‘Becoming a Physician’–medical students get acquainted with disadvantaged populations, and practise sensitive and effective communication

Background The three-year pre-medical programme ‘Becoming a Physician’ focuses on different aspects of medical professionalism. Objectives are to increase awareness and sensitivity to disadvantaged populations, and practise sensitive effective communication skills. Methods The curriculum includes: (1) Visits to treatment centres for people with special needs, mental illnesses, substance abuse issues, physically or sexually abused, and prisoners. Students tour the facility, hold discussions with residents, and discuss ethical professional interrelations to the medical world. Students then write ‘reflective diaries’ summarizing their thoughts and emotions. (2) Participation in a communication course that focuses on learning by practising patient-oriented communication. Qualitative data were collected from three sources: reflective diaries, studentsʼ course evaluations, and interviews with the studentsʼ tutors. Results Data indicated that the students were very satisfied with the programme. They indicated an increase in awareness of the special needs of diverse populations, and in the sense of efficacy for conducting interviews tailored to patients' needs. Tutors reported a sense of ‘personal growth’ following their role as mentors. Reflections Interactions of medical students with diverse populations, when accompanied by appropriate feedback mechanisms and strengthening of communication skills, can improve awareness and sensitivity to patients' special needs. This could help students become more sensitive and thoughtful physicians.

qualities. The content of the course is appealing to most physicians and a way to enrich their daily routine, so many are happy to volunteer.
The programme objective is to expose young students to different psycho-social aspects of the medical profession during the years devoted to pre-med scientific studies so they would be better prepared for their clinical years. This includes: different working environments; multidisciplinary professionals; patients with diverse sociocultural backgrounds; challenging ethical issues; different aspects of the 'medical life'; and impacts of professional life on one's personal life. The programme also aims to teach and practise patient-centred communication, using Gagné's nine steps of instruction [2,3]. Students share their feelings, thoughts and experiences in a formal manner at closing discussions that are held at the end of each meeting, as well as informally during their after-school get-together. The programme also gives the students a 'second chance' to examine their choice to become physicians and their personal compatibility for medical life. The interactive nature allows tutors to identify students who may benefit from emotional support or professional consultation regarding their choice of a medical career.
The objective of this Show and Tell contribution is to introduce our unique pre-medical educational programme, present some -preliminary-qualitative evaluations, and discuss our reflections on the programme.

Course curriculum
Different aspects of the physician's work are stressed during the programme. In the first year students are introduced to the hospital setting-inpatients, different departments and professions. In the second year students reach out to the community, meet disadvantaged populations, learn and practise effective and sensitive patient-centred communication. In the third year multi-cultural aspects of medicine are presented, and the students are challenged with complex ethical dilemmas using insights they have sustained from their two previous years. Second year programme curriculum includes: 1. Meeting disadvantaged populations. The goal is to familiarize students with populations that need special attention and care; deal with dogmatic beliefs, prejudice and emotions that arise from meeting the unfamiliar, including: elderly people in geriatric hospitals or nursing homes; children and adults with special needs (mental or physical handicaps); people with mental illnesses in hospitals or in community hostels; battered women in shelters, and sexually abused women; people with drug or alcohol addiction; and prisoners in jail. A typical meeting in a community care centre includes an intro-duction about the goals and special services the facility provides to their unique population; meetings between students and the facility's residents; and a final gathering with their tutor for ventilating emotions, sharing thoughts and discussing professional and ethical linkages to the medical world. 2. Improving communication skills. The goal is to enhance communication skills emphasizing sociocultural sensitivity. The methods include a theoretical session on communication methods, based on the key tasks in communication, as described by Maguire & Pitceathly [4]; a practice session using role play; practising patientphysician communication in primary clinics; and implementation of communication skills learnt during each visit to a community centre.

Course evaluation
We use three qualitative evaluation methods: (1) Students' feedback questionnaires (150 feedback questionnaires reviewed).
(2) Oral feedback sessions with the tutors (8 annual sessions with 10-15 tutors each were reviewed).
(3) Students' 'reflective diaries'. Following each meeting students wrote diaries about their reflections following the visit. The tutors send written feedbacks (36 annual diaries of 14 meetings each were studied).
Overall the programme ranked highly in students' satisfaction questionnaires, mostly because they felt that their voice was heard, that the discussions within the group were respectful and non-judgmental, and that they could freely express their emotions. Many said that it was the most significant programme during their pre-clinical studies. Students were satisfied with meeting disadvantaged populations. Many asked: 'How come I was never introduced to such populations before?' Students and tutors reported an increase in their awareness and sensitivity to the special needs of different populations, and felt that their interviewing skills had significantly improved. Selected quotes describing students and tutors impressions are presented in Tab. 1. Some students who had personally experienced a health/social issue affecting the populations they met (e.g. having a sib with special needs) reported that they finally had a chance to openly and intimately discuss their feelings with fellows, and that their tutors provided emotional support.

Discussion
In the past academic medical education was strictly separated between 'pre-clinical' (theoretical basic sciences) and 'clinical' (rotations in hospital departments) years [5]. The Our programme holds many of these educational goals: exposing young students to different aspects of the medical profession; enhancing their sensitivity to special needs of disadvantaged populations; improving their communication skills, and their ability to reflect on their experiences.
We believe that this programme held positive effects on increasing medical students' awareness and sensitivity to the special needs of disadvantaged populations. This was mainly achieved by means of personal unmediated meetings with a diversity of people, accompanied by a communication skills' course and appropriate feedback mechanisms. The sensitivity of our students developed concomitantly with their sense of comfort to conduct patient-centred interviews.
The main limitation is that the evaluations are based on self-report questionnaires and diaries, and unfortunately the relation between self-reports and what actually happens in real life is not necessarily very strong. Furthermore, the findings of the evaluation are, due to its qualitative nature, subjected to our interpretation.
Although all students studied at one faculty, the programme involved 7 hospitals and over 20 community facilities, thus students met different patients and had different experiences, which is true for any clinical rotation.

Conclusion
Based on our impression, we suggest that exposure of young medical students to disadvantaged populations in the community, when accompanied by appropriate feedback mechanisms, and with measures to strengthen communication skills, improves students' understanding of special needs of different populations. The communication skills trend nowadays is to incorporate some elements of clinical exposure in a spiral fashion along all the years, including early pre-clinical years. Dornan et al. showed that such early clinical experience eased students' introduction into the clinical environment, improved their motivation, strengthened their confidence in approaching patients, increased their awareness of themselves and others, and clarified the role of medical profession within the social and behavioural context of health care organizations [6]. Early experience in the community helped students acquire basic communication and clinical skills that were invaluable to them. Community exposure enabled students to improve their affective skills, such as empathy; increased their self-awareness; helped them feel more content with their choice to practise medicine; and decreased their anxiety associated with meeting patients. Students' exposure to the community early in the course of their medical studies also contributed to their tutors, health care providers in the community and patients [7].
Teaching communication skills as part of the curriculum of medical studies is gaining popularity and is very successful [4,[8][9][10]. Yedidia et al. [11] have shown that developing a comprehensive educational syllabus in the field of communication skills, and implementing it from the very early stages, improved students' communication abilities, and improved their skills in building inter-personal relationsskills that are important for the success of treatment and for patient satisfaction [11][12][13]. Exercise, feedback and reflection are integral parts of such courses. The use of reflection techniques as an educational and feedback tool encourages processing, introspection and critical thinking on all actions and experiences of the individual and team, thus encouraging learning and improvements [14,15].

Tab. 1 Selected quotes describing students and tutors' impressions
After a visit to a hostel for battered women a student wrote: 'Even though the hostel is adjacent to my home, I had no idea who lived there, and why the doors were always locked. The women, who always entered the house very quickly, were transparent to me. I had no idea what burdens they carried on their shoulders… It's not that I didn't want to know more, I simply had no way or opportunity to get closer' Following a visit to a day-care facility for adults with severe mental retardation another student wrote: 'My attitude to people suffering from mental retardation has completely changed'; 'I was surprised at how much every activity taking place in the day-care was oriented to allow free choice for the residents, and to respect their free will, even of the most profoundly mentally challenged people'; 'Now I see "them" as human beings, who can be sad or happy, who have their own desires, which we need to respect'