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Promoting Interpersonal Skills and Cultural Sensitivity Among Dental Students

Key words: cultural competence, patient instructor, communication, interpersonal skills

Submitted for publication 08/08/05; accepted 12/07/05

	Abstract

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This study evaluated interpersonal communication skills among third- and fourth-year dental students during two clinical communications training programs. Students participated in two clinical communications (CC) training sessions, each comprised of four encounters with patient instructors (PIs) who were trained to enact standardized patient scenarios. Scenarios in CC1 addressed straightforward patient care situations in dentistry (e.g., bridge adjustment), while CC2 added cultural sensitivity issues to the dental scenarios. After each encounter, patient instructors used the Arizona Clinical Interviewing Rating Scale (ACIR) to rate the students’ interpersonal skills and gave the students feedback on their performance. The students also received feedback and coaching from dental school faculty in debriefings after encounters with the PIs. Students anonymously rated the program at the end of each session. To evaluate the program, students’ performance was compared within and between the two training sessions. Analysis showed statistically significant increases in interpersonal communication skills within each training session (p<0.05) from unsatisfactory to above satisfactory levels. Performance scores at the start of CC2 were statistically lower than at the end of CC1, suggesting that performance wanes without practice. Student evaluations of the program were very positive. Interpersonal communication skills improved during this patient instructor program.

Patient instructor programs to improve interpersonal communication skills of dental and medical students for many years have been reported in the literature,^7–10 including a study published in 1996 by the lead author (HB) of this article.⁹ This current project extends that work, which reviewed the implementation of patient instructor (PI) training sessions for dental students. In the initial version of our PI program, a training session known as Clinical Communications 1 (CC1) was scheduled at the beginning of the junior year. During CC1, students encountered PIs who presented straightforward patient care situations in dentistry such as a bridge adjustment. We now have added for our students a second PI experience known as Clinical Communications 2 (CC2), which is scheduled at the beginning of the senior year and incorporates a variety of subjective, sociocultural factors in the scenarios portrayed by the PIs in order to challenge the students’ awareness of cultural issues in patient care. The goals of the study reported here were to 1) assess the effectiveness of the PI training programs for enhancing students’ interpersonal communication skills; 2) measure the stability of the students’ interviewing skills from the beginning of the junior year to the beginning of the senior year; and 3) obtain students’ evaluations of the PI program.

	Methods

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The subjects were 143 students from two consecutive dental school classes at one dental school (New Jersey Dental School). This mandatory communications program included all of the students; therefore, we had 100 percent participation. Forty-eight percent of the students were female. Students were of varying nationalities including Russian, East Indian, Polish, Lebanese, Japanese, Vietnamese, Italian, Afghani, Portuguese, Puerto Rican, Cuban, Haitian, Korean, and others.

The clinical communications program consisted of two required rotations. Clinical Communications 1 (CC1) was completed in the fall of the students’ third year in dental school and Clinical Communications 2 (CC2) in July (approximately nine months later). As a prerequisite for CC1, students completed two didactic modules on communication and interviewing during the spring of their second year; as a prerequisite for CC2, students completed a course titled "Communication in Health Care" in the spring of their third year. The sophomore modules included information on data-gathering and issues associated with positive patient-doctor communication. The Communication in Health Care course consisted of twenty-eight hours. Part one of the course included information on patient fear and anxiety, the emotionality of pain, and relaxation techniques. Part two dealt with working with diverse populations. Communication styles, expectations, and special needs from the perspectives of the provider, patient, and health care system were discussed. Sessions included lectures as well as experiential and interactive exercises using trigger tapes and intercultural sensitizers to incorporate problematic (yet not uncommon) communication issues with diverse populations in the dental/health clinic setting. The overall goals of the didactic and patient instructor exercises were to increase student knowledge and awareness of effective patient-doctor communication including cultural sensitivity and patient-centered care.

Use of patient instructors originated at the University of Arizona Medical School in the 1970s to assist in the teaching of patient-doctor communication and patient assessment skills. This technique is now used at all medical schools as an integral component of the student’s curriculum and assessment for interviewing and physical examination skills.^11–13 The patient instructor (PI) is a lay person who has been trained to simulate a patient’s illness or condition in a standardized fashion. PIs also function as teachers and evaluators by providing feedback and assessing the students regarding the interview content and process. Patient instructors in the program at New Jersey Dental School are mostly actors or retired teachers who receive an hourly wage ($20). New PIs receive nine hours of training during weekly three-hour sessions. During the first training session, the PIs learn to use the Arizona Clinical Interviewing Rating (ACIR) Scale (described in the next section), a standardized instrument designed to assess interpersonal interviewing skills.¹¹ During the second session, the PIs practice six patient scenarios (an example of a scenario appears in the Appendix) and are coached on how to provide positive feedback and constructive criticism to the students. Finally, during the third session, the PIs practice their scenarios by role-playing with one another and with three New Jersey Dental School faculty members. These rehearsals give the PIs practice in both using the ACIR and in providing constructive feedback. Two PIs are trained on each scenario to provide backup in case of absenteeism. Historically, ACIR percent agreement scores for all the PIs in our program have ranged from 88 to 100 percent. Each year the returning PIs are recalibrated using videotapes or role-playing sessions. Inter-rater reliability is consistent with the above agreement scores.

The Arizona Clinical Interviewing Rating Scale^11–13 is a widely used rating scale to evaluate interpersonal interviewing skills in a health setting. The thirteen items assessed are process skills that are listed in Table 1. The ACIR has a 5-point behaviorally anchored scale: 1=poor, 3=average, and 5=excellent. Criteria for the scores are provided in the ACIR manual. Internal consistency ranges on the scale from .60 to .72 with reported interjudge and intrajudge reliability ratings of .85.¹⁰

In both Clinical Communications 1 and 2, each student completed four interviews with patient instructors (PIs). Each of the PIs enacted one of six standard scenarios that they had learned to portray. Typically, four students participated in each rotation that consists of four patient encounters. Each patient encounter was termed a round. Hence, the four encounters constituted a round-robin session, in which the students independently interviewed a different PI in each round. Students reviewed the charts before seeing each PI. The patient encounters included querying patients about their chief complaint as well as their medical, dental, and psychosocial history. Following each fifteen-minute interview, the PIs independently rated the students using the ACIR and then provided them with ten to fifteen minutes of feedback from the patient’s perspective. After all of the interviews were completed, the course director debriefed the PIs regarding student performance, and then held a seminar with the group of students to discuss the process, reinforce theoretical and practical issues regarding the patient scenarios, and highlight specific cultural sensitivity questions pertinent to effective communication and treatment planning. Finally, the students completed an anonymous course evaluation consisting of five items designed to assess the impact of their training in areas of value to the student (see Table 2). Additional written comments were also sought. A single PI session, including the debriefing, was completed within a three-hour period.

	Results

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In our analysis, we first evaluated whether any differences existed between classes. As none were demonstrated, our further analysis collapsed the two classes and evaluated the changes within and between each training period.

Figure 1 shows the mean scores (+/– SEM) for each round during the first and second training sessions. The analysis showed an overall statistically significant effect for time of training on students’ performance (F(3.405)=211.8, p<.001). Post hoc comparisons indicated that improvements were evident between each successive training round (all p’s<.05). That is, the ratings of the students’ clinical communication showed reliable improvements between rounds 1 and 2, and 2 and 3, and 3 and 4. Performance scores in rounds 3 and 4 were well within the "satisfactory" range, as defined by Stillman et al.^11,12 Analysis also showed an interaction of round by session (F(3,405)=7.82, p<.001), indicating that the slope of the line relating improvement over rounds during the second training session was less than that seen during the first training session. This result is largely a function of the higher baseline at the start of the second session. Post hoc comparisons showed that the students’ performance during the first round of session 2 was below their performance in round 4 of CC1 and also above their performance during round 1 of CC1 (both p’s<.05). Thus, some of the improvement noted at the end of the first training period may have been lost, but students were still performing above the level of their initial baseline scores. Thus, the results show a beneficial impact on the students’ ACIR scores during each course of training.

View larger version (17K): [in this window] [in a new window]   Figure 1. Mean (SEM) ACIR score, averaged over thirteen questions by session and round

To evaluate any differences in the students’ ratings of the value of their clinical communication experience between sessions and to obtain feedback about the educational value of the training, students completed a course evaluation consisting of five questions at the end of CC1 and CC2. Table 2 shows that the students’ mean ratings for all five items after both sessions were 4.4 or higher on a five-point scale, but the ratings were slightly lower after CC2.

The students’ written responses about the impact of the training included the following: "great experience," "good exercise in both junior and senior year," "learned a lot," "good program," "stimulating and thought-provoking," and "the simulated interviews are very helpful for real-life clinical situations." Other general comments included: "allowed students to get important feedback, improve throughout the session, and apply knowledge learned from the coursework in Communications in Health Care." Comments on the timing of the program included: "should be done throughout the clinical years, before entering clinic, again at the time of graduation, to reinforce add another session, and perhaps as a continuing education program."

	Discussion

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Assessment of the students’ ACIR scores demonstrates that their interpersonal skills improved from below satisfactory levels at baseline to above satisfactory in both the third- and fourth-year sessions. The results for CC1, based on similar scenarios, replicate our previous findings.⁹ These results and our earlier findings suggest that the use of patient instructors is an effective mode of teaching interpersonal communication among dental students. The longitudinal data suggest a substantial loss in the clinical skills measured by the ACIR between the end of CC1 during the fall of their third year and the beginning of CC2, which was conducted during the summer of the students’ fourth year. That is, performance during the first round of CC2 was both greater than the first round of CC1, indicating some skill retention, but also less than the last round of CC1, indicating loss of skill. This finding suggests that these communication skills may not be reinforced in their everyday clinical program as students treat actual patients in the clinic. Because most of the "new" patients that students have in their treatment group are interviewed during the fall of their junior year and retained throughout the year, the students do not have opportunities to regularly practice their data-gathering skills and to develop rapport with new patients during much of the academic year. It should be noted that the scenarios enacted in CC1 required attention primarily to clinical fact-finding and interpersonal interviewing. Those enacted in CC2 required, in addition, sensitivity to sociocultural and psychosocial issues, such as religion and mental health. This difference imposes a limitation on the interpretation of the current data, as the apparent reduction in skills between the two training sessions might not merely reflect lack of practice and reinforcement, as suggested above, but may be due to the change in material. Thus, further research is needed to determine whether the students’ apparent loss of skill would have occurred if they were retested with scenarios similar to their first training. Future investigation is also needed to assess the stability of skills following the second training session.

If communication skills wane without practice, programs that provide additional reinforcement of these skills, perhaps supervised by their clinical instructors, deserve attention. In dental clinical settings without a diverse group of patients, externship programs may allow students this valuable practice. A program such as the one described in this article might also be offered through continuing education programs for dental professionals and clinical instructors seeking additional skills in cultural competency. The LEARN model for cross-cultural encounters in health care and also Kleinman et al.’s^14,15,18 interviewing techniques have been incorporated into the didactic course, Communication in Health Care, which is a prerequisite for CC2. The LEARN model emphasizes the following behaviors: listen, explain, acknowledge, recommend, and negotiate. Using open-ended questions and probing appropriately to better understand an individual’s health beliefs and expectations for care are considered crucial for effective patient management.^14,15 Interestingly, the consistently lower level of performance on the use of positive reinforcement in Clinical Communications 2 than Clinical Communications 1 may reflect students’ uneasiness with establishing rapport and/or displaying verbal empathic behaviors with patients from "different" backgrounds. The p-level of .22 suggests that there is no evidence that students’ use of positive reinforcement in CC1 differs from CC2. Such skills are notably critical in the ongoing process of developing cultural competence. For example, although the student may be organized in resolving solutions for specific oral health problems related to diagnosis and treatment planning, incorporating psychosocial support and understanding the context in which the patient resides are inherent in getting patients to adhere to treatment regimens.^16,17

Each of the scenarios has specific learning nuances for the dental provider. In the case of the victim of spousal abuse or the patient with oral cancer, for example, the possible incorporation of awareness and respect for the health beliefs and context that the patient experiences may be critical in developing rapport. The male student must be sensitive about issues such as physical contact, which a female Moslem patient may consider inappropriate. Inebriated patients should not receive treatment because they cannot provide acceptable informed consent. Inquiring about the patient’s perception regarding the etiology of the condition and utilization patterns when negotiating an acceptable treatment plan is crucial in working with patients who use alternative health practices (e.g., herbs, curanderos) or embrace supernatural beliefs. Such teaching issues are explored in the forty-five-minute seminar with the students and the course director (HB) at the close of each session.

Use of reflective learning is critical as the students self-evaluate and consider the specific sociocultural issues inherent in the scenarios. Cultural sensitivity versus stereotyping is emphasized as the students acknowledge the relevance of their foundation knowledge and applying such skills in their development toward cultural competence. Through their experiences and introspection regarding their own biases and patient encounters, it is recognized that gaining cultural sensitivity and competence is an ongoing process.¹⁹ The self-reflection process is viewed as a key tool in the program and has been recognized by other dental educators.²⁰

It is also noteworthy that the results from the communication program have provided data and a rationale for changing the screening clinic for this upcoming year at our school. In the future, the student screening the "new" patient will become that patient’s dental provider. This change will allow students to practice their intake interviewing skills knowing that it can impact their patient’s receptivity to become part of the student’s patient roster. Future research is needed to assess whether the rate of patients’ compliance with treatment plans and becoming patients of record increase with this change in patient screening and assignment.

	APPENDIX

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Summary of one patient scenario identified by patient identification; chief complaint and history of present illness; medical history (MH); dental history (DH); and personal history (PH).

Osteogenic sarcoma complicated by traditional Muslim belief system:

Ms. M is a thirty-five-year-old female who presented at the emergency dental clinic yesterday with acute pain in the lower right jaw. About six weeks ago, she was hit in the jaw area by a swinging kitchen cabinet door, but wasn’t badly hurt and there was no apparent bruising. It has been a little achy since then, but was not significantly painful until about forty-eight hours ago. Her regular dentist is on vacation, and she decided to come to the dental clinic. She has noticed that one of her molars feels loose as well. She feels that she has a lump on her right lower gum. Upon arrival at the clinic, she was examined by a student who found no obvious problem with her teeth or gums. An X-ray followed by a Panorex (X-ray) was taken, and then she was sent for a biopsy. She is returning today to get the findings, but has no idea that something might be seriously wrong.

She will admit that she feels very guilty about the condition and she wonders if it is "God’s will—for something she may have done." However, she will defer all decisions to her husband. If the student is distant or "too clinical," the patient will become more anxious and distraught. The patient is very concerned about the impact that this will have on her life as a preschool teacher: how much time will it take to heal, etc.

MH: Ms. M has been healthy and takes no medications. She has no significant past history of hospitalizations, surgeries, accidents, or illness. She has never smoked and does not drink alcohol. Her father died of bladder cancer, but there is no other history of cancer. She has had only female doctors.

DH: Ms. M had regular dental care through high school. Following a bout of dental phobia as a young adult, she again gets regular care. About three years ago, she found a dentist that she liked. Ms. M’s last dental appointment occurred about one year ago. No X-rays were taken at that time, and no cavities were found. Treatment was restricted to routine cleaning. She reports brushing and flossing regularly. She wants to see the female doctor who last treated her.

PH: Ms. M is married and has one grandchild who is seven. She currently works at home as a day care teacher. She has family and a good support system in the area. She is very active with her mosque. She is dependent on her husband for transportation. She wears traditional Moslem clothing.

	Footnotes

 
Dr. Broder is the Endowed Hunterdon Professor of Community Health, and Dr. Janal is Senior Research Associate, Departments of Community Health and Psychiatry—both at the University of Medicine and Dentistry of New Jersey-New Jersey Dental School. Direct correspondence and requests for reprints to Dr. H.L. Broder, Department of Community Health, 110 Bergen Street, P.O. Box 1709, University of Medicine and Dentistry of New Jersey-New Jersey Dental School, Newark, NJ 07101-1709; 973-972-3612 phone; 973-972-8046 fax; broder{at}umdnj.edu.

	REFERENCES

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