Can Japanese students embrace learner-centered methods for teaching medical interviewing skills? Focus groups

Abstract

Background: Students’ perceptions of learner-centered methods for teaching medical interviewing skills have not been fully explored.

Aim: To explore Japanese students’ perceptions of learner-centered methods for teaching medical interviewing skills such as role play with student-created scenarios, peer-assisted video reviews, and student-led small group debriefing.

Methods: We conducted three focus groups with a total of 15 students who participated in the learner-centered seminars on medical interviewing skills at the Nagoya University School of Medicine. The transcripts were analyzed by two authors independently. Keywords and concepts were identified and a thematic framework was developed.

Results: Overall, students valued the experience of writing their own scenarios for role play, but some questioned their realism. Many students commented that peer-assisted video reviews provided them with more objective perspectives on their performance. However, some students expressed concerns about competitiveness during the video reviews. While students appreciated teachers’ minimum involvement in the group debriefing, some criticized that teachers did not explain the objectives of the seminar clearly. Many students had difficulties in exchanging constructive feedback.

Conclusion: We were able to gain new insights into positive and negative perceptions of students about learner-centered methods for teaching medical interviewing skills at one medical school in Japan.

Introduction

It is well known that learner-centered methods, such as role play, peer-assisted video reviews, and small group debriefing, can effectively improve learners’ medical interviewing skills (Aspegren 1999; Maguire & Pitceathly 2002; Yedidia et al. 2003; Kurtz et al. 2005). Role play enables repetitive practice of specific communication skills and permits instant observation and feedback (Kurtz et al. 2005). Peer-assisted video reviews enable a detailed analysis of the interview performance, including non-verbal behaviors (Westberg & Jason 1994). In small group debriefing, learners can compare themselves with peers and learn from them (Westberg & Jason 1996).

In Japan, as well as many other medical schools in Asia, class sizes are often large, and opportunities for students to work in small groups and to pursue independent or elective learning are limited (Amin & Eng 2003). In addition, students are used to take on a rather passive role and the general culture of teaching tends to favor summative over formative assessments. On the other hand, there is a positive trend in Asia toward more systematic and evidence-based approaches to medical education (Amin & Eng 2003). Many Japanese medical schools have also adopted various types of learner-centered methods despite logistical challenges.

Japanese medical school lasts 6 years, with the last 2 years consisting of clinical clerkships. The Nagoya University School of Medicine offers medical interview training for 4th- and 5th-year students. Prior to clerkship, 4th-year students participate in a 3-day communication skills seminar involving simulated/standardized patients. As part of clinical clerkships, 5th-year students attend a 2-day, learner-centered, small group seminar on medical interviewing skills described in Box 1. Three learner-centered methods such as role play, peer-assisted video reviews, and student-led small group debriefing are incorporated into our seminar. One of the notable characteristics of our seminar is that we ask students to create patient scenarios for role play, encouraging them to be more invested in the situation to be role-played. A sample of such scenarios is shown in Box 2.

Box 1. Two-day, learner-centered small group seminar on medical interviewing skills for 5th-year students

	Learning activities	Goals	Student tasks	Teacher tasks
Day 1 Trigger tape critique (2 h)	Trigger tape review	To reflect on effective and ineffective communication skills acquired during the 4th-year	• Review a trigger tape • Identify and discuss effective and ineffective communication behaviors • Discuss characteristics of ideal medical interviewing	• Show the trigger tape • Facilitate the group discussion
	Instructions for student-created scenario writing	To explain a purpose and rules of creating a patient scenario	• Clarify homework instructions	• Provide homework instructions • Emphasize opportunity to learn about patient's point of view (e.g., situations, emotions)
Home-Work	Creation of role play scenario	To gain insights into a patient's perspective	• Create a detailed scenario (see example in Box 2)
Day 2 Medical interview practice^a (6 h)	Role play	To practice medical interviewing skills	• Take on a patient role to enact one's own scenario • Take on a doctor role	• Review structure and objectives of the seminar • Organize students in pairs • Operate the video recorder
	Student-led debriefing	To enhance understanding of interviewing skills and patient experiences	• Review the video-taped interviews • Self-assess one's own performance • Exchange feedback • Lead the debriefing	• Review structure and objectives of seminar • Oversee the student-led group debriefing
	Student-led group discussion of the differential diagnoses	To enhance diagnostic reasoning skills	• Arrive at differential diagnoses for the scenario • Lead the discussion

Note: ^aThree activities on Day 2 are repeated until all students have taken on the role of patient, doctor, and small group facilitator/discussion leader.

Box 2. An example of student-created scenarios (written by the student B from focus group 1)

• ORIGIN OF THE CASE: Based on my mother's experience

• AGE AND GENDER: 43-year-old woman

• SETTING: A clinic in the city

• PAST MEDICAL HISTORY: Constipation (Medication: Sennoside)

• PATIENT BACKGROUND : A part-time office worker, lives with her husband and two daughters.

• HISTORY OF THE PRESENT ILLNESS: Yesterday she was working at her office as usual. She had lunch (noodles) with her colleague at the cafeteria. In the evening she felt slightly sick. After she went home, she had a light meal with her family since she did not have a good appetite. After that she vomited and noticed that she had low grade fever. She went to bed earlier than usual. At night she woke up because of epigastric pain. She took an over-the-counter medication for gastritis which she had bought the year before. Although the pain was not relieved by the medication, she decided to go back to sleep. The next morning she had severe pain at his right lower abdomen. Her husband recommended that she go to the hospital and he brought her to the clinic. When she arrived at the clinic, she had fever, fatigue, and continuous right lower abdominal pain.

• PATIENT’S EXPLANATORY MODEL: I have never experienced such a pain. The noodle which I ate at lunch was oily. I should have avoided having such oily food since I was feeling sick a little bit since yesterday morning.

• PATIENT’S OTHER PERSPECTIVES: Although I wanted to stay at home just to rest, my husband brought me to the clinic.

• MOST LIKELY DIAGNOSIS: Appendicitis

• DIFFERENTIAL DIAGNOSES: Diverticulitis, urinary tract stone, gastroenteritis

Although there is a wealth of literature about teaching communication skills to students, few studies have explored in depth their views and experiences of learning methods for communication skills teaching (Aspegren 1999; Rees et al. 2004), especially in Japan, where interpersonal communication and learning styles are somewhat different from western countries. As learning and work-places become more culturally diverse through the influx of an increasing number of international students and teachers, it is useful to have more cross-cultural perspectives on learning preferences (Balandin et al. 2007).

In our previous survey of 101 5th-year students who participated in our seminar in the academic year 2003–2004, they preferred more teacher-control, such as logical sequencing and discussion guidance (Saiki et al. 2004). In the following year, we conducted focus groups to further explore our students’ perceptions toward learner-centered methods for teaching medical interviewing skills.

Table

Practice points

A combination of learner-centered methods can facilitate teaching medical interviewing skills for students. Students’ concerns about realism of role play with student-created scenarios and competitiveness during peer-assisted video reviews should be considered by teachers of medical interviewing skills. Further studies will provide additional insights into learner-centered methods especially role play with student-created scenarios for teaching medical interviewing skills.

Methods

Design and participants

In May 2004, three focus groups with a total of 15 5th-year students were facilitated by the first author – a general practitioner and clinician–educator – who was heavily involved in the development of the seminar and well known to the students. They had participated in our seminar on medical interviewing skills at various times during the academic year 2003–2004. (See Box. 3 for participant characteristics.)

Box 3. Characteristics of focus group participants

Student identification	Focus group number	Gender	Age (years)	Level
A	1	Female	23	Undergraduate
B		Female	24	Undergraduate
C		Male	24	Undergraduate
D		Female	24	Undergraduate
E	2	Male	25	Undergraduate
F		Male	24	Undergraduate
G		Male	29	Graduate
H		Male	25	Undergraduate
I		Male	24	Undergraduate
J		Male	25	Graduate
K	3	Male	24	Undergraduate
L		Male	23	Undergraduate
M		Male	23	Undergraduate
N		Male	26	Graduate
O		Male	24	Undergraduate

Data gathering

The facilitator explained that the objectives of the focus groups were to gain an in-depth understanding of student experiences in the seminar, particularly focusing on teaching methods such as role play with student-created scenarios, peer-assisted video reviews, and student-led small group debriefing. To stimulate the discussion, the facilitator inquired about the advantages and disadvantages of each teaching method, encouraged interactions among students, and ensured that all participants had sufficient opportunity to express their views. Each focus group lasted 45 min. After assurances that responses would be reported in an anonymous fashion, students gave oral consent to allow the discussion to be videotaped.

Data analysis

Videotapes were fully transcribed by the first author. The transcript was read and approved by three students (one per group). Two of the authors (Takuya Saiki and Kei Mukohara) independently reviewed the transcript with videotapes, identified keywords and concepts for coding, and developed a thematic map. Interpretations of data were agreed upon by consensus between the two authors. When they could not reach consensus, the discrepancies were resolved by involving the third author (Nobutaro Ban). To validate the constructs, preliminary results were shared with three teaching staff members at the Nagoya University Hospital who were not involved with the seminars and focus groups. The study was approved by the Nagoya University Hospital Institutional Review Board.

Results

Data from the focus groups were categorized according to three learning methods: role play with student-created scenarios, peer-assisted video reviews, and student-led small group debriefing (Appendix). Representative comments for each theme were selected to illustrate the students’ perceptions.

Role play with student-created scenarios

In-depth understanding of the patient

Students valued the scenario writing highly because they felt that consideration of patient narrative improved their medical interviewing skills.

When I was writing my scenario, I could consider deeply how this patient was worried about her medical condition. After that, I felt it became easier for me in the doctor role to listen to the patient and to ask questions.

(Student B, Group 1)

Many students valued playing patients’ role as they could analyze the behavior of students in the doctor role carefully from the patients’ point of view:

Playing the patient role is a new experience and fun, since it is rare for us to be a patient. I could see both appropriate and inappropriate behaviors of the student who portrayed the doctor.

(Student E, Group 2)

Questions on realism

Some students questioned the realism of student-created scenarios and role play.

Some of the scenarios were too complicated and unrealistic for role play.

(Student M, Group 3)

In my case, I couldn’t stop laughing since my classmate played a patient role too seriously!

(Student B, Group 1)

Peer-assisted video reviews

Readiness to feedback from peers

Many students indicated that peer-assisted video reviews enabled them to see themselves objectively and to prepare for subsequent discussions by becoming receptive to feedback from peers:

Without reviewing the videotape together, I would not have understood what actually happened in my role play. If others gave me feedback without watching the recorded role play together, I wouldn’t be able to accept negative feedback from them. Peer video review provides a basis for the subsequent discussion.

(Student G, Group 2)

Some felt hesitation to watch the video with their peers:

I was actually shy about reviewing my own role play with classmates. I wish I could review the video in my home by myself and write down some learning points.

(Student O, Group 3)

Effectiveness of peer-assisted video reviews

Many students indicated that they could construct and share the conceptual framework of the appropriate medical interview gradually by watching a series of videotaped role plays:

When we repeated video reviews and group debriefings, we were able to gradually understand what the ideal medical interviewing is like.

(Student M, Group 3)

Complicated group atmosphere

However, some students felt that the atmosphere was competitive when they compared their own interviewing skills to those of others:

The quality of the interview in the first role play seemed to be lower than the last one…It was unfair for the student who played the doctors’ role first.

(Student N, Group 3)

Student-led small group debriefing

Appropriateness of teachers’ role

In general, students appreciated teachers’ presence but minimum involvement in the learner-centered seminar:

We were able to talk freely because the teachers remained silent.

(Student J, Group 2)

Even when the discussion got lost, I was at ease because I knew that the teacher would offer appropriate help in such situations.

(Student D, Group 1)

Some students criticized that the teachers did not explain the objectives of the seminar clearly:

I didn’t know what the teachers’ intensions for the seminar were. We didn’t understand what the point of the discussion was.

(Student K, Group 3)

Difficulties in exchanging feedback

Many students had difficulties in exchanging constructive negative feedback during the group discussions. They felt that performance critiques led to a negative and unproductive atmosphere.

In my group, I felt that some students did not show respect to others because they only gave negative feedback.

(Student N, Group 3)

Yes, the atmosphere was very critical.

(Student K, Group 3)

I felt really nervous and depressed when I saw my poor interviewing skills on the video. I was wondering if others felt the same way. Then I decided to stop giving negative feedback on other students’ performance since I didn’t want to hurt their feelings.

(Student B, Group 1)

On the other hand, they seemed to understand that superficial positive feedback does not necessarily contribute to productive discussions:

In my group, we gave only safe and positive feedback. So, the discussion wasn’t interesting.

(Student L, Group 3)

Discussion

By using focus groups at one medical school in Japan, we were able to explore in depth students’ positive and negative perceptions of the learner-centered methods for teaching medical interviewing skills. To the best of our knowledge, this is one of the few studies to date to evaluate these widely used methods for teaching medical interviewing skills from students’ perspectives.

This study identified scenario writing for role play by students as a significant learning experience. Our method is to have students provide a detailed description of a patient they have seen, read, or thought about. They build the case on their own experiences as a patient or model it on sick relatives or others they encountered. In the interview practice session, they take on the role of that patient. This approach is different from the spontaneous role play widely described (Cohen-Cole et al. 1995) in which the students are asked to take a moment to think of an appropriate case. Based on student responses, scenario writing seems to deepen the learners’ understanding of patients’ suffering or anxiety about what they were going through. Despite the lack of realism which was noted by some, this strategy seems to build empathy in students and could significantly contribute to the improvement of their medical interviewing skills.

Many students indicated that playing the patient role enabled them to observe the doctors’ behaviors through the patient's point of view: a significant learning experience as noted in the previous literature (Mansfield 1991; Cohen-Cole et al. 1995; Kurtz et al. 2005; Joyner & Young 2006).

Our students’ positive and negative perceptions of peer-assisted video reviews fit well with the findings of the past literature (Mansfield 1991; Beckman & Cohen 1994; Westberg & Jason 1994). It is widely accepted that video reviewing has many advantages such as being able to see one's own behaviors objectively during self-assessment and having actual performance data for a microanalysis of the interview (Westberg & Jason 1994). However, these benefits come with some discomforts to learners (Beckman & Cohen 1994). The previous randomized trial found that both individual and group reviews of videotaped standardized patient encounters were received well by the 4th-year medical students in the United States (Parish et al. 2006). However, there was a statistically significant difference in favor of the individual review format. In our study, there were some students who hesitated to review their videotaped interview with group members. Some students were very competitive and could not bear the idea of performing less well than others, despite the faculty's assurance, at the beginning of each seminar, that this is a learning exercise. This problem could be resolved by stressing that the objective of the seminar is to share the skills for an appropriate medical interviewing with others and by creating a safe learning environment. It is of note that other students regarded the peer-assisted video reviews as a good strategy to learn how to accept negative feedback constructively. Thus, the group format may have additional benefits when students feel comfortable enough with each other.

With regard to student-led small group debriefing, many students appreciated teachers’ presence but minimal involvement. This finding is consistent with the literature indicating that learners can be engaged in safe, systematic and supervised practice of communication skills, assess themselves and receive constructive feedback from group members in small group discussion (Westberg & Jason 1996). Also our method of student-led style is comparable to the previous literature showing the favorable results of student-led problem-based learning (PBL) tutorial in which student tutors were rated better than faculty tutors in providing feedback to the group and in understanding difficulties students encountered (Kassab et al. 2005).

Some students expressed difficulties in giving negative feedback constructively because they feared that their critical comments could be hurtful to their colleagues. They decided to give only positive feedback and refrain from negative feedback. Difficulties of students in giving negative feedback to individuals within the small group discussion have been noted as a challenge (Iputo 2005). The literature on student-led PBL tutorial noted the necessity of special training for students in leadership, questioning, and feedback before allowing them to tutor (Kassab et al. 2005).

There could be several other explanations for difficulties of our students in giving and receiving constructive feedback during small group debriefing. One of the explanations may be a lack of clinical experience. The literature suggested that students in clinical years were more satisfied with peer assessment in group discussion than those in preclinical years since they had more clinical experience and were more mature (Rees et al. 2004). The higher dissatisfaction rates in pre-clerkship students were attributed to their being too polite to criticize or their inability to offer constructive criticism due to the lack of knowledge and experience (Rees et al. 2004). These general challenges could be compounded by cultural norms specific to our Japanese student population. Another explanation could be that self-esteem of Japanese medical students is low. Individuals whose self-esteem are low and those who generally lack confidence in their skills may be reluctant to expose themselves to failure and less able to handle criticism (Reasoner 2004). In fact, Japanese score much lower on measures of self-esteem than North Americans (Heine et al. 1999). Further studies are needed to examine how student-led small group debriefing can be applied well in teaching medical interviewing skills in the Japanese cultural context.

Our study has limitations. First, the results might have not been as favorable to our teaching methods if an independent person facilitated the focus groups. By having a facilitator who was well known to the students and intimately involved in the development of the seminar, students might not have expressed their negative feelings for fear of negative evaluation at the school. This lack of candor might have occurred even though the facilitator assured them that the study had nothing to do with their academic standing. Second, the study was conducted at one medical school in Japan. Although qualitative research is not meant to be generalized to global situations, transferability to other settings cannot be ensured.

We were able to gain new insights into positive and negative perceptions of students about learner-centered methods for teaching medical interviewing skills at one medical school in Japan. Our findings may be useful in improving the quality of such teaching.

Acknowledgements

We thank the students of Nagoya University School of Medicine who participated in the focus groups. We thank Elizabeth Kachur, PhD, in New York for the helpful comments on this manuscript.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.

Appendix: Thematic map