What are the most effective ways to improve interpersonal communication skills in medical students?
Posted on 4th June 2021 by Charlotte Englund and Sophie Hu
In this blog, Charlotte and Sophie (final year medical students) discuss a recent Cochrane review that assessed ‘Interventions for improving medical students’ interpersonal communication in medical consultations’ and reflect on the implications of the findings.
Effective communication and interpersonal skills are essential for all medical professionals to ensure positive patient and interprofessional interactions occur. Much like a doctor’s diagnostic or procedural skills, their communication skills significantly impact patient outcomes [2,3].
Traditionally in medical schools, far more weight has been placed on so-called ‘hard’ or technical skills in contrast to the non-technical or ‘soft’ skills like communication. However, there has been a shift towards including communication skills within curricula, especially as communication skills in clinical settings have been recognised as different to those in everyday communication and should be developed through teaching and experiential learning [4,5]. Prior to this review, there was little pooled evidence to indicate which educational approaches were likely to be most effective in improving the interpersonal communication skills of undergraduate medical students.
What does the evidence say?
The reviewers searched five internet databases in September of 2020, as well as screening the reference lists of relevant articles. This process yielded 91 papers relating to 76 separate studies (RCTs, quasi-RCTs, C-RCTs, quasi C-RCTs) involving a total of 10,124 students from both undergraduate and graduate entry (pre-registration) medical programs. 42 studies were included in the meta-analysis and the primary outcomes for comparison were students’ overall communication skills, empathy, relationship building/rapport, information gathering skills, explanation and planning skills, specific communication tasks (e.g. open/closed questioning) and simulated or real patient appraisals of the consultation.
Some of the pertinent results are as follows:
- In comparison to usual curricula or a control, communication skill interventions may improve overall communication skills and empathy when evaluated by experts, but not simulated patients.
- Tailored and specific feedback probably improves students’ communication skills compared to generalised or no feedback
- Electronic/online communication skills interventions are equivalent to face-to-face education in some communication outcomes (empathy, rapport) but may have a small negative impact on information giving skills.
- When comparing simulated patient versus peer role play interventions, there may be little to no difference between effects on empathy. Other realms of communication skills were unable to be compared and hence overall skills comparison is uncertain.
- The quality of evidence for most findings was low- to very-low due to substantial risk of bias and heterogeneity of included studies.
Student perspective on the results
The improvement in communications skills and empathy, when evaluated by experts, is encouraging as it demonstrates that interpersonal communication skills can be taught. However, the disparity of perceived improvement between expert assessors and simulated patients suggests that medical or educational professionals and ‘lay’ people have different expectations of communication in medical consultations. This may indicate a need for more rigorous assessor training or evaluation, both expert and simulated patients, to ensure their desired communication outcomes align with that of real patients, the primary stakeholders.
The second result is validating as many medical students can probably appreciate that receiving targeted feedback is the most effective way to identify specific areas requiring improvement. It emphasises the need for educational courses to strive to provide specific feedback wherever possible and also to empower students to proactively seek it in order to develop their skills.
The finding that online interventions are equivalent to in person interventions in some domains (empathy) but potentially inferior in others (information giving) is particularly interesting in light of the COVID-19 pandemic, which has necessitated a move from face-to-face communication learning to online mediums for many medical schools globally. This suggests that while online teaching is adequate for some communication skills, face-to-face teaching may currently be preferred for information giving and gathering skills. This represents an opportunity for research and innovation to improve online teaching for skills normally developed in person, to ensure students educated electronically can achieve the interpersonal competencies required of medical graduates.
The lack of a statistically significant difference between the use of simulated patients and peer role-play in communication skills teaching is a surprising result. As fifth-year students, we have experienced both in our curricula and have found simulated patients to be an invaluable resource, particularly in pre-clinical years. Prior to significant clinical experience, we found that we and our peers typically did not act as believable patients, e.g. being extremely forthcoming with history information or not using lay language. In contrast, professional simulated patients were much more realistic in their portrayal, allowing us to gain ‘real world’ communication skills. However, in clinical years this distinction became much more subtle as we became more aware and well-practiced. Whilst this is just anecdotal evidence we wonder if differentiating by year group would affect the results. The evidence supporting this finding was of very low quality, highlighting the need for more research. However, if this finding was upheld it would have significant implications. In particular, simulated patients are costly and a move to peer role play would allow for finances to be redirected to other areas of medical schooling.
Main limitations of this study are that the reviewed studies were of low quality and that real-world effects of improved interpersonal communication skills of medical students are not explored in the primary studies.
In medical education research, evidence is often rated as low quality due to small sample sizes and variable interventions. Other factors include overall high or unclear risk of bias, high statistical heterogeneity and result imprecision which all lead to the lack of certainty in summarised results. Some of these factors are inherent in medical education research due to practical limitations however, an emphasis on consistent measures, clear presentation of methodology in published research and further subgroup analyses may help strengthen results.
Real-world effects of improved communication skills would be ideally demonstrated through the inclusion of long-term outcome measures that are directly applicable to real patient interactions.
Only 4 of the 76 included studies followed up outcomes outside of the year the intervention was run, meaning there is little evidence that communication teaching leads to long-term improvements in interpersonal skills. As students who have received such classes over the past four years, we anecdotally believe there is a long-term benefit and that so long as communication skills are continued to be utilised they can be retained, however more research on this topic is needed.
There was also an absence of real patient involvement in the studies analysed. Simulated patients were mainly used to represent the patient perspective, however incorporating or designing future studies that analyse outcomes in real-world patient settings would intuitively provide a more accurate depiction of the effect of interpersonal communication interventions.
Overall ‘Interventions for Improving Medical Student’s Interpersonal Communication in Medical Consultations’ has provided evidence supporting the importance of interpersonal communication skill interventions in medical school. Results demonstrate the value of personalised feedback and face-to-face skill learning, but also indicate the need for further research and analysis to understand the role of online learning, peer role-play and validity of expert expectations compared to real patients. The review also highlights the scope in future projects to include real patient perspectives and measurements of long-term improvement outcomes to help create a more comprehensive conclusion of the effect of interpersonal communication skill interventions.