Four overarching themes emerged which relate to the training of medical students; the importance of experience, the value of role-models, the structure of a consultation, and confidence. Within the first two themes, sub-themes were identified as described below. Quotes from experienced clinicians (experts) are labelled as E[participant] and those from students are labelled as S[participant].
Learning from experience
Both students (n = 9) and experienced clinicians (n = 11) reflected on the value of experience in developing their skills, and particularly, knowing what questions to ask and what areas to explore. Clinicians credited the development of their techniques and confidence to the extensive experience they had gained over thousands of patient consultations.
“Unless you’ve literally spoken to hundreds of people with this problem, your radar for picking up these subtler things isn’t there.” [E5]
“I see something or I feel something that’s wrong. It’s the experience, you pick it up. There’s no training, there’s no chapter in the book [that compares].” [E11]
Also, most clinicians stated that they had very little teaching of communication skills during their own training, so they predominantly learnt ‘on the job’.
“We just do what we do and then we try and interpret it as to what strategy were you trying to use. Like you just learn because you’re doing something…I went through medicine in an era where there’s none of this ‘how do you talk to people properly’ this is a new phenomenon.” [E13]
“No mock training, just learning on the job. We did no role playing when I was in medical school.” [E8]
Students saw their lack of experience as a weakness and aspired to the confidence they saw in ‘good communicators’ who had developed their skills over many consultations.
“[What’s important] is me feeling like I’m doing it in a professional manner, and I understand that that comes with experience, that as you learn the key features to look for and you’re doing the sort of diagnosis in your head as you’re going along, you’ll get better and better at it.” [S4]
“Inexperience [is my weakness]. You see a good consultant do it and they make it look really easy, and then you try and do it and it’s really not easy at all.” [S11]
Learning from practice opportunities
Five of the clinicians and fourteen students highlighted the role of practice in their acquisition of good communication skills, with clinicians in particular mentioning the importance of “repetition” [E10 and E15]. Clinicians also reflected on the learning process as one involving making and learning from mistakes, as well as being an ongoing process of professional development.
“…over a series of 27,000 patients or so you develop an intuition and you develop some strategy. You’ve made plenty of mistakes so you’ve learnt over time.” [E18]
“We’re taught it as medical students - we learnt it more as residents and registrars. It’s just an accumulative [process] of learning how to take a history and direct the history.” [E8]
Students also referred to the value of practice, but it was clear that not all practice opportunities were equal, with several students contrasting the value of role-plays with simulated patients (actors) to those with peers (playing patient roles).
“I don’t think it’s that great interviewing other medical students. I’m not sure that it’s that beneficial. You’re interviewing people that know exactly what you want or you’re getting at, sometimes their answers are artificial and tailored and fake.” [S5]
“Having two students run a mock interview is a lot more difficult than having an actor… if it’s an actor it’s far more real.” [S12]
“…with friends, we all know sort of how it’s meant to be and so the answers they give might not be like how a patient would normally give it...” [S8]
“When you’re in the hot seat it’s quite challenging to come up with the right questions and get the patient to deliver the right information. [Actors] are good, they do play their roles, so they don’t sit there and spill their story, they dole it out to you based on how relevant the questions are.” [S6]
This concept of the realism of role-plays was reinforced in comments made by two students who indicated that they had a different approach between observed or assessed interactions and those with real patients:
“I guess it depends on the time constraints and who’s watching. If no one else is there I’d probably be more leading, trying to get the information that I know that I need to get on with my job, but if someone else is watching me and for the purpose of assessment I tend to be more open-ended with my questions and allow patients to just talk and tell their story.” [S2]
“I hate mock interviews. I hate doing them because I think you’ve got a lot of pressure on you and you know that your communication skills are being watched; …I come away feeling very frustrated a lot of the time from them, because I suppose I feel like I’m being judged and I don’t think I’m giving maybe a real performance or a realistic one.” [S20]
The discomfort of having many people watching role-plays was also commonly raised, and cited as causing anxiety among students.
“They’re awful, though, when you normally have 10 classmates sitting around and you don’t know what’s happening, and you’re always getting judged as the doctor, so you don’t want to make a mistake. So I found them quite stressful. In the skills lab, we have a Simulation Man…and it’s all videotaped in one room and you can watch it in another room, so it would probably actually be beneficial if people were in another room watching...it’s kind of out of sight, out of mind.” [S17]
The value of practicing in the safety of a simulated environment with actors was also discussed, with students appreciating the opportunities to “pause at different points and… discuss what techniques you’re using” [S15] and practice techniques before using them with real patients.
“We do a little bit of an interview and then it gets stopped and we talk about how we think we’ve went [sic] you can feel like you can try a few different things that you might not otherwise try in front of an actual patient, when you could get an awkward response or muddle your words and stuff things up a little bit. It makes you feel a bit more confident in using those skills.” [S11]
The most highly valued practice opportunities were those with real patients:
“I think any interviewing is better than no interviewing, but whether it translates to patient care, yeah, but not that much….It’s just so different to when communicating with patients.” [S5]
“I think the only way you can get any better is with real people….” [S15]
The value of role-models
Three clinicians and four students described the importance of mentorship on their learning to become effective communicators. Clinicians discussed their role as mentors in training junior staff and their own learning from “watching [their] mentors.” [E1]
“…learn about what sort of a doctor you want to be and who you’re trying to emulate like who are your good role models.” [P13]
Students commented on opportunities to observe consultations, and desires for more such experiences:
“They seem to make it look really easy, and I think they probably use a lot of strategies that I don’t even pick up on.” [S11]
“It would be nice to observe more senior people interact with real live patients.” [S1]
The importance of feedback
Several students and clinicians made reference to the importance of feedback in teaching:
“I’ll sit with [a junior doctor] and watch a consultation and afterwards we’ll discuss what he did do, what he didn’t do…in another month’s time I’ll go there again and see if he’s picked it up.” [E11]
[The teaching experience could be improved] “if we had an opportunity to talk to someone, do a role play, and have an assessor write some notes on how we could better handle this.” [S3]
One student struggled with the type of feedback being provided:
“I’ve been trying to incorporate previous feedback which, on the whole, is appalling, the feedback we receive. So you try to incorporate that feedback but each clinician tells you you’re doing wrong, but you’ve changed it from the previous clinician. So there’s a large variability in what is acceptable or appropriate. And that varies day-to-day from a lot of senior clinicians. I don’t think they’re receiving any instruction on how to give feedback.” [S19]
Five clinicians and nine students discussed the utility of having a solid understanding of effective communication skills which can facilitate gathering information from patients. Clinicians described an ability to have a conversation and then return to the structure to cover outstanding content.
“I think sometimes it might sound to an untrained observer that I’m just having a conversation, and that’s exactly the way I want it. I want it to feel and look that we might be having a conversation, but I’ve got clear ideas what information I want to get…near the end … I might say I’ve missed a few things, I’m just going to ask you now some direct questions to make sure I’ve covered everything.” [E1]
“As much as I hate - like most people - rote learning, I strong[ly] believe you first have to nail the box and dice approach, the textbook.” [E1]
“That’s why you got to rote learn your chosen profession’s questions, so that eventually through that boring phase of your training…it’s all in there, so then it releases you from going ‘what do I say next? What’s the next question I’m meant to ask’.” [E1]
Most students agreed that they had learnt a framework or structure of some kind to guide their history-taking and patient interactions, but the utility of these frameworks was brought into question in their real patient interviews. In particular, the ability to cover both the content of the framework and the varied emotional or social needs of patients poses a challenge to students.
“When you’re inexperienced, sometimes even just the anxiety, confusion can prevent you from displaying empathy, really listening to the patient because you’re so frantic and worried about not missing anything.” [S5]
“I think when you’re new, you’re busy focusing on ‘do I know all the technical guff behind what the presenting symptom means?’… it’s very hard to ask insightful questions if you can’t discriminate between differential diagnoses, you need to know what’s at the end, so you can ask the right question ...” [S6]
“ [Experience helps you] being able to be flexible with the way that you interact with patients, not everyone’s going to respond in the same way to the information presented in one way, it needs to be variable.” [S2]
“The mock interviews didn't prepare me: they had been given a mock scenario, and it was just sort of back pain or backache, I knew how to respond to those things because I’d been prepared to respond to those things particularly, so I haven’t really interacted with a patient that has had more serious conditions.” [S1]
The clinicians’ reflections also reinforced the challenge for students and junior doctors in balancing these aspects of the consultation and the uncertainty inherent in dealing with a range of complex individuals and issues.
“You can tell they [students and junior doctors] are not listening properly, because the person gives them some juicy information and it’s like they didn’t hear.” [E1]
“I think what junior doctors often do is uncomfortable with the uncertainty of those situations, they’re much happier to have an answer that you should do this, this is what medicine says, as opposed to balancing what medicine says and the patients’ priorities and patients’ thoughts… It’s much easier to have a guideline that’s very definite.” [E3]
Lack of confidence emerged as an important factor throughout each of the themes above, but it also stands alone as a theme, given the capacity for effective education to build confidence in students. Constructive feedback and opportunities to practice can build confidence which can be linked with job or learner satisfaction and ultimately can lead to improved patient outcomes. This topic was raised by four of the experts and four of the students, with key sentiments illustrated in:
“I wish I was even more confident... patients can sense that, and if … they’re more comfortable and more open ... it encourages them to partake in the interview better if they’re trusting you more.” [S5]
“Often the young ones [students] - until they get their confidence up - are just stuck in their little bubble of ‘this is my scope of practice, these are the questions I’ve got to ask’ ….”. [E10]
“I think communication is hard…I’ve been learning a lot about it in the last five years and it’s been opening my world up and it really helps my satisfaction with my work.” [E14]