Improving Medical Students' Written Communication Skills
Improving Medical Students' Written Communication Skills
Background and objectives Written and verbal communication skills are important skills for all physicians. While verbal skills are taught and assessed in medical school, medical students report limited instruction in written communication skills. This study examined the impact of a curriculum delivered during a 6-week clinical rotation in Internal Medicine on the objective assessment of medical students' written communication skills.
Methods The curriculum consisted of two educational programmes: a medical student communication tutorial and a resident feedback workshop. The study was conducted from March 2012 to January 2013 at McMaster University in Hamilton, Ontario, Canada. The study featured three arms: (1) control, (2) medical student communication tutorial alone and (3) student tutorial and resident feedback workshop. Data were collected on 126 students during 6-week Internal Medicine clerkship rotations. Students' written consultation notes were collected prior to the educational programmes and at 6 weeks. Blinded faculty assessors used an independently validated Assessment Checklist to evaluate consultation notes.
Results Consultation note scores improved from week 1 to week 6 across all study arms. However, the change was statistically significant only in arm 3, featuring both the medical student tutorial and the resident feedback workshop, with mean scores improving from 4.75 (SD=1.496) to 5.56 (SD=0.984) out of 7. The mean difference between week 1 and week 6 was significantly different (0.806, p=0.002, 95% CI 0.306 to 1.058).
Conclusions The combination of a resident feedback workshop with medical student written communication tutorial improves objective evaluations of consultation note scores over student tutorial alone.
Deficiencies in written and verbal communication within a healthcare team have been directly linked to increased incidence of patient-related errors. Despite the critical nature of these competencies in practice, the teaching of communication skills to medical students is often informal, either through an apprenticeship model without formal feedback or through the hidden curriculum. The literature addressing communication skills in medical education often focuses on verbal communication between the physician and the patient. Few studies address the important facets of communication that involve the synthesis of historical information into written admission notes, leading to a paucity of information on best practices. Written documentation of an initial patient encounter, referred to as a consultation notes, represents a complex, multifaceted task in which a student must collect, organise and synthesise a wealth of information from a patient interaction. The written case presentation is a fundamental skill across all disciplines in medicine and a necessary competency for students to achieve in medical training.
It has been previously reported that medical students largely learn communication skills through trial and error, and that they rely heavily on feedback from residents and staff physicians to refine their abilities. A key setting for developing these skills is during on-call shifts, where students communicate directly with residents and staff about specific patient encounters. The feedback and instruction that students receive on their written documentation during and immediately following a call shift are highly dependent on several factors, including the available time for supervising residents or staff to give directed instruction, the resident or staff comfort with delivering constructive feedback, as well as staff and resident preferences as to what written documentation should include. Such variables result in a heterogeneous mixture of medical student competency and comfort with oral and written communication at the end of rotations.
Many medical schools in Canada attempt to facilitate feedback on communication skills using encounter cards. Encounter cards are portable evaluation tools for a specific skill (eg, history taking, physical examination (PE), etc) and are used following the assessor observing the student in a clinical encounter. Encounter cards have permitted some assessment of communication abilities but their use has not been shown to result in improvement of medical student's oral presentation or written communication skills. The Reporter, Interpreter, Manager, and Educator (RIME) model for delivering feedback, designed by Pangaro and colleagues, is the most well-studied assessment system for junior trainees, including both medical students and early residents. Though intended for oral case presentation feedback, the model can be adapted to provide feedback on written communication skills, as the structure is similar. The RIME model allows the feedback provider to stratify learners into categories on the learning continuum, providing a framework for the student to gauge their progress and set clear goals for improvement. Studies have demonstrated that ratings assigned by senior residents and faculty using RIME were predictive of students' final examination performance in clerkship placements, both in Internal Medicine and in Emergency Medicine. Interestingly, the residents' scores of students were most predictive of a student's final examination performance in Internal Medicine, highlighting the fact that senior residents may be best able to deliver accurate feedback relevant to the learner, perhaps due to proximity of training and increased face time. The RIME model is easily translated in the clinical context and facilitates delivery of real-time, learner-centred feedback on clinical performance. Developing a process of structured feedback on written communication skills could result in both global consistency and individual improvements in written communication.
The importance of instruction in written communication in medical education has been well described in the literature, yet interventions designed to produce concrete improvements in written communication skills have not been well studied. There exists no national or international consensus on the specific constructs defining an adequate or exemplary consultation note, limiting the ability to provide meaningful feedback or objective assessment of these skills. To assess communication skill training in our own institution and to inform our study, we administered an electronic needs assessment survey to 90 students who had completed their clerkship rotation in Internal Medicine at McMaster University. The survey focused on the students' experiences with teaching and feedback on communication skills during their Internal Medicine rotation. Of the students contacted, 58/90 (64%) completed the survey. Of the students, 53/58 (91%) indicated that they would have liked more instruction on how to document an Internal Medicine consult note.
Our study objective was to improve the quality of medical student written communication skills, using the consultation note, by way of increasing instruction and feedback that medical students receive on these skills. We hypothesised that delivering educational programmes would objectively improve the quality of student written communication skills.
Abstract and Introduction
Abstract
Background and objectives Written and verbal communication skills are important skills for all physicians. While verbal skills are taught and assessed in medical school, medical students report limited instruction in written communication skills. This study examined the impact of a curriculum delivered during a 6-week clinical rotation in Internal Medicine on the objective assessment of medical students' written communication skills.
Methods The curriculum consisted of two educational programmes: a medical student communication tutorial and a resident feedback workshop. The study was conducted from March 2012 to January 2013 at McMaster University in Hamilton, Ontario, Canada. The study featured three arms: (1) control, (2) medical student communication tutorial alone and (3) student tutorial and resident feedback workshop. Data were collected on 126 students during 6-week Internal Medicine clerkship rotations. Students' written consultation notes were collected prior to the educational programmes and at 6 weeks. Blinded faculty assessors used an independently validated Assessment Checklist to evaluate consultation notes.
Results Consultation note scores improved from week 1 to week 6 across all study arms. However, the change was statistically significant only in arm 3, featuring both the medical student tutorial and the resident feedback workshop, with mean scores improving from 4.75 (SD=1.496) to 5.56 (SD=0.984) out of 7. The mean difference between week 1 and week 6 was significantly different (0.806, p=0.002, 95% CI 0.306 to 1.058).
Conclusions The combination of a resident feedback workshop with medical student written communication tutorial improves objective evaluations of consultation note scores over student tutorial alone.
Introduction
Deficiencies in written and verbal communication within a healthcare team have been directly linked to increased incidence of patient-related errors. Despite the critical nature of these competencies in practice, the teaching of communication skills to medical students is often informal, either through an apprenticeship model without formal feedback or through the hidden curriculum. The literature addressing communication skills in medical education often focuses on verbal communication between the physician and the patient. Few studies address the important facets of communication that involve the synthesis of historical information into written admission notes, leading to a paucity of information on best practices. Written documentation of an initial patient encounter, referred to as a consultation notes, represents a complex, multifaceted task in which a student must collect, organise and synthesise a wealth of information from a patient interaction. The written case presentation is a fundamental skill across all disciplines in medicine and a necessary competency for students to achieve in medical training.
It has been previously reported that medical students largely learn communication skills through trial and error, and that they rely heavily on feedback from residents and staff physicians to refine their abilities. A key setting for developing these skills is during on-call shifts, where students communicate directly with residents and staff about specific patient encounters. The feedback and instruction that students receive on their written documentation during and immediately following a call shift are highly dependent on several factors, including the available time for supervising residents or staff to give directed instruction, the resident or staff comfort with delivering constructive feedback, as well as staff and resident preferences as to what written documentation should include. Such variables result in a heterogeneous mixture of medical student competency and comfort with oral and written communication at the end of rotations.
Many medical schools in Canada attempt to facilitate feedback on communication skills using encounter cards. Encounter cards are portable evaluation tools for a specific skill (eg, history taking, physical examination (PE), etc) and are used following the assessor observing the student in a clinical encounter. Encounter cards have permitted some assessment of communication abilities but their use has not been shown to result in improvement of medical student's oral presentation or written communication skills. The Reporter, Interpreter, Manager, and Educator (RIME) model for delivering feedback, designed by Pangaro and colleagues, is the most well-studied assessment system for junior trainees, including both medical students and early residents. Though intended for oral case presentation feedback, the model can be adapted to provide feedback on written communication skills, as the structure is similar. The RIME model allows the feedback provider to stratify learners into categories on the learning continuum, providing a framework for the student to gauge their progress and set clear goals for improvement. Studies have demonstrated that ratings assigned by senior residents and faculty using RIME were predictive of students' final examination performance in clerkship placements, both in Internal Medicine and in Emergency Medicine. Interestingly, the residents' scores of students were most predictive of a student's final examination performance in Internal Medicine, highlighting the fact that senior residents may be best able to deliver accurate feedback relevant to the learner, perhaps due to proximity of training and increased face time. The RIME model is easily translated in the clinical context and facilitates delivery of real-time, learner-centred feedback on clinical performance. Developing a process of structured feedback on written communication skills could result in both global consistency and individual improvements in written communication.
The importance of instruction in written communication in medical education has been well described in the literature, yet interventions designed to produce concrete improvements in written communication skills have not been well studied. There exists no national or international consensus on the specific constructs defining an adequate or exemplary consultation note, limiting the ability to provide meaningful feedback or objective assessment of these skills. To assess communication skill training in our own institution and to inform our study, we administered an electronic needs assessment survey to 90 students who had completed their clerkship rotation in Internal Medicine at McMaster University. The survey focused on the students' experiences with teaching and feedback on communication skills during their Internal Medicine rotation. Of the students contacted, 58/90 (64%) completed the survey. Of the students, 53/58 (91%) indicated that they would have liked more instruction on how to document an Internal Medicine consult note.
Our study objective was to improve the quality of medical student written communication skills, using the consultation note, by way of increasing instruction and feedback that medical students receive on these skills. We hypothesised that delivering educational programmes would objectively improve the quality of student written communication skills.
