Instrumental strategy: A stage in students’ consultation skills training?

Abstract

Objectives. To explore and examine students’ abilities to communicate with patients during a general practice course in the final year of the curriculum and to analyse and consider this experience in relation to earlier consultation training. Setting. General practice courses in the undergraduate curriculum. Design. Qualitative data analysis was used. A special focus-group interview of experienced supervisors was performed and analysed (editing analysis). Credibility of data was tested at local seminars and conferences. Authors’ experiences of observing student consultations over many years were also used. Results. A main theme, ‘open invitation’, emerged based on categories ‘initially attentive’ and ‘listening attitude’. In contrast, the second main theme was ‘instrumental strategy’, based on the following categories: ‘one-sided collection of medical facts’ and ‘relationship-building lost’. The students also had difficulties in devoting attention to patients’ life experiences. An hourglass metaphor of students’ and young physicians’ progression of communication strategies is presented. The narrow part of the hourglass corresponds to an instrumental strategy at the end of undergraduate clinical education. Conclusions. An instrumental strategy may be a stage in student's consultation learning progression that interferes with communication training. A question is raised: is training of a patient-centred approach throughout the clinical curriculum needed for optimal development of consultation skills? Further research is needed to test this hypothesis.

• Consultation skills
• focus group
• general practice course
• qualitative analysis
• patient-centred approach
• undergraduate medical education

Deterioration in students’ empathetic ability and understanding of the patient's situation has been reported in undergraduate medical education. A more spontaneous, humane attitude has been replaced by a technical approach – a doctor-centred style. It has been claimed that adaptation to the clinical culture counteracts the medical students’ sensitivity to the patient's personal and psychosocial circumstances [1], [2].

During the last two decades, general practice has had a greater impact on medical curricula and training in consultation skills has been established in many undergraduate general practice courses. Patient communication and life conditions of the patient are learning objectives in these programmes [3]. The picture of students’ communication styles and abilities at the end of the curriculum is, however, scant and fragmentary.

In the medical curriculum in Göteborg, Sweden a Consultation Skills (CS) course, coordinated by the Department of Primary Health Care, is given at the beginning of the clinical phase (5th term). Students learn the basics of the consultation by supervision in primary health care centres. The patient-centred approach is a central theme which implies inviting the patient to present the reason for attendance, allowing the patient to convey symptoms, and actively facilitating the patient to bring out ideas, expectations, and concerns. By these measures, the physician recognizes that the relation is asymmetrical and actively strengthens patients’ autonomy and control of the interview process by suggesting and negotiating an agenda, summing up and checking, aiming at a shared understanding of the patient's problem [4], [5]. The patient-centred approach integrates patients’ agenda with the doctor's agenda, and creates a valid history, better working alliance, and better outcomes in terms of adherence to prescribed treatment [6], [7]. An opposing common approach is called doctor-centred, characterized by closed questions and the mapping of symptoms and diseases. In addition, a balancing concept called ‘dialogue-centred medicine’ has recently been suggested [8].

Within a nine-week course, one week is exclusively spent on video-based consultation training using the Kagan Interpersonal process recall (IPR) method [9]. Similar models, developed in general practice, are also used [10]. Experiences from the CS courses are usually positive and the students express interest and empathy in the patient as a person [11], [12]. During the final year (10th term), three years after the CS course, a core course in general practice is given. Students then attend primary healthcare centres for two weeks with GPs as tutors and students are asked to present videotaped consultations with primary care patients at follow-up sessions.

The aim of the project was to explore and examine the students’ abilities to communicate with patients during the general practice course at the end of the curriculum (10th term). A further aim was to analyse this experience in relation to earlier training including the CS course and subsequent training during clinical rotations in the curriculum.

Material and methods

Qualitative analysis was performed and data collected in the following ways:

Focus-group interview

A focus-group interview was carried through in two steps. Four experienced supervisors (two psychologists and two doctors; both sexes) from the CS course assessed separately videotaped general practice students’ consultations in the 10th term. The four supervisors assessed all videos. The supervisors had about 15 years of experience in facilitating student groups during the CS courses in term 5 and postgraduate Kagan courses for physicians (i.e. interviewing in oncology) forming a substantial clinical experience – corresponding to altogether 60 years of observing CS courses for students and doctors. The supervisors were also involved in Balint supervision work for both students and physicians and were interested in teaching and motivated to share.

Students on the general practice course in the 10th term were asked to voluntarily share their videotapes for analysis and 12 out of 24 students agreed to participate. The consultations covered ‘ordinary’ patients’ reasons for encounter, e.g. infections, fatigue, hypertension, dizziness, and lasted about 15 minutes each.

The supervisors saw all the videotapes separately and then participated in a focus-group interview. The focus group interview took place about one week after the assessors viewed the students’ videotapes. Several open-ended questions were distributed to the supervisors in advance as an indicator of areas to be covered in the interview:

• What were your immediate impressions of the students’ communication skills? What was positive? What was negative?

• How have the students’ communications skills developed?

• Reflect on the changes you observed between the consultation skills course and the final year!

The focus group lasted for three hours, and comprised a detailed discussion and at the end a longer period of reflection and afterthoughts. The focus-group interview was transcribed verbatim and analysed qualitatively according to Krueger and the editing analysis style described by Malterud [13–15]. In interpretation, the patient-centred model was the theoretical frame of reference.

The procedure for the data analysis included the following steps:

1. In order to obtain a global understanding of the content, tapes were listened to several times and all the interview texts read repeatedly.

2. Elements of meaning in the text were identified.

3. The elements were extracted from the text and coded according to preliminary subcategories.

4. Preliminary interpretations of the subcategories were sent in advance by mail to the supervisors and were presented during a 1.5-hour-long validation meeting.

5. The subcategories were re-evaluated during this second discussion, observations were made and notes were taken. Categories were established.

6. Finally, the categories were condensed into themes.

A framework of the analysis is given in Table I (see Results).

Table I.  A framework of the focus-group analysis process.

Elements of meaning (examples)	Subcategory	Category	Theme
…they looked, with respect to their body language, as if they were listening closely … engaged posture … were very listening from the beginning…	Inviting body language	Initially attentive
…open questions … they listened to the patients and often let them finish what they had to say…	Open questionsListening	Listening attitude	Open invitation
…with this type of wide-open attitude, no boundaries are set, so the patient is abandoned instead … they play a waiting game…	Patient left in interview structure	One-sided collection of medical facts	Instrumental strategy
…some kind of medical checklist, you must not forget anything… questions such as ‘What medication are you taking?’ ‘Do you have any illnesses? ‘, aimed at objects or facts…	Following a medical checklist
…they do not regard the patient as a person; he/she is a symptom…	Patient's life experiences absent
…not so spontaneous, more fixed by rules and norms…	Lack of spontaneity	Relationship building cost
…you are somewhat replaceable in the encounter … anyone could meet this patient and ask the same questions…	Replaceability
….they so completely overlook the patients’ anxiety, actually, even when it's severe…	Emotions not noticed

Between 1993 and 2003 two of the authors (MW, BM) were teachers at various stages of the Göteborg curriculum including a course leadership at the CS course and the core general practice course. They have analysed, discussed, and examined altogether at least 200 sit-ins or videotaped consultations in seminars and teachers’ meetings together with other experienced staff in the department. The curriculum has been unchanged over the last eight years. The process of compiling a large body of information has thus been going on for a number of years and data from different sources have been brought together. The group interview provided the most in-depth data, and subcategories emerging from the interviews, merged with other information, provided more comprehensive categories. Finally themes were created. A metaphor is presented at the end. The Research Ethics Committee at Göteborg University's Medical Faculty accepted the study.

Results

A framework of the analysis is presented in Table I, which includes examples of citations.

Open invitation

A main theme, ‘Open invitation’, emerged and was seen in the beginning of the students’ consultations. Underpinning this theme were the categories ‘Initially attentive’ and ‘Listening attitude’.

Initially attentive

Students were, especially initially, engaged and attentive.

Listening attitude

The students often gave the patient scope in the consultation by adopting an open, listening attitude and by demonstrating emotional presence.

The following subcategories supported these categories.

Open questions, listening

Most students started their consultation by an open question to the patient and let the patient finish what he/she had to say.

Inviting body language

The patients were met by the students’ clear attention in eye contact and body posture.

Instrumental strategy

Instrumental strategy became the second main theme in the description of how the students communicate. This theme is supported by two categories.

One-sided collecting of medical facts

Facts relating to symptoms and previous medical investigations are compiled through recurring closed questions. The students often actively register and write down the answers given by the patients but seldom use them in a dialogue.

Relationship building lost

The students approached the patients without noticeable interest in the patient as a person; furthermore, they did not permit their own individuality to emerge in the encounter. The attitude toward the patient could in this part thus be described more as objectifying than relating. One quality had been lost: the student's personal and unique contribution to the relationship.

The following subcategories were the foundation for these categories.

Patient left in interview structure

The consultations are characterized by students’ difficulties in setting the framework, i.e. actively leading the consultation in some direction in order to make the patient safe and facilitate the patient's concerns.

Following a checklist

The students often follow a checklist, primarily asking factual questions, usually as part of a traditional medical history. Many of the questions are asked for the sake of completeness and disrupt the rhythm of the conversation.

Patient's life experiences absent

Little attention is devoted to the patient's life history or social context. The ill person is not given a chance to appear in the consultation.

Emotions not noticed

A lack of emotional/affective response emerges as a clear subcategory. The students avoid the patient's emotional material and often change the subject when emotional areas are mentioned. Instead, they ask objectively oriented questions, which distract.

The hourglass metaphor

Thus, it appears that an instrumental strategy is prominent in these students’ behaviour. The development of students’ and doctors’ communication with the patient can be visualized metaphorically by an hourglass (Figure 1). The tentative model was given by the informants.

Figure 1. An hourglass as a tentative metaphor for physicians’ development of communication strategies. An instrumental influence seems to occur during undergraduate clinical education that affects students’ communication strategies. The widening in the lower part of the hourglass may depend on postgraduate consultation training.

The wide, upper portion of the hourglass corresponds to students’ varying and personal ways of conversing and interacting at the start of their education. The narrow portion in the middle of the figure corresponds to a skill-training, standardizing phase, in which the instrumental demands of the medical profession affect the student's creation of a professional role. Due to this influence, variations in the manner of communicating diminish until graduation. Later there is a chance to develop an individual, personal manner of communicating, during postgraduate education and training; this phase corresponds to the lower, more open part of the hourglass.

Discussion

In the general practice course at the end of the curriculum the students in our study were inviting the patient openly and they were listening. However, the patients seemed to be left within a too wide-open structure of the interview framework. The students often omitted patients’ life experiences and did not respond to their emotions. A relationship-building strategy is lacking; instead, an instrumental, doctor-centred strategy is prominent in the consultation.

Comments on method

Data have been collected in different ways and on various occasions over several years. A considerable amount of information has been used in creating the categories. The establishment of themes was mainly yielded in the group interviews but additional information from various sources in context seemed to be mutually supportive.

Limitations of the qualitative research method used in our study concern credibility. Studying supervisors’ view of students’ communication abilities in video consultations might be seen as an indirect way of approaching these phenomena. Risks for bias from preconceptions also appear when supervisors’ and authors’ experiences are used in collection and interpretation of data. However, we try to reduce these risks by transparent reporting of a theoretical perspective and by conveying the analysis performed [14]. Furthermore, supervisors were asked to comment on preliminary findings in a validation meeting (see earlier, analysis description). We also prepared supervisors in a pilot phase. Older videotapes of student–patient consultations were studied and discussed in order to systematize supervisors’ observations and make them more focused and concordant. Findings have also been triangulated at seminars and in congresses by several teachers and educators from other medical schools, mainly Nordic. Many of these colleagues recognize and reinforce our main experiences and it seems as if our findings are transferable to their context. In conclusion, after having considered some important objections, we think that the results are credible and especially relevant for medical educators.

The students in focus groups represented the interested half of a general practice course and were probably more inclined to demonstrate their communication abilities than their non-participating peers. The course that was studied through the focus group was ordinary in terms of content and student characteristics, and we compared the students’ examination results in the general practice course and in internal medicine – a major clinical rotation. No differences were found in passed/approved rates between the participating and the non-participating students.

Comments on results

An open invitation and open questions at the beginning of the medical interview are stressed in training during the CS course in the fifth term. The students’ approach in the consultations described in the theme ‘Open invitation’ is the positive part of the result with regard to a patient-centred approach. This theme may represent the retention of the CS course in term 10. The instrumental strategy displayed seems to fit in with results from earlier studies [2], [16]. An explicit task delegated to a novice in hospital culture is history-taking, to collect medical facts and produce a medical record [17]. Hence, it looks as if a patient-centred approach not has been developed during intermediate rotations. However, it appears from evidence in medical education research that clinical content and communication in relation to it are such closely linked dimensions that the two cannot be separated [18], [19].

Instrumental strategy could also be a consequence of students’ relatively short independent training in the clinical context. This shortage may lead to lack of confidence in the professional role and a compensatory drive to imitate the physician's ‘executive tasks’.

In the hourglass illustration, the narrow middle portion corresponds to a period of high instrumental demands. In the Göteborg curriculum the general practice course, the focus of our interest, is situated in a period of collecting facts shortly before graduation. In the Swedish system, six months of general practice during internship training (“allmäntjänstgöring”) at health centres is compulsory to become a registered doctor. Additional consultation skills training during vocational training in general practice and other specialties can reinforce and change young doctors’ communication strategies in a patient-centred direction. This phase and further clinical practice corresponds to the lower, more open part of the hourglass. However, findings from Denmark suggest that learning of a patient-centred approach does not occur spontaneously by meeting many patients as a doctor. Patient–doctor communication must be addressed and trained specifically [20].

Practice implications

Should optimal education of consultation skills comprise longitudinal training, throughout the clinical curriculum?

This question emerges from our results and it has been addressed previously [21]. Further research is required for its answer. In longitudinal training, facilitator–student continuity and students’ active participation are vital factors in identifying learning needs [22]. A longitudinal learning and supportive relationship with a facilitator creates trust, which is a prerequisite for learning and developing consultation skills and other professional skills [23]. If the facilitator approaches the student in a student-centred way it provides a model for the student's development of a patient-centred approach [11].

The patient-centred approach was once developed within the field of general practice and general practice can initiate integration of this perspective in undergraduate education within ‘doctoring’ or professional development curricula [24], [25]. General practice departments can play a central role in organizing longitudinal consultation skills attachments, in cooperation with clinical colleagues and specialities experienced in the patient-centred approach.

Most clinical medical education consists of disease-related knowledge and short attachments, so that an understanding of the patient's situation is scarcely brought to light.

• Exploration of students’ abilities to communicate with patients at the end of the curriculum displays an open invitation followed by an instrumental strategy.

• An hourglass metaphor of communication strategies during medical education is proposed in which the narrow part corresponds to an instrumental strategy at the end of undergraduate education.

• Is training of a patient-centred approach needed throughout the clinical curriculum for optimal development of students’ consultation skills?

The authors would like to thank the students who participated in the study, the tutors on the general practice course and the patients in primary health care for their contribution. The project was supported by The Primary Health Care Organization of Göteborg, Region Västra Götaland, Sweden and The Göteborg Medical Society.