A short, intensive small group seminar on medical interviewing appeared to have had an impact on some specific skills, pertaining to "eliciting and understanding the patient's perspectives." It did not seemed to have improved the skills associated with the other tasks: establishing initial rapport, surveying the patient's reason(s) for the visit, determining the patient's chief concern, and managing flow – providing the structure for the interview, and the skills for building relationships.
There are several strengths of our study. First, this is one of the few empirical, controlled studies from a non-English speaking country. Even though the students were not strictly randomized into intervention and control groups, the assignment occurred arbitrarily by the administration, without regard to students' preferences or interests in medical interviewing. Thus, it is unlikely that the higher scores in the intervention group are attributable to self-selection. Although there was a significant difference between the groups in proportions of students who did a self-study for the OSCE, which might have caused the results of no difference in most of the skills, the other characteristics such as age and gender were similarly distributed (Table ). Second, interventions and evaluations were guided by the conceptual framework, modelled after the 3 widely used theoretical models that are based on rigorous, empirical research in the field of patient-physician communication [2
]. Third, the communication skills evaluation instrument was matched with the competencies taught in the small group sessions [13
]. By carefully delineating and defining specific communication skills that should be addressed in the teaching session and by evaluating the effect of the teaching intervention on these individual skills, we sought to examine whether some skills were more teachable than others in such a brief, small group sessions.
Our study also has weaknesses that should be addressed. First, our teaching method was based on the research findings in Western world, and this is based on the untested assumption that these findings are equally valid in Japan. There is evidence that patient-physician communication patterns in Japan are different from those in the West. Previous research by Ohtaki and colleagues compared patient-physician communication patterns in Japan and the USA [14
]. It included 20 outpatient consultations of four physicians in Japan and 20 outpatient consultations of five physicians in the USA. Japanese physicians spent less time on social talk than the USA counterparts (5% vs. 12%). Japanese patient-physician encounters included more pauses than those in the USA (30% vs. 8.2% of the total consultation length). There is a need for more empirical studies linking physicians' communication skills to patient outcomes specifically for Japanese population. Second, our assessment of students' communication skills was based on observations of a single, five-minute OSCE station. The reliability of which as a measure of communication skills is known to be low [15
]. Third, because we assessed the students' skills at only one time, we could not assess the change in students' performance before and after the intervention. Fourth, the use of junior students as standardized patients may have influenced the performance of the examinees. The accuracy of student-standardized-patients' (student-SPs') portrayal would be a critical issue especially when the OSCE is used to grade students. Although we did not objectively investigate the consistencies of the portrayal by student-SPs, our examinees rated highly the fidelity of student-SPs, i.e., the degree to which they were acting as if they were real patients (mean score, 3.9 on a 5-point Likert scale) [12
]. Fifth, our study might have only shown that the intervention was effective in improving students' skills for eliciting 'expert' observations of patient perspectives, not actual patient perspectives. We did not ask student-SPs whether examinees elicited their perspectives. Rather, we judged examinees' ability to elicit patient perspectives through their 'observable' behaviours from the experts' point of view. The role of student-SPs in evaluating fellow students' communication skills, particularly skills for eliciting patient perspectives should be addressed in future studies. Finally, the statistically significant difference observed for only 1 skill among a total of 16 skills could be due to chance alone. It is certainly possible that our intervention was too weak to influence any of the 16 communication skills.
One can hypothesize the reasons why the intervention appeared to make a difference to some communication skills competencies but not to others. One could speculate that the competencies that were not influenced by the intervention were either very easy in general or too difficult to acquire in such a short teaching session. For example, the skills for establishing initial rapport (greet patient and obtain the patient's name, introduce self and clarify roles) and skills for determining the patient's chief concern (ask closed-ended questions that are non-leading and one at a time, define the concern completely) may be already present from the outset or so easy to acquire that a self-study just before the OSCE would make no differences in scores between the groups regardless of the intervention. On the other hand, the skills for surveying the patient's reason(s) for the visit, which requires being open at the beginning of the interview, may be too difficult for students to demonstrate, with or without the intervention. In particular, only 9% in the intervention group and 6% in the control group demonstrated an acceptable performance for the skills of allowing patients to complete their opening statements. These very low scores may also indicate that during small group sessions, we did not emphasize enough the importance of not interrupting patients at the beginning of the interview. Another explanation is that 'content' skills (i.e., what we communicate) are easier for students to acquire than 'process' skills (i.e., how we communicate). Kurtz at al. noted that the skills for understanding patient's perspectives, which our intervention made a difference, are actually 'content' skills, not 'process' skills [16
]. One could argue that the intervention was just too short to influence other 'process' skills. These interesting hypotheses should require further investigations.