Mixed messages in learning communication skills? Students comparing role model behaviour in clerkships with formal training

Figures & data

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Practice points

During clerkships, students saw physicians using communication skills, which not always match with the skills they learned during training programmes. Especially in exploring thoughts, expectations and feelings, students often perceived bad examples. There were significant differences between the first (internal medicine and surgery) and the last two clerkships (paediatrics and primary care). Physicians educating medical students need to discuss communication behaviour in their consultations. Formal training and clinical practice need to be more in accordance.

Figure 1. Medical curriculum of the Radboud University Nijmegen Medical Centre and Order of episodes and clerkships.

Table 1  Respondent numbers and number of observed doctors

	Number of	Number of doctors observed in clerkship
Clerkship	students	0	1	2–4	5 or more
1 Internal medicine	81	1	2	19	59
3 Surgery	73	0	0	6	67
4 Paediatrics	55	1	2	5	47
7 Primary Care	80	0	0	25	55
Total	289	2	4	55	228

Table 2  Frequency examples of communication similar to C&C training per clerkship (%)

	Very often/ regularly	Not so often/ almost never
1 Internal medicine	37 (46^†)	43 (54)
3 Surgery	35 (49)	37 (51)
4 Paediatrics	30 (58)	22 (42)
7 Primary care	48 (63)	28 (37)
Total^‡	150 (54)	132 (46)

^†χ²(Clerkship 1×Clerkship 7) = 6400 (p < 0.10); linear by linear association = 5.737 (p < 0.05).

^‡Linear by linear association = 5.106 (p < 0.05).

Table 3  Frequency of examples of information gathering (%)

	Very often/ regularly	Not so often/ almost never	Significant differences between clerkships
Good examples of exploring patient's physical perspective	263 (90)	26 (10)
Bad examples of exploring patient's physical perspective	27 (10)	262 (90)
Good examples of exploring cognitions and emotions	118 (41)	171 (59)	1 < 4^†
			1 < 7^‡
			3 < 4^§
			3 < 7^‡
Bad examples of exploring cognitions and emotions	104 (37)	185 (63)	1 > 4
			1 > 7^§
			3 > 4
			3 ∼ 7
Good examples of exploring behaviour	156 (54)	133 (46)	1 > 4^§
Bad examples of exploring behaviour	61 (21)	228 (79)	1 < 3^†
			1 > 7^‡
			4 < 7^§
Good examples of exploring social context	120 (41)	169 (58)	3 < 4^†
			4 > 7^†
Bad examples of exploring social context	79 (28)	210 (72)	1 < 3^§
			1 < 7^§
Good examples of exploring medical history	262 (91)	24 (9)
Bad examples of exploring medical history	54 (19)	235 (81)	3 > 4^†
			4 < 7^†

†p < 0.01; ‡p < 0.00; §p < 0.05.

Clerkships 1: internal medicine; 3: surgery; 4: paediatrics; 7: primary and community care.

Table 4  Reacting to patient, reflecting feelings, providing information and shared decision making (%)

	Very often/ regularly	Not so often/ almost never	Significant differences between clerkships
Good examples of reacting to patient cues	209 (72)	80 (28)	3 < 4*
Bad examples of reacting to patient cues	81 (28)	208 (72)	1 < 3^†
			1 < 7^†
			3 > 4^†
			4 < 7*
Good examples of reflecting feelings	194 (67)	95 (33)	1 < 7*
			4 < 7*
Bad examples of reflecting feelings	63 (22)	226 (78)	1 < 3^†
			1 < 7^†
Providing information meeting patient's needs	271 (94)	18 (6)
Providing information meeting patient's pace	211 (73)	78 (27)
Coming to a shared decision on management	229 (75)	60 (25)
In fact the doctor took decision on management	174 (60)	115 (40)

*p < 0.05; †p < 0.01.

Clerkships 1: internal medicine; 3: surgery; 4: paediatrics; 7: primary and community care.

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Appendix 1 Questionnaire
Gender	0 Male	0 Female
Age	yrs
	Dutch	Other	Mixed
Ethnic-cultural identity: I primarily feel	0	0	0
Clerkship number
During clerkships you practiced on patient-centred communication skills in the consultation and communication training program (C&C). We would like to know what examples of different aspects of the C&C training program you saw during clerkships. When answering the questions, think back of what you learned in the C&C communication training program. Please mark the answer to the following questions according to your experiences.
	Very often	Regularly	Not so often	Almost never
1. How often were you able to watch your supervising doctor's consultations during the clerkship?	0	0	0	0
2. In general, how often did you see examples of communication similar to C&C training, in the consultations you observed?	0	0	0	0
From here on we will ask for some more details. Which of the following aspects of patient centred communication did you see?
3. I saw good examples of exploring the patient's perspective concerning the symptoms	0	0	0	0
4. I saw good examples of exploring the patient's cognitions and emotions	0	0	0	0
5. I saw good examples of exploring the patient's behavior	0	0	0	0
6. I saw good examples of exploring the patient's social context	0	0	0	0
7. I saw bad examples of exploring the patient's perspective concerning the symptoms	0	0	0	0
8. I saw bad examples of exploring the patient's cognitions and emotions	0	0	0	0
9. I saw bad examples of exploring the patient's behavior	0	0	0	0
10. I saw bad examples of exploring the patient's social context	0	0	0	0
11. I saw good examples of medical history taking	0	0	0	0
12. I saw bad examples of medical history taking	0	0	0	0
13. I saw good examples of reacting to patient cues	0	0	0	0
14. I saw good examples of reflecting patient's feelings	0	0	0	0
15. I saw bad examples of reacting to patient cues	0	0	0	0
16. I saw bad examples of reflecting patient's feelings	0	0	0	0
17. I saw good examples of providing information meeting the patient's needs	0	0	0	0
18. I saw good examples of providing information meeting the patient's pace	0	0	0	0
19. I saw good examples of shared decision making concerning management of the problem	0	0	0	0
20. I saw examples where in fact the doctor took the decision for the patient concerning management of the problem	0	0	0	0
	More than 5	2–5	1–2	None
21. I saw examples of a number of different doctors	0	0	0	0
22. What conclusion do you draw from your observations?