Transition from “physician-centred” to “patient-centred” approach of treatment in our context of “see-do-teach” themed medical school is challenging. The challenge of teaching CS is daunting as this soft skill is thought unteachable, unlearnable and that skills acquired during the training period tends to decline over time. The high level of student participation during the initial stages of the intervention was unexpected but encouraging. Our students were not exposed to any form of such formal training so they valued this unique opportunity indicating early sensitivity towards this crucial trait. The never-ending litigations against doctors with poor CS could be another factor driving students to enrol in the intervention. Also, newly admitted medical students could have unrealistic and high notions regarding importance of CS. It suggested early need of intervention among medical students.[1, 7]
Lectures, PowerPoint presentations, e-books, video-tape, role-playing and small-group discussions were used as teaching learning methods in our intervention. Various strategies have been used worldwide in teaching medical CS with one superior to the other.[8, 9] We opted inexpensive methods over CS labs and simulated patients (SP) due to financial constraints. All the study materials were in accordance with the TU curriculum, Calgary-Cambridge model and Kalamazoo Essential Elements Communication Checklists.[3, 4]
There are conflicting reports on change in attitude of medical students post-CS course. Our study reported improvement in learning attitude post-intervention as evidenced by CSAS score indicating attitude to be a learned response amenable to change. Dissimilar reports could have been because of different context and intervention methods.
In the present study, we employed TBL and small group teaching as teaching-learning method. Though small group teaching puts huge work burden on the trainer, only one trainer was utilized to minimize trainer discrepancies between groups. Also, evaluation was conducted by other investigators to avoid biasness. Most medical schools in our part of the world use English as primary instructional method. The patients, however, use native language for communication during medical consultation. We employed Nepali language as both instructional and assessment method. The impact of using native language as instructional method has not been studies. On one hand it could be fruitful for future doctors wanting to work in Nepal but, on the other hand could not be as productive to foreign aspirants.
Defying CS learning as unteachable and unlearnable myth, students’ performance improved significantly in post-interventional summative assessment scores, highlighting the effectiveness of early intervention. There was statistically significant improvement in knowledge scores in either sex, entry-type or past educational institute. This suggests every type of medical students could learn CS. Studies have shown a decline in CS of medical students with passing years. The present study needs to be more comprehensive to extract such a conclusion. Improvement in knowledge has been assessed using various strategies like OSCE (Objective Structured Clinical Examination),[12, 13] SP, True False Statements, Multiple and Single Choice Questions. No goal standard assessment model has been suggested as different assessment methods have different values.[8, 9, 14] Use of SP’s and CS-lab has been widely reported in literature to evaluate CS of the students. The lack of funds hindered both our intervention and evaluation plan with SP’s using CS-lab.
The early enthusiasm with encouraging participation was short-lived. During subsequent formative assessments, the progress and assessment scores were not promising. High-stake knowledge-based exams in our part of world could avert medical students towards learning CS. Also, TU provision of Not Fit for Technical education (NFTE) after 5 unsuccessful passing attempts in other basic science subjects could help lack motivation to studying CS.