Effective physician–patient communication correlates with improved health outcomes, patient adherence, and patient satisfaction.1–3
As key components of professional competence, interpersonal and communication skills learning begins in medical school, although communication skills teaching methods vary across schools.4
Most include experiential exercises such as interactive workshops, role-play with standardized patients (SPs), videotape review, and practice with peers.5,6
The participation of SPs in teaching and evaluating communication skills is effective.7
Medical students who receive instruction from SPs reflecting the patient perspective demonstrate improved communication skills and higher satisfaction, even when compared to receipt of feedback from faculty or real patients.8–11
However, SP training is costly and time consuming.
Most United States medical schools conduct a comprehensive clinical skills examination to assess professional competence, including communication skills.12
Preparatory educational activities reinforce key concepts and improve performance on high-stakes examinations.13
Because comprehensive clinical skills examinations generally involve SPs, practice with SP encounters is helpful for clinical skills test preparation.14,15
However, there is limited data on optimal timing and format of test preparation strategies. Existing studies differ on whether preparation strategies employed just prior to testing (i.e. “last-minute” preparation) are effective.16–19
Web-based learning in medical education is associated with positive learning outcomes and appears to be as effective as traditional teaching methods.20,21
Web-based SP teaching modules typically consist of videotaped clinical encounters between medical students and SPs with expert clinician commentary; they are more cost-effective, convenient for students, and easier to administer although less preferred by students than in-person SP modules.13
In our prior study, students who used a web-based SP module or in-person teaching exam with SPs to prepare months in advance for a high-stakes Clinical Performance Examination (CPX) scored higher than historical controls on history-taking and physical examination skills but showed no difference in communication skills.13
Given the importance of communication skills in clinical practice, we sought to develop a new method to enhance students’ communication skills performance.
We describe an innovative web-based SP module to teach communication skills effectively. We hypothesized that students who accessed optional web-based SP modules with detailed SP and faculty commentary proximal to a high-stakes clinical skills examination would demonstrate improved communication skills performance.
Setting and Participants
Participants were 147 early fourth-year medical students after their core clerkships at a public medical school in 2008–2009. All students participate in an eight-station, high-stakes CPX at the beginning of their fourth year; a passing score is required for graduation. The school is one of eight schools of the California Consortium for the Assessment of Clinical Competence (CCACC), which collaborates to determine examination and checklist content. Cases represent common ambulatory medicine problems and are incorporated into the CPX after being piloted by CCACC schools. In each clinical encounter, students spend 15 minutes with a SP performing a history and physical examination and communicating an initial assessment and plan. SPs evaluate students immediately after each encounter using faculty-developed checklists. CPX score reliability and correlation between performance in SP examinations and clinical practice have been reported previously.22–24
We created a web-based SP module with three videotaped clinical encounters, each between a different medical student and SP, based on common ambulatory chief complaints similar in content and difficulty level to CPX cases. Each case included 20 minutes of interaction between student and SP with five additional minutes of interspersed commentary from a clinician and three from a SP. Expert clinician voiceover intermittently explained clinical reasoning and expected clinical skills for the encounter, and SP voiceover critiqued students’ communication skills from the patient’s perspective. Clinician narratives were scripted and narrated by study authors (C.A.L., A.C., and C.L.C.) based on history/physical examination scoring checklists aligned with diagnostic evaluation of the patient's chief complaint. Patient narratives were spoken by SPs who had undergone 20+ hours of training for these cases and based their comments on a standardized, validated checklist for communication skills.25
One month before the CPX, CPX directors emailed all 147 students recommending that they view at least two of the three module cases prior to the CPX. Students received two subsequent weekly reminder emails. Because students were already required to participate in a formative in-person SP examination as a preparatory activity six months prior, we timed the module to occur closer to the CPX date and made the module voluntary. Each student received a unique login and password for module access. The time of login and logout was recorded to determine total time students accessed the module. The medical school institutional review board approved this study.
The primary outcome measure was CPX communication scores; history/physical examination and overall performance scores were also examined.
We compared scores between students who used the web-based module and those who did not. A series of multiple regression analyses was conducted to examine the association between module use and CPX scores. To control for baseline differences between these two student groups, we used USMLE Step 1 scores and core clerkship ratings as covariates. Clerkship ratings were derived from the medical school’s 10-item summary evaluation form. Students’ average ratings across required core clerkships (Anesthesiology, Family Medicine, Internal Medicine, Neurology, Obstetrics/Gynecology, Pediatrics, Psychiatry, Surgery, and Surgical sub-specialties) were used to create the following covariates: 1) fund of knowledge; 2) history-taking; 3) physical exam; 4) oral presentation; 5) record keeping; 6) problem solving; 7) attributes and responsibility; 8) self-improvement; 9) relationships with patients and families; and 10) relationship with the health care team. We then examined use of the web-based module as the only predictor of CPX scores. Subsequently, covariates were added separately to this baseline model to examine the effect of each covariate on the relationship between module use and CPX scores. P values < 0.05 were considered statistically significant. SPSS Version 18.0 was used for all analyses.
Of the 106 students (72%) who viewed the web-based module before the CPX, 51 (48%) were male, consistent with the class composition. Students logged into the module from 1 to 1346 minutes (mean 86.4, median 29). Eighty-four (79%) students viewed the module within 48 hours of the CPX, and most (75, 71%) viewed it within 24 hours. There were no statistically significant differences in USMLE Step 1 scores or clerkship summary scores between students who viewed the module and those who did not.
Students who did not watch the module had mean CPX communication scores of 67.79% (SD
5.51) and overall scores of 68.80% (SD
6.64). Students who watched the module scored significantly higher on CPX communication (70.46%, p
0.004) and overall (70.92%, p=
0.03) (Table ) compared to their classmates, even after controlling for USMLE scores and clerkship ratings (Table ). Use of the module did not significantly affect history/physical examination scores (71.11%, p
0.12) in the baseline model or in the models including covariates. Three of 106 students (3%) who watched the module failed the CPX, compared to 7 of 41 students (17%) who did not watch the module (p
Correlation Between a Web-Based Module and Clinical Performance Examination (CPX) Scores
Association of Web-Based Module Use with Clinical Performance Examination Score in Multivariate Models