Finding the Words: Medical Students’ Reflections on Communication Challenges in Clinic

摘要

Background and Objectives: Interpersonal communication is essential to providing excellent patient care and requires ongoing development. Although aspects of medical student interpersonal communication may degrade throughout career progression, it is unknown what specific elements pose challenges. We aimed to characterize clerkship students’ perspectives on communication challenges in the outpatient setting to help inform curricular development.Methods: Third-year medical students in a required family medicine clerkship were asked to describe a communication challenge they encountered. Open-ended written responses were collected through a mandatory post-clerkship survey. Responses were qualitatively coded using an a priori framework for teaching and assessing communication skills (The SEGUE Framework for Teaching and Assessing Communication Skills) with data-derived additions to the framework, followed by a team-based thematic analysis.Results: We collected 799 reflections written by 518 students from 2007–2014. Three dominant themes emerged from the analysis: challenges with (1) effectively exchanging information with patients, (2) managing emotional aspects of the patient encounter, and (3) negotiating terms of the encounter.Conclusions: Communication curricula focus on content and process of the medical interview, but insufficient time and energy are devoted to psychosocial factors, including aspects of the encounter that are emotionally charged or conflicting. While gaps in students’ communication skillsets may be anticipated or observed by educators, this study offers an analysis of students’ own perceptions of the challenges they face.(Fam Med 2016;48(10):775-83.)Interpersonal communication has long been recognized as essential to the doctor-patient relationship and is centrally situated within the broader frameworks of respect for persons and patient-centered care.1,2 Effective communication between physicians and patients has been linked to critical outcomes measures such as patient satisfaction, adherence to treatment protocols, physiologic indicators and pain control, and rates of malpractice suits and patient complaints.3-6While structured inquiry into physician-patient communication began in the late 1960s,7 coordinated efforts to streamline communication teaching have occurred since the early 1990s, from the Toronto8 and Kalamazoo9 conference consensus statements to the Association of American Medical Colleges (AAMC) Medical School Objectives Project examination of communication in medicine10 and the Liaison Committee on Medical Education’s accreditation criterion for specific instruction in communication skills.11 More recently, the AAMC has designated interpersonal communication a core competency for entering medical students.12 As educational bodies’ recommendations are incorporated at the curricular level, medical students are regularly assessed on their communication competencies throughout training, from pre-clerkship standardized patient encounters, to clerkship evaluations of communication with patients and colleagues, to the United States Medical Licensing Examination Step 2-Clinical Skills.Despite the bourgeoning focus on effective communication, the literature has noted degradation in medical students’ communication skills13,14 and patient-centeredness15-17 with progression through training. Such findings beg the question whether solid foundations are adequately established and demand renewed educational innovation and intervention at the trainee level. Existing research on communication challenges perceived by undergraduate medical students suggests managing conversational flow and grappling with the psychosocial/emotional dimensions of patient encounters are among the most frequently student-cited sources of difficulty,18-21 with conversations centered around giving bad news being particularly salient.22,23 Much of this research is with pre-clerkship or very early clerkship students, and thus there is