Teaching communication in medical students – a cornerstone for patient’s outcome

Communication is definitely one of the most important contributing factor for an ideal doctor-patient relationship. The major importance of communication is to build a proper relationship with the patients, in which the empathy and respect play an essential role and can be taught and improved with proper training. This process is defined as cross-culture communication and it has to be taught during medical school. Patient-centered communication is a concept closely related to cross-culture communication and it might be defined by the physician’s ability to tailor communication to each patient’s need and level of understanding in order to provide patient-centered care. Training of clinical communication skills in medical students is an incontestable emergency for the patient’s outcome. Medical education formerly focused on training students for solving only the medical problems by providing the treatment for their organic problems. Medical schools recently included in undergraduate curricula clinical communication courses in order to improve student’s and future physician’s the ability to obtain relevant information from their patients, to build strong doctorpatient relationships and provide patient-centered care. Various models were elaborated for teaching and assessing clinical communication skills, which were found to improve multiple aspects of physician-patient communication among which counseling, interviewing techniques and prescription. Medical schools should properly address to clinical communication skills by including training courses in each year of education focused on the specific of the learned medical fields. It is crucial for implementing proper assessment methods in order to prevent and diminish as much as possible the factors that might negatively impact the development of doctor-patient relationship. Proper medical training in terms of clinical communication skills should be initiated during medical school in all students that deal with patients, but also after the graduation, periodically in all health care providers for assuring an ideal outcome for their patients.


INTRODUCTION
Communication is definitely one of the most important contributing factor for an ideal doctor-patient relationship. It is true that most often communication is forgotten during the medical act, and healthcare providers tend to focus only on the therapeutic plan and on providing the necessary supportive or etiologic treatment. They do not usually acknowledge the major importance of building a proper relationship with their patients, which cannot be achieved without great communication skills. Thus, communication skills should be the main asset for all physicians in their daily practice. It is a well-documented fact that empathy and respect depend mostly on innate emotional and cultural sources, but they can be taught and improved with proper training (1)(2)(3)(4). Incontestably, teaching of communication skills should be initiated in medical students as soon as possible in order to increase their awareness regarding its importance for the patient's outcome. In addition, proper communication skills benefit also the physician and not only the patient since it was proved that proficient physicians communication equals professional accomplishment, satisfaction and confidence (5). It is worth mentioning that partially communication skills are inherited or developed during the 1 st years of life being related mostly to the family behavior and habits or primary school patterns. Physicians must display versatility in order to obtain patient's satisfaction since they often face patients with different social, cultural or emotional backgrounds. On the other hand, physicians themselves come from different countries, have certain religious beliefs, different ethnicities, cultural habits and social levels and they must overpass these barriers and focus providing a proper communication with their patient (6). This process is defined as cross-culture communication and it has to be taught during medical school (6). Patient-centered communication is a concept closely related to cross-culture communication and it might be defined by the physician's ability to tailor communication to each patient's need and level of understanding in order to provide patient-centered care. In certain medical fields, such as pediatrics, communication is peculiar since it is not a dialogue, but a trialogue involving and least three persons, i.e. pediatrician, patient and family/care-givers. Thus, in pediatrics we might redefine this concept, and name it family-centered communication because the pediatrician must acknowledge the family needs and develop also a strong relationship with the child. Parent's anxiety is the most common barrier that might hinder a proper communication and pediatrician's patience and empathy should be centered on both child and family, communicating in a proper manner with the child according to his age and level of understanding. This in not a single particular case of communication and thus medical students should receive proper training for all situations that carry certain peculiarities. Moreover, it was proved that good communication skills are essential for enabling the patient to express his stress and distress in order to allow the doctor to properly diagnose their emotional and psychological issues and to fulfill their needs (7).
Based on the afore mentioned facts, communications skills and training medical students in terms of this topic should be carefully addressed in all medical schools.

THE ROLE OF COMMUNICATION TRAINING IN MEDICAL STUDENTS
Medical education formerly focused on training students for solving only the medical problems by providing the treatment for their organic problems. Nevertheless, currently there is a tendency of increasing awareness regarding the role of proper communication in all medical schools worldwide, which became a crucial goal for medical education. Medical schools recently included in undergraduate curricula clinical communication courses in order to improve student's and future physician's the ability to obtain relevant information from their patients, to build strong doctor-patient relationships and provide patient-centered care (8,9). Students were proven to be extremely motivated and avidly for developing clinical communication skills in comparison to other medical skills (10). The learning process of these skills depend on student's personality and gender being proved that females are more prone to develop patient-centered care, to be more emphatic, to display an increased availability for developing interpersonal relationships and to be more focused on learning and approaching these skills (6).
Various models were elaborated for teaching and assessing clinical communication skills, such as Calgary-Cambridge Observation Guide (11) and SEGUE Framework (12), which were found to improve multiple aspects of physician-patient communication among which counseling, interviewing techniques and prescription (13). These achievements must be maintained even after medical school graduations since it was underlined that these skills were proven to deteriorate in time when not reinforced properly from time to time (14). Therefore, periodical teaching of these clinical communication skills is mandatory to maintain the physician's effective communication with his patients. The deterioration of these skills over time might be partially explained by the physician's busy schedule and his permanent intention and focus on treating as much patients as possible resulting in a considerable reduction of time allocated to each patient. We might state that it is not necessary a voluntary deterioration of this skills, but most-likely created by the complex and time-consuming medical life itself. Thus, periodic assessment of clinical communication skills in terms of retention and application by each physician is essential to prove the appropriateness of doctor-patient relationship and persistence of these learned skills. Multiple methods have been proposed for assessing both 'remembering the skill' and/or 'applying the skill' such video presentations with essay, multiple-choice exam or oral questions (15); surveys involving real or simulated patient experience in clinical situations; checklists filled by observers of student's communication skills during simulated or real doctor-patient encounters, and peer and/or self-assessment of these skills (4,16,17). Of these methods, clinical encounters involving simulated patients previously trained to respect standardized scenarios are widely used due to their particularity of providing an objective assessment with an increased level of validity and reliability (4). Taking into account that they provide a thorough assessment of how students objectively perform and the patient's perspective regarding the student's communication skills as well, they are worth using in practice for a proper assessment.
As we already mentioned, empathy is probably the most important and difficult to be learned component of doctor-patient communication, being fairly known as the 'backbone' of an effective and solid relationship (6). Physician's empathy for the patient must be completed by patient's compassion for the doctor in order to obtain a partnership based on mutual understanding and respect (18). Multiple dimensions of empathy were described such as cognitive and behavioral (listening carefully and acting accordingly) and emotional dimension (address and respond emotions). The first two were notice to be more easily validated during a simulated interview than the latter one (19). Empathy is a controversial topic when it comes to assessing its decline or persistence in medical students (4). Moreover, studies noticed a decline of other communication components during clerkship in undergraduate medical students: process-oriented skills, patient-centered attitudes and attitudes toward the doctor patient relationship (4,(20)(21)(22). Contrariwise, several cross-sectional or longitudinal studies proved that in terms of self-assessed empathy, the decline in medical undergraduate student is most-likely exaggerated reporting an increase or no major differences in this aspect of communication during the medical course (23)(24)(25). Nonetheless, certain factors were definitely proven to negatively influence the persistence of empathy like an intimidating educational environment, negative attitudes from residents and clinical faculty, overwhelming demanding educational assignments, patient reluctance or perception of brittleness (26,27). Additionally, role-models, i.e. clinical teachers, tend to display the most powerful influence in terms of empathy development (28,29).
Multiple challenges were proven to arose in terms of influencing clinical communication skills learned during the first years of undergraduate medical educations, and these are closely related to demanding contexts, time constraints, role models with various communication styles and real patients, the latter being possible, on the contrary, to display a positive influence on retention of clinical communication skills (4). Thus, the perception and persistence of clinical communica-tion skills learned during medical school are clearly impacted by a wide-spectrum of variable and they tend to be related mostly to the student's personality and his former ability to communicate effectively with his peers. Aside from gender and cultural background, other factors were also emphasized to deeply influence the retention of these skills in medical student such as specialty preferences, demographic variables, experience in clinical practice or their attitude towards training communication skills and the importance of these communication abilities (4,30,31).
Good doctor-patient communication is hard to be defined and a gold-standard of this communication is still lacking in our days, but fortunately, communication training has gained lately its deserved place in medical curricula since more and more universities acknowledged lately its importance and introduced proper approaches related to this topic in medical students. Certain aspects were defined as core elements of good doctor-patient communications such as those related to patient-centered care (emphasis on patient's concerns, ideas and emotions), proper relationship building, or facilitating and negotiating patient's cooperation (32). Patient's satisfaction remains the most important factor that contributes to the development of a solid doctor-patient partnership. Thus, each physician must be extremely carefully when it comes to patient's satisfaction and take into account the following key elements that were proven to increase patient's satisfaction: to actively listen and take into account the patient's ideas, expectations and concerns, as well as to express a friendly, warm and understanding attitude at all encounters (32). Moreover, the doctor's ability to delineate the biomedical and psychological problems of each patient in order to provide clear information by using an understandable language in terms of diagnosis, pathogenesis and treatment were also proven to be related to an increased patient's satisfaction (32).
The implementation of clinical communication training in all medical schools is a real emergency for the patient's outcome, albeit this is not an easy step. The training should focus on generic skills, but at the same time it should include specific crucial topics like genetic counseling, Unfortunately, training is limited in time and most-often not included properly in the curricula, albeit it should be included in each year and integrate the specialties learned step by step. Breaking bad news is a hard topic since it is extremely unpleasant and it might be defined as a key moment in the relationship between doctor-patient since it requires professionalism, patience, confidence and vitality for the patient to accept his condition (6). A study that assessed the patient's judgement of how doctors deliver bad news showed that 95% of the variance in terms of patients' acceptability judgements depends on the emotional strength and quality of information, whereas the severity of the condition had no influence since the single patients' expectations were sympathy and information quality independently of how terrible the news was (33). Another real challenge of implementing communication training in medical students is related to the didactical techniques which are often not accommodated to the student's nature. Least, but not last, a proper reinforcement of these communication skills is definitely needed when students enter the hospital for clerkships, even in residents, specialists and primary physicians (32). Taking into account that hospital settings usually promote diagnosis oriented, doctor centered and acute interventions care, outpatient departments and primary care seem a better alternative for training and reinforcing communication skills. Moreover, certain curricula included simulated doctor-patient encounters for a better practical exercise, but unfortunately, supervision and feedback of their performance is often lacking (34).
A proper and effective training of clinical communication skills should be centered on providing an adequate number of training hours if possible, during each year of faculty, improving both theory and practice, implementing proper supervision and assessment, as well as assuring the continuity and persistence of the achieved skills.

CONCLUSIONS
Training of clinical communication skills in medical students is an incontestable emergency for the patient's outcome. Thus, medical schools should properly address this problem by including training courses in each year of education focused on the specific of the learned medical fields. The acknowledgement of communication skills deterioration over time is crucial for implementing proper assessment methods in order to prevent and diminish as much as possible the factors that might negatively impact the development or even ruin a former effective doctor-patient relationship. Proper medical training in terms of clinical communication skills should be initiated during medical school in all students that deal with patients, but also after the graduation, periodically in all health care providers for assuring an ideal outcome for their patients.