‘I wouldn’t get that feedback from anywhere else’: learning partnerships and the use of high school students as simulated patients to enhance medical students’ communication skills

Workshop programme

The Learning Partnerships education methodology was developed by the first author in 1993, initially for use in training adolescent fellows at the Centre for Adolescent Health. This was later incorporated into a study in the training of General Practitioners, conducted by Lena Sanci [22], and formed the basis of an education PhD in 2008 [4]. Learning Partnerships has been used in the University of Melbourne undergraduate medical curriculum in the Faculty of Medicine and the Centre for Adolescent Health, Royal Children’s Hospital since 2003.

Classes of medical students in the fifth year of their training participate in a two-hour workshop with classes of high school students (typically aged 15 – 16 years). Medical students participate in the workshop when on speciality rotations of women's health, child and adolescent health, aged care and mental health. They have yet to do their General Practice rotation in final year and have already done (in year 4) their general medicine and surgery terms in hospital settings. While they have learned the basic building blocks of communication in the earlier pre-clinical years (1–3) they have not yet applied these skills to children or young people in community settings, and have not yet learned how to engage with hidden agendas and health promotion through anticipatory guidance. During the period of research, seven medical education workshops were run, each with a separate class of medical students. Where possible the workshops take place in the school during scheduled class time and within a subject home (such as Drama or English). This places the activity within the school curriculum, thus contributing to its status and the sustainability of the program.

The medical students (in groups of 20–25) participate in one two-hour communication-training workshop with around 25 adolescent students. Each medical session is co-facilitated by a classroom teacher and a medical educator, using a detailed agenda to guide the process. The classroom teachers prepare the school students during their timetabled class time (about 3–5 lessons) assisting them to develop skills in authentic portrayal of the patient and techniques for providing formative feedback. Medical students attend one session, and groups of school students commonly participate in two sessions with different groups of medical students.

The medical students play the family physician and use the HEEADSSS psychosocial screening tool to practice asking questions about the simulated patient’s home, education, eating, activities, drug and alcohol use, sexual activity and safety [23,24]. The school students play the fictional character of “Jo”, which has been specially devised for this exercise (see Additional file 1). The adolescents participate both as actors playing the patient, and as coaches, providing feedback to the medical students on how well the communication is progressing in the simulation. The participants work in doctor-patient dyads for most of the workshop. The simulations are interrupted at each phase of the screening so as the school students can provide coaching and feedback to their partner. Additional coaching and demonstrations are provided in fishbowl mode to demonstrate key skills such as making the confidentiality statement, arranging for time alone with the adolescent patient, use of suitably framed normalising or non-judgemental smorgasbord questions, and explaining the purpose of the screening.

Focus groups

Focus groups are semi-structured interview-like discussions with a small group of participants (4–12) [26]. The focus groups generated dynamic group discussion, and enabled participants to elaborate on, question or support the responses of other group members [27]. Focus groups had between 4–9 participants of mixed gender, and ranged from 15–30 minutes in length.

Two focus group interviews were conducted either immediately prior to or in the week prior to involvement in workshops with 13 medical students (5 females, 8 males) who were invited by researchers, and who volunteered to participate. Respondents were asked how they feel about initiating conversations with young people, and how confident they feel using the HEADSSS screening questions in consultations. A further five follow-up focus groups were conducted with 39 medical students (22 females, 17 males) immediately after the workshops. The respondents in the two pre-workshop focus groups also participated in the post-workshop focus groups. The post-intervention focus groups were used to explore what respondents perceived they had gained from the workshops and the degree to which this experience would inform their professional approach. Both pre-and post-interviews followed a topic guide.

Seven focus groups were also conducted with 38 school students (28 females, 10 males) prior to the workshops, and a further set of 12 focus groups were conducted post-workshop with 69 school students (47 females, 22 males). All focus groups were audio recorded and transcribed verbatim, and were analysed and coded thematically. Transcripts were coded separately by two researchers and compared to cross-check themes and ensure rigour [26,27]. An effort was made to include the same school students in both pre and post focus group interviews; however this was not always possible due to student absences. Pre-workshop focus groups were conducted with school students one to two weeks prior to participating in the first of two Learning Partnerships workshops. The number of focus groups and individual participants was higher in post- than pre-focus groups as focus groups were conducted opportunistically immediately following workshops whilst students were still present.

Surveys

The following section discusses findings from the focus group interviews conducted prior to workshops which explored their concerns about communicating with adolescents about sensitive issues using the HEADSS screening tool.

Medical students’ concerns about communicating with adolescents prior to workshops

Some were concerned that initiating questions around sexual health might seem ‘a bit creepy’ unless there was a presenting complaint, and unless the patient understood why the questions were being asked, believing that it may be better to respond than to initiate.

Evaluating learning partnerships

Survey data shows that the medical students found the workshops valuable in improving their skills in communicating with young people and understandings of adolescent health needs. Respondents ranked the usefulness of the workshops out of 10 (1 = not at all useful, 10 = extremely useful) across areas such as skills and understanding, value of learning activities and overall value of the workshop. The mean was 7.72 or higher for all ‘skills and understanding’ items on the survey, with ‘Understand importance of informing young people about confidentiality’ (mean 8.41), ‘Knowledge of how to apply the HEADSS psycho-social screening tool’ (mean 8.41) and ‘Understand the challenges adolescents can encounter in disclosing experiences relating to drugs or sex’ (mean 8.38) as the mostly highly rated items. The highest rated learning activities were ‘Trying out techniques in role-play’ (mean 8.58), ‘Getting feedback and advice from the school students’ (mean 8.52) and ‘Discussion following the activity’ (mean 7.99). The items relating to the overall value of workshop were also highly rated. ‘Provided opportunities to improve capacity to communicate well with adolescents’ had a mean score of 8.43; ‘Increased confidence about the possibility of building positive relationships with adolescent patients’ scored a mean of 8.29, and ‘Provided better insight into the needs of adolescent patients’ scored a mean of 7.95. The survey data shows that the workshops were rated by medical students as highly useful in enhancing their skills and confidence initiating conversations with adolescents about sensitive issues, and for providing them with greater insight into the needs that young people had for adults to take the lead in initiating these conversations.

School students

Survey data shows that the school students also found the workshops valuable for increasing their understanding and trust of doctors and their confidence that doctors could be a useful source of help on problems relating to sex, drugs and mental health. The mean for items in the ‘skills and understandings’ ranged from 6.92 to 8.70, with ‘Learn about confidentiality at the doctors’ (mean 8.70), ‘Get a better understanding of how to handle problems if they come up in the future’ (mean 8.17) and ‘Understand the doctor’s job in helping teenage patients with problems to do with sex, drugs or mental health’ (mean 8.15) as the top three highest rated items. The most highly rated learning activities for school students were ‘Discussion with the doctors’ (mean 8.35), ‘Giving feedback and advice to the doctors’ (mean 8.23) and ‘The coaching and replay in fishbowl activity conducted by facilitator’ (mean 8.03). The highest rated ‘overall outcome’ was the item ‘Increase your confidence that doctors may be useful when young people have personal health problems’ (mean 8.13).

Overall, the school students and medical students described that the encounters and activities in workshops gave them a greater understanding of each other, and more confidence in the possibility of relating effectively with each other.