The aim of this study was to confirm the non-inferiority of the objective educational outcomes of medical interview training using CYPT compared with faculty-led training (FLT), and to explore qualitatively the educational benefits of CYPT for undergraduate communication training.
Hirosaki University in Hirosaki, Japan provides a six-year undergraduate medical education program. CYPT sessions are conducted in the medical interview training module in the pre-clinical intensive training course for fourth-year medical students, who have no experience in clinical training. This pre-clinical training includes a 4-week off-the-job course consisting of training in medical interviews, systematic physical examination, basic surgical skills, basic cardiopulmonary resuscitation, and a lecture series on professionalism. Students are required to take a summative Objective Structured Clinical Examination (OSCE) covering the basic clinical skills after completion of the course. OSCE is managed by the government-run Common Achievement Test Organization (CATO) in Japan, and includes assessments of skills in medical interviewing, systematic physical examination, basic surgery, and basic cardiopulmonary resuscitation.
In the medical interview training module, students take four sessions consisting of a lecture on basic interviewing skills (1.5 h), a large-group demonstration of a medical interview session (3 h), a structured small-group role-play of a medical interview (3 h), and a similar small group medical interview session with actors playing the role of patients (3 h).
The present study was conducted during the third small-group structured role-play session (3 h) out of four sessions in the medical interview training module.
Tutor selection and tutor training
Our student tutors were recruited on a voluntary basis from among the ranks of fifth year students without any financial incentive. Although all the tutors attended the same session as students in the previous year, none of them had any experience as a tutor and/or teacher at the university. As this trial was conducted using communication training within the standard medical curriculum, all six student tutors were involved in the training of the CYPT intervention group. Under the supervision of faculty physicians, student tutors received one hour of tutor-training in terms of providing effective feedback in the medical interview training sessions as described in the previous studies [1, 24].
As part of this convergent mixed methods study, we conducted a randomized controlled non-inferiority trial for the quantitative component concurrently with two focus groups for the qualitative component, and analyzed the results of both after completion. This study was performed from January 2014 to February 2014.
The randomized non-inferiority trial was performed using fourth-year students randomly assigned to two groups. Of the 123 4th-year students, 116 students agreed to participate. We randomly assigned 58 students to the CYPT group and 58 to the FLT group by computer-generated, permuted block randomization (Fig. 1). For the CYPT group, teaching was led by a group of six student tutors from year 5. In the FLT group, students were taught by a group of six physicians. Seven students who declined to participate were removed from the study cohort and returned to the normal courses taught by the faculty.
Efficacy was determined by comparing the performance of students in the CYPT group with that of students in the FLT group on a ten-minute OSCE for the medical interview. The OSCE was conducted one week after the training session under the supervision of CATO.
The quantitative part of this study was based on the hypothesis that CYPT would not be inferior to FLT in relation to the OSCE score (0 to 100). We defined the non-inferiority margin as a score of 3.0 considered to be educationally meaningful in our setting and context. This decision was made after careful discussion among the researchers based on the previous test results and their experiences at our university.
We calculated that a sample size of 114 students would give a power of 80%, sufficient to determine whether CYPT was not inferior to FLT in relation to the OSCE score while also taking into account the non-inferiority margin (3.0), a one-sided α error of 0.025, and a standard deviation estimate of 5.7 based on the OSCE scores obtained in the previous year at our university.
Two focus group attended by the four tutees from the CYPT group and all six tutors were held separately prior to the OSCE. The four tutees volunteered to join the focus group in response to our invitation, which was announced to all 4th-year-students at the beginning of the medical interview training module. Discussion was structured by a series of questions, but participants were encouraged to comment freely on any aspect of this experience. They were interviewed by the first author in a private room at the university hospital for approximately 60 min. The interview was audiotaped and transcribed verbatim. A Modified Grounded Theory Approach, a version of the grounded theory approach adapted for greater practicability, was used for analysis . First, we reviewed the transcripts to identify the concepts and compared the concepts with each other until no further new concepts emerged. Next, we analyzed the relationships among the concepts, and generated categories. Finally, we reviewed the relationships between the categories while referring to theoretical notes and made diagrams of the concepts and categories showing their interactions. Through the process of interpretive analysis, we focused on sample characteristics and repeatedly reviewed the data. To enhance the credibility of the analysis, the first author mainly performed the analysis and discussed the results periodically with the second author. All discrepancies were discussed until agreement was achieved. The third author afterwards reviewed the conceptual model for triangulation.
This study was approved by the ethics committee of Hirosaki University Graduate School of Medicine and written informed consent was obtained from all participants.