Of the 34 MSs that participated in the previous study and were contacted for this qualitative study, we received responses from 30 (85.7% of those contacted and 73% of all MSs in Spain; 5 private schools). Five main thematic categories were identified, each with different subcategories. Table 1 provides a list of the barriers identified:
Table 1: Barriers to teaching/learning communicative skills in Spanish medical schools
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Negative attitudes of teachers and academic leaders (as a result of opinions such as...)
(23 comments)
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CS are not practically used
The material used to teach CS is not scientific
CS are innate skills
CS cannot be taught
The introduction of CS training threatens both teachers’ subjects and their own academic statuses
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Marginal presence in the curriculum: organisation and structure
(30 comments)
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CS training is incorporated as a theoretical subject in an ad hoc style during preclinical periods
CS training is incorporated in a fragmented way (in different subjects)
CS training is included in subjects with other non-clinical content (humanities, ethics, history of medicine, psychology)
There is no transversal structure with coherent teaching aims
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Negative student attitudes (as a result of opinions such as...)
(11 comments)
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Students do not understand the use of CS
CS training includes reductionist and scientific epistemological interpretations
CS training is not important because it is not assessed
CS training is not useful for the MIR (medical intern) exam
CS training is not important because it is of a marginal or secondary nature in the curriculum
CS are innate and subjective and cannot be learned
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Limited and poorly trained teaching staff
(13 comments)
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There are no teachers with an appropriate academic status
The clinicians use a weak or negative model
Teachers have no training in CS or teaching methods
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Teaching and assessment methods needed
(21 comments)
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Teachers do not use experience-based teaching methods
Experience-based methods are expensive
CS training requires more time
CS training requires continuity and the commitment of teaching staff
CS training requires a relatively sophisticated infrastructure
CS training requires complex assessment systems that are not necessarily well known
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The comments under this category illustrated that the principal barrier is the negative attitudes of academic leaders and university professors who teach traditional subjects and their influence on the way the CS curriculum is incorporated and structured.
Respondents’ perceptions of the responsibility for CS curricula indicated that academic leaders feel that CS are not very useful:
"The inclusion of CC as an interdisciplinary subject or skill was outlandish and unnecessary, taking time away from real teaching". (U-5)
"Teachers of unrelated subjects or content believe it to be ‘superfluous’, ‘not very serious’, ‘lacking content’, etc.” (U-11)
Some respondents who were responsible for the curricula felt that some university professors think that there is no scientific (biomedical) evidence to support teaching CS:
"Many teachers and board members... believe that the important thing in medicine is basic research and medical knowledge in order to get a good result on the MIR exam, so subjects like this distract students from what is important". (U-21)
"It's believed to be a ‘soft science’ by the academic and professional community, who are more interested in technology". (U-22)
Other respondents who were responsible for the curricula thought that academic leaders do not perceive CS to not be useful but to be something that threatens their own teaching statuses:
"There are a lot of people in the university, or ‘the establishment’, especially in the pre-clinics, who don't see the relevance of these skills in medicine. There are also clinicians rooted in a medical education model that dates back to the middle of the 19th century". (U-28)
"Because of ignorance and a lack of understanding and consideration by academic leaders, most of whom are heads of departments and/or full-time lecturers, they don't value it and see it as an ‘easy subject’ that takes away teaching time from what is really important for them". (U-17)
Finally, some respondents who were responsible for the curricula believed that many academic leaders think that CS are learned by modelling:
"The undergraduate degree administrators don't forcefully or confidently support training in these skills... as they consider it to be something that you learn through imitation". (U-10)
Organisation, structure and presence of CS training in the curriculum
Comments under this category were the most frequent and repeated comments by key respondents; these comments suggest that CS training is primarily included as a legal obligation and is therefore implemented without an adequate teaching plan:
Incorporated in an ad hoc, theoretical way during preclinical periods:
"It's (CC is) covered in an ad hoc way as part of another subject, preclinical psychology, where it's taught in a theoretical manner with no practical training alongside other clinical skills that are developed during clinical periods". (U-16)
Incorporated where it is easiest, i.e., together with other secondary subjects:
"... it (CC) is crammed in, given no time of its own, with legal medicine, bioethics, ...and at different points in time, which makes it difficult to organise. It seems as though there is no other way to incorporate these skills, and so they are crammed in where there are a few credits leftover". (U-17)
Incorporated in a fragmented way with no coherent framework that includes objectives:
"...as it's not a ‘respected’ skill by academic leaders, it's only covered in an ad hoc and very limited way as part of smaller subjects, often optional, within different clinical and practical subjects, but with no specific objectives (as though the student would be able acquire them ‘by magic’)...it's a genuinely ‘orphaned skill’”. (U-26)
Need to be incorporated into curricula in a structured, transversal way at a supra-departmental level:
"An institutional or structural barrier is that curricula do not incorporate the subject in an obvious way. In general, they recognise the need for it but do not explain how it will be carried out and where the necessary credits will come from". (U-23)
Negative student attitudes
The respondents identified student attitudes towards CC as a major barrier. They linked these attitudes to a number of different causes.
Negative attitudes towards CS because of a lack of understanding of why they are useful:
"It's basically covered in second-year psychology when the majority of students are, in my opinion, not mature enough to understand the importance of this topic in their future clinical roles". (U-13)
"The main barrier is that the subject is covered in second-year medicine, at the same time as the Golgi apparatus, cranial nerves and the Starling Law, so for the students, its use is relative, given that it will be at least another two years before they work with patients and can see why it's important to their work as doctors". (U-28)
Negative attitudes towards CS due to biomedical epistemological interpretations:
"Many students believe that the education consists of gaining a lot of medical knowledge". (U-17)
"Students tend to want to ‘objectivise’ all the assessment schemes (when tackling exam revision, trying to boost results and competing for grades). This makes an overall assessment of communicative skills difficult and entails going through meticulous and debatable evaluations". (U-11)
Negative attitudes towards CS training due to it not being assessed:
"Although student attitudes have changed in the last few years... due to (CC) not being a continuous feature of a stable assessment scheme... they don't have enough motivation to study it". (U-23)
Negative attitudes towards CS training due to it not being useful for the MIR exam:
"Medical students continue to have a pre-academic profile for the MIR exam that prioritises the absorption of knowledge... so it (CC) has a passive role in clerkships, with no or little feedback or reflection on their communication...they are demotivated" (U-24)
Negative attitudes towards CS training because of how it is included and taught in curricula:
"By including it (CS training) as something secondary within other subjects, generally pre-clinics, using inadequate teaching method, if any, and with no thought as to how it is assessed, students see it as something that is not very important or related to their own personality" (U-26)
Lack or absence of trained teachers
The comments in this category referenced the absence of trained teachers in regard to both adequately teaching the content (offering feedback, etc.) and adequately planning it in the curriculum:
"There aren't enough trained associate teachers involved in this subject area to be able to establish proper parameters for communication skills, teaching objectives and teaching methods". (U-4)
"There aren't enough trained teachers to teach it (CC) properly. It is left ‘in the hands’ of the teaching clinicians in charge of clerkships. The psychologists don't generally have trained teachers that know the clinic". (U-5)
Problems linked to teaching methods and the necessary educational logistics for CS training to be taught
The comments under this category indicated that the teaching method designed specifically for teaching CC poses a significant barrier to CC assessment.
Technical/infrastructure requirements:
"The type of teaching necessary: active learning environments, with simulated patients, video recordings, self-evaluation..." (U-9)
"It requires a specific infrastructure for it to be carried out, spaces for simulation, video recording and reproduction systems..." (U-14)
Insufficient time:
"The main barrier we face in communication workshops is, without a doubt, a lack of time...for students to individually put into practice what they have learned, give subsequent feedback on how to improve any error made in the practice interview with a pretend patient". (U-19)
Structured feedback:
"Every student would have to be given personalised feedback while interacting with pretend or real patients". (U-23)
Continuity and commitment of teaching staff:
"It's not thought that this type of learning needs to be continually incorporated throughout the degree. It's thought that by merely studying subjects such as psychology, oncology, palliative care or psychiatry, students will learn communication skills...in reality, during clerkships, which is when students are faced with communication problems, they really are alone. In general, there is no feedback given by teaching clinicians". (U-26)
High cost:
"This subject would have to receive more investment than others: SP, Gesell chamber..." (U-30)
Problems derived from the type of assessment that CS require:
"Assessment makes it (CC) a major burden. Exams here are worthless; they (students) should be assessed on what they do, how they really communicate and not what they know" (U-11)
"The students have to take an objective test (a simulated exam with a standardised patient) for the skills they've acquired to be assessed...and this is difficult to carry out and expensive". (U-19)