Communication is the cornerstone of the relationship between the patient and physician. Communication includes several important domains: emotional relationship, including the establishment of trust and expression of compassion, bidirectional transmission of key information between patient and physician, and motivation and engagement in decision-making, behavior change, and self-care. History-taking skills are foundational for students in order to master more advanced and complex areas of communication, including conveying “bad news”, discussing end-of-life decisions (9), and addressing the concerns of angry and dissatisfied patients and families (10–12). Students must also learn to communicate effectively with peers and members of the clinical team. Research has shown that effective communication is critical to improving health outcomes for patients and to ensuring patient satisfaction and patient safety (1, 3, 12, 13).
An important question, then, is where and how do students acquire clinical skills? The clinical environment is a rich learning environment in which students can practice clinical skills with guidance and feedback from experienced clinicians as well as peers and near-peers. They learn through modeling themselves after those with greater clinical experience, and they learn through the practical application of the knowledge they have acquired through their pre-clinical curriculum. However, this apprenticeship model, while necessary and valuable, may not be sufficient to guarantee the acquisition of the range of skills or the level of competence expected of a year 4 student who is then prepared to move to the higher levels of clinical responsibility and independence expected in years 5 and 6.
Our study underscores several important points. The first is that at baseline, as they enter the clinical environment of their clerkships, students at Haiphong UMP, like students at many medical schools without a formal curriculum for clinical skills and limited clinical exposure in pre-clerkship years, have poorly developed clinical skills in the 4 key clinical areas studied. However, our study demonstrates that these skills can be taught and that a formal curriculum can lead to significant improvement. Thus, our study adds to a substantial body of evidence that formal training in clinical skills is possible and effective, and that there is a multitude of effective teaching strategies. For example, a review of strategies for teaching medical history identifies several effective approaches, including role-plays, interviews with real patients followed by feedback and discussion, and opportunities for videotaped reviews (14). Niedermier describes the effectiveness of a formal curriculum for medical students in documentation in an electronic medical record (15).
It is beyond the scope of this study to discuss the relative effectiveness of specific teaching strategies, but evidence suggests that a dedicated course and curriculum are superior to learning through informal exposure. In a study by Ahmed (16), medical students at the University of Bahr Elghazal, Khartoum, Sudan, where clinical skills were integrated into other educational programs, without a dedicated clinical skills curriculum, clerkship students were found to lack basic communication skills. In contrast, students at Maastricht University learn communication skills through a highly structured skills lab curriculum (17). The curriculum is longitudinal (once every 2 weeks throughout their 6 years of medical school), and graduated, whereby students are taught increasingly complex communication skills and are exposed to increasingly complex clinical settings beginning with a fully artificial setting, followed by role-plays, and graduating to standardized and finally real patients. The program was evaluated yearly by a questionnaire using a 5-point scale to measure student satisfaction and endorsement of the value of the curriculum (1 = disagree completely – 5 = agree completely.) The findings indicate strong student support for the value of a dedicated longitudinal curriculum focusing on communication and physical exam skills.
Research by Josephine et al. (18) on third-year medical students focused on an intervention to improve evidence-based medicine (EBM) skills by promoting history taking skills. This quasi-experimental study using a pre-post-test design measured attitudes and skills in applying EBM among a sample of third-year student volunteers. The average score in two key EBM skills, precise clinical questioning and finding the best clinical evidence increased from 3 to 4 on a 5-point scale, statistically significant at the p < 0.05 level.
Our study also suggests the potential value of a formal curriculum as a catalyst and promoter of informal learning in the clinical environment. In our study, the difference between the students who received formal and standardized training in clinical skills early in year 4 not only persisted but widened over the 2-year observation period. One can presume that students in the control and intervention groups had similar clinical exposures during their clerkship. The fact that the differences in performance persisted and widened suggests that as educators, we cannot count on exposure and role modeling alone; students must have formal training as well as clinical exposure in order to master clinical skills. It is possible that the skills learned through the formal curriculum allowed the students in the intervention group to benefit and consolidate the skills that they learn through clinical exposure and from role models. Although both control and intervention students had multiple opportunities to learn through repeated practice, perhaps the curriculum provided students in the intervention group not only with a toolbox of concrete skills to begin with but also with a framework for deliberate, self-directed learning with which to approach their learning in the clinical environment. Communication, history taking, and documentation are discrete skills up to a point. They are also highly interdependent. Indeed, most formal models for teaching clinical skills integrate several domains. For example, both One Minute Preceptor (19) and SNAPPS (20) are effective methods for teaching communication skills. But both also teach history-taking skills, clinical reasoning, and diagnostic skills. It is possible that through exposure to formal curricula in clinical skills, students gain practice integrating their knowledge and skills that serve as a foundation for their continued learning in the clinical environment.
Further studies, including qualitative studies of how students apply to learn from a curriculum such as ours to learning in the clinical environment, might shed light on which specific aspects of the curriculum contribute to the sustained and widening advantage that the curriculum provided.