Meeting the Students on Their Own Territory

BackgroundMedical students receive communication skills training but there is little research into how effectively, or indeed whether, these skills can be transferred into clinical settings. This paper reflects upon a project aimed at supporting students in communicating with patientsin clinical settings during their undergraduate years.MethodDuring 2012, 36 year medical students were directly observed leading consultations with real patients in in-patient settings by a communications skills expert. Each observed session involved focused feedback on performance and agreeing areas for future practice involving a student peer and the member of faculty.Results and DiscussionStudents positively evaluated this work-based experience, specifically, valuing the authenticity of engaging with ‘real patients’ in ‘real settings’. They reported learning to deal with environmental issues such as noise, interruptions – the hallmark of busy clinical settings. They gained from observing the Communication Skills teacher model effective communication within the consultation process and receiving immediate focused one-to-one feedback. Moreover, they were able to maximise the feedback through immediately applying it to further consultations. The challenges of rolling out such a programme to more students are discussed.ImplicationsObserved practice in work-based settings helps students to recontextualise knowledge learnt in the classroom setting. Their learning is greatly enhanced by having the supported opportunity to apply their skills in an authentic setting. However, implementing such a project can be resource intensive and logistically challenging

Training to enhance psychiatrist communication with patients with psychosis (TEMPO): cluster randomised controlled trial

Background A better therapeutic relationship predicts better outcomes. However, there is no trial-based evidence on how to improve therapeutic relationships in psychosis. Aims To test the effectiveness of communication training for psychiatrists on improving shared understanding and the therapeutic relationship (trial registration: ISRCTN94846422). Method In a cluster randomised controlled trial in the UK, 21 psychiatrists were randomised. Ninety-seven (51% of those approached) out-patients with schizophrenia/schizoaffective disorder were recruited, and 64 (66% of the sample recruited at baseline) were followed up after 5 months. The intervention group received four group and one individualised session. The primary outcome, rated blind, was psychiatrist effort in establishing shared understanding (self-repair). Secondary outcome was the therapeutic relationship. Results Psychiatrists receiving the intervention used 44% more self-repair than the control group (adjusted difference in means 6.4, 95% CI 1.46–11.33, P<0.011, a large effect) adjusting for baseline self-repair. Psychiatrists rated the therapeutic relationship more positively (adjusted difference in means 0.20, 95% CI 0.03–0.37, P = 0.022, a medium effect), as did patients (adjusted difference in means 0.21, 95% CI 0.01–0.41, P = 0.043, a medium effect). Conclusions Shared understanding can be successfully targeted in training and improves relationships in treating psychosis

Improving health care professionals' feedback on communication skills: Development of an on-line resource

Objective: This project aimed to develop an open-access on-line resource to assist health care professionals in providing effective feedback on patient-centered clinical and communication skills. The collaborative nature of the development of this learning resource is outlined and evaluation of its use is discussed. Methods: An inter-professional team of teaching staff from two London Universities employed a researcher to interview experienced clinical and academic health care professionals and gather examples of difficult feedback situations. Material was used to develop short video clips illustrating some common challenges in giving feedback on clinical and communication skills. Initial evaluation following use of the scenarios in workshops was undertaken by means of a “talking wall” technique. Results: Evaluation indicated that the resource enhanced the learning experience by providing realistic and challenging scenarios to focus discussion. Conclusion: Inter-professional working and piloting the use of the video scenarios in workshops enabled the improvement and refinement of an on-line staff development resource on feedback. Practical implications: The on-line resource is now available as an open access learning tool, with eight scenarios and guidelines for providing effective feedback in the academic or clinical setting. It can be used for self-study or as part of a group training session

Breaking bad news: experiences, views and difficulties of pre-registration house officers

Objectives: To obtain information regarding the involvement of pre-registration house officers (PRHOs) in the discussions on bad news, and the competency and difficulties they perceive in clinical practice. Design: Structured telephone interviews. Participants: 104 PRHOs. Main outcome measures: Information about frequency and quality of involvement of PRHOs in discussions on bad news with patients and relatives, perceived competency and difficulties related to this task as well as ethical views concerning the disclosure of bad news. Results: 82 PRHOs (78.9%) had initiated the breaking of bad news to a patient at least once, whilst patients themselves had initiated discussions of bad news by asking the doctors questions (92.3%). Almost all (96.2%), indicated that they had broken bad news to relatives of a patient. The majority of the junior doctors participating in our study felt fairly or very confident (90.4%) to break bad news. ‘Often’ quoted difficulties for over a fifth of the sample included ‘Thinking I was not the appropriate person to discuss the bad news', ‘Having all the relevant information available’, ‘Dealing with emotions of patient/ relative’, ‘Lack of privacy’ and ‘Patients/relatives do not speak English’. Although 99 PRHOs (95.2%) believed that patients should be informed about a serious life threatening illness, 30.8% of the participants stated that doctors need to judge whether or not to tell a patient bad news. Factors most frequently selected by the PRHOs from a given list of possible factors contributing to a gap between theory and practice included problems with the organization of clinics (73.1%), insufficient postgraduate training (63.5%) and lack of staff (54.8%). Conclusions: The results indicate that PRHOs are frequently involved in the breaking of bad news. Whilst no claims can be made for their actual performance in practice, their perceptions of competency would indicate that the extensive and compulsory undergraduate teaching they had received on this subject has served to prepare them for this difficult task. Organizational and structural aspects need to be taken into account as factors assisting or undermining doctors in their efforts to put into practice ethically sound and skilled communication when disclosing bad news

Grainyheadlike 2 distribution reveals novel pathophysiological differences between human idiopathic pulmonary fibrosis and mouse models of pulmonary fibrosis

Chronic injury of alveolar lung epithelium leads to epithelial disintegrity in idiopathic pulmonary fibrosis (IPF). We had reported earlier that Grhl2, a transcriptional factor maintains alveolar epithelial cell integrity by directly regulating components of adherens and tight junctions and thus hypothesized an important role of GRHL2 in pathogenesis of IPF. Comparison of GRHL2 distribution at different stages of human lung development showed its abundance in developing lung epithelium and in adult lung epithelium. However, GRHL2 is detected in normal human lung mesenchyme only at early fetal stage (week 9). Similar Mesenchymal re-expression of GRHL2 was also observed in IPF. Immunofluorescence analysis in serial sections from three IPF patients revealed at least two subsets of alveolar epithelial cells (AEC), based on differential GRHL2 expression and the converse fluorescence intensities for epithelial versus mesenchymal markers. Grhl2 was not detected in mesenchyme in IP bleomycin-induced injury as well as in spontaneously occurring fibrosis in HPS1/2 mutant mice, while in contrast in a radiation-induced fibrosis model, with forced Forkhead box M1 (Foxm1) expression, an overlap of Grhl2 with a mesenchymal marker was observed in fibrotic regions. Grhl2's role in alveolar epithelial cell-plasticity was confirmed by altered Grhl2 gene expression analysis in IPF and further by in vitro manipulation of its expression in alveolar epithelial cell lines. Our findings reveal important patho-physiological differences between human IPF and specific mouse models of fibrosis and support a crucial role of GRHL2 in epithelial activation in lung fibrosis and perhaps also in epithelial plasticity