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A Patient-Instructor Program to Promote Dental Students’ Communication Skills with Diverse Patients

Key words: standardized patients, culture, dentistry, education, communication, teaching, diversity

Submitted for publication 04/26/07; accepted 09/01/07

	Abstract

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This article describes the design and evaluation of a patient-instructor (PI) program that was developed to teach and assess dental student communication skills with patients, with an emphasis on cross-cultural patient encounters. The PIs were individuals from the community trained to portray specific simulated patients. One hundred eighteen dental students (three graduating classes) completed two half-day rotations that occurred in the junior year; seventy-nine of those students (two graduating classes) also completed a third rotation that occurred in the senior year. On each rotation, students worked with several simulated patients in mock clinic appointments. PIs used a standardized rating scale and case-specific content checklists to assess students’ ability to elicit and provide essential information. Across counterbalanced cases, students improved as they progressed through encounters. Rate of improvement varied by rotation, but students improved most during their first rotation. Overall performance was best on the final rotation. Qualitative review of content checklist items indicated areas of strengths and weaknesses in communication regarding medical, dental, psychosocial, and cultural content. Results can direct curriculum changes to improve communication skills. Future research should address the effects of the PI program on students’ diversity-related attitudes and behaviors.

Communication skills are not best taught through traditional didactic methods¹ and are not best evaluated with traditional paper and pencil exams. Widely used in medical schools and in a handful of dental schools, patient-instructors (PIs) have been shown to be an effective mode of instruction and evaluation of students’ communication skills.^2–7 PIs teach communication skills in standardized role-playing scenarios. PIs typically assess student communication skills using standardized rating scales and/or scenario-specific content checklists.

We know of only one report of PIs being used specifically to teach cross-cultural communication.⁸ In that report, Broder and Janal demonstrated that students improved their cross-cultural communications skills and that they retained some, but not all, of their communication skills from their first PI rotation to a second, as measured with a standardized rating scale.

At the University of Connecticut School of Dental Medicine (UConn SDM), students participate in three PI rotations in the junior and senior years that are designed to improve the student’s communication skills with patients. During these rotations, students interview trained patients known as patient- instructors (PIs). Students are assessed by the PIs who use case-specific content checklists that indicate predetermined pieces of information the student must either gather from, or communicate to, the PI. The PIs then provide students with corrective feedback. Students are also observed by faculty who provide supplemental corrective feedback. The aims of this article are to 1) describe the patient-instructor program at UConn SDM, 2) investigate its effects on student communication skills across three rotations as measured by content checklist scores, and 3) explore patterns of student performance on content checklist items.

	Methods

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Patient-Instructor Rotations.
During three rotations in the junior and senior years, UConn SDM students conduct clinical interviews with PIs during a mock clinic "appointment." PIs are individuals from the community who are drawn from diverse racial, ethnic, and socioeconomic groups. Students are aware that the encounter is simulated and is being evaluated. Each PI evaluates the content of the interview using checklists. Then, the PI gives the student immediate, individualized, and detailed feedback about his or her interviewing skills, interpersonal style, and ascertainment of information specific to that case. During feedback, student strengths and weaknesses are discussed from the perspective of both student and PI, and students are given the opportunity to role-play again the most important weaknesses. Clinical dental and behavioral science faculty preceptors observe students in real time via audiovisual equipment, and they also give feedback to students at the end of each rotation during a small group debriefing session.

To provide sufficient background to students, each case is accompanied by a medical history intake form that was completed by the patient as would normally be done in the waiting room prior to an appointment. As appropriate, each case may also be accompanied by supporting materials such as radiographs, a letter from a referring health care provider, laboratory results, or a dental hygienist’s notes. However, clinic data-gathering forms are not used by the students in order to promote a patient-centered and conversational interpersonal style, rather than a rote, form-driven, question and answer style.

The number of PI encounters and the goals for those encounters differ by rotation. At the beginning of their junior year, students participate in their first rotation. They interview three PIs (twenty minutes each) over the course of an afternoon. These encounters give the student the chance to practice basic interviewing skills in a dental history-taking exercise. Cases cover routine dental chief complaints such as a loose bridge, thermal sensitivity, and gingivitis. Students receive detailed, individualized feedback; however, students do not receive a grade per se. At the end of their junior year, students participate in their second rotation. Students interview four new PIs. These cases give the student the chance to practice higher level interviewing as well as counseling skills. Cases cover more complex dental encounters such as smoking cessation, substance abuse, and belligerent patient behavior. Furthermore, these PIs present the student with cross-cultural communication challenges. Again, students receive detailed, individualized feedback, but this time they are graded pass/fail. Students who fail receive remediation, which consists of faculty and student reviewing videotapes of the encounters followed by faculty coaching the student in practice. In the fall of their senior year, students participate in the third rotation. Students interview five new PIs, who present even more difficult communication challenges. Cases cover issues such as a complex medical history, noncompliance, and unexplained symptoms, again with a cross-cultural overlay. In this final experience, students who fail are remediated until they pass as a requirement for graduation. Each rotation may include a slightly different composition of cases, depending upon availability of PIs (see Table 1 for sample cases by rotations).

	Patient-Instructors

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Patient-instructors (PIs) typically work on a part-time basis and are paid an hourly wage (approximately $20 per hour). Because the UConn School of Medicine has a longstanding PI program, the SDM PIs are usually hired through word of mouth from current PIs. PIs have various backgrounds, but are often current or retired teachers, actors, and health care professionals. PIs do not necessarily have the dental, medical, and social histories they are portraying, although sometimes they do. In either case, in order for PIs to be perceived as authentic by students, cases are kept as close to the PIs’ own history as possible while still illustrating the communication challenge of interest to the curriculum.

PIs are trained extensively to portray a fictional patient with a specific history and presentation and to evaluate student performance in interpersonal skills and their ability to obtain and provide case-specific information. Based on the PI orientation protocol recommended by Hook and Pfeiffer,⁹ PIs at UConn SDM complete at least four hours of training that focuses on how to evaluate student performance and how to provide constructive feedback to students. PIs observe videotapes depicting students communicating with dental patients that have been scored to a standard by faculty. PIs practice scoring these tapes. Errors of leniency and stringency are discouraged, and PIs are encouraged to use a range of scores. Practice continues until inter-rater agreement is >80 percent with faculty standard (or the PI is dropped after several sessions). PIs are regularly recalibrated against faculty and clinical skills staff to ensure that their evaluations are consistent. Inter-rater reliability above .80 is required and typically exceeds .90. A randomly selected rotation from those reported in this article had inter-rater reliability scores among the PI, clinical skills staff, and faculty standard ranging from .92 to .99 (M=.96), based on four independent faculty and clinical skills staff observations of each PI. The PIs received routine feedback about their portrayal and scoring and the quality of their feedback.

PIs are trained to portray cases that represent a range of patients with various types of oral health and co-morbid medical conditions. Development of the cases is an iterative process with contributions from both the faculty and the PIs. A simulated patient history is written for each case that includes a chief complaint, medical, dental, and social histories, and cultural characteristics designed to broaden the students’ communication skills. Challenging cultural characteristics may include English as a second language, insurance status, immigration status, religious influences, use of alternative healing strategies, beliefs about oral health, attitudes toward health care providers, health care decision-making practices, and culturally specific nonverbal communication patterns.

PIs evaluate student performance, and the results of the PI evaluation form the basis for the students’ grades. Pass levels are determined by faculty using an Ebel-like standard-setting procedure.¹⁰ During standard setting, the seven PI faculty preceptors classify each content checklist item for relevance (essential, important, indicated, or unimportant). Then, for each importance level, the percent of items required for passing is judged and averaged across faculty. Students scoring below this percent on the majority of cases in a given rotation fail. Typically, two or three students (out of classes averaging thirty-five to forty students) require remediation after the second and third rotations. Remediation occurs on a one-on-one basis with the student and a faculty preceptor and typically takes approximately two to three hours of student time and one to two hours of faculty time. Students review their own videotapes, review videotapes of others portraying satisfactory performance, write essays about their strengths and weaknesses, and role-play difficult situations with the faculty member. In general, we have found that students are aware of their own shortcomings and are receptive to intervention.

	Measures

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Content checklists.
A content checklist is a list of specific, predetermined pieces of information that the student must either gather from or communicate to the PI. Content checklists usually range from fifteen to twenty-five items and include information about the chief complaint, medical, dental, and social histories, and cultural influences. Items on the content checklist are scored by the PI as "yes" or "no." Each item objectively reflects student verbal behavior and does not require inference on the part of the PI or faculty member. The total content checklist score is calculated as the percentage of items completed by the student.

Patterns of Content Checklist Items.
Individual content checklist items for all scenarios in the first, second, and third rotations were evaluated to identify areas of strengths and weaknesses among the students. A total of 312 individual content checklist items were analyzed that were associated with sixteen PI cases. Items that were passed by at least 90 percent of the students were inspected, as were items that were missed by at least 75 percent of the students. (Different criteria for passed and failed items were employed post hoc in order to capture sufficient variability in items. For example, when using a 90 percent failure criteria, only five items were available to analyze.) Using a qualitative approach, these items were categorized thematically based on their specific content.

Students.
The PI rotations are required at UConn SDM. All students who participated in the PI rotations since summer 2004 until this writing were investigated. One hundred eighteen students (three graduating classes) completed the first and second rotations in the junior year. Of them, seventy-nine students (two graduating classes) also completed the third rotation in the senior year.

Analyses.
The first rotation entailed three PI encounters, the second rotation entailed four PI encounters, and the third rotation entailed five PI encounters. For the purposes of this study, three encounters per rotation were included in the analyses to allow comparison across rotations with different numbers of PI encounters. The first, second, and third consecutive encounters for each rotation were analyzed. To investigate differences in student performance across rotations and encounters, a 3 (rotation) by 3 (encounter) repeated measures ANCOVA was performed, with content checklist percentage scores as the dependent variable after controlling for graduating class membership. To investigate patterns of passed/failed content checklist items, crosstabs were calculated, indicating the percent of students who failed each item. Data were analyzed using SPSS.

	Results

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Overall, students performed well, with two to four students failing each rotation. Figure 1 shows the mean percentage content checklist scores, adjusted for class membership, for each encounter during the first, second, and third rotations. Analysis showed a main effect for encounter on checklist scores, F(2,544)=4.67, p<.05. Comparisons of marginal means indicated that, on a given day, improvements were evident from encounter 1 to 2, p<.001, and from 2 to 3, p<.05. Analysis also showed a main effect for rotation F(2,272)=13.48, p<.001. Students performed significantly better on their first and third rotations compared to their second rotation, both p<.01. Analysis showed an interaction of encounter by rotation, F(4,544)=3.21, p<.05, as well, indicating that students improved at different rates across the different rotations. Students improved most on their first rotation and least on their third rotation.

View larger version (15K): [in this window] [in a new window]   Figure 1. Encounter by rotation adjusted mean percent content checklist score (SEM)

Among the dental items, those most frequently passed pertained to the nature, onset, and progression of chief complaint (e.g., bleeding gums, dry mouth), aggravating and alleviating factors of pain (e.g., chewing, temperature), and counseling for better oral hygiene (e.g., regular flossing). Dental items most frequently missed pertained to oral hygiene habits (e.g., frequency of brushing, fluoride rinse), history of oral health care (e.g., regular or sporadic), detailed pain assessment (e.g., severity and quality of pain), and the relationship between oral and systemic health (e.g., diabetes and periodontal disease, side effects of certain medications leading to caries risk).

Among the psychosocial items, those most frequently passed pertained to students’ verbal assessment of any remarkable psychological state (e.g., impatience, anxiety), living situation (e.g., married or living alone), and determining if the patient currently smoked and providing advice to quit smoking (e.g., readiness to quit). Psychosocial items most frequently missed pertained to sensitive topics (e.g., illicit drug use, employment status), offering specific behavioral quitting strategies for smokers (e.g., setting a quit date, avoiding smoking situations while quitting), and discovering covert patient concerns (e.g., confidentiality, aesthetics).

Among the cultural items, those most frequently passed pertained to patient confusion regarding insurance coverage and related financial concerns (e.g., a recent immigrant unsure of insurance coverage). Cultural items most frequently missed pertained to language barriers (e.g., offering an interpreter to patients who speak English as a second language), use of alternative healing strategies (e.g., home remedies, over-the-counter medications, herbal treatments), access to care (e.g., insurance, finances, childcare), and support systems (e.g., inviting the patient to bring a family member to the next appointment).

	Discussion

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Analysis of the data revealed five primary findings: 1) overall, the majority of students demonstrated adequate communication skills; 2) on a given rotation, students improved from their first to third PI encounters; 3) the rate of improvement within rotations was variable, with the most improvement on their first rotation; 4) students showed variable performance across rotations, with their best performance on their final rotation; and 5) specific content checklist items were routinely difficult for students.

The majority of students performed well, with a low failure rate. Consistent with past reports,^2,3 students improved from one PI encounter to the next. This indicates that students are able to take the feedback from one PI and make use of it in their next encounter.

Students had variable performance across rotations. They performed best on their third rotation and worst on the second. We suggest that the unexpected relatively poor performance during the second rotation (compared to the first) reflects the match of the student’s skills to the demands of the rotation. In their first rotation, students are asked to perform relatively easy history-taking tasks. In their second and third rotations, students are asked to perform more difficult tasks. However, of these two latter experiences, students are better prepared to meet the challenges of the third rotation, by virtue of an additional academic year in clinic as well as previous experience with challenging PIs. Furthermore, students who fail the second rotation benefit from remediation before advancing to the third. There is no such remediation following the first rotation.

Consistent with Broder and Janal’s findings,⁸ students improved most during their first rotation. We suggest that junior students are more open to the role-play experience and more receptive to the feedback offered by PIs. Alternatively, this may be due to the nature of the tasks they are asked to perform in the first, second, and third rotations. On their first rotation, they have the opportunity to practice three data-gathering encounters, for which their main task is to collect basic medical, dental, and social history data. During this first rotation, they are practicing the same skills across three encounters. For the second and third rotations, however, the tasks vary by the encounter. For example, one encounter may require the student to perform smoking cessation counseling, another may involve discussing a difficult diagnosis, and another may involve calming a belligerent patient. Thus, the learning that takes place on the first encounter may not directly translate to the student’s subsequent encounter.

An analysis of the most frequently missed content checklist items showed a meaningful pattern of student strengths and weaknesses. Strengths included ascertaining the chief complaint, major medical problems and their treatment, attention to the patient’s presenting emotional state, and appreciation for patient confusion regarding insurance coverage and related financial concerns. Weaknesses included health items where the student had to document specific patient information such as symptom analysis or past hospitalizations. We suspect that many of these items were missed by students because of the role-play environment in which they focused primarily on communication skills and did not have the benefit of clinic forms and checklists, which are routinely available during regular patient appointments. Problem areas also included psychosocial items such as smoking cessation strategies and assessment of illicit drug use. We suspect that these items were missed because students are uncomfortable asking about personal or sensitive topics. Cultural items frequently missed include alternative healing strategies, language proficiency, and access to care. Some of these items may have been missed because students are still developing the language and conversational strategy for a comfortable and efficient way of tapping into cultural aspects of health care.

Analysis of specific items can direct curriculum development to better prepare students to communicate about these issues. It should be noted that these cases are designed to be challenging for students. Nearly 80 percent of health, psychosocial, and cultural content checklist items are in fact passed satisfactorily by the majority of students. We noted the exceptions to illustrate the types of items that students tend to find difficult and how the data can be used to direct curriculum changes.

In conclusion, a three-rotation PI program improved dental students’ communication skills and cross-cultural communication skills. By revealing patterns of student weaknesses, it also helped identify areas for curriculum enhancement. Future research should investigate the effects of PI training on students’ diversity-related attitudes and behaviors.

	Footnotes

 
Dr. Wagner is Assistant Professor, Division of Behavioral Sciences and Community Health, School of Dental Medicine; Dr. Arteaga is Assistant Clinical Professor, Division of Prosthodontics and Operative Dentistry, School of Dental Medicine; Dr. D’Ambrosio is Associate Professor and Chair, Division of Oral Medicine, School of Dental Medicine; Dr. Hodge is Assistant Professor, Division of Behavioral Sciences, and Assistant Dean of Admissions and Outreach, School of Dental Medicine; Dr. Ioannidou is Assistant Clinical Professor, Division of Periodontology, School of Dental Medicine; Dr. Pfeiffer is Associate Professor, Department of Medicine and Director, Clinical Skills Assessment Program, School of Medicine; Dr. Yong is a Post- doctoral Fellow, Division of Behavioral Sciences and Community Health, School of Dental Medicine; and Dr. Reisine is Professor and Chair, Division of Behavioral Sciences and Community Health, and Associate Dean for Research, School of Dental Medicine—all at the University of Connecticut Health Center. Direct correspondence and requests for reprints to Dr. Julie Wagner, Division of Behavioral Sciences and Community Health MC3910, University of Connecticut Health Center, School of Dental Medicine, 263 Farmington Ave., Farmington, CT 06410; 860-679-4508 phone; 860-679-1342 fax; juwagner{at}uchc.edu.

This project was supported by a grant from the Robert Wood Johnson Foundation.

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