Our results indicate that communication training combined with supervised clinical work with patients is most strongly correlated with high scores for knowledge of clinical communication skills, especially when the combination takes place early in the medical school curriculum.
Strengths and limitations of the study
The present study employed a nationwide cross-sectional survey involving all four medical schools in Norway. Subjects were present at all stages of training, which allowed subanalyses of the results at the level of the relevant curriculum elements.
Several factors may limit the validity of our findings. A higher response rate might have resulted in different scores, since scores often differ between responders and non-responders [12]. Also, non-responders may be academically weaker [13].
Our questionnaire is an abridged version of the test of van Dalen et al., and the two questionnaires exhibit similar internal consistency [7]. However, the scores of the students at our medical schools were substantially higher (at year 6; 81–86%) than those of students at the same level in Maastricht and Leiden, The Netherlands (52–59%) [7]. This may be attributable to the selection of items that obtained the most consistent scoring in our pilot study. Consequently, our results cannot be compared with those of van Dalen et al. Nevertheless, the same questionnaire was applied throughout our study, and the differences in scores related to the effects of curriculum elements should be valid.
Our data are not suitable for analysing the potential importance of supervised clinical work in preceptorship or communication courses alone. Linear regression proved futile, since the R
2 value was 0.02, probably because the entered curriculum variables were strongly clustered in accordance with the curriculum. However, the effect of the combination of preceptorship and communication training is striking, especially if it takes place early in the study (Early/PBL schools) or early in the clinical part of the study (Traditional school).
There is also a close relationship between 1st-year early patient contact, communication training and the PBL-based curriculum, as only the two Early/PBL schools have these curricular elements. We therefore cannot rule out any crossover effect of being exposed to PBL-based training and an increased knowledge of communication skills.
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.