Communication skills interventions for medical students

What are the best ways to teach medical students how to talk to patients?

Teaching interpersonal skills

We use interpersonal skills every day when we talk and interact with other people. Interpersonal skills include communication skills such as listening, speaking, and asking questions. Good communication between doctor and patient is vital for all medical consultations. Doctors need to build relationships, show empathy, gather information, explain concepts, and plan treatment with their patients.

Medical students need to prove they are competent in interpersonal and communication skills before they graduate. Approaches to teaching medical students these skills include face-to-face teaching, online courses, programmes that give students personalised or tailored feedback, and use of role-play with peers or with actors playing the role of the patient.

Why we did this Cochrane Review

Medical schools and universities around the world use different approaches to teach interpersonal and communication skills. We wanted to find out which types of educational programmes work best.

What did we do?

We searched for studies that assessed educational programmes to teach interpersonal and communication skills to medical students.

Search date: we included evidence published up to September 2020.

What we found

We found 90 relevant studies involving 10,124 students, conducted in the USA and in countries in Europe, the Middle East, and Asia Pacific. These studies assessed educational programmes to teach interpersonal and communication skills, including individual role-play and feedback, and large group demonstrations. Programmes were delivered by face-to-face teaching, by video, or online. In most studies, results were assessed immediately after the educational programme concluded, and up to 12 months later.

We compared the results of studies conducted to find out how the different programmes affected:

· overall communication skills;

· understanding of what another person is feeling (empathy);

· relationship building or understanding one another's feelings or ideas (rapport);

· gathering of information, including patients' satisfaction, understanding, or views; and

· explaining and planning (giving of information).

What are the main results of our review?

Comparing interpersonal programmes against the usual educational programmes or being on a waiting list for an interpersonal programme showed that these programmes:

· may slightly improve students' overall communication skills (evidence from 18 studies, with 1356 students) and empathy (6 studies; 831 students);

· probably improve skills in gathering information about the patient's views (5 studies, 405 students); but

· may have little to no effect on rapport skills (9 studies, 834 students).

We are uncertain about how the interpersonal programmes affected skills in giving information (5 studies, 659 students).

We are uncertain how online or self-taught programmes affected students' overall communication skills (4 studies, 1578 students) or skills in gathering information (1 study, 164 students) compared with face-to-face teaching.

Online or self-directed programmes compared with face-to-face teaching:

· may have little to no effect on students' empathy skills (3 studies, 421 students);

· probably have little to no effect on rapport skills (3 studies, 176 students); but

· may slightly reduce skills in giving information (1 study, 122 students).

Programmes that give students personalised or tailored feedback compared with those that involve general or no feedback:

· probably slightly improved overall communication skills (6 studies, 502 students); and

· may slightly improve empathy skills (1 study, 66 students) and skills in gathering information (1 study, 48 students).

We are uncertain how programmes with personalised or tailored feedback affected rapport skills (1 study, 190 students). No studies reported results for effects on skills in giving information.

We are uncertain whether programmes involving role-play with people acting as patients improved students' overall communication skills (4 studies, 637 students) compared with programmes involving role-play with peers. Role-play with people acting as patients may slightly improve empathy skills (2 studies, 213 students). No studies reported results for how role-play with people acting as patients affected skills in rapport or gathering and giving of information.

No studies reported any unwanted effects for any of the education programmes assessed.

How confident are we in our results?

We are moderately confident that interpersonal education programmes and programmes involving personalised, specific feedback probably improve overall communication skills.

We are not confident in our results for the other types of programmes. Some studies had limitations in the ways they were designed, such as how students taking part were assigned to different groups. Other studies had widely varying results, and some had short follow-up times. Further research is likely to change our results.

Key messages

Interpersonal education programmes for medical students had positive effects on most of the interpersonal skills we looked at, although these effects were small and our confidence in some of our results is low.

Programmes that include personalised feedback probably improve medical students' overall communication skills more than programmes that involve general or no feedback.

Online or self-directed programmes may make little to no difference in improving skills in empathy or rapport compared with face-to-face teaching.

Authors' conclusions: 

This review represents a substantial body of evidence from which to draw, but further research is needed to strengthen the quality of the evidence base, to consider the long-term effects of interventions on students’ behaviour as they progress through training and into practice, and to assess effects of interventions on patient outcomes. Efforts to standardise assessment and evaluation of interpersonal skills will strengthen future research efforts.

Read the full abstract...
Background: 

Communication is a common element in all medical consultations, affecting a range of outcomes for doctors and patients. The increasing demand for medical students to be trained to communicate effectively has seen the emergence of interpersonal communication skills as core graduate competencies in medical training around the world. Medical schools have adopted a range of approaches to develop and evaluate these competencies.

Objectives: 

To assess the effects of interventions for medical students that aim to improve interpersonal communication in medical consultations.

Search strategy: 

We searched five electronic databases: Cochrane Central Register of Controlled Trials, MEDLINE, Embase, PsycINFO, and ERIC (Educational Resource Information Centre) in September 2020, with no language, date, or publication status restrictions. We also screened reference lists of relevant articles and contacted authors of included studies.

Selection criteria: 

We included randomised controlled trials (RCTs), cluster-RCTs (C-RCTs), and non-randomised controlled trials (quasi-RCTs) evaluating the effectiveness of interventions delivered to students in undergraduate or graduate-entry medical programmes. We included studies of interventions aiming to improve medical students’ interpersonal communication during medical consultations. Included interventions targeted communication skills associated with empathy, relationship building, gathering information, and explanation and planning, as well as specific communication tasks such as listening, appropriate structure, and question style.

Data collection and analysis: 

We used standard methodological procedures expected by Cochrane. Two review authors independently reviewed all search results, extracted data, assessed the risk of bias of included studies, and rated the quality of evidence using GRADE.

Main results: 

We found 91 publications relating to 76 separate studies (involving 10,124 students): 55 RCTs, 9 quasi-RCTs, 7 C-RCTs, and 5 quasi-C-RCTs. We performed meta-analysis according to comparison and outcome. Among both effectiveness and comparative effectiveness analyses, we separated outcomes reporting on overall communication skills, empathy, rapport or relationship building, patient perceptions/satisfaction, information gathering, and explanation and planning. Overall communication skills and empathy were further divided as examiner- or simulated patient-assessed. The overall quality of evidence ranged from moderate to very low, and there was high, unexplained heterogeneity.

Overall, interventions had positive effects on most outcomes, but generally small effect sizes and evidence quality limit the conclusions that can be drawn. Communication skills interventions in comparison to usual curricula or control may improve both overall communication skills (standardised mean difference (SMD) 0.92, 95% confidence interval (CI) 0.53 to 1.31; 18 studies, 1356 participants; I² = 90%; low-quality evidence) and empathy (SMD 0.64, 95% CI 0.23 to 1.05; 6 studies, 831 participants; I² = 86%; low-quality evidence) when assessed by experts, but not by simulated patients. Students’ skills in information gathering probably also improve with educational intervention (SMD 1.07, 95% CI 0.61 to 1.54; 5 studies, 405 participants; I² = 78%; moderate-quality evidence), but there may be little to no effect on students' rapport (SMD 0.18, 95% CI -0.15 to 0.51; 9 studies, 834 participants; I² = 81%; low-quality evidence), and effects on information giving skills are uncertain (very low-quality evidence).

We are uncertain whether experiential interventions improve overall communication skills in comparison to didactic approaches (SMD 0.08, 95% CI -0.02 to 0.19; 4 studies, 1578 participants; I² = 4%; very low-quality evidence). Electronic learning approaches may have little to no effect on students’ empathy scores (SMD -0.13, 95% CI -0.68 to 0.43; 3 studies, 421 participants; I² = 82%; low-quality evidence) or on rapport (SMD 0.02, 95% CI -0.33 to 0.38; 3 studies, 176 participants; I² = 19%; moderate-quality evidence) compared to face-to-face approaches. There may be small negative effects of electronic interventions on information giving skills (low-quality evidence), and effects on information gathering skills are uncertain (very low-quality evidence). 

Personalised/specific feedback probably improves overall communication skills to a small degree in comparison to generic or no feedback (SMD 0.58, 95% CI 0.29 to 0.87; 6 studies, 502 participants; I² = 56%; moderate-quality evidence). There may be small positive effects of personalised feedback on empathy and information gathering skills (low quality), but effects on rapport are uncertain (very low quality), and we found no evidence on information giving skills.

We are uncertain whether role-play with simulated patients outperforms peer role-play in improving students’ overall communication skills (SMD 0.17, 95% CI -0.33 to 0.67; 4 studies, 637 participants; I² = 87%; very low-quality evidence). There may be little to no difference between effects of simulated patient and peer role-play on students' empathy (low-quality evidence) with no evidence on other outcomes for this comparison.

Descriptive syntheses of results that could not be included in meta-analyses across outcomes and comparisons were mixed, as were effects of different interventions and comparisons on specific communication skills assessed by the included trials. Quality of evidence was downgraded due to methodological limitations across several risk of bias domains, high unexplained heterogeneity, and imprecision of results.

In general, results remain consistent in sensitivity analysis based on risk of bias and adjustment for clustering. No adverse effects were reported. 

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