Curricular disconnects in learning communication skills: What and how students learn about communication during clinical clerkships

Abstract

Objective

In many medical schools, formal training in clinical communication skills (CCS) mainly occurs during pre-clinical training prior to clinical rotations. The current research examined student perceptions of both what and how they learn about CCS during clinical rotations.

Methods

During 2008 and 2009, 4th year medical students were invited to participate in interviews focused on learning of CCS during clinical rotations. Interview transcripts were analyzed to identify salient themes in their discussions of CCS in clinical learning experiences.

Results

107 senior students participated and reported learning CCS during clinical rotations mainly by: (1) observing faculty and residents; (2) conducting interviews themselves; and (3) through feedback on patient presentations. Teacher role modeling tended to not reinforce what they had learned pre-clinically about CCS and clinical teachers rarely discussed CCS. Feedback on patient presentations affected students’ communication styles, at times prompting them to omit use of CCS they had learned pre-clinically.

Conclusions

Students reported that clinical learning experiences often do not reinforce the CCS they learn pre-clinically.

Practical implications

Disconnects between pre-clinical and clinical CCS teaching need to be reconciled through more explicit pedagogical attention to CCS issues during clinical rotations both in the formal and informal curriculum.

Introduction

Teaching and assessment of clinical communication skills (CCS) is a core curricular activity in medical schools throughout the US and the world. The majority of US schools provide some type of formal instruction in CCS during pre-clinical training and far fewer schools continue this formal training during the clinical years of medical school [1], [2], [3]. Several authors have argued that students’ CCS can deteriorate over the course of their training, especially between classroom-based pre-clinical training and training in the context of clinical clerkships [3], [4], [5], [6], [7], [8], [9].

In the last 20 years the concept of the “hidden curriculum” has received much attention from the medical education community [10], [11], [12]. The premise of this hidden or informal curriculum is that students learn such things as professional behavior not only in classes but also in their day to day interactions with faculty, residents, staff and patients in the context of clinical care. The content of the hidden curriculum can outweigh more formal learning and has been pointed to as one of the reasons that students demonstrate a deterioration of certain skills and attitudes as they go through clinical training. In specific relation to CCS, many authors argue that what students have learned in the classroom is potentially not being modeled or reinforced by teachers (faculty and residents) during clinical rotations [6], [7], [13], [14]. Much of the research on deterioration of CCS has focused on assessing students’ individual knowledge, attitudes and skills through objective measures, examinations or observations of interviews with real and/or simulated patients [4], [5], [9], [13]. However, students’ own perceptions of their clinical training experiences have not been thoroughly investigated and the majority of these studies have been conducted outside the US [14], [15], [16], [17], [18]. An in-depth examination of student's perceptions could provide insight into the impact of those clinical learning experiences on their CCS.

The purpose of the current study was to examine students’ perceptions concerning the manner and extent to which CCS are emphasized on clinical rotations, and which factors influence whether or not CCS are addressed either formally or informally during their clinical training.