Introduction
Over the last 30 years, communication skills have received considerable attention in the medical school curriculum.1, 2 Studies have shown that effective communication skills improve the doctor-patient relationship and are associated with favourable health outcomes in the form of improved compliance, satisfaction with care, and benefits to physical and psychological health.3, 4 Currently, NMC has introduced a module for Attitude and Communication (AETCOM) skills training in a phased manner; still, it is essential to design and provide communication skill training for medical students that integrates knowledge and competencies through the early implementation of clinical experiences during their first founding years.5, 6 This will inculcate in them the habit of communicating effectively with their patients as future physicians.
It is always observed that doctors who speak effectively in understandable language, listen actively, encourage their patients for clarifications and value the confidentiality and comfort of their patients are always appreciated. In addition, the non-verbal aspects of communication such as body language, eye contact, facial expression, personal touch, gestures, and distance are of extreme importance in building rapport between the doctor and the patient. 5 Therefore, for communication to be effective doctors have to priorities their ways of communication according to the situation and person. This can only be achieved by prior training.7
Early Clinical Exposure (ECE) makes the students more satisfied with their curriculum and reduces the stress of meeting with patients. This also has potential benefits for teachers, healthcare organizations, patients, and populations.8 The objective of the study was to teach and assess communication skills as an element of ECE in first year medical students. The study was undertaken as a part of Advanced Course of Medical Education (ACME) project in 2019.
Materials and Methods
Study participants
All the students of MBBS first professional batch 2018-19 who were present and willing to participate were enrolled in the study. Total 122 students participated.
Study site
Field practice area of Rural Health Training Centre of the tertiary care hospital under Sri Guru Ram Das Institute of Medical Sciences and Research, Amritsar, Punjab.
Data collection
After obtaining the prior approval of the institutional ethical committee, the fellow faculty who were willing to participate were sensitized about the communication skills assessment. The students were sensitized about the verbal and non-verbal aspects of communication skills in theory lectures with the help of power point presentation, videos and role plays. They were given the option to refer any notes, books or internet to improve their knowledge. The study was conducted in four batches on four different days. Students were taken to the field practice area of RHTC, where they used their communication skills to create awareness about personal hygiene among the community. The students’ communication skills were observed by the trained faculty.
A validated feedback proforma including both open and closed ended questions was administered to the students. The proforma included questions regarding knowledge about the communication skills and their perceptions after visiting and communicating with the community people. Knowledge was graded as poor, average and good according to the likert scale.
The trained faculty members assessed the students by using Kalamazoo Essential Elements Communication Checklist which identifies seven essential sets of communication tasks: (1) build the doctor–patient relationship; (2) open the discussion; (3) gather information; (4) understand the patient's perspective; (5) share information; (6) reach agreement on problems and plans; and (7) provide closure.9
How well the learner performs the above tasks varies from: Poor/Fair/Good/V. Good/Excellent. The Score varies from 7-35 and the communication skills were graded as Poor (7-13), Average (14-20), Good (21-27) and Excellent (28-35).
A Focus Group discussion (FGD) of the faculty regarding their opinion was conducted to take faculty’s feedback and valid conclusions drawn using a five-point likert scale.
Results
One hundred and twenty-two undergraduate first year medical students willingly participated in this study. The mean age of the participants was 20 ± 1.1 years. Among these students, 51% were females while 49% were male participants. When the students were assessed on their knowledge scores, it was observed that 52 (42.6%) had poor knowledge, 45 (36.9%) had average and 25 (20.5%) had good knowledge about communication skills after sensitization.
Figure 1
Distribution of students according to their communication skills (based on Kalamazoo essential elements communication check list)
Table 1
Items identified through content analysis of focus group discussion with students
Table 2
Items identified through content analysis of focus group discussion with faculty
Table 3
Perceptions of faculty regarding introduction of communication skills as an element of ECE
Figure 1 depicts that 81.1% of the students acquired good to average communication skills based on Kalamazoo essential elements communication checklist within the community. 14.8% had poor skills and only 4.1% had excellent communication skills.
Table 1 shows the items identified after the discussion with the students regarding their experience in the community, the difficulties they faced, how the exercise will help them in future and what did they learn. The subsequent figures show that 93.4% replied that the experience was good, 54.1% faced no difficulty, 24.6% said that they gained confidence and 55.7% replied that they learnt to communicate effectively.
Table 2 reveals the results of the focus group discussion with the faculty. Most of the faculty thought that learning communication skills is necessary for improving the doctor-patient relationship.
Perusal of Table 3 showed that all the faculty members agreed that learning communication skills are essential for the students and 60% agreed that students learnt about the social problems in the community, gained confidence and learnt to empathise. 60% agreed that resource constraints may occur.
Discussion
The acquisition of communication skills is recognized and documented as a core competency for physician training in many countries.10, 11 In India, though it is included as a requirement in the 1997 Graduate Medical Education (GME) regulations of the Medical Council of India (MCI), not enough concerted efforts have been made to teach or assess them in most medical schools.12
The Vision 2015 document of the MCI reaffirms the need to schedule dedicated time for training in communication skills for Indian medical graduates. They are expected to communicate appropriately with patients, families, colleagues and community, and behave as leaders and members of the health care team and system.13
It is evident from the present study that 57.4% of the total students acquired average to good knowledge about communication skills and 85.2% acquired average to excellent communication skills when assessed by Kalamazoo essential elements communication checklist after sensitization. Most of the students appreciated the ECE experience as they found it to be very interesting and motivating. Some of the students contacted after completion of the task and showed their interest in communicating again with the community. Some admitted that they had a doctor feeling for the first time. They said that they learnt to communicate effectively and empathetically. They could see the social factors affecting health in the community settings. Almost similar results were found by Govindrajan S. et al14 in their study in Coimbatore. Another study by Sathish Kumar S et al15 also observed that students’ interest in the subject increased after ECE and it also increased their sensitivity toward patient problems and their needs. Dr Surekha et al16 in their study demonstrated that students enjoyed the experience of early clinical exposure and it motivated the learning process. Riskin A et al17 reported that early experience in the community helped students acquire basic communication skills and enabled students to improve their affective skills, such as empathy, increased their self-awareness, helped them feel more confident with their choice to practise medicine and decreased their anxiety associated with meeting patients. Dornan T et al18 and Sheshgiri C et al19 also stated that early experience helps medical students socialize to their chosen profession. It helps them acquire a range of subject matter and makes their learning more real and relevant. It can influence career choices and helps in maintaining and boosting up one’s enthusiasm to become a doctor respectively.
When feedback was collected from the faculty, almost 100% agreed that learning communication skills is essential for the students and it should be a part of ECE from the very first year. Similar findings on students’ and faculty feedback were observed by Petek Šter M20 in Ljubljana. Approximately 40% of the faculty members talked about the challenges in the form of lack of resources, time, faculty and requirement of prior training. Tayade M C et al21 in their study also noted that faculties believed that ECE consumes more manpower, infrastructure, time and requires extra efforts on their part. All faculty agreed that some level of training may be required.
Conclusions
Learning effective communication skills as an element of early clinical exposure will improve their role as future physicians. They learn how to start communication with the patients, give respect to others, role of empathy, how to listen patiently and importance of vernacular language. But this needs pre-sensitization of students as well as faculty and more resources including manpower and time.
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