TEACHING EXCELLENCE DATABASE

Medical communication training is challenged to meet the demands of a more internationalized world and at the same time applying a student-centred approach. Therefore, our interdisciplinary simulation-based course is designed to improve doctor-patient interaction skills to enable each participant to take medical history effectively in an empathetic manner. At the University of Pécs, Medical School, Hungary, the American standardized patient model from the 1960’s is adapted to advance patient-interviewing, problem-solving, and medical reporting skills. The history taking course in English for international students utilizes actors and lay people to perform as simulated patients under the close observation of medical specialists and linguists. This innovative course is designed to train and navigate students among medical, linguistic, emotional, and socio-cultural complexities of patients. Experts in medicine and language assess student performance, offering feedback and providing individualized training that students might improve their professional and communicative competencies. Through responding to medical emergencies, miscommunications, and conflicts in a safe environment, medical students prepare to deal with a diverse patient context, that more qualified and empathetic health personnel may be employed throughout clinics worldwide. The simulated cases are presented in the Medical Skills Laboratory providing an authentic setting to our course with a hospital ward-like environment. During each session students initiate patient interviews and history taking in small groups (3-4 students), later individually with the lay or actor simulated patient. Feedback is given to the participants based on observation by other student members of the group, the simulated patient, the clinician and the linguist. Our aim is to enable students to learn structured patient-interviews and cope with communication obstacles. Using assertive communication strategies and also expressing empathy to elicit information from the patient, medical students find themselves in life-like situations where they can learn and make mistakes without causing real harm. Therefore, students can enhance at a lower stress level. They also learn case reporting, so from the data collected from the patient they select medically related information and present it to the clinician. We can see a gradually developing code – switch awareness in students from an everyday language to a medical jargon.

Methodology

Prior to the launch of the current student-centred course, linguists, communication instructors, psychologists and clinicians collaborated to design education materials and patient profiles. Clinicians selected authentic patient cases to be written and finalized as “roles” with regard to the genre of medical history. Initially, teaching assistant students were asked to play the role of a patient in the pilot course. Later, the roles were transferred to simulated patients (SP) for learning. Presentations of professionally authentic patient profiles embodied by lay or actor SPs were performed as a simulated scenario of relevant clinical cases (in the field of internal medicine: cardiology, gastroenterology, nephrology, endocrinology, and also dermatology, neurology, surgery, psychiatry) and were controlled, moderated and assessed by clinicians and linguists. In the present English course native American simulated patients and professional Hungarian actors (one who finished her acting studies in the USA then in the UK, and also played in Hollywood movies, and two who act in the puppet theatre and improvisational theatre of Pécs and speak English) help to portray patient characters. From the next year we intend to start collaboration with a retired British simulated patient living in Hungary as well, to provide diversity in accents, age, sex, and ethnicity. Simulated patients prepare for their roles in two ways: by observing a real patient interview at the clinic carried out by a physician and a patient, or through being supported by an SP trainer and a clinician. During this phase, the SP becomes familiar with relevant questions and answers appropriate to the clinical case. Moreover, the SP learns about behavioural patterns characteristic of the given medical history (e.g. anger, anxiety, pain-induced disability). The next step is case interpretation with the clinician and the linguist. The SP collects the important tools to portray the patient’s character they have been assigned, and learns the patient’s psychosomatic disorders, clinical features, chief and accompanying complaints, and manners related to the disease. The clinician explains the leading symptoms, the process of diagnostic investigations including laboratory tests (e.g. blood, urine) or imaging techniques (e.g. ECG, abdominal CT), and informs the SP of prognosis of therapies and surgical interventions. We apply the online and offline preparatory consultation options as well, both of them work efficiently. In the third phase, the psychologist and the linguist form a life-like patient history, including a family and social background to enable the SP to identify with the patient in the scenario. The psychologist determines the cooperative (or uncooperative) nature of the patient, and the conditions the patient suffers from (e.g., depression, drug or alcohol abuse) and how these factors will influence the patient’s attitudes during history taking. The linguist provides the linguistic tools and communication strategies for all these considerations (e.g. monotonous speech, verbal hesitancy, non-verbal cues: refraining from eye-contact, pulled up shoulders and so on) and the case is sent back to the clinician for approval. In the last preparation phase, the SP is sent the finalized case and learns the role. Simulated cases are presented in an authentic setting, the MediSkillsLab at the University of Pécs, Medical School. The medical laboratory includes a patient’s bed, examination table, and other medical tools designed to create an authentic clinical environment. Our interdisciplinary course enables students to start patient interviews and history taking in small groups (3-4 students) at the beginning of the course, then individually with the lay and actor simulated patient. The simulated practice is divided into three parts. First, students practice taking patients’ histories in structured patient-interviews. The patient interview has five main elements: asking about present complaints, past medical history (previous diseases, surgeries, medications taken), review of the systems (any abnormalities, altered functions from top to toe), family history (any diseases running in the family), and social history (employment, living conditions, risk factors: smoking, drinking alcohol, drug abuse). Afterwards, students use the information elicited from the patient to report about the patient’s case to the clinician within a specific timeframe. To enable students to select medically related information from the patient’s history a written case report sample is shared in our online platform preceding the class. Besides, the clinician also gives an exemplary summary of the collected data and uses a medical term-loaded jargon to report about the patient in the way it is authentically done in the everyday clinical routine. Students in that method can gradually improve code – switch awareness. From a language understandable to the laymen students shift and present to their supervising physician with appropriate clarity using medical terminology. Thirdly, students receive feedback on their performance from three perspectives: 1, professional/medical (from the clinician)- medical content-based feedback, symptom/complaint-related questions, clinical presentation techniques 2, linguistic and communicative (from the linguist) - applied interviewing strategy, structural elements of history taking, brief nominalized case presentation, non-verbal, para-verbal and verbal communication- always in a supportive manner and 3, a patient-centred perspective (from the simulated patient)- focusing on empathy Each training session includes two or three scenarios and smaller encounters (e.g. informing a relative about visiting restrictions due to Covid-regulations). Medical histories taken from actor-patients are recorded (digitally) throughout the semester, thus students and instructors can closely monitor personal and teamwork development regarding professional language and communication skills. During online education on Microsoft Teams the sessions were also recorded.

Tools, equipment, technology used

Simulated cases are presented in an authentic setting: the MediSkillsLab at the University of Pécs, Medical School. The medical laboratory includes a patient’s bed, examination table, and other required medical tools (ECG, ultrasound etc.) to create a realistic environment. The high-technology devices of the MediSkillsLab are essential to efficient implementation of the simulation-based programme, since not only the patients are simulated patients but the environment also needs to be life-like. The scenarios are video-recorded for further analysis and objective feedback purposes. Recording classes from different camera angles provides invaluable opportunities for all participants to observe student progression. The course instructors can also learn from the recorded verbal and non-verbal misbehaviour and introduce changes accordingly. Our inclusive and diverse course enables students to initiate patient interviews and history taking in small groups as well as individually with the simulated patient. They have to ask for the patient’s permission to use their IPads or notebook to take notes. In our practice it seemed, elderly simulated patients preferred to see students taking notes in their notebooks, the younger ones were pleased with the IPads too with occasional glimpse up to the patient’s eyes. Their encounters were observed, evaluated and assessed by other student members of the group, the clinician and the linguist. During the online semesters due to Covid-regulations, the classes took place on Teams platform, so the simulated patients could also join the scenarios. To enable some privacy to the simulated scene, only the active participants were seen on the screen, the others were asked to turn off their cameras and microphones. The fall semester of 2021/2022 went back to the offline format, however, some clinicians and simulated patients (due to their busy schedule or current Covid-infections) could not come to the class in person, only were able to join us online. So, the Microsoft Teams application provided us with the opportunity to sustain simulated medical interviews to enhance students’ progession. Prior to the simulations theoretical briefings are held using Padlet/ Quizlet applications to collect relevant questions belonging to history taking, present complaints (SOCRATES model) or breaking bad news (SPIKE model). We intend to continue using this blended-learning method for better outcomes.

Outcomes and outputs, main results

Our student-centred course integrating case-based, feedback-based, and co-teaching methods aimed and succeeded to facilitate development of medical communication skills, doctor-to-patient, doctor-to-doctor, and doctor-to-relative interaction skills, politeness strategies, and conflict management. The feedback ‘triad’ contributed to the growth of self-confidence, self-esteem and professional knowledge. By introducing students to the simulated medical environment during their undergraduate years, we provide context and tools to better prepare them for their clinical practice courses, decreasing the burden on clinicians dealing with a growing number of students. We found it unquestionably useful to provide a wide spectrum of doctor-patient encounters from internal medicine through surgery to psychiatry. The gradually increasing challenges ensure the feeling of success; the lay simulated patients acted like everyday patients, while more difficult scenes (e.g. breaking bad news like a lethal diagnosis) demanded actor simulated patients to identify with a character who can get despaired, turn into tears or burst into anger. In these life-like situations students can learn and make mistakes without causing real harm to patients. This student-centred type of education ensures lower stress level to improve skills. Several times the actor simulated patients were asked to portray the role of Serbian, Greek, Hungarian patients with certain accents, cultural beliefs, and higher or lower qualifications. Sensitizing students to intercultural diversity and cope with difficulties arising from them was an important result. Our course is an effective contribution to the high-standard training similar to those available in the target language country as students participate in authentic encounters with English speaking patients and also learn assertive communication techniques including empathy. A significant outcome is a confident future medical specialist with interpersonal clinical skills to interview a patient successfully that will potentially lead to better diagnosis.

Lessons learnt

Launching this type of course is already a success, however, it needs to be controlled and managed focusing on the students’ needs. We have learnt, that: 1, students with advanced motivation and engagement can start the course even in their junior years, but those with more constrained characters are rather advised to register for a course like this in more senior years (from year 3 onward) 2, lay simulated patients can play the role of everyday patients in internal medical scenarios, cardiology and gastroenterology scenes, however, more emotionally depleting situations require professional actors to do it realistically 3, to further enhance feedback-giving skills of the simulated patients further trainings should be made available every academic year (we have introduced that also after the first semester, it is ongoing) 4, based on the chosen SP for a class the scenarios require regular reediting to match the age, sex, personality of the patient (online consultations with the clinicians have to be planned for professional confirmation of the changed scenario, e.g. the same disorder may manifest differently in elderly women than young men)

Adaptability and sustainability of the best practice (for other institutions)

Not only communication courses but other clinical practice courses can also adapt the design of the course to bridge the gap between the high number of students and the low number of patients who could actively contribute to the student’s development. The growing number of our simulated patients (understandably more lay SPs than professional actor SPs due to limitations in financial resources) can meet the increasing requirements of other departments of the faculty and also enable us to start collaboration at national in as much international level. The main idea of the course can be adapted in any fields of higher education, with its student-centredness that provides experience-based learning of the skills, and context needed for the future profession with reproducible situations, safe environment for practice, applying the archives and feedbacks to ensure opportunity for personalized improvement. It increases learning motivation, and generates fruitful collaboration of clinic and faculty. With the help of online platforms collaborations can start with universities of neighbour countries or worldwide. Sustainability is ensured by online application of the programme too, and also the common ground and comprehension of the need to do teamwork.

Promotion of best practice

We participate in international conferences with presentations of the diverse aspects of the student-centred interdisciplinary medical communication course (Head, STUDSJ, AMSE) We publish articles on the course (Porta Lingua), national symposiums, conferences on educational methods We participate in university TV interviews, workshops sharing best practice, starting collaboration with other smaller units of the faculty based on the model

Scope and impact

• Course/department level
• Faculty level
• Institutional level
• Cross-institutional level
• National level
• EU/EHEA/International level

We launched Practice-oriented Communication courses within the framework of Synergy project based on our model (involving three departments: Department of Family Medicine, Behavioural Studies and Languages for Biomedical Purposes and Communication) in three language programmes. We have already started collaboration with the Semmelweis University, we trained SPs for their history taking courses in online trainings.

6.1 Digitalization

• Outstanding, innovative, excellent practices of online / blended / hybrid learning
• Innovative, novel methodology in using digital tools/devices in teaching
• Digital skills development and assessment both general and profession-related, embedded in course design, in teaching and assessment
• Novel digital solutions (tools, frameworks, devices, tasks to enhance efficiency and motivation)

Reasoning: It is innovative in its interdisciplinary and blended learning way; more fields of medicine and communication are involved, co-teaching takes place, students of diverse ethnicity and medical background are present. It is hybrid providing the chance for participants to join online, they can practise telemedicine, it uses digital devices/applications for collecting students’ opinions, answers, history taking questions (Padlet/Quizlet), and assessment options (film analysis)

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6.2 Internationalization

• Outstanding practices of international online collaborative learning
• Developing students' multicultural awareness
• Courses implemented in international cooperation (projects, co-teaching, virtual/blended mobility, etc.)
• Courses offered to international multicultural students both online and offline
• International projects/research results embedded into course development and T&L

Reasoning: The course design provides and outstanding international collaborative learning opportunity online or offline too (with medical schools of the participating universities). Non-verbal and verbal communication tools are used and their implementation is discussed by the participating multicultural students, simulated patients (native American/ British/German/Hungarian). Differences in patient interviews are drawn attention to. The design was based on American, Australian, German research.

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6.3 Inclusion and diversity, universal design

• Inclusive course design, universally designed divers activities to meet special students' needs
• Innovative teaching methodology for inclusion and meet diverse student needs
• (Innovative) use of devices and tools for inclusion
• Senzitivizing students to consider special needs when practicing their profession
• Course includes hints on how the services/products of the profession could be universally designed/inclusive

Reasoning: Students of diverse gender, age and ethnic backgrounds make the future medical team, so we represent an innovative model for inclusion and diversity. Students experience team dynamics in offline and online communication (smooth turn-takings) and identify with different roles (leader/supporter), those with special needs are supported by the team members. We facilitate social growth, develop empathy and improve conscious medical communication skills.

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6.4 Sustainability

• Sustainability goals are addressed in the course(s)
• Teaching material contains profession related sustainability aspects
• Extra-curricular student activities for sustainability
• Environmental attitude, skill development and assessment either general or profession-related
• Sustainability aspects are considered in all phases of the learning practice - "hidden curriculum"

Reasoning: Sustainable practices support ecological, human, and economic health and vitality, and our student-centred course acts similarly. It provides an environment for safe and individual growth for each student, and with the cautiously prepared design, the ongoing trainings of the simulated patients (online and offline), and the three-dimensional feedback system the course is a sustainable form of education offline and online too. Individual assessment is guaranteed (individual tasks).

3.3 Public contact datas

Name	Email address	Website
Katalin Eklicsné Dr. Lepenye	kata.eklics@aok.pte.hu