship. One interpretation may be that knowledge of communication skills may be transitory in nature. However, as the 5th year preceptorship focuses on practical supervised training with few theoretical elements and little or no formal communication training, it would appear likely that knowledge of communication skills is more easily recalled when students work in a clinical context with extensive patient contact.

There is a 5% difference in scores at end of the 6th year. The scores of students at the Traditional and the Integrated schools increased significantly, while there was less change in the scores of those from the two Early/PBL schools. The difference is highly statistically significant, but is it also relevant? One-twentieth of the total score range may appear unimpressive as an effect difference; however, it is not an uncommon finding when evaluating the effects of feedback-based communication training [17].

Improved knowledge and attitudes are not sufficient in themselves to change behaviour in daily practice; practical training is also needed [18]. However, just as theoretical knowledge about practical procedural skills is needed in training, relevant theoretical knowledge may also help students when training communication skills. Hulsman et al. reported that the success of communication skills training depends on whether the trainees intend to change their behaviour [6]. An intention to change may be more easily formed when the trainee has distinct concepts regarding what to train. Consequently, we consider it likely that knowledge of communication skills will increase the success of training such skills, although this notion requires verification by further research.