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Educational Methodologies |
Dr. Hannah is Lecturer, Department of Psychological Medicine, Dunedin School of Medicine; Dr. Millichamp is Lecturer, Department of Psychological Medicine, Dunedin School of Medicine; and Dr. Ayers is Senior Lecturer, Department of Oral Sciences, Faculty of Dentistry—all at the University of Otago, Dunedin, New Zealand. Direct correspondence and requests for reprints to Dr. Annette Hannah, Department of Psychological Medicine, Dunedin School of Medicine, University of Otago, P.O. Box 913, Dunedin, New Zealand; 64-3-474-7989 phone; 64-3-474-7934 fax; annette.hannah{at}stonebow.otago.ac.nz.
Key words: communication, dentist-patient relations, dental education, program evaluation, psychosocial factors, behavioral sciences
Submitted for publication 04/29/04; accepted 07/06/04
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Abstract |
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The importance of behavioral sciences, and in particular communication skills, was formally recognized in the United Kingdom with the 1990 publication of the General Dental Council’s guidelines for the inclusion of behavioral sciences teaching in dental schools.10 In the United States, the American Association of Dental Schools’ 1993 guidelines11 identified core areas of behavioral science and communication skills in the dental curriculum.
Amongst dental practitioners themselves and specialist groups working in the field, there has also been a general acceptance of behavioral sciences and communication skills as important components of dental education.12–15 Dental students and teaching staff have evaluated communication skills training as highly relevant as well.12,16–20 Only a small minority of surveys have indicated that attitudes towards communication skills training and behavioral sciences have been less positive or have worsened over time.10,15
Despite widespread recognition of the importance of communication skills training in the dental curriculum, the reality of what is practiced is somewhat different. Two recent reviews, one of North American dental schools and one of UK dental schools, have identified a number of problems with communication skills training to date. Yoshida et al.21 conducted a survey of forty U.S. and Canadian dental schools and found that only one-third of them had courses focusing specifically on interpersonal communication. The authors noted that where programs did exist, they often took the form of lectures or passive learning rather than active skills-based practice using simulated or real patients. Training tended to occur on a one-course only basis, with little opportunity for students to learn in a gradual, systematic fashion with increasingly complex material. Assessment of students was generally conducted by grading participation in class exercises, rather than directly evaluating student performance or assessing knowledge via written or oral tests. The authors concluded that there is a current lack of emphasis on teaching communication skills in North America.
McGoldrick and Pine22 conducted a review of behavioral sciences teaching, including communication skills, in all fourteen dental schools in the United Kingdom. They found that thirteen schools offered formal behavioral sciences programs in the undergraduate curriculum, with all fourteen schools covering the topic of communication skills to some extent. However, considerable variation was found with regard to the course content, the teaching methods employed, and the credentials of teaching staff involved. In particular, many programs emphasized theoretical aspects of communication rather than providing opportunities for skills-based practice. Teaching methods generally entailed the use of a didactic teaching style and a large group format, and teaching staff were usually selected from one discipline only (e.g., dentists) with little interdisciplinary teaching by dentists, psychologists, and sociologists. McGoldrick and Pine expressed concern over the lack of time and resources allocated to communication skills training and the failure of many programs to adopt a skills training approach.
The need for systematic teaching of communication skills in dentistry is widely recognized, but there has been limited research that delineates teaching approaches and compares the effectiveness of different strategies. Many articles were published in the 1970s that addressed teaching communication skills, but most of them were discussion papers and few presented research. There have also been few attempts to describe the nature of such teaching programs in the literature.
When reviewing the literature, we found two studies that compared strategies for teaching communication skills to dental students. Ter Horst et al.23 compared two randomly assigned groups of dental students: those who received a three-day communication skills training program, and those who received no training (control group). Students were assessed in terms of their written responses to videotaped dentist-patient interactions. The students who received communication skills training were significantly more likely to explore and recapitulate patients’ statements than the control students. However, the authors concluded that methodological problems raised questions about the validity of their findings.
Davis et al.24 compared the effects of two methods of instruction for teaching communication skills to senior dental students. They found no significant differences between conventional instruction, in which instructors provided students with formal feedback about their interactions with patients, and videotape feedback instruction, which entailed an instructor-guided review of videotaped student-patient interviews. In the study conducted by Davis et al., students in both instructional groups interviewed actual dental patients, rather than simulated patients.
One further study, Koerber et al.25 explored the effect of brief motivational interviewing (BMI) training in relation to smoking cessation counseling. They found both clinical and statistically significant improvements in interviews conducted by those dental students who had completed three sessions (twelve hours) of BMI training compared to the control group. On the other hand, there was no effective difference in rapport between the student and the simulated patient across the two groups.
The field of medicine has generated a number of research studies to evaluate the effects of different teaching methods and materials in communication skills training.26–30 Some important principles for effective teaching have been identified by such research. Teaching recommendations include the use of: 1) a skills-based approach (as opposed to a didactic approach), 2) clinically relevant scenarios, 3) self-assessment by students, 4) videotaping methods, 5) simulated patients with expertise in a variety of clinical roles and in the monitoring of student performance and the delivery of feedback, 6) an integrated teaching team comprising health sciences staff and human sciences disciplines, and 7) small groups for optimal student learning.
The purpose of this article is to describe a communication skills program that was offered for the first time in 2003 to third-year dental students at the Otago School of Dentistry, Dunedin, New Zealand. The program was based on a format designed and used for communication skills teaching of medical students at the Dunedin School of Medicine, Otago University, New Zealand, and based on the research findings for effective communication skills teaching. New roleplay scenarios were developed to portray challenging aspects of dental practice. Components of the program included videotaped interviews, simulated patients, an interview of a member of the public, self-evaluation, interdisciplinary teaching teams, and group and individual student feedback.
Program evaluation was conducted after the course was completed. Retrospective student reports of their views about the importance of communication skills training prior to and after completion of the program were sought. Ideally, we would have sought students’ opinions on communication skills prior to commencing the program. However, as this data was not available, we asked students to provide this information retrospectively.
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Methods |
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Attendance and participation in the communication skills course were mandatory for all students. The class comprised thirty-five females and thirty-two males with a mean age of 22.6 years and 22.3 years, respectively. A student communication skills handbook documented the course objectives, course outline, student groups, evidence-based rationale, and specific communication skills to be learned. This handbook was designed to facilitate self-directed learning and complement in-class instruction. A student logbook was developed to further encourage self-directed homework exercises and personal analysis of each student’s individual communication style. The first assignment consisted of a reflective exercise to analyze the student’s videotaped interview with a simulated patient. The second assignment required each student to interview a member of the public to obtain information about what people liked and/or disliked about their dentist’s communication and clinical practice.
The first two-hour class was an introductory workshop in which the tutor outlined the course and discussed specific communication skills techniques. Demonstration videotaped interviews were shown and discussed, and specific communication skills were practiced in roleplays.
In the following two workshops, each student recorded a six-minute videotaped interview with a simulated patient in front of their peers. Four different patients and scenarios were used to ensure that students did not have prior knowledge of the scenario or the patient they were interviewing. This way, students had the advantage of observing their peers’ interviewing styles and could contribute in providing group feedback to each student after their interview. Prior to their interview, each student was given a completed medical history form and some basic clinical information about the simulated patient. The tutor facilitated group feedback after each interview. A patient response form was completed by the patient (actor) after each student interview, while the tutor (psychologist) completed a student marking schedule, providing individual written feedback for each student about his or her performance. These forms were given to the students at the beginning of the final workshop after they had analyzed their own videotaped interview. A dental clinician (pediatric dentist) attended the groups on alternate weeks to provide support and clinical information related to the scenarios.
The fourth workshop concentrated on group discussion of specific skills relating to the handling of personal and patient emotion, feedback from student interviews with the public, and class participation in a revolving interview with two simulated patients (actors) using different scenarios. One student would begin the interview, and consecutive students would either continue the interview or repeat parts of it to practice different ways of gathering and giving information and engaging in personal interaction with patients. The simulated patients spent half the time with each group.
A standard University of Otago course evaluation, with additional questions about the students’ views before and after the course, offered all students an opportunity to provide anonymous feedback about the communication skills program. Evaluation forms were distributed at the end of the final workshop, completed by the students, collected by a class representative, and sent to the Higher Education Department (HEDC) for collation and initial analysis. Tutor consent was obtained before construction of the questionnaire. Student consent was implicit in their completion of the course evaluation form. A 5-point Likert-type scale was utilized (1 = not important at all to 5 = very important). The twelve closed-ended questions are presented in Table 1
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Results |
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Table 1
shows that most students were positive about the course: across all twelve questions the percentage of students giving the course a rating of 4 or 5 on the Likert scale ranged from 59 percent to 83 percent.
Interpolated median ratings31 were calculated, but as they followed a similar pattern, the means and standard deviations are presented. As can be seen from Table 1, the means were mostly around or just below M = 4.00 on the Likert scale, with the highest scores for obtaining a balance between tutor and student participation, effectiveness of the tutor, and tutor evaluations (or feedback) of students’ performance. The lowest rating was for how stimulating the students found the course (M = 3.55).
Eighty-three percent of students rated communication skills as more important after the program (Q12), while only 63 percent reported holding this opinion before the course began. A planned comparison between Question 1 and Question 12, using a Paired T-Test, demonstrated that a larger proportion of students considered communication skills to be significantly more important after the course (M = 4.2, SD = 0.9) than before the course (M = 3.7, SD 1.2), t (58) = –2.967, p < .004. However, these are retrospective reports and subject to a potential student response bias due to experiences on the course, which may color their impression of the way they might have felt. To investigate which aspects of the course may have impressed those students who increased their ratings of the importance of communication skills, participants were divided into two groups based on whether their importance ratings increased (n = 22) or did not increase (n = 36).
A 2 (group) x 12 (questions) repeated measures ANOVA was performed on the student ratings, and significant main effects of group were found for several variables. Students in the "increase" group were more convinced that the course helped them develop new communication skills and techniques (Q2); increased their interest in communication skills (Q3); reported greater increases in self-confidence (Q4); and thought that the tutor was more effective (Q5), the course reading materials were better (Q10), and the course was more stimulating (Q11) compared to the "no increase" group. There was also a trend for the "increase" group to rate the tutor evaluations as more constructive. The means, standard deviations, and significance levels of these analyses are presented in Table 2.
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Discussion |
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The results of this study showed that the majority of students rated the communication skills course highly in all areas. These results are consistent with those of previous dental studies that documented favorable evaluations of communication skills programs.12,16–19 One reason for the positive evaluations made by students in the present study may be that they found the clinical scenarios and the opportunity to practice skills with simulated patients a realistic and challenging learning task. Some students commented that they had encountered similar situations in clinical settings and they appreciated the opportunity to practice different approaches in the safety of the roleplay situation. There is research from the medical communication skills training literature to support the use of clinically relevant scenarios and simulated patients.30 In contrast, didactic teaching practices involving more abstract concepts and large group sizes may provide fewer opportunities for active student participation and skills-based practice.
The use of simulated patients (actors) who are skilled at presenting complex clinical conditions, monitoring the student’s performance, and delivering specific feedback is an essential component of this program. Simulated patients are selected to represent a wide variety of psychological, ethical, and cultural viewpoints that are common to dental practice and that students will need to handle effectively in their professional work. Students who have difficulties with the English language are able to improve their language skills and to develop expertise in areas such as the avoidance of dental jargon and familiarization with colloquialisms, which are common sources of misunderstanding.32
Realistic, clinically based scenarios are another important component of any effective communication skills program. The roleplay scenarios used in our program were specifically designed to contain psychosocial and lifestyle factors that were particularly relevant to oral disease processes. This further contributed to students’ understanding of disease processes in dentistry and the necessary precautions and treatment options that need to be addressed with each patient. Clinically relevant scenarios enable students to develop skills such as problem solving, increased knowledge of referral processes, and an awareness of ethical/legal issues.
Learning communication skills can be very challenging, as communication skills are often viewed as an intrinsic part of the person’s personality, cognitive functioning, and social experience. Students are often asked to make changes to aspects of their appearance and behavior that are of a highly personal nature. In addition, a shift from dentist-centered to patient-centered communication is necessary and requires a change in the way in which the student gathers patient information. For example, before training, students tend to focus on the disease process to the virtual exclusion of psychosocial issues.
Giving student feedback can affect intrinsic motivation to learn and elicit both emotion and arousal, which can negatively affect learning and performance.33,34 Sims-Knight and Upchurch33 suggest that classroom climate and self-reflective analysis improve students’ learning and performance more so than tutor feedback. This course was designed with a large requirement of self-reflective analysis as well as some group feedback and tutor evaluation. Feedback regarding a student’s interpersonal skills needs to be skillfully given. It should occur as soon as possible after the clinical encounter and should be constructive as well as sensitive. Students may become defensive if feedback is excessively critical or negative or if feedback is delivered in an insensitive manner when pertaining to their personal mannerisms or characteristics. The use of skilled instructors, preferably from both the social sciences/psychology field and the dental profession, has many benefits for student learning. Student evaluations of the tutors in the current program were very favorable overall. Students commented positively about the team teaching approach involving psychologists and a dental clinician. This combination allowed instructors to contribute different areas of expertise when providing feedback, answering students’ questions, and during group discussion.
Students were required to carry out self-assessments during the course. Each student analyzed his or her own videotaped interview and presented the analysis to the group for discussion. Increasing students’ awareness of their communication strengths and weaknesses is designed to promote a lifelong learning process that continues long after formalized instruction has ceased.
An interesting finding of our study was that a large percentage of students said they considered communication skills to be more important after having completed the course. This finding is not surprising to us, since in years of teaching communication skills, we have encountered initial resistance to these courses on the part of some students. Initial skepticism could be due to a lack of knowledge about the specific components of communication skills and the use of the term "communication skills," which may suggest to students that they will be learning skills that they already possess.
A related view is that skilled communication is just common sense or is acquired instinctively. This perception may stem from a lack of awareness of the unique nature of communication skills in clinical settings. In professional clinical consultations, for example, the expectation of reciprocity and equal sharing of conversation are not the same as that which occurs in ordinary conversation. Similarly, closed and leading questions are a characteristic of everyday conversation but can be counterproductive in a dental consultation. Froelich and Bishop35 have noted that "the ability to communicate skillfully and with purpose rarely occurs as a gift—it is learned."
Behavior change that is lasting requires numerous opportunities for practice and ongoing reinforcement. For this reason, it is important to introduce skills-based communication training in the students’ first clinical year and to continue training over an extended time period where possible. This is not only essential for the students’ ongoing practice of skilled communication, but is also likely to enhance patient satisfaction and public image of the dental school.
Although the majority of students favorably evaluated the current communication skills program, we would like to modify a number of features in future programs. One aspect, the large group size, may have led to lower ratings of tutor sensitivity to students’ needs, concerns, and progress than anticipated. However, it should be noted that student ratings of tutor characteristics were still very positive overall. Smaller groups would increase student participation and enable more individual teaching. Ideally, groups would contain a maximum of ten to eleven students.
Another area that could be improved relates to the manner in which students conducted their videotaped interview session. In the current program each student was asked to perform his or her interview in front of classmates. A better alternative would be for each student to conduct his or her videotaped interview with the patient in the absence of their classmates. Some students reported that it was difficult to concentrate on the patient with an audience present. Changing this would likely reduce the level of anxiety that students experienced during this interview process, which may subsequently improve student interview performance.
Further course development in collaboration with other schools would be useful. This saves "reinventing the wheel" each time a course is developed. It is also important to elicit wider support of communication skills training within the dental faculty, as well as to ensure that teaching in communication skills is consistent and being reinforced by other faculty members in all teaching situations, particularly in the clinical setting. Other proposed developments to the teaching of communication skills at Otago include the development of videotaped material for teaching purposes and initial class discussion.
While overall there has been an emphasis on the need for teaching in the area of communication skills in dentistry, there is also a need for educational research evaluating the effectiveness of communication skills-based teaching programs. Evaluative research will help ensure the continued development and delivery of effective patient-centered dental education.
Health professionals, and dentists in particular, are required to interact with patients on a very intimate level within minutes of meeting. It is essential, therefore, that dental students are provided with skills-based communication training based on the most recent research literature. In this way, dental students will be better equipped for clinical practice to deal with patient anxiety, to identify ethical issues, and to recognize significant psychosocial factors that lead to more accurate diagnosis and treatment processes, thereby increasing patient satisfaction and safety.
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This article has been cited by other articles:
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  S. K. Lanning, S. L. Ranson, and R. M. Willett Communication Skills Instruction Utilizing Interdisciplinary Peer Teachers: Program Development and Student Perceptions J Dent Educ., February 1, 2008; 72(2): 172 - 182. [Abstract] [Full Text] [PDF]
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G. F. Cannick, A. M. Horowitz, D. R. Garr, S. G. Reed, B. W. Neville, T. A. Day, R. F. Woolson, and D. T. Lackland Use of the OSCE to Evaluate Brief Communication Skills Training for Dental Students J Dent Educ., September 1, 2007; 71(9): 1203 - 1209. [Abstract] [Full Text] [PDF]
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T. L. Hottel and P. C. Hardigan Improvement in the Interpersonal Communication Skills of Dental Students J Dent Educ., February 1, 2005; 69(2): 281 - 284. [Abstract] [Full Text] [PDF]
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