communication skills for medical students: results from three experiential methods

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Article

Communication Skills for Medical Students: Results From Three Experiential Methods

Jonna Koponen1, Eeva Pyörälä2, and Pekka Isotalus3

Abstract

Background. In medical students’ communication training, the doctor-patient encounter can be simulated through experiential learning methods, such as simulated patients (SPs) and role-play. However, more theater and drama education–based methods have not been widely used in the context of medical education.

Aim. In this mixed-method study, we compare SPs, role-play, and Theatre in Education (TIE) method in teaching interpersonal communication competence (ICC) to medical students. We describe how a course in communication was based on the communication in the disciplines (CID) theoretical framework and principles of experiential learning and reflection.

Method. Second-year medical students (n = 132) were randomly assigned to three groups where SPs, role-play, and TIE method were used. Data were collected by a questionnaire, focus group interviews, and a translated version of the Communication Skills Attitude Scale. Data were analyzed using statistical methods, qualitative content analysis, and cross-case analysis.

Results. The results show that (a) the medical students perceived all three methods favorably, (b) the students’ self-reported learning outcomes were very similar in the three groups, and (c) the students’ attitudes to learning communication skills became more positive as the training progressed.

Conclusion. We present a model that can be used in designing and implementing specialty-specific communication training in other disciplines than medicine as well.

1University of Eastern Finland, Kuopio, Finland2University of Helsinki, Finland3University of Tampere, Finland

Corresponding Author:Jonna Koponen, Business School, University of Eastern Finland, Kuopio Campus, P.O. Box 1627, Kuopio 70211, Finland. Email: [email protected]

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Keywordscommunication training, cross-case analysis, doctor-patient encounter, drama techniques, experiential learning methods, interpersonal communication competence (ICC), medical students, model, qualitative content analysis, role-play, simulated patients (SPs), statistical methods, Theatre in Education (TIE)

Simulation has a long history in medical education (Alinier, 2011; J. L. Lane, Slavin, & Ziv, 2001) although real patients have always been an important part of medical education (Bokken, Rethans, Scherpbier, & van der Vleuten, 2008). The doctor-patient encounter that is required for medical students’ communication skills training can be simulated through different experiential learning methods, such as simulated patients (SPs) and role-play (J. L. Lane et al., 2001). However, drama education–based meth-ods have not been widely used in the context of medical education. Because different simulation methods offer different learning opportunities and experiences to students, this article compares SPs, role-play, and Theatre in Education (TIE) method in teach-ing interpersonal communication competence (ICC) to medical students. These meth-ods have not, as far as we are aware, been compared before. The main concepts used in the study are defined in Table 1.

ICC is considered to form an essential part of physicians’ professional competence (Frank, 2005). The importance of communication in the medical context has been demonstrated in several studies: The success of physician-patient communication has been linked to patient satisfaction, compliance with recommended treatment, under-standing and recall of information, fewer malpractice suits (Brown, Steward, & Ryan, 2003; Ong, De Haes, Hoos, & Lammes, 1995), and physician’s work satisfaction (du Pré, 2001). On the other hand, unsuccessful physician-patient communication is one of the main reasons for malpractice suits (Brown et al., 2003). Therefore, communica-tion skills are part of the skills to be acquired in medical education (AAMC, 2008; General Medical Council, 2009; Hargie, Boohan, McCoy, & Murphy, 2010).

Although communication skills are essential in the physician’s profession, several studies show that some medical students do not deem learning communication skills important at all (Rees & Garrud, 2001) and are negatively disposed to acquiring and using these skills even after communication training (Bombeke et al., 2011; Harlak, Gemalmaz, Gurel, Dereboy, & Ertekin, 2008; Rees & Sheard, 2003). They see com-munication skills as soft science, easy to learn, and not worth studying (Rees & Garrud, 2001). For all these reasons, teachers in health care need to find ways to motivate medical students to value and acquire communication skills.

Teaching and Learning Methods in Communication Training

Research on the effectiveness of medical students’ communication training has shown that the best results are achieved when communication training incorporates the use of



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learner-centered, experiential learning methods and feedback (Aspegren, 1999; Berkhof, van Rijssen, Schellart, Anema, & van der Beek, 2011). Moreover, the effec-tiveness of the communication skills training may be improved when combined with the theoretical knowledge of doctor-patient interactions (Gysels, Richardson, & Higginson, 2005). Nowadays, SPs and role-play are widely used in medical students’ communication training during the Observed Structured Clinical Examinations (OSCE; C. Lane & Rollnick, 2007; May, Park, & Lee, 2009; Wallace, 2007). More theater-based learning methods such as theater performance (Shapiro & Hunt, 2003), lectures supported by theater performance (Ünalan et al., 2009), improvisation (Hoffman, Utley, & Ciccarone, 2008), and devised theater (McCullough, 2012) have been used to teach interpersonal communication skills, history-taking skills, empathy, and compassion to medical students. However, few studies (C. Lane, Hood, & Rollnick, 2008; Mounsey, Bovbjerg, White, & Gazewood, 2006; Papadakis,

Table 1. Definitions for Main Concepts Used in the Study.

Concept Definition Sources

SP SPs portray live interactive simulations of specific communication challenges and medical problem situations, offering the students a safe learning environment with no risk of harm to real patients. SPs can be trained actors who are trained to simulate patient’s illness or real patients who are trained to present their own illness.

Barrows (1993); Kurtz, Silverman, and Draper (2005); Wallace (2007)

Role-play The idea of role-play is that of asking someone to imagine that they are either themselves or another person in a particular situation and then to behave as they feel that person would behave.

Van Ments (1989)

TIE TIE connects theater techniques with education, utilizes elements of traditional theater, educational drama and simulation, and contains structured patterns of activities around the selected topic.

Jackson (1993)

ICC ICC requires knowledge about effective and appropriate interpersonal communication, motivation to engage in interaction, and interpersonal communication skills, which are needed to act in a way that the interactants perceive to be appropriate and effective. Effectiveness refers to achievement of preferred or desired outcomes of social interaction and appropriateness refers to the perceived fitness or legitimacy of a communicator’s behavior in a given context and relationship.

Spitzberg and Cupach (2002)

Note. SP = simulated patient; TIE = Theatre in Education; ICC = interpersonal communication competence.




Croughan-Minihane, Fromm, Wilkie, & Ernster, 1997) have compared the use and the effect of different experiential learning methods in medical students’ communication training. A comparison is needed because each experiential learning method may offer the learner a unique set of experiences and opportunities for learning.

For example, role-play enables the simulation of social settings (Mariais, Michau, & Pernin, 2012), and practicing communication skills in the role of both patient and doctor. An interchange of roles is supposed to promote empathy toward patients (J. L. Lane et al., 2001). Alternatively, the SP method provides a learning experience where medical students are in the doctor’s role and they must meet a patient regarding a specific case (a trained actor who simulates the patient’s illness or a real patient trained to perform his or her own illness; Barrows, 1993). The experience is thought to be more realistic than the one gained through role-play (Kurtz, Silverman, & Draper, 2005). In both the role-play and the SP method, some students practice communication skills while others may observe the encounter. Therefore, the focus is on the learner who is practicing a professional role. This is thought to arouse anxiety in medical stu-dents (Hoffman et al., 2008). Therefore, an experiential learning method based more on drama education, such as Theatre in Education (TIE), could offer students a sup-portive learning experience based more on group work. TIE differs from SPs and role-play because a theater group first performs a short performance entailing doctor-patient interaction and the group of students then reflects on the play through drama exercises (Jackson, 1993). The whole group of students is actively involved throughout the TIE workshop.

On the basis of comprehensive reflection of the previous literature, we propose novel conceptual models which show that TIE, SPs, and role-play enable somewhat different participation levels for learning ICC. The extent of participation increases as the students shift from one participation level to another. Moreover, the participation levels include reflective thinking and debriefing. We argue that the participation levels for learning ICC are to described as (a) observing and analyzing doctor-patient inter-action individually (TIE, SPs, role-play), (b) debriefing during the exercise (TIE, SPs) and after the exercise (SPs and role-play), and (c) training communication skills in a doctor’s role individually in a social context (TIE, SPs, role-play). In addition, creat-ing a psychologically safe learning environment is vital when learning ICC through these experiential methods. The participation levels and their differences in each method are illustrated in Figures 1 to 3.

To conclude, TIE has rarely been applied to medical students’ communication training, whereas role-play and SPs are widely used. Because methods differ and they offer students different participation levels and learning opportunities, we were inter-ested in comparing SPs, role-play, and TIE in our study.

Theoretical Background of the Communication Course

Medical students’ communication training may be organized as a separate communi-cation course or it may be integrated into medical studies (communication in the dis-ciplines [CID]; Dannels, 2001). The theoretical framework of CID is grounded on



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principles of disciplinary knowledge construction, the social construction of knowl-edge, and situated learning, when learning to communicate is seen as a context-driven activity (Dannels & Housley Gaffney, 2009). So far, studies using the CID theoretical framework have explored discipline-specific contexts and communication education

Figure 1. Participation levels for learning ICC in the Theatre in Education method.Note. ICC = interpersonal communication competence.

Figure 2. Participation levels for learning ICC in the simulated patient method.Note. ICC = interpersonal communication competence.




in the technical sciences (Dannels, 2002; Darling, 2005), business studies (Cyphert, 2002), design (Dannels, 2005), dietetics (Vrchota, 2011), pharmacy (Hyvärinen, 2011), and medicine (Haber & Lingard, 2001; Lingard, Garwood, Schryer, & Spafford, 2003). Studies on the discipline-specific communication education in medicine have explored public speaking (Haber & Lingard, 2001) and case reports as a speaking context (Lingard et al., 2003). However, these studies have not explored the use and the effect of experiential learning methods in teaching ICC to medical students.

In this study, we developed a course in communication based on the CID theoreti-cal framework. Therefore, we chose a specific context relevant to medical students’ future careers, namely, patient consultation practiced using three experiential learning methods. Although the CID theoretical framework sees learning as a context-driven activity and social phenomenon (Dannels, 2001), it does not explain how learning through experience and reflection occurs. Therefore, we expanded the theoretical framework of the CID with the idea of drama education, and learning through experi-ence and reflection.

As experiential learning methods, TIE, SPs, and role-play have a link to drama education because in all these methods the setting can be seen to resemble theater: Some students engage in a fiction while others watch the fiction (Jacobsen, Baerheim, Lepp, & Schei, 2006). Drama education is playful; however, we do not play only for fun, but in order to learn. Learning in drama is seen as a creative, communal, and active process, and the concepts of learning are based on constructivism and experien-tial learning (Østern & Heikkinen, 2001).

Both experiential learning theories and constructivism are based on the assumption that learners construct knowledge when they attempt to make sense of

Figure 3. Participation levels for learning ICC in the role-play method.Note. ICC = interpersonal communication competence.



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their experiences (Yardley, Teunissen, & Dornan, 2012). We need to reflect on our experiences in order to convert the experience into learning through both the reflec-tion-in-action and reflection-on-action processes that correspond with the learning event (Schön, 1983). In this study, we used the reflection-on-action process referred to as debriefing (Crookall, 2010). Crookall (2010) emphasizes the importance of debrief-ing in order to learn from simulations and games. Participating in a role-play does not automatically guarantee learning, but debriefing is needed in order to reflect on the experience and turn it into learning (Crookall, 2010; Lederman, 1992).

This article describes a course in communication for second-year medical students, which was based on the communication in the disciplines (CID) theoretical framework and principles of experiential learning and reflection. We explain how we used TIE, SPs, and the role-play method during the course. Then we describe our methods to explore students’ perceptions of the three methods, their attitudes to learning commu-nication skills, and their self-reported learning outcomes in three groups using SPs, role-play, and TIE. We summarize the results of our sub-studies (Koponen, Pyörälä, & Isotalus, 2011a, 2011b, 2012), and focus on profound reflection of the results.

Method

In 2006, we developed a course in communication for second-year medical students in cooperation with a speech communication lecturer and seven clinical lecturers. No specific communication curriculum for medical students existed in our university, and therefore, we needed to select and train a group of eight facilitators to design and implement the course. Clinical lecturers received 3 hours of speech communication preparation to facilitate the training. The first author of this article was one of the facilitators selected for this task.

The objectives of the course were to (a) encourage the students to analyze doctor-patient communication, (b) practice interpersonal communication skills, and (c) enhance students’ understanding and appreciation of the importance of communi-cation and interpersonal communication skills in the doctor-patient relationship. The course emphasized history-taking skills (especially building a relationship with the patient, asking questions, listening skills, nonverbal communication skills, and provid-ing structure for the consultation). These skills were selected on the basis of the enhanced Calgary-Cambridge Observation Guide (Kurtz et al., 2005). A 2-hour lesson in doctor-patient communication was provided with opportunities for the learners to analyze the doctor-patient interaction shown on a DVD with specific debriefing cards. The students were divided into three groups to practice the communication skills through the TIE, SPs, or role-play methods (2 × 2 hours) and allow for opportunities to reflect on their experiences. The debriefing process in each method is described in the appendix. The patient scenarios used in each group were based on real patient cases in primary health care. Patient scenarios were written by clinical lecturers to make sure that they were suitable for second-year medical students. Three experiential learning methods were compared.




•• Method A (TIE): TIE was conducted in a small group of 14 to 16 students and two facilitators. The facilitators made a drama contract (Owens & Barber, 2001) with the students including commitment to participate in group work. Then, the students participated in warm-up exercises to focus their attention, encourage accepting one’s own and others ideas, and explore satisfactory and unsatisfac-tory doctor-patient encounters. A group of trained actors played a theatrical performance that included communication challenges (e.g., the doctor was not making eye-contact, not responding to the patient’s emotions, not asking open-ended questions, not eliciting the patient’s full story or listening carefully). The scripts were written by facilitators and the actors were trained by a speech com-munication lecturer specialized in drama education. After watching the perfor-mance, the facilitators used the drama techniques to cause the students to think about the doctor-patient interaction and take part in the fictional context created in the doctor’s role. The patient consultation was further developed with the group of students by using modified forum theater (Boal, 1995), which is explained in the appendix. Taking the doctor’s role was optional for the students in the TIE method, but not in the other two methods.

•• Method B (SP): SP exercises were conducted in small groups of six students and one facilitator. In this study, medical students practiced interviewing patient in a doctor’s role while a trained actor played the part of the patient. If the stu-dent wanted to, it was possible to stop the action and discuss the case with peer students. The exercise was followed by self-evaluation and constructive feed-back discussions with peers and a facilitator. The actors were trained by a speech communication lecturer.

•• Method C (role-play): Role-play exercises were conducted in small groups of six students and one facilitator. Role-play involved medical students practicing a patient interview in a doctor’s role with a peer student playing the part of the patient. This was followed by self-evaluation and constructive feedback discus-sions with peers and a facilitator.

Following their participation in one of the three methods, all students spent 2 days in public health centers observing and analyzing real doctor-patient encounters. Finally, the students discussed their different learning experiences in small groups. The study period was 3 months and student grading was either pass/fail, based on active participation and a written report. Ethical approval to conduct the study was obtained from our university and all participating students gave their informed consent to participate in the study.

Participants’ Demographics

All second-year medical students (N = 136) in a middle-sized university in Finland were randomly assigned to three groups. Of the 136, 132 (97%) participated in the study and completed the questionnaire following the course and 19 (14%) participated in the focus group interviews. In addition, 129 (95%) of the participants completed the



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translated version of the Communication Skills Attitude Scale (CSAS) before and after the course.

Group A (n = 43) used the TIE method and consisted of 13 males and 30 females, ranging from 20 to 29 years of age (M = 21.7; Mdn = 21). In Group B (n = 44), we used simulated patient interviews with amateur actors. The number of males to females in this group were similar to Group A; 14 males and 30 females, with ages ranging from 20 to 34 years (M = 22.6; Mdn = 22). Group C (n = 45) consisted of 19 males and 26 females who took part in the role-play with peers method. Their ages ranged from 19 to 31 years (M = 22.1; Mdn = 22). Randomization of the students into three groups was successful (χ2 = 1.659; df = 2; p = .436).

Instruments and Analysis

This study used a mixed-method design (Creswell & Plano Clark, 2011). The principal data collection instruments were (a) a questionnaire, (b) focus group interviews, and (c) a translated version of the Communication Skills Attitude Scale (CSAS; developed by Rees, Sheard, & Davies, 2002). A questionnaire and focus group interviews were conducted after the course. The questionnaire included three sections. The first section concerned respondents’ background information—age, gender, name (optional), letter of the peer group (A, B, C), and approval for the study. The second section concerned respondents’ self-reported learning outcomes—two open-ended questions. The third section dealt with respondents’ perceptions of the learning method they had experi-enced—one 5-point Likert-type-scale item and three open-ended questions. The ques-tionnaire was designed for this study and was not validated. Three focus group interviews (Creswell & Plano Clark, 2011) were conducted with volunteer students from each group by the first author of this article. Eight students from Group A (F = 3, M = 5), five from Group B (F = 4, M = 1), and six from Group C (F = 5, M = 1) took part. The interviewer built up relatively open discussion on the medical students’ per-ceptions of the learning method they had experienced. Interviews lasted from 60 to 75 minutes, and were videotaped and transcribed.

The CSAS was used before and after the communication course. The CSAS con-sists of 26 items. These items have response options along a 5-point Likert-type scale ranging from 1 (strongly disagree) to 5 (strongly agree). The CSAS has two subscales. The first subscale, the PAS, includes 13 items related to positive attitudes to learning communication skills. The second subscale, the NAS, includes 13 items related to negative attitudes to learning communication skills. The CSAS has been found to show satisfactory test-retest reliability and internal consistency (Cleland, Foster, & Moffat, 2005; Rees, Sheard, & Davies, 2002).

Qualitative data gathered by the open-ended questions and focus group interviews were analyzed using ATLAS.ti 5.5.9 qualitative data analysis software with qualitative content analysis (Frey, Botan, & Kreps, 2000) and cross-case analysis (Miles & Huberman, 1994). Quantitative data gathered by Likert-type scale evaluations and CSAS were analyzed using SPSS version 17.0. The number and percentage values of the Likert-type scale evaluations obtained by the questionnaire were calculated. Then,




the PAS and the NAS scores of the CSAS were calculated by summing response val-ues for the 13 items for each subscale. Exploratory data analysis showed that all con-tinuous variables including PAS and NAS scores were non-normally distributed. Therefore, we used non-parametric statistical tests. Internal consistency analysis con-ducted by a principal components analysis showed that the reliability of the two sub-scales was adequate (Koponen et al., 2012). Wilcoxon’s test, Mann-Whitney U test, and Kruskal-Wallis test were used to establish whether respondents’ scores on the PAS and the NAS differed significantly in the data as a whole, between genders, and in three groups measured before and after the communication course.

Results

The results from the questionnaire showed that most of the medical students (84%) in each group found TIE, SPs, and role-play as suitable learning methods for acquiring interpersonal communication competence. We found no statistically significant differ-ences (Kruskal-Wallis test, χ2 = 4.418; df = 2; p = .110) in students’ perceptions in the three groups (Koponen et al., 2011a).

The results of the cross-case analysis (containing data from open-ended questions and focus group interviews) showed that these three methods had five special elements in common: (a) the doctor’s role, (b) the patient’s role, (c) reflective participation, (d) emotional reactions, and (e) facilitators’ actions. Within these five themes, medical students indicated helpful and unhelpful aspects. First, practicing communication skills in a doctor’s role, scripts of patient roles felt to be realistic, observing the interac-tion, positive emotional reactions, and positively experienced facilitators’ actions were considered helpful elements in these learning methods. In addition, reflecting on the problematic situation together with peers in the modified forum theater stage in the TIE method and the multifaceted feedback discussion in the other two methods were reportedly helpful. Second, the unhelpful elements were avoiding being in a doctor’s role or having a negative experience of being in a doctor’s role, lack of medical knowl-edge, experiencing stress during the rehearsal, unrealistic scripts, patient cases or peer student performances, negative experience of facilitators’ actions, and, in TIE, lack of motivation and avoiding taking part (Koponen et al., 2011a).

The results of the cross-case analysis (data obtained from the open-ended questions of the questionnaire) showed that the medical students’ self-assessed learning out-comes can be summarized as following themes. The students learned (a) interpersonal communication skills, (b) awareness of one’s own and doctor’s interpersonal commu-nication competence, (c) knowledge of doctor-patient communication and understand-ing the meaning of communication and interpersonal communication skills in the doctor-patient relationship, and (d) patient-centeredness. Three students reported that they did not learn anything new (Koponen et al., 2011b). The students’ self-reported learning outcomes were very similar in each of the three groups. However, students practicing communication skills through the TIE method reported learning more patient-centeredness than did the other two groups.



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The results of the non-parametrical statistical tests (data obtained from the CSAS) revealed that medical students’ (n = 129) positive attitudes to learning communication skills improved significantly (Wilcoxon’s test, z = −3.932, p = .000), and their negative attitudes diminished significantly (Wilcoxon’s test, z = −3.677, p = .000) between the beginning and end of the communication course (Koponen et al., 2012). We found no significant differences between the three groups in the mean scores for positive atti-tude scale (PAS) measured before (Kruskal-Wallis test, χ2 = 1.570; df = 2; p = .456) or after the course (Kruskal-Wallis test, χ2 = 4.333; df = 2; p = .115). In addition, we found no significant differences between the three groups in the mean scores for nega-tive attitude scale (NAS) measured before (Kruskal-Wallis test, χ2 = 1.906; df = 2; p = .386) or after the course (Kruskal-Wallis test, χ2 = 4.097; df = 2; p = .129). According to Mann-Whitney U test, female and male students’ scores on PAS differed significantly measured before (U = 1,176, z = −2.968, p = .003) and after (U = 1,308.5, z = −2.794, p = .005) the communication course. These results show that female stu-dents had more positive attitudes to learning communication skills at the beginning and at the end of the course. Furthermore, Mann-Whitney U test showed that female and male students’ scores on NAS differed significantly measured before (U = 1,375, z = −2.111, p = .035) and after (U = 1,302.5, z = −2.824, p = .005) the communication course. These results indicate that female students had less negative attitudes to learn-ing communication skills than males before and after the communication course. In summary, female students had more positive attitudes to learning communication skills than males (Koponen et al., 2012).

Discussion

First, medical students perceived all three methods favorably. We found no statisti-cally significant differences in students’ perceptions, and the methods had five similar elements (Koponen et al., 2011a). The results are supported by earlier findings of medical students’ positive views on learning communication skills through SPs (Eagles, Calder, Nicoll, & Walker, 2001; Mönkkönen, Pyörälä, & Isotalus, 2007; Rees, Sheard, & McPherson, 2004) and role-play (Nestel & Tierney, 2007). Second, the medical students’ self-assessed learning outcomes were very similar in the three groups using TIE, SPs, and role-play (Koponen et al., 2011b) and the students’ atti-tudes to learning communication skills became more positive during the course in communication (Koponen et al., 2012). If we look at the learning outcomes achieved and compare them to the aims of the course in communication, we claim that the aims of the course were well achieved.

TIE, SPs, and role-play have not previously been compared. However, in a few studies, SPs and role-play have been found to be equally effective when teaching moti-vational interviewing to health care professionals (C. Lane et al., 2008) or third-year medical students (Mounsey et al., 2006), and when first-year medical students prac-ticed smoking-cessation techniques (Papadakis et al., 1997). In light of the results, we argue that TIE, SPs, and role-play seem equally suitable for learning ICC.




The positive change in the students’ attitudes found in this sample of students dif-fers from the work described by other researchers who have measured medical stu-dents’ attitudes to learning communication skills with the CSAS (Bombeke et al., 2011; Harlak et al., 2008; Rees & Sheard, 2003). None of the studies exploring medi-cal students’ attitudes before and after communication training with CSAS (Harlak et al., 2008; Rees & Sheard, 2003) describe integrating visits to public health centers with communication training or using mainly experiential learning methods during training, as was done in this study. One of the reasons behind the positive results of this communication course may be that it was integrated into a clinical context where stu-dents were able to observe and analyze real doctor-patient consultations, affecting transfer and making the instruction more meaningful for the students. The results showed that female medical students had more positive attitudes to learning commu-nication skills than males. This finding is consistent with previous studies (Bombeke et al., 2011; Cleland et al., 2005; Harlak et al., 2008; Rees & Sheard, 2003). One of the reasons for this difference might be that male medical students have been shown to be slower at learning communication skills than females (Aspegren, 1999; Rees & Sheard, 2003). Therefore, more attention should be paid to support males in learning communication skills.

On the basis of comprehensive reflection of the results, we argue that in all three methods at the first participation level (see Figures 1-3), learning ICC was based on students’ active observations and their own reflections about doctor-patient interac-tions shown either in the TIE play or in live interactions with simulated patients or peers (role-play). At the second participation level (see Figures 1-3), learning ICC was based on social interaction and debriefing together with other students because the students were able to discuss and reflect on problematic doctor-patient interaction with peers during and after the exercise. This active debriefing process enhances learning and these observations support the idea that learning occurs through constructing knowledge and meaning from experience through reflection (Boud, Cohen, & Walker, 1993; Yardley et al., 2012).

At the third participation level (see Figures 1-3), learning was based on having an experience of being in a doctor’s role. This was an individual experience for the stu-dents, although the exercise took place in a social context. Practicing communication skills in a doctor’s role is common in medical students’ communication skills training (Craig & Cosgrove, 2010; Hargie et al., 2010). However, according to our results, the experience was at the same time rewarding and unproductive: The students thought that the experience was realistic, challenging, interesting, supported self-confidence, and was good preparation for the doctor’s profession. In contrast, the experience was felt to be unrealistic, too difficult due to lack of medical knowledge, and stressful. Therefore, the experience of being in the doctor’s role could be described as a mean-ingful, but stressful at the same time.

All in all, learning ICC through TIE, SPs, and role-play can be described as an individual and a social process at the same time. In addition, social interaction can be seen as fundamental to experiential learning. The idea of learning through experiential methods in a specific context with others concurs with the ideas of the CID theoretical



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framework (Dannels, 2001) because learning takes place in a specific context and is social in nature. Communication education requires learning settings and situations that are as authentic as possible, and stimulate social processing and co-construction of knowledge (Lave & Wenger, 1991). All the learning methods studied provide such learning opportunities for students. In addition, the communication skills studies were immediately followed by observations in authentic health care settings in primary health care. This instructional design fostered further reflection on doctors’ communi-cation skills after the different types of simulated patient scenarios used in this study, and therefore the instructional design may have had a positive effect on creating situ-ational interest in medical students (Clapper, 2014).

Figure 4 describes the learning process of ICC through experiential learning meth-ods and illustrates the instructional design used in this study. This model can be used in designing specialty-specific communication training in other disciplines than medi-cine. When implementing this model, the facilitator needs to decide in which spe-cialty-specific context learning communication may take place. Then this context can be simulated through experiential learning methods. For example, TIE, SPs, and role-play could be applied to teaching communication in those disciplines where building a relationship with a patient/client is crucial in order to achieve the goals of the profes-sional work. Finally, simulation-based training should be followed by observations in authentic communication context.

Figure 4. Instructional design for specialty-specific communication training.Note. ICC = interpersonal communication competence.




Limitations

This study has limitations, which must be taken into consideration when evaluating and interpreting the results. In order to study the direct impact of a course in com-munication, a randomized controlled trial should have been designed, which was impossible in our university because this course was obligatory for all second-year medical students. The pre-test, post-test design or only post-test design in these studies means that differences found in respondents’ attitudes before and after a course and students’ self-reported learning outcomes may be due to factors other than the course in communication or the different experiential learning methods used. We used only subjective data and therefore we could have used other data, such as observational data, to further evaluate the effectiveness of communication studies. In addition, it is difficult to directly compare our results to those of other studies using the CSAS because, for example, the course content, duration, and methods used vary between studies. The overall sample size (n = 132) was satisfac-tory, but the numbers of respondents in the three groups were rather small. The findings on medical students’ attitudes and perceptions in these studies may be representative of this cohort, but not necessarily of all medical students in our med-ical school or in Finland. The Finnish version of the CSAS (Koponen et al., 2012) has been validated. We triangulated the quantitative data with qualitative focus group interview data.

It has been suggested that communication training should be integrated with clini-cal experience, because only in the clinical context, medical students truly realize the benefits of learning communication skills (Rees, Sheard, & McPherson, 2002). Our experience shows that the use of experiential learning methods and integrating com-munication training with an actual health care visit may help medical students to appreciate communication skills at an early stage of their studies. Also other previous studies show that preclinical patient contacts benefit medical students learning (Diemers, Dolmans, Verwijnen, Heineman, & Scherpbier, 2008). However, it is not realistic to assume that one course would ensure that young doctors graduate with superior ICC. The communication training needs to be systematically integrated into the whole of the curriculum, as it is already in many universities (Craig & Cosgrove, 2010; Hargie et al., 2010).

To conclude, our results show that TIE, SPs, and role-play seem equally suitable for learning ICC as we found no significant differences in students’ attitudes or learning outcomes between the three groups. As TIE has not been widely used in communica-tion education, we suggest that this method could be further explored by other research-ers. In addition, the oral debriefing process described in this article could be expanded with written debriefing (Clapper, 2014; Petranek, 2000) in order to promote ICC learn-ing even more. We hope that the results and reflections we report will encourage edu-cators and facilitators to use, combine, and develop SPs, role-play, and TIE as learning methods in their teaching.



Koponen et al. 249

Appendix

Debriefing in the TIE Workshop and in the SP and Role-Play Methods

In the TIE workshop, a play was reflected through drama conventions. We call this procedure modified forum theater, because the emphasis was on problematic patient-doctor interaction and not precisely in oppression as is the idea in the original forum theater developed by Augusto Boal (1995). Both scripts1 included communication challenges (e.g., the doctor was not making eye-contact, not responding to the patient’s emotions, not asking open-ended questions, not eliciting the patient’s full story or lis-tening carefully). After watching the play, the participants were asked to discuss in pairs. The facilitator asked,

1. What kind of issues did you pay your attention to while watching the play?2. Are you familiar with the interaction situation described in the play?3. Do you think something like this could happen in real life?

Second, the students were asked to go behind the characters (doctor and patient) in still-image, and articulate the characters’ hidden thoughts, in order to enhance the understanding of the characters (Owens & Barber, 2001). We used hot seat technique (Owens & Barber, 2001), where the students interviewed the doctor-actor in role in order to clarify her perspectives. The play was re-played, and the students were encour-aged to stop the action whenever they felt the doctor-actor should change her com-munication behavior. After shouting “stop!” the actors “froze” and the students could make proposals to the doctor-actor. First, the actors performed the students’ solution. Then, the students were encouraged to change roles with the doctor-actor, and try out several possible solutions and find new solutions by themselves (student-as-doctor). In the end of the workshop, they asked the students to give each character advice, reflect on their communication style, and discuss the learning experience.

We used structured oral debriefing after exercising patient interview with simulated patients and peer students (role-play). The reflective discussion was organized as fol-lows. First, the participant who was in a doctor’s role reflected his or her feelings and communication behavior. The facilitators were advised to ask the following questions:

4. How did you feel?5. How did you achieve your own goals?6. What went well? What would you change in your communication behavior if

you were to do the same exercise again?

Second, the actor or peer student playing the patient’s role was advised to comment the interaction with the doctor. The facilitators were advised to ask the following questions:

7. How did you feel as a patient?8. What kind of impression did you get from the doctor?




Third, observers gave feedback according to debriefing cards they were asked to follow. The debriefing cards were related to interpersonal communication skills (build-ing the relationship with the patient, structure of the consultation, asking questions, listening skills, and nonverbal communication skills). The facilitators asked each observer to give feedback according to feedback rules (first positive comment, then critical comments, and finally positive comments; Kurtz et al., 2005). Then, the facili-tator gave feedback and summarized the main ideas found during the debriefing ses-sion. Thereafter, the participant who was in a doctor’s role was asked to comment the feedback he or she had received. The facilitator was advised to use the following questions:

9. Would you like to comment the feedback you have received from us?10. Would you like to ask something from us?

Author Contributions

All authors contributed substantially to this article. JK and PI conceived and designed the study. JK collected the data. JK wrote the final manuscript. JK, EP, and PI wrote the first draft. JK and EP did the qualitative data interpretation. JK did most of the statistical analyses. JK, EP, and PI made numerous critiques and suggested specific wording. JK and EP designed most of the graphics. All authors contributed to the editing of the manuscript.

Acknowledgment

We thank the anonymous reviewers and Timothy Clapper for their constructive suggestions, which helped to improve this article.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Note

1. To see the full description of the scripts, please contact the corresponding author.

References

AAMC. (2008). Recommendations for clinical skills curricula for undergraduate medical edu-cation. Retrieved from https://www.aamc.org/download/163788/data/recommendations_for_preclerkship_skills_education_for_ugme.pdf

Alinier, G. (2011). Developing high-fidelity health care simulation scenarios: A guide for edu-cators and professionals. Simulation & Gaming, 42, 9-26. doi:10.1177/1046878109355683


https://www.aamc.org/download/163788/data/recommendations_for_preclerkship_skills_education_for_ugme.pdf


Koponen et al. 251

Aspegren, K. (1999). BEME Guide No. 2: Teaching and learning communication skills in med-icine—A review with quality grading of articles. Medical Teacher, 21, 563-570.

Barrows, H. (1993). An overview of the uses of standardized patients for teaching and evaluat-ing clinical skills. Academic Medicine, 68, 443-451.

Berkhof, M., van Rijssen, H. J., Schellart, A. J. M., Anema, J. R., & van der Beek, A. J. (2011). Effective training strategies for teaching communication skills to physicians: An overview of systematic reviews. Patient Education and Counseling, 84, 152-162.

Boal, A. (1995). The rainbow of the desire: The Boal method of theatre and therapy. London, England: Routledge.

Bokken, L., Rethans, J.-J., Scherpbier, A. J. J. A., & van der Vleuten, C. P. M. (2008). Strengths and weaknesses of simulated and real patients in the teaching of skills to medical students: A review. Simulation in Healthcare, 3, 161-169.

Bombeke, K., Van Roosbroeck, S., De Winter, B., Debaene, L., Schol, S., Van Hal, G., & Van Royen, P. (2011). Medical students trained in communication skills show a decline in patient-centered attitudes: An observational study comparing two cohorts during clinical clerkships. Patient Education and Counseling, 84, 310-318.

Boud, D., Cohen, R., & Walker, D. (1993). Introduction: Understanding learning from experi-ence. In D. Boud, R. Cohen, & D. Walker (Eds.), Using experience for learning (pp. 1-17). Buckingham, UK: SRHE and Open University Press.

Brown, J. B., Steward, M., & Ryan, B. L. (2003). Outcomes of patient-provider interaction. In T. Thompson, A. M. Dorsey, K. I. Miller, & R. Parrot (Eds.), Handbook of health commu-nication (pp. 141-161). Mahwah, NJ: Lawrence Erlbaum.

Clapper, T. C. (2014). Situational interest and instructional design: A guide for simulation facili-tators. Simulation & Gaming. Advance online publication. doi:10.1177/1046878113518482

Cleland, J., Foster, K., & Moffat, M. (2005). Undergraduate students’ attitudes to communication skills learning differ depending on year of study and gender. Medical Teacher, 27, 246-251.

Craig, T., & Cosgrove, E. (2010). University of New Mexico School of Medicine. Academic Medicine, 85(9), S353-S357.

Creswell, J. W., & Plano Clark, V. L. (2011). Designing and conducting mixed methods research (2nd ed.). Thousand Oaks, CA: Sage.

Crookall, D. (2010). Serious games, debriefing, and simulation/gaming as a discipline. Simulation & Gaming, 41, 898-920.

Cyphert, D. (2002). Integrating communication across the MBA curriculum. Business Communication Quarterly, 65, 81-86.

Dannels, D. P. (2001). Time to speak up: A theoretical framework of situated pedagogy and practice for communication across the curriculum. Communication Education, 50, 144-158.

Dannels, D. P. (2002). Communication across the curriculum and in the disciplines: Speaking in engineering. Communication Education, 51, 254-268.

Dannels, D. P. (2005). Performing tribal rituals: A genre analysis of “crits” in design studios. Communication Education, 54, 136-160.

Dannels, D. P., & Housley Gaffney, A. L. (2009). Communication across the curriculum and in the disciplines: A call for scholarly cross-curricular advocacy. Communication Education, 58, 124-153.

Darling, A. L. (2005). Public presentations in mechanical engineering and the discourse of technology. Communication Education, 54, 20-33.

Diemers, A. D., Dolmans, D. H. J. M., Verwijnen, M. G. M., Heineman, E., & Scherpbier, A. J. J. A. (2008). Students opinions about the effects of preclinical patient contacts on their learning. Advances in Health Sciences Education, 13, 633-647.




du, Pré, A. (2001). Accomplishing the impossible: Talking about body and soul and mind dur-ing a medical visit. Health Communication, 14, 1-21.

Eagles, J. M., Calder, S. A., Nicoll, K. S., & Walker, L. G. (2001). A comparison of real patients, simulated patients and videotaped interview in teaching medical students about alcohol misuse. Medical Teacher, 23, 490-493.

Frank, J. R. (Ed.). (2005). The CanMEDS 2005 physician competency framework. Better stan-dards. Better physicians. Better care. Ottawa, Ontario: The Royal College of Physicians and Surgeons of Canada.

Frey, L. R., Botan, C. H., & Kreps, G. L. (2000). Investigating communication: An introduction to research methods (2nd ed.). Boston, MA: Allyn & Bacon.

General Medical Council. (2009). Tomorrow’s doctors 2009. Retrieved from http://www.gmc-uk.org/education/undergraduate/tomorrows_doctors_2009.asp

Gysels, M., Richardson, A., & Higginson, I. J. (2005). Communication training for health professionals who care for patients with cancer: A systematic review of effectiveness. Supportive Care in Cancer, 12, 692-700.

Haber, R. J., & Lingard, L. A. (2001). Learning oral presentation skills: A rhetorical analysis with pedagogical and professional implications. Journal of General Internal Medicine, 16, 308-314.

Hargie, O., Boohan, M., McCoy, M., & Murphy, P. (2010). Current trends in communication skills training in UK schools of medicine. Medical Teacher, 32, 385-391.

Harlak, H., Gemalmaz, A., Gurel, F. S., Dereboy, C., & Ertekin, K. (2008). Communication skills training: Effects on attitudes toward communication skills and empathic tendency. Education for Health, 21. Retrieved from http://www.educationforhealth.net/article.asp?issn=1357-6283;year=2008;volume=21;issue.

Hoffman, A., Utley, B., & Ciccarone, D. (2008). Improving medical student communication skills through improvisational theatre. Medical Education, 42, 537-538.

Hyvärinen, M.-L. (2011). Alakohtainen vuorovaikutuskoulutus farmasiassa [Discipline specific communication education in pharmacy] (Acta Universitatis Tamperensis 1604) (Doctoral dissertation). University of Tampere, Finland.

Jackson, T. (1993). Learning through theatre: New perspectives on Theatre in Education. London, England: Routledge.

Jacobsen, T., Baerheim, A., Lepp, M. R., & Schei, E. (2006). Analysis of role-play in medical communication training using a theatrical device the fourth wall. BMC Medical Education, 6. Retrieved from http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1621062

Koponen, J., Pyörälä, E., & Isotalus, P. (2011a). A comparison of medical students’ perceptions of three experiential methods. Health Education, 111, 296-318.

Koponen, J., Pyörälä, E., & Isotalus, P. (2011b). “On tärkeää kuunnella potilasta tarkkaan ja myös osoittaa se” – lääketieteen opiskelijoiden itsearvioidut oppimistulokset kolmessa ryh-mässä [Medical students’ self-evaluated learning outcomes in three groups]. In M. Valo, A. Sivunen, & V. Laaksonen (Eds.), Prologi. Puheviestinnän vuosikirja 2011 (pp. 7-24). Jyväskylä, Finland: Prologos ry.

Koponen, J., Pyörälä, E., & Isotalus, P. (2012). Comparing three experiential learning methods and their effect on medical students’ attitudes to learning communication skills. Medical Teacher, 34, e198-e207.

Kurtz, S., Silverman, J., & Draper, J. (2005). Teaching and learning communication skills in medicine (2nd ed.). Oxford, UK: Radcliffe.

Lane, C., Hood, K., & Rollnick, S. (2008). Teaching motivational interviewing: Using role-play is as effective as using simulated patients. Medical Education, 42, 637-644.


http://www.educationforhealth.net/article.asp?issn=1357-6283;year=2008;volume=21;issue


Koponen et al. 253

Lane, C., & Rollnick, S. (2007). The use of simulated patients and role-play in communica-tion skills training: A review of the literature to August 2005. Patient Education and Counseling, 67, 13-20.

Lane, J. L., Slavin, S., & Ziv, A. (2001). Simulation in medical education: A review. Simulation & Gaming, 32, 297-314.

Lave, J., & Wenger, J. (1991). Situated learning: Legitimate peripheral participation. Cambridge, UK: University of Cambridge Press.

Lederman, L. C. (1992). Debriefing: Toward a systematic assessment of theory and practice. Simulation & Gaming, 23, 145-160.

Lingard, L., Garwood, K., Schryer, C. F., & Spafford, M. M. (2003). A certain art of uncer-tainty: Case presentation and the development of professional identity. Social Science & Medicine, 56, 603-616.

Mariais, C., Michau, F., & Pernin, J.-P. (2012). A description grid to support the design of learn-ing role-play games. Simulation & Gaming, 43, 23-33.

May, W., Park, J. H., & Lee, J. P. (2009). A ten-year review of the literature on the use of standardized patients in teaching and learning: 1996-2005. Medical Teacher, 31, 487-492.

McCullough, M. (2012). The art of medicine: Bringing drama into medical school. The Lancet, 379, 512-513.

Miles, M. B., & Huberman, A. M. (1994). Qualitative data analysis: An expanded sourcebook. Thousand Oaks, CA: Sage.

Mönkkönen, J., Pyörälä, E., & Isotalus, P. (2007). Medical students’ perceptions of simulated patient interviews with amateur actors. DRAMA: Nordisk dramapedagogisk tidsskrift, 4, 20-25.

Mounsey, A. L., Bovbjerg, V., White, L., & Gazewood, J. (2006). Do students develop better motivational interviewing skills through role-play with standardised patients or with stu-dent colleagues? Medical Education, 40, 775-780.

Nestel, D., & Tierney, T. (2007). Role-play for medical students learning about communication: Guidelines for maximising benefits. BMC Medical Education, 7, Article 3. Retrieved from www.biomedcentral.com/content/pdf/1472-6920-7-3.pdf

Ong, L. M. L., De Haes, J. C. J. M., Hoos, A. M., & Lammes, F. B. (1995). Doctor-patient com-munication: A review of the literature. Social Science & Medicine, 40, 903-918.

Østern, A.-L., & Heikkinen, H. (2001). The aesthetic doubling: A central concept for the theory of drama education? In B. Rasmussen, T. Kjølner, V. Rasmusson, & H. Heikkinen (Eds.), Nordic voices in drama theatre and education (pp. 110-123). Bergen, Norway: IDEA.

Owens, A., & Barber, K. (2001). Mapping drama. Carlisle, UK: Carel Press.Papadakis, M. A., Croughan-Minihane, M., Fromm, L. J., Wilkie, H. A., & Ernster, V. L.

(1997). A comparison of two methods to teach smoking-cessation techniques to medical students. Academic Medicine, 72, 725-727.

Petranek, C. F. (2000). Written debriefing: The next vital step in learning with simulations. Simulation & Gaming, 31, 108-118.

Rees, C. E., & Garrud, P. (2001). Identifying undergraduate medical students’ attitudes towards communication skills learning: A pilot study. Medical Teacher, 23, 400-406.

Rees, C. E., & Sheard, C. E. (2003). Evaluating first-year medical students’ attitudes to learning communication skills before and after a communication skills course. Medical Teacher, 25, 302-307.

Rees, C. E., Sheard, C. E., & Davies, S. (2002). The development of a scale to measure medi-cal students’ attitudes towards communication skills learning: The Communication Skills Attitude Scale (CSAS). Medical Education, 36, 141-147.




Rees, C. E., Sheard, C. E., & McPherson, A. C. (2002). A qualitative study to explore under-graduate medical students’ attitudes towards communication skills learning. Medical Teacher, 24, 289-293.

Rees, C. E., Sheard, C. E., & McPherson, A. C. (2004). Medical students’ views and experi-ences of methods of teaching and learning communication skills. Patient Education and Counseling, 54, 119-121.

Schön, D. A. (1983). The reflective practitioner: How professionals think in action. New York, NY: Basic Books.

Shapiro, J., & Hunt, L. (2003). All the world’s a stage: The use of theatrical performance in medical education. Medical Education, 37, 922-927.

Spitzberg, B. H., & Cupach, W. R. (2002). Interpersonal skills. In M. L. Knapp & J. A. Daly (Eds.), Handbook of interpersonal communication (3rd ed., pp. 564-611). London, England: Sage.

Ünalan, P., Uzuner, A., Ģifçili, S., Akman, M., Hancıoğlu, S., & Thulesius, H. (2009). Using Theatre in Education in a traditional lecture oriented medical curriculum. BMC Medical Education. Retrieved from http://www.biomedcentral.com/1472-6920/9/73

Van Ments, M. (1989). The effective use of role-play: A handbook for teachers and trainers. London, England: Kogan Page.

Vrchota, D. (2011). Communication in the disciplines: Interpersonal communication in dietet-ics. Communication Education, 60, 210-230.

Wallace, P. (2007). Coaching standardized patients for use in clinical competence. New York, NY: Springer.

Yardley, S., Teunissen, P. W., & Dornan, T. (2012). Experiential learning: Transforming theory into practice. Medical Teacher, 34, 161-164.

Author Biographies

Jonna Koponen, PhD, is a university lecturer in Business School at the University of Eastern Finland. She is specialized in the study of interpersonal communication, communication educa-tion, drama education, and intercultural communication.

Contact: [email protected].

Eeva Pyörälä, PhD, MME, is a senior lecturer in university pedagogy in the Faculty of Medicine at the University of Helsinki. She has devoted more than 20 years in the development, teaching, and assessment of communication skills of medical students.

Contact: eeva.pyorala@helsinki.

Pekka Isotalus, PhD, is a professor of speech communication at University of Tampere, Finland. He is specialized in the study of professional communication, teaching communication competence, and political communication.

Contact: [email protected].



communication skills for medical students: results from three experiential methods

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