Zur Erlernbarkeit der Arzt-Patienten-Kommunikation in der Medizinischen Ausbildung

Zusammenfassung: In der vorliegenden Übersichtsarbeit werden ausgewählte Arbeiten präsentiert, die belegen, dass viele Elemente einer professionellen Arzt-Patient-Kommunikation im Medizinstudium erlernbar sind; dabei sind das Ausmaß des Lernerfolges und die Möglichkeiten seiner Überprüfung abhängig von der Definition der Lernziele. Zu ihrer Begründung wird in den meisten Lehrplänen auf die Bedeutung eines eher partnerschaftlichen und nicht patriarchalischen Umgangs mit Patienten verwiesen. Dem wird hier eine Definition von Lehrzielen gegenübergestellt, die sich an den Bedürfnissen der klinischen Medizin orientiert: Studierende erheben belastbare anamnestische Angaben, sie können Gespräche explizit strukturieren und Informationen vermitteln, sie trauen sich zu, emotionale Äußerungen von Patienten aufzugreifen. Als Prüfungsformat in der professionellen Kommunikation wird das Objective Standardised Clinical Examination (OSCE) mit seinen Stärken und Schwächen diskutiert. In Zukunft wird der strukturierte Einsatz von Videoaufnahmen von Gesprächen dazu führen, dass Studierende das eigene Verhalten besser kritisch reflektieren können. Wünschenswert wäre der Einsatz von Verfahren zur unmittelbaren Rückmeldung an Studierende über arbeitsplatzbasierte Techniken wie Mini-Cex oder Workplace-based Assessment. Diese Lehr- und Prüfungsmethoden bedürfen allerdings einer nicht nur fachlich, sondern auch in der Kunst des Feedback-Gebens ausgebildeten Fakultä

Detrended Fluctuation Analysis of Systolic Blood Pressure Control Loop

We use detrended fluctuation analysis (DFA) to study the dynamics of blood pressure oscillations and its feedback control in rats by analyzing systolic pressure time series before and after a surgical procedure that interrupts its control loop. We found, for each situation, a crossover between two scaling regions characterized by exponents that reflect the nature of the feedback control and its range of operation. In addition, we found evidences of adaptation in the dynamics of blood pressure regulation a few days after surgical disruption of its main feedback circuit. Based on the paradigm of antagonistic, bipartite (vagal and sympathetic) action of the central nerve system, we propose a simple model for pressure homeostasis as the balance between two nonlinear opposing forces, successfully reproducing the crossover observed in the DFA of actual pressure signals

Open and hidden agendas of "asymptomatic" patients who request check-up exams

BACKGROUND: Current guidelines for a check-up recommend routine screening not triggered by specific symptoms for some known risk factors and diseases in the general population. Patients' perceptions and expectations regarding a check-up exam may differ from these principles. However, quantitative and qualitative data about the discrepancy between patient- and provider expectations for this type of clinic consultation is lacking. METHODS: For a year, we prospectively enrolled 66 patients who explicitly requested a "check-up" at our medical outpatient division. All patients actively denied upon prompting having any symptoms or specific health concerns at the time they made their appointment. All consultations were videotaped and analysed for information about spontaneously mentioned symptoms and reasons for the clinic consultation ("open agendas") and for cues to hidden patient agendas using the Roter interaction analysis system (RIAS). RESULTS: All patients initially declared to be asymptomatic but this was ultimately the case in only 7 out of 66 patients. The remaining 59 patients spontaneously mentioned a mean of 4.2 ± 3.3 symptoms during their first consultation. In 23 patients a total of 31 hidden agendas were revealed. The primary categories for hidden agendas were health concerns, psychosocial concerns and the patient's concept of disease. CONCLUSIONS: The majority of patients requesting a general check-up tend to be motivated by specific symptoms and health concerns and are not "asymptomatic" patients who primarily come for preventive issues. Furthermore, physicians must be alert for possible hidden agendas, as one in three patients have one or more hidden reasons for requesting a check-up

Does the inclusion of 'professional development' teaching improve medical students' communication skills?

Background: This study investigated whether the introduction of professional development teaching in the first two years of a medical course improved students' observed communication skills with simulated patients. Students' observed communication skills were related to patient-centred attitudes, confidence in communicating with patients and performance in later clinical examinations.Methods: Eighty-two medical students from two consecutive cohorts at a UK medical school completed two videoed consultations with a simulated patient: one at the beginning of year 1 and one at the end of year 2. Group 1 (n = 35) received a traditional pre-clinical curriculum. Group 2 (n = 47) received a curriculum that included communication skills training integrated into a 'professional development' vertical module. Videoed consultations were rated using the Evans Interview Rating Scale by communication skills tutors. A subset of 27% were double-coded. Inter-rater reliability is reported.Results: Students who had received the professional development teaching achieved higher ratings for use of silence, not interrupting the patient, and keeping the discussion relevant compared to students receiving the traditional curriculum. Patient-centred attitudes were not related to observed communication. Students who were less nervous and felt they knew how to listen were rated as better communicators. Students receiving the traditional curriculum and who had been rated as better communicators when they entered medical school performed less well in the final year clinical examination.Conclusions: Students receiving the professional development training showed significant improvements in certain communication skills, but students in both cohorts improved over time. The lack of a relationship between observed communication skills and patient-centred attitudes may be a reflection of students' inexperience in working with patients, resulting in 'patient-centredness' being an abstract concept. Students in the early years of their medical course may benefit from further opportunities to practise basic communication skills on a one-to-one basis with patients