In the end, out of the 34 MSs contacted, we received responses from 30, (85.7% of those contacted and 73% of all MSs in Spain). These were: Alcalá de Henares, Alfonso X El Sabio, Autónoma de Barcelona, Autónoma de Madrid, Barcelona, Castilla La Mancha (Ciudad Real campus), Castilla La Mancha (Albacete campus), Católica San Antonio de Murcia, Católica de Valencia, CEU Cardenal Herrera de Madrid, Extremadura, Francisco de Vitoria, Girona, Granada, Internacional de Cataluña, Islas Baleares, Jaume I de Castellón, La Laguna, Las Palmas de Gran Canaria, Lleida, Málaga, Miguel Hernandez de Elche, Murcia, Navarra, Oviedo, Pompeu Fabra, Rey Juan Carlos, Rovira i Virgili, Valladolid and Zaragoza. 5 main thematic areas were identified, each with different sub-areas. Table 1 shows a list of the barriers identified
Table 1: Barriers for 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...)
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Lack of practical use
Not being scientific material
They are innate skills
They cannot be taught
Its introduction threatens both their subjects and their own academic status
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Marginal presence in the curriculum: organisation and structure
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Incorporated as a theoretical subject in an ad-hoc style
During preclinical periods
In a fragmented way (in different subjects)
Part of a subject with other non-clinical content (humanities, ethics, history of medicine, psychology)
No transversal structure with coherent teaching aims
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Negative student attitudes (as a result of opinions such as...)
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They do not understand its use
Reductionist and scientific epistemological interpretations
It is not important because it is not assessed
It is not useful in the MIR (medical intern) exam
It is not important because it is of a marginal or secondary nature in the curriculum
It is innate, subjective and cannot be learnt
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Little and ill-prepared teaching staff
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There are no teachers with an influential academic status
The clinicians use a weak or negative model
They have no training in CS or teaching methods
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Teaching and assessment methods needed
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They do not use experience-based teaching methods
Experience-based methods are expensive
It needs more time
It needs continuity and the commitment of teaching staff
It needs a relatively sophisticated infrastructure
It needs complex assessment systems that are not necessarily well known
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Negative attitudes of the university professors and academic leaders
Up to 23 comments highlight the main barrier as being the negative attitudes of the university professors who teach traditional subjects and academic leaders, as well as their corresponding reasons and influence on the way the CS curriculum is incorporated and structured.
- Those responsible for curricula think that CSs are not very useful
"the inclusion of CC as an interdisciplinary subject or skill was outlandish and unnecessary as it was not considered necessary and time was taken 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
- Those responsible for the curricula feel that there is no scientific evidence (biomedical) for CSs
"Many teachers of specialist areas see this subject as "not very scientific", superficial and non-essential" U-20
"Many teachers and members of the School board... believe that the important thing in medicine is basic research and medical knowledge in order to get a good result in 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
- Those responsible for the curricula feel that CSs threaten their own teaching status
"The fact that the subject or topic is in the hands of family doctors, reduces its value, as the other teachers see them, due to not being full-time staff, as encroachers." U-19
"There are a lot of people still in the university, or "establishment", especially in the pre-clinics, who don't see the relevance of these skills in medicine, but 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 lack of understanding and consideration by academic tutors, most of whom are heads of department and/or full-time lecturers, they don't value it and see it as an "easy subject" that takes lectures on what is really important away from them" U-17
- Those responsible for the curricula feel that CSs are learned spontaneously
"The undergraduate degree administrators don't strongly and confidently up hold that training in these skills is key... as they consider it to be something that you learn through imitation" U-10
Type of organisation, structure and presence in the CC curriculum
These illustrate the most frequent and repetitive types of comments made by key respondents (up to a total of 30 comments) and note that including said skills would primarily be in response to a legal obligation, and therefore, be forcibly implemented without an adequate teaching plan
- Incorporated in an ad-hoc, theoretical way during preclinical periods
"It's covered in an ad-hoc way as part of another subject, preclinical psychology as well, 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: 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 a "rather unrespected" 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)
- Necessity to be incorporated into curriculums in a structured and transversal way from a supra-departmental level
"An institutional barrier, of a structural kind of great importance, is that curriculums 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
Up to 11 comments identify students' attitudes towards CC as a major barrier. The respondents link these attitudes to a number of different causes
- Negative attitudes towards CSs because of a lack of understanding as to 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)
"The students don't give much importance to communication as it's taught in the third year and they are perhaps not aware of how important it will be in their future clinical work" (U-25)
"By teaching this subject in the second year, the students don't think it's very important for their future work as doctors" (U-20)
- Negative attitudes towards CSs 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)
"We've seen disinterest among students in attending classes because they think it can be substituted by private study based on notes" (U-8)
- Negative attitudes towards CSs due to it not being assessed
"Although student attitudes have changed in the last few years,... due to not being (CC) a continuous feature of a stable assessment scheme... they don't have enough motivation to study it" (U-23)
- Negative attitudes towards CSs due to it not being useful in the MIR exam
"Medical students continue to have a pre-academic profile for the MIR exam which prioritises the absorption of knowledge... so it has a passive role in internships, with no or little feedback or reflection on their communication...they are demotivated" (U-24)
- Negative attitudes towards CSs because of how it is included and taught in curriculums
"By including it 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 is more something related to their own personality" (U-26)
Lack or absence of trained teachers
There were 13 comments that made reference to the lack or absence of trained teachers, not only when it comes to adequately teaching the content (offering feedback, etc.) but also in terms of 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 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 practical medicine" (U-5)
"Perhaps the most significant barrier is the lack of training that many teachers have in this subject" (U-23)
"There aren't enough teachers (associate teachers)" (U-24)
Problems linked to teaching methods and the necessary educational logistics for it to be taught
There are 21 comments that consider the characteristics of the teaching and assessment method designed specifically for learning CC effectively is a significant barrier.
- 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)
"We would have to hire semi-professional actors to help teach it and make more time for simulated activities" (U-25)
- 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 SP" (U-19)
- Structured feedback
"Every student would have to be given personalised feedback while interacting with simulated or real patients" (U-23)
- Continuity and commitment of teaching staff
"...has to be taught on an almost one-to-one basis and requires a lot of commitment by teachers...this means giving it its own budget and having to manage significant resources" (U-9)
"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, when on internships, which is when students are faced with communication problems, they really are alone. In general, there is no feedback given by faculties" (U-26)
- Budget
"This subject would have to receive more investment than others: SP, Gesell chamber..." (U-30)
- Problems deriving from the type of assessment that communicative skills require:
"Assessment makes it (CC) a major burden. Exams here are worthless, they should be assessed on what they do, how they really communicate and not what they know" (U-11)
"The need for more complete assessment of its impact on OSCEs" (U-14)
"The students have to take an objective test (simulated exam with a standard patient) for the skills they've acquired to be assessed...and this is difficult to carry out and expensive" (U-19)
"It's not assessed in a specific way, if it's done indirectly, and when that happens, they are generally criticised on what they have done wrong and then they (the students) complain" (U-26)
"the students don't understand that they are being assessed on something like CC that many think is an innate skill" (U-29)