Teaching communication and compassionate care skills: An innovative curriculum for pre-clerkship medical students

Abstract

Background: Physicians require communications training to improve effective and compassionate care. Clinicians discuss challenging communication issues in existing hospital “Schwartz Rounds.”

Aims: To improve communication skills, the Warren Alpert Medical School of Brown University designed “Schwartz Communication Sessions” for the mandatory 2-year pre-clerkship Doctoring course. Alongside learning interviewing, physical examination, and professionalism skills, the new Schwartz curriculum provides medical students with the rationale and proficiency for effective communication with patients, families and the healthcare team.

Methods: First-year students experience a graduated curriculum of three sessions on themes such as empathy and professionalism using innovative methods. Sessions highlight cases and videos depicting successful and ineffective interactions, large and small group discussions, role play and skills practice, guest patient presentations, and multi-disciplinary panels. The second-year students’ session focuses on communications with challenging patients.

Results: Students and faculty rate the sessions highly on effectiveness of enhancing communication skills, gaining perspective in healthcare communication, and appreciating the complexities of healthcare situations. Expansion of the program using case-based sessions for clerkship students is planned for a continuous and graduated experience.

Conclusions: Integrating a pre-clerkship communications curriculum may help improve future physicians’ interactions with patients and families. Implications of this curriculum for medical education are discussed.

Introduction

Effective and compassionate communication among physicians, patients, and their families is recognized as vital to the healing relationship and to patient-centered care (Delbanco 2001; Scott et al. 2008; Berwick 2009; Haidet 2010; Hargie et al. 2010). As a result, education about communication is more often now included in medical curricula than in previous years (Simpson et al. 1991; The Kalamazoo consensus statement 2001). Despite this realization of the importance of compassionate communication, barriers continue to hinder the achievement and maintenance of this ideal. Reasons for unsatisfactory communication between patients and their physicians in the United States include increasing specialization, a fragmented healthcare system, the embedded authority of the physician role, and reimbursement constraints (Delbanco 2002).

Kenneth Schwartz, a healthcare lawyer in Boston, Massachusetts, died from lung cancer in 1995 at the age of 41. Inspired by the empathy he received from care providers, he founded the Kenneth B. Schwartz Center at Massachusetts General Hospital shortly before his death, with the aim of strengthening relationships between patients and caregivers (“A patient's story,” Boston Globe Magazine 1995). One way in which the Schwartz Center fulfills its mission is through the sponsorship of “Schwartz Rounds” in more than 160 hospitals throughout the United States. These rounds present an opportunity for multidisciplinary healthcare providers to discuss troubling instances of patient care and communication, to explore ambiguities of management decisions, and to improve caregiving to patients and their families. Data indicate that Schwartz Rounds help caregivers connect with patients emotionally, enhance their understanding of the effects of illness on patients and their families, improve communication among caregivers, and decrease feelings of isolation and stress among caregivers (Rosen & Lynch 2008; Lown & Manning 2010).

Medical students are socialized early into the traditionally authoritarian physician role in their training by the subtle or not so subtle messages of the “hidden curriculum” that implicitly teach medical students that their place is at the top of the medical hierarchy (Konner 1988; Klass 1994; Hafferty 1998; Nieto 2002; Horn 2003). As they master human anatomy, physiology and pathology, students learn to take a medical history, perform a physical examination, extract medical information efficiently, prioritize problems, and set goals for care. As competence in these vital skills increases, students may often perceive that establishing rapport and maintaining empathic listening are less important in the physician–patient encounter (Bombeke et al. 2010; Pederson 2010).

Inspired by the experience of hospital Schwartz Rounds, we initiated a program of communication sessions at the Warren Alpert Medical School of Brown University in the pre-clerkship Doctoring course to foster enhanced communication and superior care in the next generation of physicians. The Doctoring course is a mandatory 2-year curriculum designed to teach students the skills of the medical interview, physical examination, and professionalism. Its goal is to teach students the knowledge, skills, attitudes, and behaviors of the competent, ethical, and humane physician. In 2006, a generous 4-year grant from the Donald W. Reynolds Foundation, concurrent with a medical school curriculum redesign, facilitated integration of adequate aging-related content throughout the first 2 years of the Alpert Medical School curriculum. Using the infrastructure of the Reynolds award, lead faculty on that project applied for and received grant funds from the Schwartz Center in 2009 to develop and implement “Schwartz Communication Sessions” (SCSs). These sessions were designed to teach first- and second-year medical students necessary skills for effective communication with patients. The SCSs are a skills- and discussion-based communication program that enhance the philosophy of the Doctoring course. The pilot and first year of SCSs are reported here.

Table

Practice points

Teaching communication skills to medical students helps demystify the subject. Communication sessions integrate communication and empathy in the Doctoring course. Patient cases, videos, role play, skills practice, and small and large discussions are effective components of the curriculum. Faculty experiences and strategies stimulate discussion and helps prepare students for clerkships. Guest physician patients have been positively received.

Methods

Overall structure of the sessions. Each SCS consists of discussions about clinical cases in large and small group settings, using a variety of didactic methods in a similar format. Table 1 describes the teaching elements employed in each of the sessions (Table 1). In general, students read a case and relevant readings and/or view a videotape prior to each session. Following an introduction to the subject which may include guest speakers, they discuss the material and/or perform role plays in small groups. They also discuss and may practice communication strategies their small group leaders have found useful in their experience. Finally, students and faculty members usually regroup for a final large group discussion involving an expert panel. The pilot session was held in the spring of the first-year medical student (MS1) class of 2008–2009. In 2009–2010, three 3 h MS1 and one 1 h second-year medical student (MS2) class Schwartz sessions were held. In academic year 2010–2011, three additional MS1 and one additional MS2 sessions have occurred, following the pattern established by the sessions of the prior year, for a total of nine sessions to date. Students and faculty were asked to evaluate each SCS. The following briefly describes these sessions.

Table 1.  Structure and content of SCSs

	Pilot session MS1	Session # 1 MS1	Session #2 MS1	Session #3 MS1	Session #4 MS2
Large group session (60 min)	Attorney Brief case	Video examples of “good”/“bad” communication; Woman with breast mass case	Cultural competence; video from “When Things Go Wrong”	Medical error: patient presentation (90 min)	Attorney Brief case; the family meeting
Small group session (60 min)	Students role play physician, nurse and patient's son	Students role play (1) patient and spouse and (2) patient and physician	Students role play third-year medical student (1) Southeast Asian woman refusing Pap smear and (2) Liberian woman refusing CXR	Students discuss patient cases; practice communication strategies (90 min)	N/A
Panel and case wrap-up (60 min)	Geriatrician, Internist, Social Worker, University Chaplain	Geriatrician, Internist, Social Worker, University Chaplain	Dean of Minority Affairs, Internist for LBGT patients, Pediatrician for immigrant patients, health-care agency for local Southeast Asian patient population	N/A	N/A

Description of individual sessions

Pilot session, Spring, MS1: Advanced communication skills

Case description

Students read the case of George Brief, a 76-year-old lawyer living alone following his wife's death from Alzheimer's disease. The senior partner in his law firm with his two sons, Mr. Brief was his wife's major caregiver. During an episode of delirium following a fall, hip fracture, and subsequent surgery, the younger son is appointed as his guardian and the family home is sold. His sons then persuade him to move to a retirement community. Mr. Brief frequently states his desire not to have his life prolonged for any reason. However, following a cardiac arrest 3 years later, he is resuscitated, placed on a ventilator, and admitted to the Intensive Care Unit of the nearby hospital. He communicates with a letter board that he does not want the feeding tube, but the sons insist it be maintained since he never executed an advance directive.

Educational methods and session's agenda

This session employs readings, video, a case study, student role plays, and small and large group discussion.

Large group discussion with video

At the session's start, course leaders introduce the goals of the SCS and show the video, “When Things Go Wrong,” chronicling several patients’ negative medical outcomes and inadequate communication with caregivers (Delbanco & Angello 2006).

Small group sessions: Discussion and role play

In each small group discussion of eight students and two faculty members (one physician and one social or behavioral scientist), students discuss the case, perform a role play involving the younger son, the physician, and the nurse, and consider the quality of communication among the participants.

Reconvening the large group: Multi-disciplinary discussion and sum-up

With the entire class reconvened for a panel discussion, students learn the case's conclusion that after a family meeting, the feeding tube was removed. Discussion follows with the students, University Chaplain, a geriatrician, a primary care physician, a hospital social worker, and Doctoring course faculty members. Students report on challenges they encountered in performing role play and appreciating other points of view.

Learning objectives of the session

The session's aims are to:

• introduce the students to the primacy of communication in the clinical encounter;

• understand the importance of perspective in communication; and

• begin to practice skills in effective communication through role play

Academic year 2009–2010

Session #1, Fall semester, MS1: Empathy and professionalism

Case description

A 35-year-old woman presents to her physician with a breast mass. Entering the exam room 45 min late, the physician repeatedly interrupts the patient as she describes her problem, forgets that the patient has a same-sex partner, and impatiently presents a management plan. After receiving negative mammogram results, the patient subsequently transfers her care to another physician.

Educational methods – session's agenda

This session employs readings, videos, a case study, faculty enactment, a communication checklist, student role plays, and small and large group discussion.

Prior to the session

Students read three articles (Schwartz 1995; Kahn 2008; Chen 2009) and the patient case of the 35-year-old woman prior to the session.

Large group discussion

In class, students watch video clip examples of doctor–patient interviews and document behaviors that characterize good and bad communication on a communication checklist designed for this purpose (Table 2). Two physician course leaders enact the case. Students note elements that constitute “effective” and “less successful” communication. Discussion centers on students’ judgments of these interactions.

Table 2.  Elements of “effective” and “less successful” communication (add your specific comments)

Panel A: Schwartz session: physician–patient communication – large group session
	Video #1 “One Story, Two Voices”	Video #2 “Back Pain”	Video #3 “Elaine's rash”	Faculty enactment of the KM and Dr. X case
Elements of “effective” communication - Do:
Greet patient warmly
Pay attention
Allow patient to speak
Make eye contact
Ask follow-up questions
Other (specify below or on other side of page)
Elements of “less successful” communication - Don't:
Act indifferent
Interrupt patient
Attend to distractions
Dismiss patient concerns
Show distancing body language (e.g., crossed arms, back to pt, going to door):
Other (specify below or on other side of page)
Panel B: Schwartz session: physician–patient communication – small group session
	Role play #1 comments		Role play #2 comments
Elements of “effective” communication - Do:
Greet patient warmly
Pay attention
Allow patient to speak
Make eye contact
Ask follow-up questions
Other (specify below or on other side of page)
Elements of “less successful” communication - Don't:
Act indifferent
Interrupt patient
Attend to distractions
Dismiss patient concerns
Show distancing body language (e.g., crossed arms, back to pt, going to door):
Other (specify below or on other side of page)

Small group discussion

In their small groups, students role play two scenarios inspired by the large group case enactment. In role play: (1) the patient angrily discusses her doctor's appointment with her partner, and in role play (2) the patient and physician replay an improved interaction. The goal of the first role play is to help students understand the impact that physician behaviors can have on patients; the second role play allows students to practice communication skills to improve the interaction. Students discuss effective ways to convey empathy and professionalism to patients. Small group faculty offer their experiences and strategies they have found useful in their medical encounters.

Reconvened large group session

Students now learn new contextual information of the case. The physician is an overwhelmed new mother, recently returned from maternity leave to her busy primary care practice. With the perspectives of the panelists and faculty, students consider their initial assumptions, the physician's behavior, and the challenges of maintaining professionalism and self-care.

Learning objectives of the session

The session's aims are to:

• identify elements of effective and unsatisfactory communication;

• understand the importance of professionalism;

• develop insight in others’ points of view; and

• improve skills in effective communication through role play

Session #2, Fall Semester, MS1: Cultural competence

Case description

In class, students view the “Immigrant Narrative” video clip of “When Things Go Wrong” (Delbanco & Angello 2006). In this video excerpt, a Hispanic patient who is fluent in English is given morphine for a sickle cell crisis after the patient and his family alert the medical team about a prior hypotensive crisis after receiving morphine.

Educational methods and session's agenda

This session employs readings, state demographic data, a video, two case studies, student role plays, and small and large group discussion with a guest panel.

Prior to the session

Students review demographic information and data from the state of Rhode Island's Department of Health about health status of minority persons prior to the session and read an article about cultural competence (Kleinman & Benson 2006).

Large group discussion with video

Students discuss the communication problems and the concept of cultural competence (Robins et al. 1998; Donini-Lenhoff and Hedrick 2000; Betancourt et al. 2002). The discussion focuses on how cultural misunderstandings informed the care depicted in the video.

Small group session: Discussion and role plays of cases

In their small groups, students discuss the information about minority populations of the capital city of Providence, Rhode Island, and role play two scenarios. In the first, a third-year medical student encounters a 29-year-old Vietnamese woman who presents for a physical exam required by her new job. When she refuses the gynecological exam, the student assumes cultural modesty is the reason, but then learns through an accompanying family member that the patient had experienced sexual trauma in the past. In the second scenario, a third-year medical student interviews a Liberian woman with a cough who refuses a chest radiograph. Students discuss their initial assumptions and the challenges of the patient–provider relationship with people of varying cultural backgrounds. Students also discuss how they currently interact with people who they perceive are “different” from them.

Reconvening the large group: Panel discussion

The large group features a panel discussion with the medical school's Assistant Dean of Minority Affairs, a general internist providing care for lesbian women, a pediatrician providing care for West African refugees and immigrants, and the founders of a home health agency serving the local Southeast Asian population. Each notes the health needs of specific populations and how providers’ cultural biases affects healthcare. Discussion includes students’ reports about the small group role play experiences.

Learning objectives of the session

The session's aims are to:

• think about, challenge, and define the meaning of cultural competence and humility;

• recognize the broad scope of patients’ “culture;”

• ask concrete questions to elicit information critical to a patient's care; and

• recognize how physicians’ attitudes and backgrounds can impact provider–patient communication.

Session #3, Spring semester, MS1: Advanced communication skills

Case description

For this session, students read the case of Mr. Brief (see above description).

Educational methods and session's agenda

This session employs readings, a guest patient presentation, video, a case study, communication strategy practice, and small and large group discussion. In response to student suggestions, a patient who is a physician was invited to speak in the large group session in the next SCS, and the small group discussion time was extended to include consideration of communication strategies in place of role play.

Prior to the session

For this session, students read the case of Mr. Brief and view the “Doctor's Narrative” video clip from the “When Things Go Wrong” video (Delbanco & Angello 2006), describing a bad medical outcome experienced by Dr. Georges Peter.

Large group discussion with video

Students note effective, less effective and ineffective elements of communication in the encounter. Dr. Peter then speaks in person about the experience depicted in the video.

Small group session: Discussion and skills practice

In their small groups, students discuss the cases of Dr. Peter and Mr. Brief, are introduced to the purpose of family meetings and the medical team, and consider student and faculty suggestions of communication strategies in situations in which: (1) students must inform a patient about a medical error; and (2) they must explain a patient's preferences regarding goals of care to family members.

Learning objectives of the session

The session's aims are to:

• understand the impact of communication on patient care;

• learn basic principles of effective communication; and

• learn basic principles of family meetings and the “medical team.”

Session #4, Spring semester, MS2: Family meetings and the challenging patient

The topic of this session for second-year students is to discuss the family meeting and strategies for dealing with challenging patients. Students first review the case of Mr. Brief, in which the attending physician has confirmed that Attorney Brief does not wish to pursue life-sustaining measures. In the large group setting, a panel consisting of a geriatrician, family practitioner, and the University Chaplain, discuss components of a family meeting and introduce the topic of communicating with challenging patients. Panelists discuss end-of-life care for Mr. Brief, and students consider other unaddressed medical issues that may have interfered with his decision-making capacity. Using the Brief case as impetus, small groups and their faculty leaders further discuss the case and practice communication strategies for challenging patients and difficult situations, including the family meeting.

Results

All 93 first-year medical students of the Alpert Medical School of Brown University participated in three SCSs during the academic year 2009–2010, and 99 MS1 students participated in two additional SCSs in fall 2010 (AY 2010–2011) that repeated the sessions from the prior year. A total of 94 second-year medical students participated in the pilot communication session as first year students (AY 2008–2009) and in one SCS as second-year medical students (AY 2009–2010). The response rate of the first-year evaluations ranged from 66% to 95% for the three SCSs, while the response rate for the second-year class ranged from 71% to 80% for the two sessions. In academic year 2010–2011, two additional sessions have taken place and been evaluated. A total of 24 faculty members for each class participated in the SCS, and the response rate for evaluations ranged from 42% to 92%. Modifications to the program respond to some suggestions in the student and faculty evaluations.

Overall ratings – quantitative results

The overall evaluation data for the SCSs is shown in Figure 1. A total of 93% of faculty and 83% of students who completed the evaluations rated the sessions as good, excellent, or exceptional on the five-point Likert scale. The sessions most positively rated by students and faculty as excellent or exceptional were: (1) the role of the family meeting (92% faculty and 62% students); (2) empathy and professionalism (83.3% faculty and 51.9% students); and (3) advanced communication skills (50% faculty and 59% students).

Figure 1. Overall rating of SCSs.

Achievement of learning objectives – quantitative results

Figure 2 illustrates the achievement of the learning objectives, as rated by students and faculty. About 80% of students and 96% of faculty who completed the evaluations responded that they believed that students gained knowledge from the SCSs that will help them care for patients. In addition, 75% of student responses and 96% of faculty responses indicated that the SCSs will help students communicate better with patients and family members. In general, students and faculty agreed that in each session: (1) the case was relevant to the students’ medical education; (2) the small group discussion was effective; and (3) the guest faculty provided valuable perspectives to the large group discussion.

Figure 2. Achievement of learning objectives.

Comments and suggestions by students and faculty – qualitative results

A majority of students and faculty members completing evaluations also offered comments and suggestions regarding the SCSs. Student and faculty comments praising the sessions were common, as illustrated by “Good job!” from one small group faculty leader, and by “Today's session was fantastic!” from a student. Students appreciated the organization of the sessions (“I thought it was a very well-planned Schwartz session”), expressed that the SCSs targeted important subjects (“Addressed important issues that normally are not taught in basic science classes,” “The session is integral to the development of a physician,” and “Helpful to address these complicated issues early on”), and noted that SCS organizers were receptive to student input (“I liked that the Doctoring Course leaders made changes based on student suggestions”).

Students also commented on the structure of the sessions, appreciating the “diversity of the panel [as] having real life experience leaves the deepest impression” and the blend of “open forum and lecture-style presentation that gave us an insightful perspective—very useful.” Students and faculty enjoyed the use of real-life cases, as noted by one student who commented that the “retelling of experiences helped stimulate and impacted the reality and importance of the discussion,” and a faculty member who stated that “Having MD/patient meet with the large group was particularly effective and moving.” Students and faculty were likewise positive about the methods in which communication skills were taught. One student recognized that there were “excellent cases that forced us to examine prejudices or assumptions about people or situations,” and a faculty member commented that the topic covered was “extremely important with many complex aspects, although difficult to explore them in this brief time span.”

Examples of faculty and student suggestions include recommendations for more real-life examples, more inclusion of the “doctor's point of view—what's it like to say ‘sorry’?” and examples of “support we could get as physicians when in these difficult situations.” Some faculty members also noted that role play can be a “struggle” for some students not comfortable with this learning method.

Discussion

Previous reports have indicated that effective physician–patient communication improves patient care and should be taught in medical school curricula (Simpson et al. 1991; Delbanco 2001; The Kalamazoo consensus statement 2001; Scott et al. 2008; Berwick 2009; Haidet 2010; Pederson 2010). The pre-clinical SCS curriculum at Alpert Medical School concretely addresses this goal. The curriculum has been well received by both students and faculty members. The overwhelming majority of students and faculty gave the sessions a “good,” “excellent,” or “exceptional” overall rating, and found that each session achieved the established learning objectives. The use of both quantitative and qualitative evaluation assessments has been useful to obtain a clearer understanding of student and faculty response and has helped to make effective refinements to the program.

The consistently positive results may indicate how important the students and faculty perceive the addition of this education to be to their medical training. Curriculum leaders are continually modifying the SCSs in response to accumulated experience and the value of constructive feedback. MS1 students may have responded well to the principles of relationship that are articulated in the sessions and that perpetuate the reasons that led them to medical school. While some students downplay the importance of communication and empathy, others express appreciation that principles of interactions and relationship are explicitly taught, and they indicate that they are eager for practical strategies to help them in their clerkship years and beyond. Challenging the notion that these traits are innate and immutable and the mentality that you either “have them or you don’t,” the curriculum stresses learned behaviors, principles and strategies to demystify the subject. MS2 students are more advanced in their medical education, have a greater knowledge base, have had more patient experiences, and have experienced the SCS exposure in the MS1 year, and hence may be better able to appreciate and understand the medical and ethical complexities of the patient cases presented in the SCS than MS1 students.

Inserting a communications curriculum within the pre-clerkship Doctoring course is a potential strategy to maintain students’ altruistic motivation for entering medical school by teaching them basic skills of effective communication based on real patient cases. Each session has been marked by students and faculty members actively engaged in often passionate discussion of diverse views. Students seem to grasp the need for this kind of education: they note the positive impact of including a patient who told his story in one of the SCSs, and they express eagerness to learn practical ways to communicate with patients in real-life and realistic scenarios. Hence, faculty members are encouraged to offer examples from their clinical lives to describe the dilemmas and challenges they face, the strategies they used, and their patients’ responses to their efforts. Even more active brainstorming of solutions for clinical situations and the sharing of experiences have been important features of the SCSs in academic year 2010–2011.

Limitations and future directions

The challenges of introducing the SCS curriculum in the pre-clerkship years have also been apparent, though not as daunting as expected. Pre-clerkship students at Alpert and other medical schools are intent on mastering voluminous basic science knowledge from courses; in addition, they are focused on the national board examinations that they take at the end of their second year. As has been shown elsewhere, students’ concern about test performance and their concentration on memorizing pathways and pathophysiological facts tend to relegate the Doctoring course's SCSs’ attention to “soft” subjects, such as communication and compassion, to second class status, a less pressing priority (Pederson 2010). Adding new didactic content to an already-full syllabus is also a challenge to the program. This content may be seen to compete with additional physical examination skills practice, for example.

The incorporation of communications teaching directly challenges the false notion that effective communication and empathy are innate and immutable characteristics of the learner. As noted above, recommendations from faculty and students to include presentations by patients, for example, have led to enhancements to the curriculum as the program continues to evolve and improve. We are optimistic that continued experience with the pre-clerkship SCSs and the development of the Schwartz Rounds program for clerkship students will help cement the effectiveness of these sessions in meeting the challenges of clinical rotations in the complex hospital setting and preparing medical students to become compassionate practicing physicians following graduation.

Conclusions

As is well known, medical knowledge alone does not suffice in the education of proficient physicians. Effective communication helps physicians decipher patients’ complex medical histories, and fosters the necessary alliance with patients to ensure optimal care. Our SCS curriculum provides medical students with basic tools to develop and enhance their communication skills in the pre-clinical years. The continuation and extension of this curriculum into the clerkship years is expected to fortify a structure of empathic values and practical skills to aid the next generation of physicians in communicating effectively with and providing superior care to patients.

Ethical approval

Ethical approval was not required for this report of a curricular enhancement and its anonymous evaluation by participating students and faculty members.

Acknowledgments

The authors wish to thank the generous support from the Donald W. Reynolds Foundation for the implementation and evaluation of Mandatory Geriatrics Education for Brown Medical School: Comprehensive Curriculum Redesign (Richard W. Besdine, MD, Principal Investigator, 2006–2010). Additional funding was received from the Kenneth B. Schwartz Center for the proposal, “Schwartz Communications Sessions.”

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