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Linköping Studies in Arts and Science • No. 565

At the Faculty of Arts and Science at Linköping University, research and doctoral studies are

carried out within broad problem areas. Research is organized in interdisciplinary research

environments and doctoral studies are mainly in graduate schools. Jointly, they publish the

Linköping Studies in Arts and Science series. This thesis comes from the Division of Health

and Society at the Department of Medical and Health Sciences.

Distributed by:

Department of Medical and Health Sciences

Division of Health and Society

Linköping University

SE 581 83 Linköping

Antje Lumma Sellenthin

Learning professional skills and attitudes.

Medical students attitudes towards communication skills and group learning.

Edition 1:1

© Antje Lumma SellenthinDepartment of Medical and Health Sciences, 2013

Published papers have been reprinted with the permission of the copyright holdersCover: “Sammanträdet – the meeting” by Kanevad Träsnideriet, Linköping

Printed in Sweden by LiU tryck, Linköping, Sweden, 2013

ISBN: 978 91 7519 759 3

ISSN: 0282 9800

ISSN: 1651 1646

CONTENTS

Acknowledgements ...................................................................................................................................... iii

1 INTRODUCTION AND BACKGROUND...............................................................................1

1.1 Communication and professional identity .......................................................................................2

1.2 Aims of the thesis ...........................................................................................................................4

1.3 Overview of the dissertation ...........................................................................................................5

2 COMMUNICATION SKILLS AND TEAMWORK – EDUCATIONAL GUIDELINES .....7

2.1 Guidelines for patient centered communication..............................................................................72.1.2 Historical perspective on patient centered communication models ................................................. 82.1.3 Patient centered communication skills.............................................................................................. 9

2.2 Guidelines for teaching teamwork skills and interprofessional competence...................................11

2.3 Summary ......................................................................................................................................12

3 TEACHING AND LEARNING – AIMS, METHODS, AND LEARNING PROCESSES.. 13

3.1 Aims of traditional and problem based learning approaches .........................................................13

3.3 Effects of problem based learning on learning outcomes...............................................................143.3.1 Problem based learning and patient centered skills........................................................................ 153.3.2 Problem based learning and teamwork skills .................................................................................. 153.3.3 Problem based learning and self regulation skills ........................................................................... 16

3.4 Teaching and learning communication skills ..................................................................................173.4.1 Teaching methods ............................................................................................................................ 183.4.2 Real and standardized patients ........................................................................................................ 193.4.3 Students’ difficulties with learning communication skills ................................................................ 20

3.5 Summary ......................................................................................................................................21

4 STUDENTS’ ATTITUDES TOWARDS PATIENT CENTERED COMMUNICATIONAND CARE ......................................................................................................................................... 23

4.1 Attitudes towards learning communication skills ..........................................................................244.1.1 Assessing attitudes towards communication skills learning – the “Communication Skills AttitudeScale” 254.1.2 Correlates of a positive attitude towards communication skills ...................................................... 25

4.2 Attitude towards patient oriented care.........................................................................................26

4.3 Attitudes towards group learning..................................................................................................284.3.1 Learning styles and preferences towards group learning ................................................................ 284.3.2 The theory of planned behavior ...................................................................................................... 29

4.4 Awareness of learning strategies...................................................................................................30

4.5 Summary ......................................................................................................................................31

5 THE STUDY ............................................................................................................................ 33

5.1 The video study ............................................................................................................................345.1.1 Study design ............................................................................................................................... ...... 345.1.2 Participants............................................................................................................................... ........ 34

5.1.2.1 Aims of the communication skills course......................................................................... 345.1.2.2 Procedure of a course lesson............................................................................................ 36

5.1.3 Data collection............................................................................................................................... ... 365.1.4 Ethical approval ............................................................................................................................... . 365.1.5 Data analysis............................................................................................................................... ..... 375.1.6 Methodological considerations........................................................................................................ 37

5.2 The survey study...........................................................................................................................385.2.1 Study design ............................................................................................................................... ...... 385.2.2 Participating medical schools ........................................................................................................... 38

5.2.2.1 Medical Faculty at the University at Witten/Herdecke ................................................... 395.2.2.2 Faculty of Health Sciences at Linköping ........................................................................... 405.2.2.3 Sahlgrenska Institute at the Swedish University of Gothenburg ..................................... 415.2.2.4 Medical Faculty at the Philipps University at Marburg..................................................... 41

5.2.3 Data collection............................................................................................................................... ... 425.2.4 Ethical considerations ...................................................................................................................... 425.2.5 Instruments ............................................................................................................................... ....... 42

5.2.5.1 Attitudes towards individual and group learning scale.................................................... 455.2.5.2 Metacognitive Awareness Inventory ............................................................................... 455.2.5.3 Communication Skills Attitude Scale (CSAS) .................................................................... 465.2.5.4 Patient Practitioner Orientation Scale............................................................................. 46

5.2.6 Data analysis............................................................................................................................... ...... 465.2.7 Methodological considerations........................................................................................................ 47

6 RESULTS ................................................................................................................................. 51

6.1 Study I .........................................................................................................................................51

6.2 Study II ........................................................................................................................................52

6.3 Study III .......................................................................................................................................53

6.4 Study IV .......................................................................................................................................54

7 DISCUSSION AND CONCLUSIONS .................................................................................... 55

7.1 Implications for educational practice............................................................................................57

7.2 Recommendations for future research .........................................................................................59

References ..................................................................................................................................................61

Appendix.....................................................................................................................................................81

PAPERS I IV

The following papers are presented in Part II:

I Hydén, L. C., & Lumma, A. (2007). Learning to talk and talking about talk:Professional identity and communicative technology. In S. Olin Lauritzen & L.C. Hyden (Eds.),Medical Technologies and the Life World: The social construction ofnormality (pp. 18 39). London: Routledge.

II Lumma Sellenthin, A. (2009). Talking with patients and peers: Medicalstudents’ difficulties with learning communication skills, Medical Teacher, 31(6), 528 534. Copyright © 2009, Informa Healthcare. Reproduced withpermission of Informa Healthcare.

III Lumma Sellenthin, A. (2012). Medical students’ attitudes towards groupand self regulated learning. International Journal of Medical Education, 3, 46 56.

IV Lumma Sellenthin, A. (2012). Students’ attitudes towards learningcommunication skills: correlating attitudes, demographic and metacognitivevariables. International Journal of Medical Education, 3, 201 208.

All included papers are used with permission of the copyright holders.

i

PART I

ii

iii

Acknowledgements

This thesis is the result of a couple of years of work and several breaks thatwere both creative and reflective. These were dedicated to family experience,including sleepless nights, and gave me the opportunity to live in twocountries. After having been a single exchange student in Sweden, I movedback to Germany after almost ten years, with a husband and three children.Therefore, first of all, I have to thank my family – Mark, Tim, Linnéa, Florian,and Raphael – for filling my days and nights with emotions, experiences, andurgent needs. Unexpectedly, after all, this time prepared me for finishing thisthesis. Of course, my warmest thanks are dedicated to my parents, BrigitteLumma and Bertold Lumma, and my brother Olaf, for always being there forme.

Concerning my time in Sweden, I first want to thank my supervisor, Dr.Jan Andersson, VTI, who already supervised my master’s thesis. You showedme the entrance to the world of academic research. Through all the years, youimpressed me with your phenomenal enthusiasm and motivating power, andwith your request for methodological fidelity, which is not one of my realstrengths. Then, I am grateful for having had Professor Lars Christer Hydén asa teacher. I actually remember parts of these lessons! I am really grateful foryour patience and constancy as my supervisor. Although my confidence mayhave fluctuated, I think that you always believed that my PhD. project wouldfind a happy end.

Remembering my start at Linköping University’s former “TemaKommunikation”, I want to say that the “00 or” group was a very nice gang ofdoctoral students. Even several years have gone by since then, I hope that you– Kristina Karlsson, Anna Kullberg, Sofia Seyfarth, and Emma Eldelin – alsorecall this time as special. There are more colleagues from that time whom Ireally would like to meet again – Pia Bülow, Viktoria Wibeck, Lina Larsson,Johanna Nählinder, Selina Mård, Ericka Johnson, and many others. At least,you, Linda and Elli, are still there.

In the course of the planning of the thesis and the data collection, Ireceived a lot of input from Prof. Claes Nilholm, School of Education andCommunication, Jönköping University, who was one of my supervisorsduring the first period. The idea of studying how medical students learn totalk with patients and the access to this field was initiated by Dr. PerGustavsson, of the Institute for Clinical and Experimental Medicine, and Dr.Mats Foldevi, Division of Community Medicine, both at Linköping University.I am especially indebted to all students, general practitioners, and other

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supervisors who allowed me insights into their struggles with the complextask of encountering patients. And I am likewise indebted to all the patientswho consented to participate in the video study. Also the survey was a projectthat demanded help from many quarters – the kind permissions of ProfessorEd Krupat, Harvard Medical School, Professor Charlotte Rees, Centre forMedical Education at the University of Dundee, and Professor GregorySchraw, Department of Education Psychology, University of Nevada, LasVegas, to use their questionnaires. Necessary translations were provided byNorman Davies of the Department of Culture and Communication. Theapplication of the resulting survey required the skillful editing of DanielFranzén, Franzén Consulting, Linköping. The survey study was financed bythe HSFR, the former Swedish Society for Research in the Humanities andSocial Sciences. My special thanks go to all students and course teachers inLinköping, Gothenburg, Marburg, and Witten/Herdecke who voluntarilyparticipated in the survey study, and helped with the data collection.

During the intermediate and the final seminars, I received valuablecomments with regard to data analysis and the structure of the thesis fromProfessor John Carstensen, Department of Medical and Health Sciences, andfrom Professor Madeleine Abrandt Dahlgren, Division of CommunityMedicine, Linköping University.

Although I only come to Sweden nowadays for the nice summers, somefriendships have survived. First of all, thank you, Robban, Line, and family forthe friendship that we have. Staffan, Suzanne, and all your kids – this thesiswould probably not have been finished without your encouraging words!Daniel, Sofie, and family – you have been there the whole long way andalways gave me shelter when I came to Linköping.

My very warm thanks to Margot Lundquist for reviewing my papers andthe dissertation. It feels good to know that you were able to understand myEnglish.

Since I have been living in Germany, many friends encouraged me tocontinue writing. In the final phase, Andrea had the perseverance andpatience to read the long version – thanks a lot for your comments!

It’s very likely that I forgot to include someone in my thanks, and I mayrecall them just when the thesis has been printed. I want apologize to you formy bad memory, and offer you my gratitude too!

1

1 INTRODUCTION AND BACKGROUND

On a backpacking tour through Vietnam, I happened to eat somethingthat caused the worst stomach ache I have ever had, and I had to visit a doctor.The sanitary conditions in Vietnamese hospitals are hard for us to imagine, butfor ten dollars I promptly met a doctor and we talked about my symptoms andprobably about my trip to Asia. He diagnosed an acute enteritis, probablycaused by parasites and gave me metronidazole, a type of antibiotic. I don’tremember his exact words but I do recall the quiet, unstressed atmosphere,and the feeling of trust in a totally strange place that I never would visitvoluntarily. It must have been something in the doctor’s way of talking andhis behavior that gave me a feeling of trust and safety. One week later, I hadmanaged somehow to return to my hometown in Germany and was admittedto the university hospital. I was locked up in an isolation room with the samediagnosis, and treated with the same antibiotics. However, the only person Irecall talking to there was the cleaning man who had to enter my room once aday. At this place, I felt much sicker than in Vietnam, and I really wanted to gohome as soon as possible.

A physician’s everyday work includes talking with patients. Thepatients have their own life situations, their emotions, and expectations abouthow they want to be encountered by a doctor. One of a doctor’s many tasks inthe clinical interview is to respect their “patients’ double needs”: “the need toknow and understand” about their medical conditions, and “need to berecognized and understood” in their personal situations (Engel 1988). Thus,core skills that future physicians need to acquire during their studies areinterest in and respect for their patients, and the readiness to share and explainmedical information with them.

Skillful communication with patients is a central aspect of a physician’sprofessional identity. However, acquiring a communication style thatrecognizes the patient as a person who is embedded in a life situation, andresponding to the patient’s complaints in an empathetic way, is a complex taskcompared to the acquisition of factual knowledge. Many students experiencethe training of “patient centered” consultations as a challenge that can causedistress and, in the worst case, result in the decay of an initially humanistic

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attitude. In contact with health care professionals from other specialties,communication skills also play an important role.

Teaching methods that involve group learning and demand self directedstudy strategies have aimed to facilitate acquisition of communication skills.These methods have been implemented consistently in problem basedlearning approaches. The learning outcomes of different teaching methodshave been evaluated in many studies. However, one aspect has been neglectedin research – the role of students’ attitudes towards developing theircommunication behavior, and towards being involved in group settings.Attitudes and personal values can be assumed to play important roles in theprocess that transforms a student’s identity into that of a physician.

1.1 Communication and professional identity

Professional attitudes and skills constitute the basis of a physician’sidentity (Armstrong 2002). Therefore, medical education aims at teachingprofessional responsibilities that range from individual, over interpersonal, topolitical levels (Archer et al. 2008; Arnold and Stern 2006; Cruess and Cruess2008; General Medical Council 2009; Hodges et al. 2011). In socioculturallearning theories, this socialization process has been described as acontinuously increasing participation in a community of practice (Wenger1998). In addition to its function of imparting values, the training of clinicalcommunication skills comprises characteristics of medical technologies, e.g.biomedical diagnostics. However, the development of a communication styleprobably involves more complex learning processes that are based onstudents’ reflections and evaluations of their behavior. This process alsodemands students’ independent regulation of their learning strategies andlifelong learning attitudes (American Board of Internal Medicine 2010; Duffyand Holmbroe 2006; Tomasello et al. 2005). The technical aspect ofprofessional communication includes the adoption of a language that is sharedwith colleagues. This professional language not only comprises a certainterminology, but also the use of language in a professional purpose, forinstance the posing of inquiring questions, the explanation of medical facts,and the structuring of interviews (Hydén and Lumma 2007).

The relationship between the patient and physician, including their rightsand obligations in the clinical encounter, is defined in theoretical models.These models determine how a certain communicative situation such as adiagnostic interview, or the breaking of bad news, should be performed.

3

Theoretical models reflect communicative ideologies and values concerningthe doctor patient relationship (Hydén and Lumma 2007). These have changedsubstantially during recent decades from a biomedical view on disease andhealth up until the 1950s, towards the biopsychosocial perspective on healththat is common today. This implies a shift of the clinical consultation frombeing a doctor and disease centered interrogation towards a patient centereddialogue that is aimed at fostering a trustful relationship between thephysician and patient. Communicative ideologies also apply to thecollaboration among health care professionals. Here, ideally, a stricthierarchical communication should be replaced by respectful interprofessionalcollaboration (American Board of Internal Medicine 2010; General MedicalCouncil 2009; Lauffs et al. 2008).

It has been suggested that the complex learning processes involving theformation of a professional identity should be made transparent for studentsand teachers (Armstrong 2002; Hydén 2001; Hydén and Lumma 2007; Newble1992; Niemi 1997). This means that medical education aims at increasingstudents’ awareness of their personal attitudes towards patient centeredcommunication and towards their appreciation of their colleagues.

The training of patient centered communication has been integrated intomany medical curricula, commonly in combination with learner centeredteaching methods such as problem based teaching approaches that aim atpromoting collaborative and independent learning (McLean and Gibbs 2010).However, despite training and theoretical instruction, some students are notinterested in learning communication skills, and their empathy towardspatients decreases after some study experience (Hojat et al. 2004; Hojat et al.2009; Ogur et al. 2007). Those aspects of doctor patient communication thatstudents perceive as difficult have been addressed in only a few studies. It canbe assumed that the nature of the subject – the adaption of certain values andideologies and the involvement of the students’ emotions – result in learningprocesses and problems that differ from other academic learning.

Differences are found between particular medical students’ interest inlearning professional attitudes and skills. Negative attitudes towards learningcommunication skills are recurrently expressed by male students, and bystudents without work experience in the health care sector (Rees and Garrud2001; Rees and Sheard 2003). Likewise, it is known that students’ willingnessto participate in learning contexts that aim at promoting professionalinteraction, e.g. in group learning, varies. However, there is little knowledgeavailable concerning relevant correlates, although an impact of contextualvariable has been assumed. However cognitive abilities – like the ability to

4

control one’s learning behavior – may also have an impact on students’motivation to engage in group situations (Cantwell and Andrews 2002). Thereare reasons to consider students’ study motivation as a more important factorfor their learning success than the effect of a particular teaching method(Albanese and Mitchell 1993; Norman and Schmidt 2000; ten Cate 2001). Untilnow, knowledge and assessment of medical students’ professional skills andattitudes have been insufficient (Stern 2005). Students who are aware of theirown and their peers’ attitudes tend to show more tolerance for their peers’preferences (Hendry et al. 2005).

In conclusion, it can be assumed that medical students considerpedagogical methods in their application to a particular medical program, inparticular those who apply to problem based curricula. Their attitudestowards group learning contexts may be influenced by their experience withgroup work prior to their academic studies, e.g. in the form of workexperience in the health care sector, or during secondary school education.Differences in traditions of teaching methods concerning group work arefound between Sweden and Germany. While Swedish schools aim atproviding equal opportunities for all children and use collaboration as animportant learning source, the German school system aims at early selectionwith a focus on individual support and competition between students.

1.2 Aims of the thesis

From the previous short background description, the aim of the thesis andthe research questions of the four included studies are formulated.

The thesis explored and identified typical difficulties that studentsperceive in the process of learning patient centered communication skills. Italso compared differences in students’ attitudes towards learningcommunication skills and towards group learning between students fromSwedish and German traditional and problem based medical faculties.

The four resulting papers focused on answering the following researchquestions:

1) How can medical students’ acquisition of communication skills bedescribed as adoption of a professional technology and as transformation into

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a professional identity, which difficulties do students encounter, and whichcoping strategies do they apply?

2) How can students’ difficulties and resources in the process of learningpatient centered communication skills be categorized?

3) Are students’ attitudes towards group learning related to demographicvariables and to students’ awareness of learning strategies? Do they differbetween students from traditional versus problem based curricula, andbetween Swedish and German students?

4) Are students’ attitudes towards learning patient centered communicationskills related to demographic variables, awareness of learning strategies, andthe appreciation of patient oriented care? Do they differ between studentsfrom traditional versus problem based curricula, and between Swedish andGerman students?

1.3 Overview of the dissertation

These research questions resulted in a twofold study design. Questions 1and 2 were approached with qualitative analysis of video data that had beencollected over a period of two academic terms. Research questions 3 and 4demanded a survey study that combined several existing questionnaires witha newly developed instrument for assessing students’ attitude towards grouplearning. The following chapters provide a literature review of the theoreticalfundaments and empirical evidences over the used concepts. Chapter 2presents educational guidelines and theoretical models of patient centeredcommunication skills, and educational guidelines for the teaching ofteamwork skills and interprofessional competence. Chapter 3 describestraditional and problem based learning approaches, and presents teachingmethods for communication skills, as well as studies that refer to students’difficulties with learning communication skills. Chapter 4 concerns students’attitudes towards the training of communication skills and towardsparticipation in group learning contexts. Empirical studies that comparestudents’ attitudes in traditional and problem based are presented. Chapter 5describes the performed studies, including the participating medical faculties,the applied questionnaires, the data collection, and qualitative and statisticalanalyses. In chapter 6, the study results are summarized, and chapter 7

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provides the discussion and conclusions, including implications foreducational practice and research.

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2 COMMUNICATION SKILLS AND TEAMWORK – EDUCATIONAL

GUIDELINES

Medical teaching should aim at educating socially accountable health careproviders (Woollard and Boelen 2012). This includes a patient centeredorientation including communication skills and the ability to participate inteamwork. National agencies set standards for the teaching of medical skills.The following section presents their guidelines for teaching patient centeredcommunication and teamwork skills.

2.1 Guidelines for patient-centered communication

Patients in Western countries have the legal right to receive individuallytailored information that enables them to give their informed consent todiagnostic and treatment measures (Kuehn 2009; Makoul 2008). These legalconditions imply that the relationship between physician and patient has to bebased on trust and equality. National associations and medical programs haveformulated guidelines concerning the doctor patient relationship (Associationof American Medical Colleges 1999; Makoul and Schofield 1999; Simpson et al.1991; Workshop Planning Committee 1992).

Unanimously, a partnership relation is regarded as the base of the patientdoctor relationship. This includes a balanced distribution of power and controlin the doctor patient encounter (BVMD 2006; General Medical Council 2009;Institute of Medicine 2001; Makoul 2001). The patient’s autonomy and hisrights, such as those that give informed consent to treatment decisions, and toreceive a second opinion, have to be respected. Communication should betailored individually and consider the patient’s “health literacy”, i.e. thedegree to which the patient can obtain, process, and understand the basicbiomedical information for making appropriate decisions (Makoul 2008).

As an example, the ethical guidelines formulated by the General MedicalCouncil, as the independent regulating agency of the UK, are cited (GeneralMedical Council 1993, 2009). In their guidelines “Good Medical Practice”, part

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of the “Tomorrow’s doctors” document, they define principles of the doctorpatient relationship (http://www.gmc uk.org/education/overview.asp). Theydemand that physicians recognize that

patients must be able to trust doctors with their lives and health.To justify that trust you must show respect for human life and youmust (…) work in partnership with patients, listen to patients andrespond to their concerns and preferences, give patients theinformation they want or need in a way they can understand, andrespect patients’ rights to reach decisions with you about theirtreatment and care (…). (General Medical Council 2009).

In a similar manner, the US Kalamazoo Consensus Statement (BayerFetzer Conference 1999), and in Canada the Toronto Consensus statement, setstandards for the physician patient relationship (Simpson et al. 1991). InSweden and Germany, the corresponding agencies are the Swedish Society ofMedicine, with the section for medical education (Swedish Society of Medicine2009, Swedish Association for Medical Education 2011), and the Germansociety for medical education (Gesellschaft für Medizinische Ausbildung 2003,no official English title). In 2006, core competencies were formulated for futureGerman physicians and a European consensus statement was published(BVMD 2006; IFMSA 2006).

For medical education, these overarching principles of the doctorpatient relationship have to be translated into theoretical models, which arepresented in the next section.

2.1.2 Historical perspective on patient-centered communication models

The principles of the patient doctor relationship have to be applied topractical situations, for instance in clinical interviews. The doctor’spredominant purpose in the clinical interview is to gather diagnosticinformation, to offer expert knowledge, and to make decisions in theirpatient’s best interest (Haas and Shaffir 1991). The patient seeks help andadvice. This constellation promotes an asymmetrical relationship between thephysician and the patient. Moreover, high moral expectations and hopes of thepatient support a “doctor ”, and “disease ” centered consultation style, wherethe doctor controls the encounter (Haidet et al. 2002; Krupat 1999). Theconsultation style that is demanded by the ethical principles mentioned above,in contrast, presupposes the physician’s willingness to share information andcommunicative power with the patient and to acknowledge the patient as anequal partner. In an equal relationship, the patient can fill her/his cognitive

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“need to know and understand” and the affective “need to feel known andunderstood” (Engel 1988).

Up until the 1950s, doctor and disease focused clinical interviewspredominated, favored by a biomedical perspective (Armstrong 2002). Sincethen, societal and scientific developments, such as technical developments(Conrad 2005) and the change towards marketplace competition andconsumerism have promoted the shift towards patient oriented relationshipsand communication (Conrad and Leiter 2004; Mechanic 2002).

In the 1950s, Balint introduced a humanistic and psychodynamic view ongeneral practitioners’ interaction with patients (Balint 1957). This was followedby a shift from a biomedical understanding of health and disease towards abio psychosocial view. This holistic perspective requires the doctor’s interestin the patient’s life context and considers the impact of the patient’sbiomedical conditions on everyday functioning (Engel 1977). The firsttheoretical model that defined doctor patient communication from a holisticperspective was the “patient centered clinical method” (Levenstein et al. 1986).Several theoretical concepts followed (Lipkin, Putnam and Lazare 1995;Pendleton et al. 1984; Roter and Hall 2006). Today, the ill patient is not onlyviewed in terms of deficiencies of single body parts, but as a person embeddedin a life world that consists of complex relationships between physical andmental systems (Armstrong 2002). Consequently, patients have a more activerole towards the health care system, organize themselves in self help groups,and strengthen their expert position by actions like using the internet.

A patient centered consultation style has positive effects on patients’health and well being (Simpson et al. 1991; Stewart 1995; Stewart et al. 2000). Itis also associated with better adherence to treatment and improved healthoutcomes (Stewart et al. 2000), higher patient satisfaction (Krupat 1999; Haidetet al. 2001), and improved recall and understanding of information (Kurtz etal. 1999). Conversely, ineffective doctor patient communication is associatedwith malpractice claims and suits (Kurtz, Silverman and Draper 2005;Levinson 1994; Levinson et al. 1997; Makoul 2008). It is assumed that theinfluence of doctor patient communication on health is caused by increasedtrust and treatment adherence, self care, and management of emotions (Streetet al. 2009).

2.1.3 Patient-centered communication skills Theoretical models are the basis of communication skills instruction. They

result in teaching contents that are commonly expressed in a set ofcommunication skills. In 1999, leaders and representatives from medical

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education organizations formulated a set of essential elements in physicianpatient communication that serve as a framework for teaching, assessment,and evaluation of educational programs (Makoul 2001). According to thisframework, patient centered interview should include these elements in thetemporal agenda presented:

1. Building the doctor patient relationship2. Opening the discussion3. Gathering information4. Understanding the patient’s perspective5. Sharing information6. Reaching agreement on problems and plans7. Providing closure(Makoul 2001).

From this framework, communicative skills have been derived that arerecommended for all medical specialties (Maguire and Pitceathley 2002;Stewart et al. 2003). These include:

1. Eliciting the patient’s main problems and perception of these, as well as thephysical, emotional and social impact of the patient’s problems on his/her lifesituation2. Tailoring information to the patient’s needs and checking his/herunderstanding3. Eliciting the patient’s reactions to the information given4. Assessing the patient’s wish to participate in decisions5. Discussing treatment options with the patient in an understandable way6. Maximizing the chance that the patient will comply with the decisions abouttreatment and advice concerning changes in lifestyle.

With some variations, courses in communication skills instruction aim atteaching precisely these skills. Vivid examples of patient centered interviewsare provided in the literature (Haidet and Paterniti 2003; Stewart 2001). Whenpatient centered approaches are adapted to particular clinical contexts,different aspects may be accentuated (Hudon et al. 2012). However,discrepancies between academic standards and medical practice are common.In practice, the use of patient centered communication can be restricted bymany contextual factors, such as time constraints and economic or personalresources.

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Communication and interaction are not only core elements of therelationship between the physician and the patient. They also characterize thecollaboration among health care professionals. The following section presentseducational guidelines concerning medical students’ teamwork competencies.

2.2 Guidelines for teaching teamwork skills and interprofessional competence

Communication and collaboration between health care practitioners areessential for good medical care, particularly in the context of inpatienttreatment. Therefore, teaching teamwork skills is a central aim of medicaleducation (World Health Organisation 1988). National educational standards,in particular the UK ethical “Good Medical Practice” guidelines, emphasizethe relevance of teamwork among health care professionals. They recommendfor doctors that “(…) you must: (…) work with colleagues in the ways thatbest serve patients’ interests” (General Medical Council 2009). Under theheading “working in teams”, they state that

most doctors work in teams with colleagues from otherprofessions. (…) Working in teams does not change your personalaccountability for your professional conduct and the care youprovide. When working in a team, you should act as a positiverole model and try to motivate and inspire your colleagues. Youmust: a) respect the skills and contributions of your colleagues; b)communicate effectively with colleagues within and outside theteam (…) (General Medical Council 2009).

Likewise, the ability to engage in teamwork is listed as a corecompetence in German and European consensus statements (BVMD 2006;IFMSA 2006). For Germany, no guidelines are available yet, but a positionpaper is to be published at the end of 2012. Most medical programs alreadyinclude the development of teamwork skills in their educational aims.

An important aspect of teamwork is interprofessional collaboration thatrefers to ‘‘occasions when two or more professions learn with, from, and abouteach other to improve collaboration and the quality of care’’ (Barr et al. 2005).Interprofessional collaboration fosters patient centered care by promoting theactive participation of different disciplines and the continuous respectfulcommunication among caregivers (Oandasan and Reeves 2005). Collaborationshould be based on interprofessional competence, i.e. knowledge andunderstanding of one’s own and other team members’ professional roles,

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comprehensions of teamwork, and of patient care (Hallin et al. 2009; Hargie etal. 2010; Lauffs et al. 2008). Preferably, the teaching of collaborationcompetence should include peer supported learning as the pedagogicalmethod, as it prepares for the transfer from academic to clinical settings, andinvolves multiprofessional teams (Paice and Heard 2003; Thistlethwaite andMoran 2010). The teaching of teamwork skills has not been formalized to thesame extent as have consultation skills.

2.3 Summary

Principles and standards for teaching patient centered communication andteamwork skills are defined by national medical education agencies.Theoretical models and sets of communication skills have been formulated forthe teaching of patient centered communication. Teamwork skills, in contrast,tend to be taught as implicit expertise in multi professional learning settings.

Emphasis on patient centered communication and teamwork entailed theintroduction of particular educational methods, especially problem basedlearning approaches. The characteristics of traditional and problem basedlearning and their effects on patient centered communication and teamworkskills are compared in the next section. The following chapter also presentsinstructional methods for communication skills instruction and illuminatesfindings about students’ difficulties with learning about patient centeredconsultations.

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3 TEACHING AND LEARNING – AIMS, METHODS, AND LEARNING

PROCESSES

During recent decades, teaching methods have been implemented in manymedical curricula that aim at fostering communication and group work skills.Driven by national guidelines, reforms have focused on integrating clinicalskills in early study phases and using clinicians as teachers (General MedicalCouncil 1993). The introduction of problem based learning methods had thegreatest impact on medical education (Barrows and Tamblyn 1980).

3.1 Aims of traditional and problem-based learning approaches

Traditional medical education implies outcome based, predefined goalsthat are pursued with teacher structured instructional methods, like lecturesand individual textbook reading (Rees and Richards 2004). Traditionalcurricula divide studies into a preclinical phase that aims at teaching thescientific basics of medicine, and a clinical phase in which students startworking with clinical cases, including patient contacts. Thus, during the firstterms, academic education focuses on the acquisition of factual knowledgeand practical skills. As in most countries, this curricular model waspredominant in Sweden and Germany until the 1980s.

The exclusive focus on individual, predefined, and teacher structuredlearning has several shortcomings. It complicates the students’ transition fromuniversity to working life, i.e. it induces a “practice shock” between academicformation and the first working experience (Hussey and Smith 2002).Moreover, traditional teaching methods are not adequate for adopting patientoriented professional attitudes and skills. In order to cope with theseproblems, teaching approaches were developed in the 1960s that emphasizethe student’s active role in the learning process, and that resulted in the designof problem based learning approaches (Barrows and Tamblyn 1980).

The pedagogical basis of problem based learning is student directed, casebased experiential learning in small groups that fosters the adoption of a

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humanistic approach to medical care (Archer et al. 2008; Arnold and Stern2006; Branch et al. 2001; Cruess and Cruess 2008; Dolmans and Schmidt 1996;Dolmans et al. 2005). Small groups work on clinical cases using self directedliterature searches and group discussions. Students’ learning efforts aresupported by teachers who do not serve as expert instructors, but rather asfacilitators and advisors (Harden, Sowden and Dunn 1984; Ludmerer 2004;Lycke, Grøttum and Strømsø 2006). In contrast to traditional medical curricula,problem based learning integrates study contents vertically, i.e. basic scienceand clinical cases are presented simultaneously. This interconnection ofbiomedical knowledge and clinical problems is assumed to stimulateprofound learning and understanding of biomedical principles and to fosterlifelong learning (Dahle et al. 2002). Problem based learning also implies ahorizontal integration of medical specialties, which means that different bodysystems are presented together, as they also occur in clinical practice.

Problem based learning approaches presume that learners develop theirabilities in interpersonal relationships and interactive learning (Rees 2004).They are also aimed at educate educating students as effective collaboratorsand to at developing their self directed learning skills (Candy 1991; Dolmanset al. 2005; Hmelo Silver 2004; Howe 2001; Lycke, Grøttum and Strømsø 2006;Vermetten, Vermundt and Lodewijks 2002). This results in “dynamic, complexand unstable” learning processes (Barrows and Tamblyn 1980; Bleakley 2006),and stimulates experiential and reflective learning, as well as the socialconstruction of knowledge (Gibbs, Olckers and Duncan 2007). Qualitativeanalyses of student interactions showed that discussions in problem basedgroups actually involve the intended collaboration and self directed learningprocesses (Visschers Pleijers, Dolmans and Wolfhagen 2005; Yew and Schmidt2009). Today, problem based learning approaches are complemented byexperiential methods that include electronic media, like video teaching andweb based learning.

3.3 Effects of problem-based learning on learning outcomes

Studies that compare traditional and problem based curricula havemainly focused on differences in learning outcomes in terms of knowledge,clinical skills, or other competencies in traditional and problem basedcurricula (Vernon and Blake 1993). As a disillusioning result, no generalsuperiority of one teaching method over the other could be assessed (Albanese

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and Mitchell 1993; Norman and Schmidt 2000; Schmidt, Vermeulen and vander Molen 2006; Smits et al. 2003). However, detailed studies found differencesin certain subject areas. One finding was that problem based learningpromotes active and self directed learning (Lycke, Grøttum and Strømsø2006). In a comparative study in Norway, students enrolled in curricula withintegrated teaching methods reported throughout their study time bettercommunication skills than students in a traditional curriculum (Gude et al.2005).

3.3.1 Problem-based learning and patient-centered skills Training of communication skills at an early study phase combined with

interactive and self directed learning is regarded as an effective teachingmethod (Barrows and Tamblyn 1980; Candy 1991; Christianson et al. 2007;Dolmans et al. 2005; Schmidt, Vermeulen and van der Molen 2006). Inparticular, the possibility to learn through role modeling, a non threateninglearning environment, and contact with patients with a variety of problems,foster a humanistic approach to care if they allow deep and critical reflection(Branch et al. 2001).

3.3.2 Problem-based learning and teamwork skills Collaborative learning demands the students’ active exploration of the

study material and its discussion with peer students. Such learning contextsare regarded as beneficial for the training of teamwork skills. Small groupwork is especially effective if it pursues common goals and combinesresponsibility for one’s own as well as for the group’s learning outcome(Blumenfeld et al. 1996; Johnson and Johnson 1991; Johnson and Johnson 2000;Slavin 1990). However, students are active participators in the learningprocess, and their conceptions of learning may moderate the impact ofteaching approaches on learning outcomes. Students who entered problembased curricula were found to be more aware of the importance ofconstructivist learning – e.g. cooperative learning – for their study success,compared to students in traditional curricula (Hendry et al. 2006; Loyens,Rikers and Schmidt 2009). These cognitive conceptions of learning can fosterthe development of long term oriented skills, like a lifelong learning attitude.

There are more differences between students enrolled in problem basedprograms and students in traditional curricula. Students from problem basedschools show higher appreciation for peer discussions as a learning resourcethan students from traditional schools (Lycke, Grøttum and Strømsø 2006),

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and graduates from problem based medical schools rate themselves higher oninterpersonal competencies. These competencies include their teamworkability, cognitive skills, self directed learning, and partly their generalacademic competencies, like writing reports, and task supportingcompetencies such as efficient planning skills (Schmidt, Vermeulen and vander Molen 2006). They are reported to possess better communication skillsthan students from traditional schools (Santos Gomez et al. 1990).

Students from the medical faculty at Linköping – who were instructedtogether with other health care students during the first ten weeks of theirstudies – reported more confidence in their abilities to co operate with otherhealth care professions (Faresjö et al. 2008), and showed a greater openmindedness about cooperation with other health care professions(Wilhelmsson et al. 2011). Female students were more positive than malestudents towards teamwork.

3.3.3 Problem-based learning and self-regulation skillsContinuous increase in knowledge and developments in diagnostic and

medical treatment demands that future doctors commit themselves to alifelong learning attitude (Li et al. 2010), which is included as a goal of medicaleducation in the physician charter on medical professionalism (Blank et al.2003; Candy 1991; American Board of Internal Medicine 2010). A keycompetence of lifelong learning is the ability to self regulate one’s learningactivities (Blumberg 2000; Dolmans and Schmidt 1996; Li et al. 2010; Nota,Soresi and Zimmerman 2004; Zimmerman and Schunk 1989). The concept ofself regulation embraces cognitive, motivational, affective, behavioral, andcontextual factors (Boekarts 1996; Heikkilä and Lonka 2006; Pintrich, Woltersand Baxter 2000; Schraw 2006; Zimmerman and Schunk 1989). These refer to aperson’s ability to “set task related, reasonable goals, take responsibility forhis or her learning, and maintain motivation” (Heikkilä and Lonka 2006,p.101).

Thus, self regulation is the ability to plan, monitor, and evaluate one’sown learning processes. Self regulated learning includes asking oneselfquestions such as: ‘‘What information is relevant and where do I find it?’’,‘‘When will I know that I understand a subject?”, or “How can I organizeinformation?’’ (Graesser, Halpern and Hakel 2008). Monitoring one’s mentalactivities means applying a metacognitive perspective, being aware of one’slearning strategies, evaluating their efficacy, detecting mistakes, and changingto more effective strategies (Metcalfe 2009). This kind of self awareness can beimproved by training (Volet 1991). In academic learning, core metacognitive

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aspects of self regulation are a person’s knowledge of cognition (e.g. abouttheir learning strategies), and her/his regulation of cognition (i.e. the use oflearning strategies) (Flavell 1979; Nelson 1996; Schraw and Dennison 1994)

Problem based learning approaches are aimed at promoting the selfregulation of learning, as students are required to formulate personal studygoals and evaluate their learning progress (Cutting and Susswein Saks 2012;Hussey and Smith 2002). In a qualitative study, beginning students in aproblem based program showed different personal styles in adopting selfdirective learning strategies (Evensen, Salisbury Glennon and Glenn 2001).Students in problem based learning programs are more likely to use selfregulating learning strategies than students in traditional courses, and areassumed to have better self directed learning skills (Lee, Mann and Frank2010; Lycke, Grøttum and Strømsø 2006; Ozuah, Curtis and Stein 2001;Schmidt, Vermeulen and van der Molen 2006; Shin, Haynes and Johnston1993; Vermetten, Vermundt and Lodewijks 2002).

However, not all medical students are interested in group learning andself directing study. Among veterinary students, a strong preference forindividual and teacher directed learning was observed (Raidal and Volet2009). These students perceived group work and self directed learning asunnecessarily complicated and mentally stressful conditions of their studysituation and reported little earlier positive experience with collaborative andself directed learning. In other studies, students argued that group work andself directed learning have no relevance in medical practice (Hendry et al.2005; Hendry et al. 2006; Newble 1992; Woloschuk, Harasym and Temple2004). Good self regulatory skills were found to be related to a preference forgroup learning contexts (Cantwell and Andrews 2002; Lycke, Grøttum andStrømsø 2006; Raidal and Volet 2009). The complexity of group situations maybe perceived as a positive challenge by students with good metacognitiveskills.

3.4 Teaching and learning communication skills

Until now, no international standards have existed for the instruction ofpatient centered communication, but in practice, certain teaching methods arecommon. One characteristic is students’ experience with clinical settings andpatient contact. Encounters with patients and colleagues in clinical contexts

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help students to grow into the community of physicians and adds relevance totheir academic studies (Wenger 1998). In the interaction with patients, clinicalexperience provides students with confidence and promotes their selfreflection, which helps them to acquire communication skills (Dornan et al.2006).

Patient centered communication goes beyond the gathering of informationabout the patient’s medical condition. It aims primarily at building a solidrelationship between patient and physician (Platt et al. 2001). This demandscertain attitudes on the part of the physician – i.e. empathy and opennesstowards the emotional content of the patient’s story, as well as conversationaltechniques, such as asking the right kind of questions and assuming a specialbody posture (Hydén and Lumma 2007). These multidimensional capabilitiesdemand an “integration of knowledge, skills, and attitudes” (Merriënboer andKirschner 2007) that has to be learned in practical training. In general, thepractical training of communication skills improves communicationperformance (Aspegren 1999; Kurtz and Silverman 1996; Ottoson 1999), andsupports students’ personal conceptions of communication skills (Loureiro etal. 2011). In particular, students who start with relatively poor communicationskills – more often male than female students – benefit from training(Aspegren 1999). Male students are considered to be slower in learningcommunication skills than female students (Branch et al. 2001; McLean andGibbs 2010).

3.4.1 Teaching methods Guidelines for the acquisition of communication skills are often included

in medical faculties’ study aims. However, even if conceptual frameworksexist to define desirable communication skills (Smith et al. 2000), a lack ofclarity and consistency concerning contents and assessment methods has beencriticized (Cegala and Lenzmeier Broz 2002), and teaching guidelines tend tohave low empirical evidence (Veldhuizen et al. 2007). The teaching ofcommunication skills is characterized by a great variety; while some coursesaim at teaching general communication skills, others use checklist formats ofparticular skills that can be applied for teaching and assessment (Humphris2001).

Effective communication skills training programs should last for at leastone day and be learner centered (Berkhof et al. 2011). Longitudinal traininghas proven more effective than massed instruction (vanDalen et al. 2002). Itshould also be continued during the whole period of medical studies (Ottoson1999), as the positive effects of communication skills courses tend to erode

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after the end of formal instruction (Cantwell and Ramirez 1997; Hojat et al.2004; Spencer 2004). Courses that contain these principles have beenintegrated into many medical schools during recent years (Schultz et al. 2007).

Students benefit from instruction if it involves practical communicationskills training, includes visits in health care contexts, and is integrated earlyinto medical education (Koponen, Pyörälä and Isolatus 2012). Effectiveteaching of communication skills has to be experiential and start from definedproblems (Aspegren 1999). However, even if theoretical lectures are ineffectiveas exclusive teaching methods, a model should be used for illuminating therelevance of patient centered communication for clinical practice (Williams etal. 1997). The practical training can be performed in contact with real orsimulated patients, or role playing with peers. It should be commented uponby individual feedback, and reflected in small group discussions (Berkhof etal. 2011).

The practical training should include supervised discussions and personalfeedback that support a deep understanding of the underlying ethicalprinciples (Niemi 1997; Skelton 2005), and students’ self regulation of thelearning process (Cutting and Susswein Saks 2012). The involvement of peerstudents and clinical practitioners provides rich sources for discussion ofstudents’ experiences and for finding coping strategies for difficult situations(Hydén and Lumma 2007; Lumma Sellenthin 2009). Students who receivedtraining in professional development were also observed to show bettercommunication skills compared to those of students in traditional curriculawithout professional skills training (Joekes et al. 2011).

3.4.2 Real and standardized patients The training of clinical interviews can involve different kinds of patients –

“real” patients encountered in clinical contexts or, most commonly, simulatedpatients. These can be laymen or professional actors, who have beenthoroughly rehearsed to present a standardized medical condition or difficultinterview situation; these are also called standardized patients (Cleland, Abeand Rethans 2009; Nikendei et al. 2007). Standardized patients can be trainedto give consistent responses, their presentation can be matched to the students’needs and they can be used in emotionally sensitive situations, such as for thebreaking of bad news. Which kind of patient is used for instructional purposesis determined by many factors, including the purpose of teaching orassessment, the desired degree of standardization, the emotional sensitivity ofthe student patient encounter, as well as costs and availability (Collins andHarden 1998).

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There are also advantages with in meeting real patients. Even if thesecontacts cannot be standardized, students tend to appreciate the involvementin community contexts (Rolfe et al. 1999; Wilkinson, Gower and Sainsbury2002). From a sociocultural perspective on learning, participation in workcontexts can increase students’ feelings of personal accountability andinvolvement, and promote their motivation for academic study (Wenger 1998).However, in some cases, ethical problems can arise with real patients whomay feel coerced to participate but are too polite to refuse participation ineducational situations (Rees and Knight 2008).

As the adoption of communication skills is a complex process thatinvolves practical experience, personal feedback, and reflection, many medicalstudents struggle with developing and improving their communicationbehavior.

3.4.3 Students’ difficulties with learning communication skills

Patient centered communication implies a psychosocial perspective onhealth and illness, i.e. a caring attitude towards the patient. A caring attitude isexpressed as an empathic interest in the patient’s life situation, and respect forher or his emotions and cognitions regarding illness and health. Even ifstudents appreciate patient centered concepts, they can experience problemswith being open towards the patients’ life situations (Royston 1997;Thistlethwaite and Jordan 1999). Students’ difficulties with acquiring andmaintaining psychosocial elements of patient centered communication, inparticular the adoption of an empathetic attitude, have been reported (Holm1995). After the end of formal teaching, students can even show a decreasedempathy towards patients (Hojat et al. 2004; Spencer 2004), and a tendency toavoid psychosocial issues (Craig 1992; Williams et al. 1997). Unfortunately,study experience seems to impede patient centered attitudes, i.e. studentsenrolled in later terms tend to show a more cynical attitude towards patients(Griffith and Wilson 2001). Communication techniques that foster the patient’sfree report, i.e. the use of open, exploratory questions, can be difficult toacquire (Lumma Sellenthin 2009), and tend to diminish after the end oftraining (Cantwell and Ramirez 1997).

The establishment of an empathetic relationship with patients can causeambiguous feelings (Nogueira Martins, Nogueira Martins and Turato 2006).In a study with fifth year students, they described themselves as highlydependent on positive responses from their patients for their efforts to showempathy and care and worried that they would not be able to maintain a

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patient centered attitude in the future. When confronted with patients wholived under difficult personal circumstances, the students mentioned feelingsof helplessness and high moral accountability. Ambiguous feelings towardstheir patients can be an expression of students’ ethical and emotionaldilemmas. Four basic issues in student patient interviews that can causedistress were identified: a one sided focus on “pathology versus health”, atension between “not knowing versus too much knowing”, the students’ ownemotional “vulnerability versus denial” of the patient’s emotional suffering,and a tendency to “react versus to be inactive” towards the patient’sexperiences (Rosenfield and Jones 2004). Students can solve these dilemmas byfocusing on their own emotional reactions as a diagnostic and therapeuticresource. Awareness of these possible pitfalls can help student to establish abalanced and empathetic attitude towards the patient and to develop theirprofessional identity. The importance of awareness towards ethical principlesfor patient communication was already discussed in the 1980s (Barnard 1986).It was recommended to combine education in communication skills and moralprinciples, and to consider their overlap and mutual reinforcement. Relevantissues in the contact with patients can be beneficence and non maleficence,respect for persons, and justice.

In general, physicians who feel stressed in the encounter with patients,they worry that the exploration of the patient’s problems might take up toomuch time, also increase the patients’ distress. As a consequence, physiciansmay exhibit behavior that blocks the patients’ further emotional discloses, andgive advice before the patient has brought up a central problem, or explainaway the patient’s emotions by focusing on physical symptoms (Maguire andPitceathley 2002). Thus, the training of communication skills has to reflectstudent’s perceived emotional distress and to explore their worries. In theeducational situation, students can become aware of moral and emotionaldilemmas that they have to cope with.

3.5 Summary

Problem based learning methods are regarded as more effective inteaching patient centered and teamwork skills than traditional, lecture basedinstruction is. The pedagogical basis of problem based learning is studentdirected, experiential learning in small groups that fosters the adoption of ahumanistic perspective. Involvement in clinical and community contexts,patient contact, and communication skills training are included at an early

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study phase. Problem based learning fosters collaborative learning anddiscussions among peers, is associated with better communication skills thantraditional instruction, and promotes the use of self directed learningstrategies.

Effective communication skills instruction combines practical trainingwith individual feedback on performance, and group discussion that is basedon theoretical models, and is integrated into the curriculum over a long timeperiod of time. The use of real or standardized patients is common, and bothentail advantages and shortcomings. Students tended to perceive the focus onpsychosocial topics and the adoption of an empathetic attitude as problematic.Ethical dilemmas and emotional helplessness towards the patient have beenidentified and reflected upon in communication skills training.

The next chapter illuminates students’ attitudes towards learning patientcentered communication that are an important motivational factor in thelearning process, and summarizes research about difficulties that studentsmay encounter in learning to talk with patients.

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4 STUDENTS’ ATTITUDES TOWARDS PATIENT-CENTERED COMMUNICATION

AND CARE

Learning processes can be divided into three dimensions: cognitivelearning, affective (or motivational) learning, and metacognitive regulation.Student centered curricula should consider all dimensions, but until now,curriculum designers tend to undervalue educational components that fosterstudents’ learning motivation. Although problem based learning methodsinvolve student centered learning, they are primarily aimed at promotingcognitive and metacognitive processes, like self regulated learning. However,the cognitive dimension of learning processes may not be the most sensitivedeterminant of successful learning. Medical students can be generallyregarded as capable learners and high achievers. They are able to adapt theirlearning behavior to situational demands like assessment requirements (Cooket al. 2009). Thus, their learning outcomes may not depend primarily on theteaching method but on students’ active approach towards teaching andassessment conditions, i.e. their motivation to use learning strategies(Entwistle 1991; ten Cate 2001).

If effective learning depends less on the applied pedagogical approachesand course contents than on students’ perception of, and active approachtowards the learning conditions, it is important to fostering students’ intrinsicmotivation. This requires support of their autonomy and emotional wellbeing, as well as adequate feedback (Kusurkar et al. 2012). Students’perception and evaluation of their learning conditions and contents entailsbeliefs about the pleasantness and usefulness of elements like group work, andabout intentions like improving their communication behavior. The sum of aperson’s evaluations adds up to the psychological concept of someone’s“attitude”. Attitudes influence how we think, feel, and behave. Aspsychological constructs, they comprise affective evaluations, cognitive beliefs,behavioral routines, and intentions to perform a behavior. The affectiveattitude aspect comprises feelings of like and dislike. It is regarded as theattitude dimension that is most susceptible to external influences, i.e. newexperience. Cognitive beliefs and values, on the contrary, tend to be morestable over time, but can be changed by reflection, deep insights, and criticalappraisal (Fishbein and Ajzen 2010; Schüffel 1983). The strongest impulse for

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the actual exertion of a behavior is the intention to perform it (Francke,Garssen and Huijer Abu Saad 1995).

In educational processes, the role of attitudes is complex. However, inmedical education, attitudes have been regarded as critical for the actual use ofan expertise in clinical practice (Newble 1992). Thus, it can be assumed that apositive attitude towards group learning and patient centered communicationincrease students’ motivation to apply these capabilities in the patientencounter. If medical studies aim to reform students’ attitudes towardspatient centered consultations and towards collaborative learning settings,they should be assessed and discussed at an early study stage. Congruent withthis consideration, a need to assess medical students’ attitudes towardsprofessional skills training was stated in a recent study (Anvik et al. 2007b).Assessment instruments such as questionnaires that refer to students’ patientorientation and their attitudes towards communication skills training arepresented in the next section (Krupat, Hiam and Fleming 1999; Rees, Sheardand Davies 2002). These instruments were used in the survey study that waspart of the thesis.

4.1 Attitudes towards learning communication skills

Patient centered doctor patient communication as an academic subject isaimed at teaching a particular behavior on the basis of predefined values andideologies and, in addition, it demands a certain degree of emotionalengagement. Effective teaching of communication skills presumes thatstudents recognize that their communication skills are an important clinicalcompetence that they should improve during their studies.Unfortunately, students’ and clinicians’ appreciation of communication skillsas a full fledged academic subject in which students can succeed or fail is stilltoo low. This is reflected in the insufficient allocation of curriculum time,economic budget, and personal resources like tutors, and recruitment ofsimulated patients from minorities (Hargie et al. 2010). Negative attitudestowards learning communication skills are common (Flaherty 1985; Parle,Maguire and Heaven 1997; Rees and Sheard 2003; Smith et al. 2000). Somestudents were found to assert that they do not recognize communication skillstraining as an academic subject (Rees and Garrud 2001), or that they do notperceive a need to improve their personal communication performance(Batenburg and Smal 1997; Cleland, Foster and Moffat 2005).

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4.1.1 Assessing attitudes towards communication skills learning – the “Communication Skills Attitude Scale”

An instrument for assessing medical students’ attitude towards learningcommunication skills that has been applied in numerous studies is the“Communication Skills Attitude Scale” (CSAS) (Rees, Sheard and Davies2002). The questionnaire comprises two scales. The ”Positive Attitude Scale”(PAS) refers to students’ appreciation of communication skills as an academicsubject, as well as to their beliefs about respect for the patients’ rights andabout the importance of communication with patients and colleagues. In aNorwegian study, another factor structure of the CSAS items was found thatdifferentiates between affective and cognitive dimensions of doctor patientcommunication (Anvik et al. 2007a; Anvik et al. 2007b).

Recurrent findings are that female students express more positiveattitudes towards learning communication skills. Moreover, students withpersonal work experience in health service, and students whose parents do notwork in health care, tend to be particularly positive (Batenburg and Smal 1997;Cleland, Foster and Moffat 2005; Koponen, Pyörälä and Isolatus 2012; Reesand Sheard 2002; Tsimtsiou et al. 2007). The relationship between gender andpatient oriented attitudes and behavior has been confirmed in other studies.Examples are that female students show more empathic behavior throughoutmedical education (Hojat et al. 2004; Lumsden et al. 2005). Female primarycare physicians engage in more patient centered communication and havelonger visits than their male colleagues (Roter, Hall and Aoki 2002).

A decline in students’ attitudes towards learning communication skillswas observed in several studies (Cleland, Foster and Moffat 2005; Rees andSheard 2002). Communication skills training can be perceived as emotionallychallenging, which can result in lower attitude scores on the CSAS after recentparticipation in communication skills courses (Anvik et al. 2007b; Rees andSheard 2003). There seem to be ”at risk” medical students who are particularlyvulnerable to losing their sense of empathy (Lumsden et al. 2005).

4.1.2 Correlates of a positive attitude towards communication skills

Some students are critical towards learning communication skills at thebeginning of their studies. However, attitudes towards learning patientcentered communication generally tend to decrease after some studyexperience, typically during or after the third study year (Hojat et al. 2009;

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Power and Lennie 2012). It has been argued that students in traditionalcurricula spend most of the time in their early study phase with biomedicallectures and in anatomy laboratories, which might contribute to their lowerappreciation of communication skills learning during the second and thirdstudy years, as compared to the beginning of their studies (Cleland, Foster andMoffat 2005). The best remedy for a decline of patient oriented attitudes seemsto be the early training of communication skills or the integration ofprofessional development training, and contact with clinical environments(Baerheim et al. 2007; O Sullivan et al. 2012; Tsimtsiou et al. 2007). Aninfluence of personal experience with clinical environments before theiracademic studies on students’ conception of the doctor patient relationshipwas found (Hendry et al. 2006).

The use of patient centered communication is not only determined by thephysician’s intentions. Restrictions that result from explicit and implicit normsthat are inherent to the organization of health care influence actual behavior.Explicit norms are, for instance, represented in the time that is allocated for theinterview, or the amount of money that the physician earns with a diagnosticinterview. Implicit evaluations are inherent to clinical routines and in clinicalteachers’ attitudes and behaviors. The impact of the structure of the healthcare system on students’ interest in training their communication skills wasexplored in a large scale study (Van den Brink Muinen et al. 2003).Consultation styles in different European countries were compared. Nodifferences in medical communication were found between countries wheregeneral practitioners have a gate keeping role compared to countries wherepatients can seek to specialists on their own (Van den Brink Muinen et al.2003). Instead, patient characteristics such as gender, age, psychosocialproblems, and familiarity between the doctor and the patient were variablesthat accounted for differences in doctor patient communication. In a largescale study, physicians from countries with hierarchically structured healthcare had shorter consultations than physicians from countries with flat healthcare organization. Hierarchical organizations may put more restrictions onphysician’s behavior (Meeuwesen, van den Brink Muinen and Hofstede 2009).

4.2 Attitude towards patient-oriented care

The “Patient Practitioner Orientation Scale” (PPOS) assesses students’attitudes towards patient centered care. The instrument comprises two scalesthat measure beliefs about their “caring” and a “sharing” patient orientation

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(Haidet et al. 2002; Krupat, Putnam and Yeager 1996; Krupat, Hiam andFleming 1999). A caring orientation embraces the physician’s respect andsensitivity to the patient’s emotions and experiences, and a biopsychosocialperspective on health, i.e. an interest in the patient’s life situation. A sharingorientation refers to the physician’s willingness to share medical informationand control of the clinical consultation with the patient. This includes thephysician’s readiness to give the patient individually tailored informationabout his or her medical condition, and to involve the patient in decisionsconcerning diagnostic and treatment alternatives, i.e. to prepare their“informed consent”. A match of the physician’s and the patient’s patientorientation entails higher patient satisfaction with the doctor patientrelationship (Krupat 1999).

Patient orientation scores correlate with demographic variables. Femalemedical students repeatedly showed higher scores on both patient orientationscales than male students (Haidet et al. 2001; Haidet et al. 2002; Krupat, Hiamand Fleming 1999; Tsimtsiou et al. 2007; Wahlqvist et al. 2010). In a Swedishstudy on just female students, work experience in health care was related to astronger patient orientation (Wahlqvist et al. 2010). This tendency towardsstronger patient centered attitudes and behavior is known from studies thataim at similar variables. Female physicians engage more than males inpartnership building and information giving (Roter, Lipkin and Korsgaard1991; Roter, Hall and Aoki 2002). Persisting through the medical curriculum,female students also express higher attitudes on ethical issues (Price et al.1998). In a recent study, female students’ patient orientation scores increasedslightly over study time (Wahlqvist et al. 2010). Female students’ patientoriented attitude has been explained by the “person oriented factor”, one ofthe strongest motivators for entering a medical career that tends to increasewith students’ age and maturity (Vaglum, Wiers Jenssen and Ekeberg 1999).Accordingly, higher age was associated with stronger caring and sharingattitudes in a recent study (Wahlqvist et al. 2010). Students with a parentworking as a doctor were more positive towards sharing power with theirpatients (Shankar 2006).

Caring and sharing attitudes differ with regard to their susceptibility tocultural and institutional values (Lamiani et al. 2008; Lee, Mann and Frank2008; Shankar et al. 2006). American health care professionals put moreemphasis on the patient’s autonomy than do their Italian colleagues. However,physicians from both countries did not differ on the caring dimension, i.e.recognition of their patient’s illness experience and emotion management(Lamiani et al. 2008). Evidence about the relationship of patient oriented

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beliefs to patient centered communication is contradictory (Joekes et al. 2011;Levinson and Roter 1995). While a positive relationship of physicians’psychosocial beliefs and their communication behavior has been found in anearlier study (Levinson and Roter 1995), a recent study found no relationship(Joekes et al. 2011).

4.3 Attitudes towards group learning

Teachers in medical education should be interested in promotingstudents’ belief in teamwork as a useful teaching method, and they should aimat identifying negative attitudes that may jeopardize group interaction andhamper students’ learning. Teachers who are aware of students’ attitudetowards small group work can facilitate the implementation of cooperativelearning in classrooms (Hendry et al. 2005). However, in research, a positiveevaluation of group work has not been conceptualized primarily as attitude,but as an aspect of a student’s learning style or learning preference.

4.3.1 Learning styles and preferences towards group learning

The cognitive psychological concept of learning styles reflects theassumption that students differ in their suitability for teaching approaches, forinstance for participation in individual and group learning contexts. Theidentification of learning styles aims at matching personal aptitudes withappropriate teaching methods, in order to optimize teaching efforts (Cronbach1957). Some learning style models include a dimension that refers toindividual versus interactive learning styles (Curry 1999; Grasha 1996; Owensand Straton 1980; Vermunt 1994).

The usefulness of learning style concepts for the improvement of medicaleducation has been questioned (Cook et al. 2009; Norman 2009). Medicalstudents can generally be regarded as high achieving learners who are able toadapt easily to different instructional formats. Their cognitive flexibility maysupersede the influence of their personal learning styles. For the teaching ofpatient centered values and skills, this implies that it is more useful to fosterstudents’ motivation, including their positive attitudes, towards professionalskills and attitudes, than to tailor teaching methods to their individualaptitudes.

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The concept of learning preferences does not refer to students’ aptitudes,but to their tendency to choose one object, e.g. a teaching method, overanother. Preferences for instructional formats reflect students’ perception ofthe learning environment, and their learning approach (Biggs 2003; Entwistleand Tait 1990; Struyven, Dochy and Janssens 2005). In contrast to learningstyles, preferences can change with experience or new insights. In a three levelconstruct, medical students’ preference for learning through lectures andindividual studies versus small groups were placed in the outer layer, i.e. thelevel that is most receptive for environmental influences (Curry 1991).Learning preferences are not necessarily related to learning styles (Loo 2004).

When the survey study was planned, no questionnaire was availablethat aimed at students’ attitude towards group learning. Thus, a questionnairewas developed that was based on a multi dimensional attitude concept, the“theory of planned behavior”.

4.3.2 The theory of planned behavior A commonly applied social psychological attitude concept is the “theory

of planned behavior” (Ajzen 1991, 2001; Ajzen and Gilbert Cote 2008). Themodel is based on the assumption that a person’s actions are determined bythree kinds of beliefs: beliefs concerning expectations about the respectivebehavior’s expected outcome (“outcome belief”), about important otherpersons’ norms (“normative beliefs”), and about the power of facilitating andimpeding factors (“control beliefs”). The combined effect of these componentsforms a person’s intention to engage with a particular behavior, which is amajor determinant for the transfer of knowledge, skills, and attitudes intoactual performance (Francke, Garsson and Huijer Abu Saad 1995). Apeculiarity of the concept is that it embraces the assessment of perceived socialnorms, such as what students think about the appropriateness of a studysetting (Purdie, Hattie and Douglas 1996). This may include the perceivedvalue of a task (Pintrich 1999), or the conceptions of learning (Marton,Dall’Alba and Beaty 1993; Muis and Franco 2009). A person’s actual behaviorcan best be predicted (up to 90%) from assessing her/his intention to performthe behavior – the implementation intentions (Gollwitzer 1993, 1996). Makingpeople formulate specific plans about how and when to use a certain behavioractivates their mental representations of the intended situation that serve as aneffective stimulus for the actual performance.

A questionnaire that refers to attitudes about a behavior that is based onthe “theory of planned behavior” can be designed with instructions by theauthor (Ajzen 2001). For the study, these instructions were used in developing

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31

problem based curricula. Awareness of personal learning strategies and selfregulatory control skill can be assessed with the Metacognitive AwarenessInventory (MAI) (Schraw and Dennison 1994). The original version of this selfreport instrument on the ”knowledge of cognition” and “regulation ofcognition” scales has been widely applied and has been shown to be a validand reliable measure of metacognitive awareness related to academic learningtasks (deCarvalho Filho 2010; Kleitman and Stankov 2007; Pintrich et al. 1993;Schraw and Dennison 1994; Sperling et al. 2004; Turan and Demirel 2010;Zhang 2010).

In a study with secondary school children, good metacognitive skills wererelated to the pupils’ positive feelings towards group work (Cantwell andAndrews 2002). It was argued that group interaction demands good selfregulatory skills. Thus, students who rate their self regulatory control as goodfeel positively challenged by group work, while others feel a cognitiveoverload. It appeared useful to investigate how attitudes towards group andindividual learning relate to medical students’ awareness of their learningstrategies.

4.5 Summary

Acquisition and use of patient centered communication skills are assumedto be determined by students’ attitudes that belong to the motivational aspectof learning. In earlier studies, students expressed negative attitudes towards apatient centered consultation style. Their attitudes towards communicationskills and group work should be assessed at an early study stage.

In earlier research, positive attitudes towards learning communicationskills were related to female gender, as well as personal work experience inhealth care. Early training of communication skills and contact with clinicalenvironments are regarded as preventing a decline of patient orientedattitudes. A positive relationship was found between patient orientedattitudes and female gender, higher age, and work experience.

As no appropriate instruments for assessing students’ attitudes towardsgroup learning contexts existed, an instrument was developed that includescognitive, affective, and behavioral aspects. In earlier research, positivefeelings towards group learning correlated with students’ awareness andregulatory control of learning strategies. Therefore, these metacognitive skillswere intended to be included in the survey study.

32

33

5 THE STUDY

Two starting points were chosen for understanding students’perspectives on group learning and on training patient centeredcommunication. The first approach was qualitative, considering thatcommunication skills are often learned in practical training where eachstudent’s performance is discussed in peer groups. Observing, recording, andanalyzing these group discussions was regarded as a useful method forgetting a detailed picture of problematic issues with learning to talk withpatients and of students’ coping efforts in difficult situations. Thesediscussions were also considered interesting as they are a part of theprofessional socialization process, a place where students develop and adopt acommon language for talking about doctor patient encounters.

Results obtained in such case studies provide deep insight into learningprocesses, but they are bound to the particular situation, or to similar settings.Therefore, a second methodological starting point was to collect data that canbe compared between different medical schools. Quantitative attitude datafrom medical students who have just started studying in curricula withproblem based and in traditional teaching approaches can provide insight intothe subjective conditions at the beginning of their studying. It can also givesome kind of baseline about what teachers and curriculum planners canexpect. Capturing students’ views in a standardized way can be accomplishedwith questionnaires that assess attitudes. Attitudes are evaluations of topics orbehaviors, in this case of learning to communicate with patients in a patientcentered manner, and of being involved in group learning contexts. Studentswho apply to problem based medical programs may vary in these attitudescompared with students starting programs with traditional curricula. Finally,it was reasoned that the emphasis of independent learning in problem basedcurricula might be reflected in students’ awareness of how to use learningstrategies, which should also be assessed.

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5.1 The video study

Video data were collected for exploring how the training ofcommunication skills contributes to a student’s transformation into aprofessional identity, and for identifying typical difficulties that studentsencounter in the learning process. The study design, participants, and themethodological characteristics of the video study are described in thefollowing sections.

5.1.1 Study design Group discussions of supervised student groups who participate in a

communication skills training were filmed during the course of two academicterms.

5.1.2 Participants At the Medical Faculty of Health Sciences at Linköping University, that

practices a problem based approach throughout the medical curriculum(Foldevi, Sommansson and Trell 1994), a course on “patient contact, holisticperspective, and communication” is integrated in the medical curriculum fromthe first until the fourth study term. Students practice clinical history takinginterviews with real patients in primary health care centers and discuss theirinterview performance in supervised groups.

Two student groups from early study terms agreed to participate in thestudy. At the study’s beginning, the first group was enrolled in its first studyterm, and was followed until the end of the second term. The second groupstarted at the second and moved to the third term. The first group consisted offour female and three male students, a male group therapist, and threedifferent general practitioners over the course of the study – two male and onefemale. The second group comprised five female and two male students, afemale group therapist, and a female general practitioner.

5.1.2.1 Aims of the communication skills course Students are expected to practice history taking interviews on the basis of

a theoretical model that is inspired by a psychodynamic perspective, the“response model” (Nystrup and Wretmark 1978; Wretmark and Wretmark1979; Wretmark 1984). The physician is expected to be emotionally opentowards the affective content of the patient’s account. This includes theintended use of one’s own emotions and empathy, in order to create a trustful

35

and open consultation atmosphere. The communication skills that studentsshould acquire in the course include the use of question techniques and activelistening that encourage the patient’s free narrative, and self awareness oftheir personal emotional reactions towards the patient. For achieving acomplete picture of the patient’s complaints, the doctor has to ask detailedquestions in the second interview part. Thus, students also have to learn tofollow the interview’s temporal agenda from the patient’s open account to thedetailed exploration of the medical and psychosocial history. Thecommunication skills that are defined in the course aims, and examined afterfour study terms, are listed in Table 1.

Table 1. Evaluation sheet of The strand: patient contact, medical communication,and holistic perspective communication skills course

Ability Optimal content and performance

Establishing contact Greeting, eye contact, room arrangement, inviting thepatient to sit down

Opening Give the floor to the patient, open invitation, encouragepatient to talk

Listening Active listening, using breaks, silence, ask if one does notunderstand

Leading Being directive, encourage patient to give his view

Posing questions Open questions, clear language, adequate question

Giving feedback Verbal, non verbal, confronting, supporting, bodylanguage

Summarizing Prepare the patient, summarize, ensure that one hasunderstood right, complementing questions

Time disposition Optimal distribution

Holistic perspective Considering the patient’s formal and informal networks,social situation, health behavior,

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5.1.2.2 Procedure of a course lesson The course combines practical training with supervised group discussions

that include the analysis of the videotaped patient student interviews. Twosupervisors (one general practitioner working at a primary health care centerand one psychotherapist with expertise in group therapy) are responsible for agroup of six to eight students. Classes are held every two weeks from the firstto the fifth academic term at local primary health care centers. A coursesession starts with three interviews with real patients chosen by the generalpractitioner. Each patient is interviewed by a pair of students; one studenttalks with the patient and the other films. On average, each student conductsone interview per month, i.e. about five per study term. After meeting thestudents, the patient has a regular visit with the general practitioner, attendedby the two students who met the patient. Afterwards, the whole student groupand both supervisors meet to discuss the filmed interviews.

Each student patient interview is discussed in detail for about 45 minutes.Using the videotaped interviews allows the supervisors to assess eachindividual student’s performance, and to stimulate the group’s discussionsabout adequate communicative behavior in particular situations. Thediscussions aim at fostering the students’ individual development throughreflection and expert advice from the supervisors concerning communicationin general and clinical practice.

5.1.3 Data collection The supervised group discussions were filmed with a digital video

camera. The researcher was present during all videotaped sessions, but wasnot actively involved in the discussions. As the data collection was extendedover two academic terms, the author’s and the camera’s presence became anatural part of the sessions. In total, the material comprised group discussionsof 23 student patient interviews (some sessions were cancelled due to vacationor illness), entailing about 30 hours.

5.1.4 Ethical approval A request for ethical approval of the video study was submitted to the ethicalcommittee of Linköping University. The study was approved under thecondition that all students gave their written consent to participate in thestudy, and to be filmed. All patients were informed that their interviews werepart of a study, and all consented to having the student discussions about theirinterviews saved.

37

5.1.5 Data analysis The videotapes were analyzed in several steps. Initially, all discussions aboutstudent patient interviews were screened for aspects that were described asdifficult by the students. From this overview, four group discussions wereselected that were transcribed and analyzed in detail. Selection criteria werethat the discussed difficulties should represent typical issues, and that theyshould involve four different students, both male and female. The fourdiscussions, which were about 45 minutes each, were transcribed verbatimincluding laughter, pauses, back channeling, overlaps, and emphases(O Connell and Kowal 1995). Content analyses were performed that aimed atanswering three questions: (1) Which aspects of communicating with patientwere described as difficult? (2) How did the students feel and reflect aboutdifficult issues? (3) Which resources were utilized by the students for copingwith difficult situations? During the analysis process, parts of the transcriptswere discussed with other researchers, and several teachers were involved inthe course.

5.1.6 Methodological considerations Qualitative methods provide rich and detailed data about a topic. A

particular strength is the focus on processes from the actors’ perspective(Bryman 2000). The analysis of video observations, though, demands theselection of particular sequences. These should be made on the basis ofresearch questions, but it is inevitable that the selection process reflects theresearcher’s personal perspective on the data. The same applies to theinterpretation of the results. In this case, the video data were collected in thepresence of the researcher during the video recordings, which should also beconsidered in evaluating the study’s results. Personal presence can imply acertain personal involvement and a relationship with the study participants. Inorder to consider other perspectives, parts of the transcribed discussions werediscussed with other researchers and teachers involved in the course.

Another characteristic of case studies is that the results can only partly begeneralized to similar cases. As this study involved students at an early studyphase, i.e. with little medical expertise, and concerned exploratory interviewswith a patient centered approach, the results are probably not applicable toexperienced physicians, or to different consultation context like the breakingof bad news. However, this does not mean that the findings are irrelevant forother cases. Instead, insights gained from one case study can be guideposts forother case based research.

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The data were collected in the year 2001, which implies means that someof the discussed topics’ relevance may have changed since then. However,several course supervisors confirmed the recurrent emergence of typicalthemes.

5.2 The survey study

The survey data aimed at comparing attitudes and self rated metacognitiveskills. The following sections describe its study design, participants, andmethodological features. Furthermore, it presents the applied assessmentinstruments.

5.2.1 Study design A descriptive cross sectional design with the independent factor ”medical

school” (Witten/Herdecke, Linköping, Marburg, Gothenburg) was used. Datawere collected for five types of variables:

demographic variables (age, gender, personal experience in health careprior to studies, and parents’ work in health services)attitudes towards individual and group learningawareness of learning strategiesattitudes towards communication skills learningpatient orientation.

5.2.2 Participating medical schools Four medical programs were selected to participate in the study, two

located in Sweden and two in Germany. The problem based schools werechosen as both were national pioneers in the consistent application of PBLmethods, while the programs applying mixed teaching methods were selectedas representatives of medical faculties with a long teaching tradition. In theirstudy guidelines, all participating medical faculties mention teamworkabilities and lifelong learning as central study goals. However, the schoolsapply different teaching methods. The Sahlgrenska Institute at the SwedishUniversity of Gothenburg, Sweden, and the Medical Faculty at the PhilippsUniversity at Marburg, Germany mix lectures with seminars and practicaltraining. In contrast, the Faculty of Health Sciences at Linköping, Sweden, andMedical Faculty at the University at Witten/Herdecke, Germany, apply

39

problem based teaching approaches. The Swedish programs span 5.5 years offull time studies, while German medical studies take 6 years.

5.2.2.1 Medical Faculty at the University at Witten/Herdecke As the first medical faculty in Germany, the university at Witten/Herdecke,Germany, introduced problem based learning in 1992 as a central, integrativeconcept. In the study aims, it is stated that

the physician should develop a personality that enables him/herto maintain and reconstitute health and well being on anindividual and societal level. For this purpose, in particular theability to communicate and interact, problem oriented andinterdisciplinary thinking, and the readiness for lifelong learninghave to be fostered. These aims (…) should be realized by avariety of problem based learning and integrated study andexamination forms. (Translation by the author).

During the first study phase (years 1 and 2), the central teaching and learningform is problem based learning, completed by practical training(http://medizin.uni wh.de/humanmedizin/studiengaenge/modellstudiengangmedizin/curriculum/). During the first two study years, small student groupswork on one patient paper case per week, for which they develop hypothesesconcerning causes of the medical condition and disease progress, andformulate learning goals. Problem based group learning is applied throughoutthe entire study period, while written patient cases are used during the firsttwo study years. The learning contents are taught as integrated systems, e.g.by organ systems and functional units, and contents appear repeatedly underdifferent aspects. Thus the learning process can be described as a systematicspiral with increasing levels of complexity. The problem based pedagogicalapproach implies the use of several sources for self organized learning, i.e.books, journals, interactive models (for understanding anatomic andbiochemical relationships), as well as collections of clinical cases(http://medizin.uni wh.de/humanmedizin/studiengaenge/modellstudiengangmedizin/selbstorganisiertes lernen/).Clinical communication skills are taught in a longitudinal course from the firstuntil the ninth study term, initially with simulated patients, and later with realpatients. During the first two terms, theoretical basics are taught. From thethird to the sixth term, the students have interviews with simulated patients,and receive feedback and discussion on their performance. Finally, from theseventh until the ninth term, interviews with real patients are conducted, andare videotaped and analyzed in supervised group sessions. These groups

40

consist of peer students, psychologists, and physicians. This longitudinalconcept of communication skills training is unique in German medicaleducation. Moreover, in Witten/Herdecke, the teaching of communicationskills is integrated with instruction in ethical issues.(http://www.uni wh.de/fileadmin/media/g/pflege/g_pfl_i_iekg/Manual/ICManual_SS2011_small.pdf)

5.2.2.2 Faculty of Health Sciences at Linköping The Faculty of Health Sciences at Linköping, Sweden, applies a problem

based learning approach. In Sweden, study goals are defined in the generaluniversity law (SFS 1992), and in the national study goals for medical studiesthat are noted in the university policy (“Högskoleförordningen”) SFS 1993:100,bilaga 2, examination form (bilaga 2)).Beyond developing the general ability to follow the development in thescientific field (Högskolelagen, 1 kap. 9§), the study documents emphasizethat students should acquire the preconditions for lifelong learning(http://www.hu.liu.se/lakarprogr/filarkivdokument/1.59689/Utbildningsplan20060530.pdf). The course plan for the firststudy years states that the students have to become able to evaluate thefunctioning of the learning group (base group) in order to achieve an effectiveworking mode. Moreover, they should learn to identify and reflect uponconditions of meaningful learning, reflect upon their own learning strategies,and use different types of data sources(http://www.hu.liu.se/lakarprogr/filarkivkursplaner/1.55118/KursplanstadieIrev060529.pdf). During the first sevenweeks, medical students participate in a course in “health, ethics, andlearning”. The students work in small groups of 6 8 students in base groupson problem based cases. These groups are mixed from all health careprogrammes, in order to foster interdisciplinary collaboration (Areskog 1992).Problem based learning includes the students’ personal responsibility for theirlearning process, setting of learning goals and data searching. Medicalknowledge is acquired by web based scenarios, literature, seminaries, and incontact with patients. (http://kdb5.liu.se/liu/hu/kp_detail_print_sv.lasso?&ID=302145). The admission process isbased on secondary school grades. (Undervisning/arbetsformer i stadie I(http://kdb 5.liu.se/liu/hu/kp_detail_print_sv.lasso?&ID=302143))As described in detail in the last section, communication skills are taught fromthe first until the fourth term, based on contact with real patients combinedwith video based group supervisions. This implies active interviewing for

41

each student with about three patients per term, in addition to the supervisionof the peer students’ interviews every two weeks.

5.2.2.3 Sahlgrenska Institute at the Swedish University of Gothenburg

In its study goals, the Sahlgrenska Institute at the Swedish University ofGothenburg emphasizes medical students’ ability to communicate withpatients, relatives, personnel, and society in general, and their preparednessfor permanent maintenance of knowledge and continuing development ofprofessional skills. Moreover, a physician should be aware of the limitations ofthe physician’s working area, where other professions are responsible, and thecollaboration with these(http://www.sahlgrenska.gu.se/digitalAssets/1125/1125795_lak_utbplan.pdf).During the first study terms, mixed teaching methods are applied, includinglectures, seminars, small group learning, laboratory instruction, clinical“bedside” studies, supervision with reflection, and case discussions. Thepedagogical philosophy is research based, i.e. the study contents should becritically appraised, and teaching methods are adapted to contents(http://www.sahlgrenska.gu.se/digitalAssets/1125/1125795_lak_utbplan.pdf).The primary study terms include instruction in professional training (“earlyprofessional contact”), but not the explicit training of communication skills(Hellquist et al. 2005).

5.2.2.4 Medical Faculty at the Philipps University at Marburg The study guidelines of the Medical Faculty at the Philipps University at

Marburg, Germany, state in their goals the acquisition and the readiness tocollaborate with other health care professionals and the willingness to engagein permanent education (http://www.unimarburg.de/fb20/studium/stpo/ao2004.pdf) (http://www.unimarburg.de/fb20/studium/stpo/StO Humanmedizin.pdf).The curriculum is divided into a preclinical (terms 1 4) and a clinical phase.The preclinical phase consists of lectures, seminars with 20 30 students (thesecan also be given as problem oriented seminars in small groups), and practicaltraining. The major part of instruction is based on lectures, a smaller part onpractical training, and the smallest part as seminars. At term 3, the proportionsshift towards more seminars. However, half of the study time is given aslectures to prepare practical training and seminars and “should give anoverview over the subject and hints for a meaningful focus for its elaboration.”

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(translation by the author). Since 2008, practical skills – physical examinationand communication skills – can be trained in a “skills lab” (http://www.unimarburg.de/fb20/maris). These include the training of communication skills,where laymen actors serve as simulated patients and individual feedback isprovided. At the time of data collection (2005), an optional course in doctorpatient communication was offered to a limited number of students. Thisincluded contact with real patients in private practices, reflected in individualwritten reports.

5.2.3 Data collection A descriptive cross sectional design with the independent factor ”medical

school” (Gothenburg, Linköping, Marburg, Witten/Herdecke) was used. Datawere collected for three types of variables: personal background variables,attitude measures, and metacognitive awareness ratings. At all schools, thequestionnaires were distributed to students at the end of the first and thirdstudy terms after a compulsory lecture, except at Linköping University, whereonly first term students participated. Table 5 shows the participants’ numbersper medical school and their response rates.

5.2.4 Ethical considerations The students were informed about the study’s general aim, and their

participation was anonymous and voluntary. At the time of data collection(early in 2005), the Swedish Act Concerning the Ethical Review of ResearchInvolving Humans (2003:460) comprised research dealing with sensitivepersonal data, or physical or psychological interventions (Swedish ResearchCouncil 2011). In accordance with the opinion of Linköping University’sresearch ethics representative, the study did not need to be submitted forethical approval. At all participating universities, permission for thedistribution of the questionnaire was obtained by the faculties’ deans.

5.2.5 Instruments The survey study included several questionnaires, of which some had

been used in previous research, and one was developed for the purpose of thethesis. All questionnaires were distributed to the students in one survey. Thenewly developed “attitudes towards individual and group learning scale”instrument was originally written in German and Swedish, utilizing themultiple forward” and back translations that are required for surveys used in

43

comparative studies including different languages. For publishing purposes,the questionnaire was also translated into English, and is included in itsentirety in the “Medical students’ attitudes towards group and self regulatedlearning” paper. One questionnaire, the “Tasks of Medicine” (TOMS) wasincluded in the survey, but not analyzed, as it was seen to be unsuitable foranswering the research questions. In the appendix, the Swedish and Germanversions that were applied in the study are included. An overview of theinstruments used is provided in Table 2.

Table2.Que

stionn

airesused

inthesurvey,including

scales,abb

reviations,n

umbero

fitems,an

dau

thors

Questionnaire

Scales(Variablesandvariablecategoriesfordemographic

variables)

Numberofitems

Authors

Attitude

towards

individu

alan

dgrou

plearning

scale

Scale1:Attitude

towards

individu

allearning

Scale2:Attitude

towards

grou

plearning

Scale3:So

cialexpe

ctations

towards

individu

allearning

Scale4:So

cialexpe

ctations

towards

grou

plearning

Scale5:Ex

perience

with

grou

plearning

16 11 4 3 3

(Lum

maSellenthin2012)

Metacog

nitiv

eAwareness

Inventory(M

AI)

Kno

wledg

eof

cogn

ition

Regu

latio

nof

cogn

ition

10 10(sho

rtened

version)

(Schraw

andDennison

1994)

Com

mun

icationSk

illsAttitude

Scale(CSA

S)Po

sitiv

eAttitude

Scale(PAS)

NegativeAttitude

Scale(N

AS)

13 13(C.R

eesetal.2002)

Patie

ntPractitionerO

rientatio

nScale(PPO

S)PP

OS–caring

PPOS–sharing

9 9(Krupa

teta

l.1999)

44

45

5.2.5.1 Attitudes towards individual and group learning scale A questionnaire was developed to assess attitudes towards individual and

group learning on the basis of the ”theory of planned behavior” (Ajzen 2001).The development of the pilot version and the further item reduction that wasperformed with a principal component analysis are described in the “Medicalstudents’ attitudes towards group and self regulated learning” paper. All itemformulations are also included in this paper, together with their descriptivestatistics and communalities (Anderson 2003). The paper also contains therotated component matrix of the principal component analysis. The principalcomponent analysis resulted in a five factor solution that representedmeaningful subscales. These were:Scale 1. ”Attitude towards individual learning”Scale 2. ”Attitude towards group learning”Scale 3. ”Social expectations towards individual learning”Scale 4. ”Social expectations towards group learning”Scale 5. ”Experience with group learning”.

Originally, the questionnaire was written in German by the author. Inorder to preserve its conceptual equivalence, multiple forward translationprocedures into English and Swedish were applied to each statement, and tothe questionnaire as a whole, including a professional English translator andSwedish native speakers. Back translations from the English version intoSwedish were also provided by Swedish native speakers and into German byGerman native speakers. The focus was on describing students’ views on theireveryday learning behavior. In the study, both the Swedish and Germanversions were used.

5.2.5.2 Metacognitive Awareness Inventory Students’ awareness of their personal learning strategies (“knowledge of

cognition”) and of their self regulatory control (“regulation of cognition”)were assessed with the Metacognitive Awareness Inventory (MAI) self reportinstrument (Schraw and Dennison 1994). Instead of the original version with52 items, a shortened version was used that had been applied in earlierresearch (Cantwell and Andrews). The validity and reliability of thequestionnaire are described in detail in the “Medical students’ attitudestowards group and self regulated learning” paper. The questionnaire wastranslated into German and Swedish by a professional translator.

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5.2.5.3 Communication Skills Attitude Scale (CSAS) Attitudes towards learning communication skills were measured with the

“Communication Skills Attitude Scale” (CSAS) (Rees, Sheard and Davies2002), which has been validated in several studies in the UK (Cleland, Fosterand Moffat 2005; Rees and Sheard 2003), and has also been used in Norway(Anvik et al. 2007a; Anvik et al. 2007b). It aims at assessing positive andnegative attitude aspects that students can experience towards participating inthe training of communication skills. The description of the “Positive AttitudeScale” and “Negative Attitude Scale” subscale example items and internalconsistencies are reported in the “Attitude towards communication skillslearning: relation to patient orientation, self regulation, and teachingmethods” paper. With the author’s permission, the questionnaire wastranslated into German and Swedish.

5.2.5.4 Patient-Practitioner-Orientation Scale The “Patient Practitioner Orientation Scale” (PPOS) assesses students’

attitudes towards the doctor patient relationship (Krupat, Putnam and Yeager1996; Krupat, Hiam and Fleming 1999; Krupat et al. 2000). The psychometricqualities are included in the “Attitude towards communication skills learning:relation to patient orientation, self regulation, and teaching methods” paper.The scale has been previously applied in Swedish and German research andwas used with the permission of the author.

5.2.6 Data analysis Descriptive statistics were calculated for students’ demographic variables.

Distributions of demographic variables at each medical school were comparedwith Chi square tests. For each demographic variable, differences in attitudemeasures were assessed with t tests for independent groups. Multivariatestatistics (MANOVA) with pairwise comparisons were performed between thefour medical schools for ”attitude measures” and ”metacognitive awarenessmeasures” (adjusted with the Bonferroni procedure for multiple comparisons).Finally, predictor variables for the applied attitude measures were identifiedwith multiple linear regressions. A p level <.005 was considered significant.Students who did not report variables were omitted from the respectiveanalysis.

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5.2.7 Methodological considerations The survey study has several methodological and content related

limitations that have to be discussed.The number of participants per university varied due to different class

sizes, which were smaller in problem based programs than in mixed programsand smaller in Sweden than in Germany. The lower number of students inproblem based programs is a structural characteristic of these curricula, andcould not be avoided. On the other hand, it was not possible to select anumber of students from the curricula with mixed teaching approaches inorder to match the numbers per student group. As another unforeseenshortcoming, in Linköping only students enrolled in the first term couldparticipate, while from all other schools, students from both the first and thirdterm were included. However, the inclusion of third term students increasedthe total number of participants.

The surveys were distributed after a regular lecture, which meant thatonly attending students could participate. This may have entailed a bias infavor of students who were interested in the study subject or had the time tofill in the questionnaire, as the survey was completed during leisure time.However, it was assumed that this bias applied to all samples and mightinfluence the level of total scores, but did not the limit the comparability ofstudent groups. No data were available about the non responders’background variables. The response rates were calculated as percent of thetotal number of students per term. As it can be assumed that not all studentsattended the lectures, it is probable that the response rates estimate the realparticipation ratio as too low.

The study design implies certain shortcomings. The explorative andcorrelative study design can yield insights about the possible relevance ofpersonal and contextual factors for students’ attitudes, but not about theircausal relationships. The study design cannot discern between the impacts ofproblem based and mixed teaching methods on students’ attitudes, comparedto students’ active selection of particular teaching approaches.

In general, survey studies provide data that can be analyzed with regardto their structural patterns, which are considered as static and independentfrom the researcher (Bryman, 2000). Comparative studies of student samplescan reveal statistical relationships between factors like the medical program’steaching approach and dependent measures. They do not allow conclusionsabout underlying mechanisms and mediating variables between independentconditions and dependent measures. These questions can be addressed inqualitative studies, for example those including interviews with students.

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The assessment of a person’s attitude, i.e. their subjective evaluation of atopic, is afflicted with particular difficulties. Attitudes – like otherpsychological concepts – cannot be observed or directly measured, but refer toa hypothetical construct that reflects a person’s tendency to answer in a certainmanner to questions concerning a certain issue. This implies that therelationship between a person’s attitude and his/her actual behavior cannot bereliably predicted. However, given that an attitude survey has been piloted,and checked for the clarity of item formulations, attitude measures arecomparable between student samples.

The use of a particular attitude concept – the theory of planned behavior –limits the comparability with studies that use other theoretical concepts, suchas cognitive styles. The broad perception of students’ general attitudestowards group learning limits the questionnaire’s predictive power forparticular learning situations. It must be mentioned that the assessment ofattitudes does not allow conclusions about performance of the intendedbehavior (Joekes et al. 2011; Levinson and Roter 1995). The relationship ofassessed attitudes and beliefs to the intended behavior is susceptible to manyinfluences, such as that information available at the time of attitudeassessment may not resemble the situation in which the behavior isdemanded. However, the assessment of attitudes towards patient orientedcare has its legitimation, as attitudes refer to beliefs that are relatively stableover time (Wahlqvist et al. 2010).

Self report instruments are always susceptible to social desirability biases,i.e. a tendency to answer in a manner that will be viewed favorably by others.This implies that desirable behavior will be over reported and undesirablebehavior under reported (McBurney 1994). However, in the case ofpreferences towards individual and group learning, both learning settingsmay be socially desirable. Therefore, the “attitudes towards individual andgroup learning scale” questionnaire did not include statements that aimed atassessing social desirability biases (Crowne and Marlowe 1960). Instead, onescale aimed at students’ perceived social norms about learning settings.

Self report instruments for assessing desirable skills, such as theregulation of learning strategies, entail particular problems. Self reports reflectstudents’ personal perceptions of their metacognitive skills, not their actualuse of these strategies nor their general ability to self regulate their learningprocesses. In addition to the possible social desirability bias, the estimation ofpersonal abilities is afflicted with calibration difficulties – i.e. theoverestimation or underestimation of personal skills (Linnenbrink and

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Pintrich, 2003). Some students may not be able to report their use of learningstrategies at all (Winne and Jamieson Noel 2002).

As surveys between students from different countries were compared, it ispossible that small changes between the translated versions have affected theirresponses (Schwartz and Loten 2003).

In the survey study, Cronbach’s alpha was used for determining thereliability of the questionnaires’ subscales. Cronbach’s alpha measures theinternal consistency of a scale by computing the interrelatedness of its items(Cortina 1993; Cronbach 1951; Tavakol and Dennick 2011). However,Cronbach’s alpha is susceptible to influences like the number of includeditems, which can have been relevant for the Metacognitive AwarenessInventory that was applied as a short version (Cortina 1993). Furthermore, ineach application, Cronbach’s alpha varies with the test properties of the testedpersons (Tavakol and Dennick 2011). Thus, Cronbach’s alpha assumes that allitems included in a scale refer to the same latent factor, i.e. a unidimensionalconcept. This assumption may not be fulfilled for some scales that aim atcomplex concepts, such as the “attitude towards individual/group learning”scales.

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6 RESULTS

6.1 Study I

“Learning to talk and talking about talk: professional identity andcommunicative technology” (Hydén, L. C., & Lumma, A., 2007)

The supervised group discussions were characterized by dynamic shiftsbetween the video playback of the student patient interview, the students’own and their peers’ perceptions of the occurring difficulties, and commentsfrom the supervisors. The mentioned difficulties could be subsumed underthree aspects. First, difficulties with applying particular communicative skillswere common. There were typical problems with the interview’s temporalagenda, the formulation of open versus closed questions, the suppression oftalkative patients, and the encouragement of reserved patients. Moreover, theintentional use of empathy and the expression of emotional reactions towardspatients that are encountered for the first time, were problematized.

Secondly, students reported feelings of uncertainty with adopting theprofessional role of a physician. This implied the intentional use of speechactions that are usually part of everyday talk. Difficult issues were theconscious violation of interaction rules, e.g. politeness towards strangers,small talk, and humor, in order to obtain important diagnostic information.

Finally, training communication skills as a professional technology thatcan be applied to various situations demanded of the students a reflectiveperspective on their own learning processes. This task required the adoptionof a common, self reflexive language in their communication behavior. Theself reflexive perspective implied the use of metacognitive skills – planningand structuring the interview, analyzing and self regulating performance, aswell as formulating and receiving feedback. It is in particular the self reflexiveaspect of communication skills training that characterizes the transformationof the students’ private identity into a professional one, i.e. their socializationinto the community of health care professionals.

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6.2 Study II

“Talking with patients and peers: Medical students’ difficulties withlearning communication skills” (Lumma Sellenthin, A., 2009)Students’ difficulties were summarized in seven categories:

1. Creation of a trustful atmosphere2. Assessment and structuring of the patient’s account3. Addressing sensitive topics4. Giving empathy and feedback5. Monitoring the interview6. The pedagogical setting7. The group discussions as learning resource

1. Some students worried whether their patients accepted them as competentprofessionals. Feelings of incompetence resulted in particular from thestudents’ lack of biomedical knowledge. The effects of external attributes(white coats, seating arrangement) on their trustworthiness were alsodiscussed.2. If students were confronted with detailed accounts, they reporteddifficulties with structuring the information. In other cases, they complainedthat patients were too reserved. Strategies like interrupting talkative patientsand posing directive questions could be perceived as impolite.3. Students tended to feel intrusive or curious when they addressed thepatient’s private life, or mental health problems, such as work related stress,loneliness, depression, or difficult family relations. Many did not understandto what extent the patients’ life contexts were related to their medicalconditions.4. Students reported uncertainty about their patients’ emotional needs, inparticular if they expressed suffering. Many did not know how to respondempathetically to their patients without appearing insincere.5. Self monitoring one’s interview performance – comparing one’s ownbehavior with the theoretical model – could cause cognitive overload andimpede the conversational flow. The supervisors suggested facilitatingstrategies like standard formulations for typical situations. They helped thestudents to develop a professional language for typical situations and types ofpatients that contained metaphoric and categorizing expressions.6. The intense evaluation of their personal performance could be perceived asemotionally stressful. This included the formulation of feedback comments.The video camera was experienced as a hinder for the spontaneity andopenness, while the contact with real patients was appreciated.

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7. Peer students were used for role plays that aimed at applying particulartechniques.

6.3 Study III

“Medical students’ attitudes towards group and self regulated learning”(Lumma Sellenthin, A., 2012)

The study related beginning students’ attitudes towards group learningand their awareness of learning strategies, to demographic variables, and toproblem based and mixed curricula.

No differences were found between female and male students’ attitudestowards individual and group learning, and their awareness of learningstrategies. However, students who had worked in health care before studyingmedicine reported more group learning experience (t(341) = 2.971, p = .003), andbetter knowledge (t(340) = 2.258, p = .025), and regulation of learning strategies(t =(333) 3.307, p = .001) than students without prior practical experience.Students whose parents worked in health care also reported better knowledgeof their learning strategies (t(340) = 2.255, p = .025), than students without thisfamiliar background. They reported feeling stronger social norms towardsengaging in group learning (t(337) = 3.014, p = .003).

Students from the German problem based school at Witten/Herdecke hadbeen most involved in group learning, while students from Marburg – theGerman program with traditional teaching methods – reported the least groupwork experience (largest mean difference Witten/Herdecke : Marburg = 1.45on a Likert scale from 1 to 7, std. error =.181, p = .000). Witten/Herdecke hadthe greatest amount of students with personal work experience in healthservices (Witten/Herdecke = 90, Linköping = 48%; Marburg = 64%; Gothenburg= 51%). Between the Swedish schools, no difference in group learningexperience was found. Students from Witten/Herdecke were also better atregulating their learning strategies than students from Gothenburg (meandifference .18, std. error = .084, p = .034).

Finally, students from Linköping perceived significantly stronger socialexpectations to engage in group learning than all other students (meandifference Linköping: Witten/Herdecke 1.71, std. error = .303, p = .000;Linköping: Gothenburg 1.81; std. error = .281, p = .000; Linköping: Marburg2.24; std. error = .271, p = .000).Thus, neither students’ attitudes towards individual learning and group work,nor their awareness of learning strategies were related to their gender or age.

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However, personal or parents’ work experience correlated with metacognitiveskills and experience with group work. Thus, students’ clinical experience thatis gained before academic studies may provide basic preconditions ofsuccessful learning of professional skills.

6.4 Study IV

“Students’ attitudes towards learning communication skills: correlatingattitudes, demographic and metacognitive variables” (Lumma Sellenthin,A., 2012)

The study explored the relationship of students’ attitudes towardslearning communication skills to demographic variables, metacognitive skills,and the appreciation of patient oriented care, in traditional and problem basedcurricula in Sweden and Germany.

Students’ positive attitudes towards learning communication skills waspredicted by a caring patient orientation, good self regulation of learningstrategies, and female gender (R2= .23, F(9,310) = 9.72, p < .001). On the otherhand, a caring patient orientation was predicted by students’ attitudestowards learning communication skills, female gender, and higher age (R2=.23, F(9,307) = 13.48, p < .001).

Students from the German traditional curriculum at Marburg weresignificantly less positive towards learning communication skills than studentsfrom Witten/Herdecke (Positive Attitude Scale (PAS): mean difference .49, ona 7 point Likert scale; SE = .07, p < .001), from Linköping (PAS: mean difference.46, SE = .09, p<.001), and Gothenburg (PAS mean difference .47, SE = .06,p<.001).

Students enrolled in Witten/Herdecke were significantly more positivetowards sharing information and power with their patients compared tostudents from Linköping (PPOS sharing: mean difference .35, SE = .13, p <.041).

Thus, attitudes towards learning communication skills and their caringpatient orientation are interrelated concepts. Both are appreciated more byfemale students. However, students who expressed positive attitudes towardstraining their communication skills tended to report better self regulatoryskills than students with negative attitudes. For a caring patient orientation, onthe other hand, metacognitive skills were irrelevant, but higher age and workexperience were positively related. For the teaching of patient centeredcommunication techniques, both a caring attitude, and metacognitive skills arerelevant.

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7 DISCUSSION AND CONCLUSIONS

The video study showed that many students were not familiar with thepractice of patient centered communication. Although most studentsappreciated the contact with real patients and were interested inunderstanding their complaints from a patient centered perspective, they wereuncomfortable with asking patients about their feelings and private lives. Theyexperienced moral qualms if they explored the patient’s life, and reportedfeelings of uncertainty about expressing their empathy, in particular if thepatients’ reports were emotionally loaded. However, students appreciated theinterviews with real patients as a possibility to test their own behavior in livesituations and to get a picture of the everyday tasks of a doctor. Evidently,involvement in clinical practice stimulated students’ intrinsic motivation toimprove their professional skills, develop their personal styles of patientcentered consultation and, thus, develop a professional identity.

Early contact with clinical environments may contain even more potentialfor academic learning than just an increased motivation. Both the video studyand the survey revealed that clinical experience is related to self regulatedlearning. The process of communication skills training implies the continuousshift between practical training and reflection of one’s own and peers’performance. This kind of learning demands metacognitive awareness, i.e.monitoring and evaluating of the interview, and commenting on theperformance. As the course proceeds, students continuously develop theseskills. Students develop several communicative skills; they learn to applycertain kinds of questions, paraphrasing comments, summaries, and affectiveresponses in the interview with the patient. This language includes standardformulations for opening questions, and for the transition between thepatient’s open account and the detailed exploration of symptoms. In thecourse of the group discussions, another language emerges that aims atevaluating the interview on the basis of the theoretical consultation model.This language is meant to be used among colleagues, and to support the selfevaluation of the students’ learning process. It includes categorizations oftypical interview situations, typical communicative behavior shown bypatients, and typical complaints. The formulations and metaphors of thislanguage emerge to a great extent from the clinical teachers’ work experience.

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Therefore, the group discussions foster the socialization into the professionand the development of a professional identity.

From the study, it can be concluded that practical training that is part ofclinical communication skills instruction is necessary for students’ ability tobenefit from the theoretical course elements. The positive effect of practiceexperience on metacognition is supported by a study that related teachers’practice experience to their metacognitive skills. With the same instrument formetacognition (MAI) they observed an increase in self regulation – but notknowledge of cognition – for teachers of different grade levels as a function ofage and teaching experience (Cooper and Stewart 2006). It was argued thatteaching experience fosters the development of a “sense of what works best”in their content area.

Self regulated or self directed learning skills are preconditions for lifelonglearning, defined as the ability to actively seek new knowledge and followscientific developments, discern relevant aspects, and integrate them intoone’s personal conceptual understanding and knowledge. Such abilities haveto be cultivated during academic education, and teachers should facilitatethese by helping students set appropriate learning goals and plans forachieving them, and by offering training and self assessment (Li et al. 2010).Metacognitive skills, like monitoring and self evaluation of one’scommunication performance, together with the acquisition of a professionallanguage, are probably a central aspect in the transformative process that aimsat forming a professional identity.

In accordance with many other studies, female students were moreinterested in learning to talk with patients and valued patient oriented carehigher than male students. As all future physicians need to adopt a patientcentered perspective, it is important that teachers and students are aware ofpossible prejudices and negative beliefs that male students might hold.

Attitudes towards training communication skills were stronglyinterrelated with a caring attitude towards patients. However, while students’attitudes towards learning skills were more positive if their rated their selfregulation as good, metacognitive skills played no role for their patientorientation. This finding emphasizes that students are aware that the trainingof interview skills demands skills like self evaluation and regulation.

Clinical experience may affect the development of self regulatory controlmore than the participation in problem based curricula.Students from Witten/Herdecke reported better self regulatory control thanstudents from Gothenburg. However, this difference may not be directlyrelated to different teaching methods. Instead, it may reflect that more

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students from Witten/Herdecke entered their studies with clinical experiencethat may have increased their appreciation of a trustful doctor patientrelationship for clinical practice, and promoted their awareness for and use ofeffective, goal oriented learning strategies. Students from Witten/Herdeckealso put more emphasis on sharing medical information with their patientsthan students from Linköping. This result might indicate that a doctor’s tasksare defined differently in German and Swedish health care. However, therewas no difference between German and Swedish students enrolled intraditional curricula. In total, the comparison between curricula withtraditional and problem based approaches showed more differences betweenthe German schools than in Sweden.

Students from Marburg were least interested in learning communicationskills, which could not be explained with other assessed variables. This findingmay possibly reflect that students who applied to Marburg were not preparedto change their communication behavior. Such differences were not foundbetween Linköping and Gothenburg, although Gothenburg does not offer acourse in communication training.

Concerning attitudes such as beliefs, evaluations, and behavioralintentions towards group learning, no relationships to the includeddemographic variables were observed. Swedish students differed in oneaspect – students in Linköping felt more than all other students that theyshould learn in collaborative settings. Group learning is a prominentcharacteristic of medical studies in Linköping that has been evaluated in manystudies, of which students appear to be aware. The video study wasperformed at Linköping University, where students are used to group workand discussions. However, they experienced the setting that included videofeedback of interview behavior as stressful.

The study’s findings allow recommendations for educational practice andfuture research in this area.

7.1 Implications for educational practice

Medical studies should aim from the beginning to improve students’ selfregulatory control of their learning behavior. Increasing students’ andteachers’ awareness of the importance of self regulation of their attitudestowards collaborative learning fosters the effects of these student centeredpedagogical formats (Lindblom Ylänne 2004) and enhances their tolerancetowards and benefit from working with others (Hendry et al. 2005).

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As the study could show, early contact with clinical environments isrelated to good self regulation, and is probably a necessary condition fordeveloping these. The learning processes that inform patient centeredcommunication demand metacognitive skills that can go beyond theknowledge and regulation of individual learning strategies. They include theformulation of feedback and the shift between everyday and professionallanguage. The relevance of this common language should be made explicit tostudents, as it is a basis for self evaluating interviews even after the end offormal teaching. Experience in clinical and community settings and the contactwith patients should therefore be integrated early in the medical curriculum.

The study affirms the suggestion to use gender mixed groups in coursesthat aim at teaching patient centered skills, in order to benefit from femalestudents’ tendencies to be more patient oriented (Wahlqvist et al. 2010).Teachers and facilitators should try to identify students who struggle withadopting patient centered attitudes and skills and actively address topics thatcan cause moral qualms or feelings of unambiguity. Explaining the functionalrelationship of psychosocial factors and biomedical conditions to beginningstudents is an important issue. Likewise, the value of empathy for thediagnostic and treatment success needs to be made explicit and practiced.Discussions and role play of desired responses in difficult interview situationshave proven to be effective tools for changing students’ attitudes and emotions(Smith et al. 2000). However, students should be prepared for possibledifficulties in the learning process – conceptual difficulties or emotional stressthat they may encounter (Lumma Sellenthin 2009). In contrast to thepedagogical method used in Linköping, it may be less stressful for students tointerview patients without being videotaped. One suggestion is to base thegroup sessions on students’ accounts of their encounters, and use videos ofstudents from earlier terms for illustration. In order to optimize the use of realpatients but avoid having students feel that they are being intrusive, courseformats where students meet patients on several occasions are desirable.

Communication skills courses should also aim at stimulating discussionsand reflections about the impact of norms, practices, and cultural habits for thedoctor patient relationship and their communication. From an early phase,students should understand the necessity to be competent in communicatingin all kinds of doctor patient encounters (Makoul 2008). Curricula thatemphasize patient oriented care can prevent the erosion of students’ patientcentered orientation (Krupat et al. 2009; Ogur et al. 2007). Particularly inGermany, where consultation practices are diverse and students’ attitudesvary between traditional and problem based teaching methods, an early

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integration of communication skills instruction can be recommended. Studentsand teachers can be recommended to discuss the global values of healthcentered care in the context of the practical possibilities and limitations of theclinical frame conditions and norms (Stewart 2001). Open discussions fosterthe acknowledgement of societal frame conditions that determine therealization of traditional professional values (Cruess and Cruess 2008).

7.2 Recommendations for future research

Effective design of communication skills instruction demands knowledgeof students’ common problems. New insight could be gained if students withdifferent medical expertise were studied. It would be helpful to explorewhether students’ level of expert knowledge is related to their ability toestablish trustful relationships with their patients. These questions can beanswered in qualitative, observational studies with a longitudinal design.Students’ reflections about their acquisition of communication skills could becollected in interviews or focus groups. The relationship between attitudesand communication behavior needs to be explored, as there is evidence that apositive attitude towards patient oriented care was not being reflected inbetter communication skills (Joekes et al. 2011).

Information on students’ knowledge and reflections about the influence ofthe health care system on their relationships with patients is needed. Thisincludes the relationship of students’ willingness to share information withtheir patients to sociocultural factors. Studies that involve interviews withstudents could help illuminate how students become aware of norms aboutprofessional behaviors and which other factors affect their attitudes. The lattercan include medical teachers’ personal values and the hidden curriculum(Haidet, Kelly and Shou 2005).

There is a need to learn more about the preconditions for effective grouplearning, e.g. how social norms and students’ perception of norms aboutgroup learning and student directed learning approaches influence students’learning preferences and behavior. A useful complement to the selfassessment of self regulation skills may be instruments and qualitativeapproaches that assess students’ awareness of their learning strategies duringinteraction. An example here may be how self monitoring during groupdiscussions works (Hurme, Palonen and Järvelä 2006; Vauras et al. 2003).

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Appendix

Surveys in Swedish and German (plus information paper)

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