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The Use of the Objective Structured Clinical Examination (OSCE) with Video-taped Feedback Assessment as a Teaching Tool of Communication Skills
Paula Nunes
Public Health and Primary Care Unit, University of the West Indies, St. Augustine Campus
Abstract
Background:
Communication is an inevitable part of the doctor patient interaction. Poor communication skills can adversely affect the outcome of a consultation. There is therefore increasing emphasis on the teaching and assessment of communication skills in medical schools.
Aim:
To assess the potential of the OSCE with Video-taped Feedback Assessment as a Teaching Tool of Communication Skills.
Method:
Final year students were taught using traditional methods. The students were then videotaped in various clinical scenarios with a simulated patient. OSCE checklists of competence in communication skills were used to assess performance at the stations and these were marked by a lecturer. A tally of student’s performance on the checklist was collated. The videotapes were then reviewed and analysed by the student, their peers and their lecturer. After the feedback exercise students were asked to fill out a questionnaire.
Results:
The majority of students felt that the exercise helped them in their preparation for their final year examination. The videotaping of the scenario was not considered by most students to be a deterrent. Positive comments of continued use of the OSCE scenarios with video assessment feedback as an aid to learning communication skills were noted.
Conclusion:
The implementation of a highly interactive teaching tool met with a favorable response by both students and tutors.
The Use of the Objective Structured Clinical Examination (OSCE) with Video-taped Feedback Assessment as a Teaching Tool of Communication Skills
Communication is an inevitable part of the doctor patient interaction. The outcome of a consultation can be adversely affected by poor communication skills. There is therefore increasing emphasis on the teaching and assessment of communication skills in medical schools. The aim of this paper was to assess the potential of implementing a multi-faceted, interactive teaching approach, including an OSCE with video-taped feedback assessment as a teaching tool of communication skills.
Final year medical students were taught using traditional methods. The students were then videotaped in various clinical scenarios with a simulated patient. OSCE checklists of competence in communication skills were used to assess performance at the stations and these were marked by an examiner. The videotapes were then reviewed and analysed by the student, their peers and their lecturer. After the feedback exercise students were asked to fill out a questionnaire.
The majority of students felt that the exercise helped them in their preparation for their final year examination. The videotaping of the scenario was not considered by most students to be a deterrent. Positive comments of continued use of the OSCE scenarios with video assessment feedback as an aid to learning communication skills were noted.
Conclusion: The implementation of a highly interactive teaching tool met with a favourable response by both students and tutors.
Communication is an essential part of an effective and positive consultation. Good communication skills are essential in building a bond of trust and respect between the doctor and his/her patient. (McGovern & Dean, 1991)
Effective communication skills have been shown to lead to better health outcomes following consultation between physicians and their patients. This includes more accurate identification of patients' problems, and a better understanding by patients of their treatment plans. Patient satisfaction is also positively linked to their perception of the quality of communication skills displayed by their doctor. (McGuire and Pitceathly 2002).Conversely, poor communication is often cited as the grounds for complaints against doctors. Anderson, Allan & Finucane (2001); Meryn S,(1998) Poor communication is one of the main reasons that patients are non-compliant with medication or unable to maintain advised changes in lifestyle and why patients are dissatisfied with their physician. Poor communication may hamper the ability of a patient to deal with bad news and thereby affect there long term psychological adjustment. (Davis 1991)
Unfortunately medical students often view teaching sessions on communication skills as unnecessary and irrelevant to their development as clinicians. This may be reflected in their attitude to these classes. They are often apathetic and disinterested in these sessions, and may disregard communication skills sessions, or simply not attend. Benbasset et al demonstrated that students' attitudes towards communication skills often reflected the low importance placed on the subject by them (Benbasset 1996).
Given the importance of communication skills to the clinical consultation process and students' professional development, we decided that a re-organisation of the communication skills programme was required, to make it more interactive, relevant and challenging for the students. The new approach also involves the introduction of reflection and feedback over the course of the learning experience to provide reinforcement of learning. To achieve higher order learning a combination of different methods of teaching communication skills are used
Students' learning is often driven by the examination process. To this end, a formative objective structured clinical examination (OSCE) was introduced as part of the communication skills exercise. The OSCE is viewed as a reliable tool for the assessment of clinical and communication skills.
Videotaping has been used for some time in the social sciences, and has proved an effective means of providing feedback and support for students during their development. While the presence of the video camera may inhibit some students, the majority appears to adapt to its presence and do not object to this method of monitoring (McGovern and Dean 1991).
This paper recounts the experience of implementing an innovative programme for teaching communication skills to medical students in the final year of their MBBS programme. The aim of the assessments was primarily to determine if the mode of teaching was acceptable to the students, who had been accustomed to traditional didactic methods of teaching, and secondly to determine if this approach is effective in improving communication skills.
This paper describes the implementation of a communication skills training module for undergraduate students, within a structured and non- threatening environment, and using a hierarchy of learning techniques to reinforce behavioural and attitudinal change.
The communication skills module developed for our students consisted of five stages.
Students were introduced to various consultation models initially in a more traditional classroom setting. Consultation models discussed during these seminars included the Calgary - Cambridge Observation Guide; the Pendleton consultation model, the patient centred approach and the SEGUE framework. Classroom sessions were also used to review important interview techniques and discuss strategies that could be used to improve the outcome of certain potentially difficult consultations.
Learner centred, experiential and interactive learning methods such as brainstorming and group discussions were used to develop frameworks for interviewing patients. Subsequent to teaching on consultation models role play scenarios were enacted using cases taken from the lecturer's own experience and the students' encounters in clinics. This ensured that the cases were important and of interest to the students. The students were then expected to develop templates of activities that they thought would be likely to result in the completion of a successful consultation. Underlying motives for different approaches to consultation were also explored. To encompass a range of difficult topics and effect attitudinal change, specific cases were included:
Challenging ethical situations such as consultations involving parents who want information about their adolescent.
Initiating or assisting patients in behaviour change - e.g. smoking cessation
Role play sessions with peers were used to allow learners to put into practice the strategies they had identified as potentially useful in the brainstorming sessions. These sessions utilised learners as physicians, simulated patients and observers. This allowed them to better understand both the doctor's and patient's perspective for any given consultation. During these role play sessions, feedback was offered throughout the exercise. Immediate feedback to individual participants allowed subsequent adjustment of their consultation technique. In a general debriefing following the session, students identified common themes which may have been encountered in individual consultations and shared experiences unique to their specific scenarios.
OSCE sessions using simulated patients and checklists to assess students' performance were used to reinforce the key components of good consultations in different scenarios. Each OSCE session was a 7 minute consultation with a simulated patient, with specific consultation goals, followed by an immediate 1 - 2 minute debrief and feedback session from the simulated patient and/or the examiner to the student. Some of these sessions were video taped. The videotaped consultation was marked independently by a `second marker' to assess inter-rater reliability. The videotaped OSCE sessions were used to provide individual feedback to students as well as create an opportunity for discussion by the entire group. Review of the videotapes by peers allowed more detailed discussion on verbal and non verbal communication. Students also offered suggestions on different strategies which could be employed in specific situations. This process permitted students to develop through the use of their peers as role models. Videos chosen for peer review included those in which students had performed particularly well, and those in which the consultation was thought to be especially challenging. Students gave informed consent for both the videotaping itself and the viewing of their consultation during the peer review process
The acceptability and effectiveness of this new approach to communication skills teaching was assessed by three separate means. Firstly, students were asked to fill out a Reflection exercise at the end of the OSCE session. The questions asked in this exercise were as follows:
Outline what did you think went well with the consultation and why?
Outline what could have been done differently and why.
What do you think you have learnt from this exercise?
What learning needs have you identified?
Secondly, a questionnaire was administered to the students to assess their views on the exercise after the videotape feedback session. Each student was also seen individually to discuss any issues peculiar to them. Table 1 shows the questionnaire administered to students following the videotape feedback session.
Do you think that having an OSCE review session has helped you in your preparation for the final year examination? Please explain.
Did doing a video of your OSCE session interfere with your performance? Please explain your answer.
Did reviewing your video and that of your colleague assist further in helping you to prepare for the examination? Please explain your answer.
Would having a video of your OSCE performance deter you from being involved in a review exercise of this nature again? Please explain your answer.
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Finally, a group discussion was held with the simulated patients following the end of year OSCE examination for these students. The simulated patients have performed their roles for several years, and would have seen students in the final year OSCE before and after the introduction of our new communication skills training module. These simulated patients were asked to discuss and describe any differences noted in the group of students who had benefited from the new module and those of previous years.
In all, one hundred and six (106) medical students benefited from the communication skills programme. Of these five (5) did not attend the OSCE session and only one refused to be videotaped despite participating in the OSCE. All students who attended the OSCE session also attended the videotaped feedback session and filled out their questionnaire. All students filled out their reflection exercise.
The general consensus among students was that the videotaping exercise was acceptable. Five (5) students out of the total responded that the videotape interfered with their performance. However, all five (5) of these students described the video feedback session as a positive experience and only one (1) indicated that they would not like to be videotaped again. All students felt that exercise helped them in their preparation for their final year examination. All students were in favour of continuing the OSCE and the group feedback exercises. Suggestions were made by the students to introduce this teaching tool as early as year 1 and to extend the method to teach clinical skills as well as communications skills.
Comments made by the students in their reflection exercises were analyzed for common themes. The following themes were identified: (also included are excerpts from the student's transcripts)
Improved consultation skills were perceived as an important factor in promoting the patient- doctor relationship and doctor satisfaction.
`I stopped to ask if the patient had any questions and if she understood what I had said”
“The patient -doctor interview was more 2-way”
Personal gains: Communication skills training built confidence, created better organization to the consultation and better prepared them for the final examination and clinical practice.
`I felt comfortable in the consultation and was able to pace myself”
Attitudinal and behavioural changes: the students recognized that attention to patients' concerns and beliefs was a significant part of the consultation process.
“Dealing with patient's anxieties [is] as important as offering treatment “
`Sensitivity to the patient's situation”
The consensus by the simulated patients in discussion held after the final MBBS examination was that the students were generally more at ease in their consultations, developed better rapport, used less “medspeak” and were more patient centered.
Communication skills are now recognized as a core competency of the undergraduate medical education programme in developed countries. The General Medical Council of the United Kingdom in their booklet “Tomorrow's doctors” includes communications skills as a core competency expected of all medical graduates (GMC 1993). Despite this, an appraisal of the teaching methods used in the Faculty of Medical Science, St Augustine Campus revealed that there was insufficient attention paid to the teaching of communication skills in their undergraduate programme. It was also noted that the predominant approach to teaching was by a combination of didactic lecturing and problem based learning. Chickering & Gamson (1987) offer seven principles of good practice for undergraduate education based on research on good teaching and learning in colleges and universities. These principles include more active learning, cooperation between students and faculty and prompt feedback. Following these principles, a more interactive and integrated approach was adopted for the teaching of communication skills to students.
Improving communications skills using a collaborative approach presented quite a challenge. This necessitated a change in teaching style for the lecturers and the students from a predominantly didactic model of lecturing to a learner based style, which required interaction between the students and the lecturers with a sharing of ideas.
Although research shows that the collaborative approach has many beneficial outcomes a change of this nature is often met with resistance on the part of both the student and the tutor because of changes in the status quo (Johnson & Johnson, 1994). (McGuire and Pitceathly, 2002)
In the new programme, active engagement in learning was associated with increased levels of enthusiasm for the subject area among our students. Students showed higher levels of motivation and enjoyed the discussions between peers and lecturers (Hutchinson, 2003)
Jacques, (2005) points out that interactive group learning `can also develop the more instrumental skills of listening, presenting ideas, persuading and working as a team.' Students showed improvement in their ability to express themselves verbally while voicing their opinion and when in role. They also demonstrated better negotiation skills in role play scenarios.
According to educational research, students become actively involved in learning when tasks are relevant. (Chickering &Gamson, 1987). The exercise of learning depends on the motivator. Many medical students use a surface approach to learning. Their learning is examination-oriented with the prime goal being success at the examination. Surface learning is also more likely to occur when learning is isolated from practice. In attempt to achieve higher order and deeper learning students are informed of the approach to learning, the reason for the approach and the aim to achieve both agendas of success at examination and an appreciation of the doctor patient interaction. (Atherton, J.S., 2005)
The Objective Structured Clinical Examination (OSCE) is a performance based assessment tool used in the final MBBS examination at the University of the West Indies. The checklists for the OSCE used in our communication skills training have been designed on the basis of well validated communication skills frameworks including the SEGUE framework for teaching and assessing communication skills, the Calgary - Cambridge Observation Guide.
Role play scenarios with simulated patients were found to be more challenging by the students. The integration of skills require a level of involvement in role that may not be fully appreciated by all learners in the classroom setting, although, many students felt that the exercises helped them to put their theory into practice.
Two of the goals of the programme were to explore attitudes and effect changes that would encourage enhanced communication skills. Role play of a variety of cases such as a patient presenting who is a victim of domestic violence allowed for exploration of personal attitudes. Students worked in groups of three where one was the doctor, patient and observer and roles were subsequently interchanged. Students were encouraged to examine the feelings experienced in their various roles to allow them to see the particular perspectives of the players involved in the consultation ( Luckner,J.,&Nadler,R.,(1999)[Author ID2: at Mon Jul 31 07:53:00 2006
]
Kolb, D. A. (1984) suggests that learning is most effective when based on experience. Boud, Keogh and Walker (1985) in their book Reflection :Turning experience into learning, write that to achieve a greater understanding and appreciation of a learned activity students also need to explore their experiences through the process of reflection. In essence, learners should reflect on what they have learned. Students were asked to reflect both verbally and in writing on what was learnt, the difficulties encountered in their consultations and the learning needs identified. Feedback discussions were invariably seen by the students as an important part of the learning process as they reinforced activities learnt.
The audiovisual feedback was universally described by students as a good experience as the process highlighted their strengths and weaknesses. The session also acted as a springboard for further learning with group feedback providing strong reinforcement for nurturing good communication styles. The reflective logs proved on the other hand to be valuable pointers of the strengths and weakness of the programme
A programme as outlined above has proved to be quite labour intensive particularly because of the inadequate staffing, increasing numbers of medical students, limited access to clinical settings and restrictions of time. The gains however of communication skills training are tremendous and students and staff alike have expressed a desire to have this programme continued and implemented across the clinical fields.
Sharing learning objectives and developing criteria of achievement with students assists them in being more focused on learning. Reflection exercises teach self-evaluative skills. This programme has been a learning process for both lecturers and students as we strive to achieve better outcomes in the provision of higher quality education to students, and enhanced communication to our patients.
Atherton, J.S., (2005) Learning and Teaching: Deep and Surface learning. Retrieved July 30, 2006 from http://www.doceo.co.uk/academic/assignment_presentation.htm#Referencing
Anderson,K.,Allan,D.,Finucane,P.,(2001) A 30-month study of patient complaints at a major Australian hospital. J. Qual. Clin. Practice Vol.21 pp109-111
Benbassat, J., (1996) Teaching the social sciences to undergraduate medical students. Israel J Med Sc Vol. 32 pp 217-221
Boud, D., Keogh, R., & Walker, D. (1985). Promoting reflection in learning: a model. In D. Walker (Ed.), Reflection: Turning experience into learning (pp. 18-40). London: Kogan Page.
Chickering, A.W. & Gamson, Z.F., Seven Principles for Good Practice in Undergraduate Education. Retrieved July 30, 2006 from
Hutchinson.L, ( 2003), ABC of learning and teaching: Educational environment BMJ Vol. 326 pp 810-812
Jaques,D.(2003). ABC of learning and teaching in medicine. Teaching small groups BMJ Vol.326 pp492-4
Kolb,D.A., (1984) , Retrieved on July 30,2006 from Instructional Development Unit Manual Some Teaching and Learning Strategies . UWI
(Luckner,J.,&Nadler,R.,(1999) Retrieved July 30,2006 from http://www.sabrehq.com/cutting-edge/teambuilding-components.htm
Maguire,P.,& Pitceathly,C.,(2002) Key communication skills and how to acquire them. BMJ Vol. 325 pp 697-700
Mc Govern, M.A., & Dean, E.C. (1991). Clinical education: the supervisory process. British Journal of disordered Communication, 26(3), 373-81
Meryn,S.,(1998) Improving doctor-patient communication Editorial BMJ Vol.316
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