Third Year Medical School Students' Experiences of Revealing Patients' Stories through Role Playing

Objective: Studying medicine is hard and it takes longer time compared to other majors. In addition, medical students find medical education boring. It is now necessary to turn medical education into an enjoyable and interesting way. The aim of this study is to evaluate the impact of an educational program related to how to learn taking medical history and how an effective patient-doctor interview should be. The program is structured in various scenarios, on the students learning skills, by the " role playing " method. Materials and Methods: A scenario prepared by the lecturer was employed in this study. While one of the students acted in a doctor role, the other one played in the role of patient's relative. The lecturer always played in the role of patient. After performing the role playing , students' written and oral feedbacks were gathered. Data were analysed by using SPSS 20.0 program. Results: A total of 470 feedbacks (51.3% were given by the female students) were taken from the students. Thirty-three volunteer students , nineteen of them were male, took part in the role playing. In the patient-doctor interview, the field that students were best were greeting the patients and dealing only with patients during the examination. The mean scores were 3.81±0.95 and 3.79±0.94 respectively. The ability to " summarize " and to " address the patient with his/ her name " had the lowest scores; the mean scores of the students in these areas were 2.94±1.11 and 2.70±1.31, respectively. Conclusion: Medical education is a long and tough process. Therefore , it should be interesting, attention getting and cheerful. Role playing can be effective in meeting that need.


Introduction
Communication represents a significant aspect of our daily lives, and is also an important part of patient-doctor relationships.The quality of patient-doctor communication is one of the most important indicators of patient satisfaction.Effective knowledge and the use of communication techniques grant individuals a significant advantage when resolving the problems encountered in social life and during various interactions.The manner in which a phrase is expressed is often more important than its actual meaning.This statement is more valid during patient-doctor interactions.However, describing the most effective way in which the patient-doctor relationships should be conducted, and presenting a role model for such interactions can be quite difficult for many instructors [1].Although doctors have many responsibilities, arguably one of their most important tasks is to serve as a role model for the people they treat, their students, their assistants and their colleagues [2].
Simulation and video-based role playing was demonstrated to be an effective method for inducing behaviour modification, improved decision-making, and professionalization among individuals working in the areas such as education, military, and health-care services [3].Behaviour modification and behaviour acquisition are especially difficult for adults.Although learning is a lifelong process, most of the behaviours are acquired during childhood.However, it is very important for medical faculty students to acquire certain behaviour models and skills during their education.The ability to take patient history effectively represents one such skill.
The aim of this study was to evaluate medical faculty students' experiences in taking patient history after practicing the "role playing" method, which was implemented in our medical faculty for the first time.

Materials and Methods
During the 2012-2013 academic year, the medical and professional education program of junior-year medical faculty students included a course in taking patient history.This course was used as an environment for implementing the role playing method.Scenarios prepared by a faculty member were applied to students who were willing to participate in role playing activities.During these activities, one of the students assumed the role of doctor, while another student assumed the role of a patient relative (depending on the scenario being implemented).The other students observed the role playing activity, and later provided their feedbacks.Prior to each activity, the faculty member informed the students on how they could provide constructive feedbacks.The faculty member who taught the class, on the other hand, always assumed the role of the patient.After each roleplaying activity, a pre-prepared questionnaire which includes 21 questions relevant to roll player's attitudes and behaviours; such as meeting the patient in an appropriate manner, introducing his/herself to the patient, listening to the patient without interruption to the patient was applied to the observer students.After the role playing activity was completed, feedback was provided both verbally and in writing.Feedback was also obtained from the faculty member and the student who assumed the role of the doctor.The results are given as numbers (n) and percentages (%).The collected data were analysed using the Statistical Package for Social Sciences (SPSS) 20.0 program.

Statistical Analysis
The results are given as mean, standart deviasion, numbers (n) and percentages (%).The collected data were analysed using SPSS 20.0 program (SPSS Inc, Chicago, IL, USA).

Results
A total of 470 feedbacks were obtained from the students organized in small groups.Of the students, 51.3% (n=241) were female.A total of 33 students (14 female and 19 male) voluntarily assumed the role of doctor during the role play activities.
The areas in which the students performed best were the ability to "greet the patient in an appropriate way" and to "not be preoccupied with other tasks during the patient visit;" the mean scores of the students in these areas were 3.81±0.95and 3.79±0.94,respectively.The ability to "summarize" and to "address the patient with his/her name" had the lowest scores; the mean scores of the students in these areas were 2.94±1.11and 2.70±1.31,respectively (Table 1).The scores for the ability to "introduce oneself to the patients, " to "ask the patient whether he/she has any questions, " and to "take notes without interrupting the conversation" were relatively higher (Table 2).
In their feedback regarding the role playing activities, students who assumed the role of the doctor described their experiences by stating that, "It was a really enjoyable class;" "We really felt like doctors;" "Being a doctor is not as easy as I previously thought;" "Communication is really important after all, " "We really liked this activity;" and "I wish other classes were like this." The faculty member who taught the class also described that he really enjoyed participating in this activity, and mentioned that this activity strengthened the students' communication skills.The faculty member also expressed that different and alternative activities should be performed with the students.The scenarios used in the role playing activities were prepared by the faculty member based on real events and his previous experiences.

Discussion
During the classes in which patient-doctor relationships were taught, the areas in which the students performed best were the ability to "greet the patient in an appropriate way" and to "not be preoccupied with other tasks during the patient visit." A previous study described that using the role playing method in teaching patient-doctor communication provided an alternative approach that resulted in positive experiences for the students [4].In the current study, the role playing method was also employed as a teaching approach during the classes.Both the students and the faculty mem-ber teaching the class provided quite positive feedbacks regarding this method.Using this method for teaching not only rendered the classes more enjoyable in comparison to conventional approaches, but it also served to demonstrate, through role play, the areas in which the students needed to develop and improve themselves.Moreover, the students, themselves, had the opportunity to sense their own areas of development.In another study conducted on nurses, educational activities involving role play with peers resulted in a learning experience that was more interactive, and which provided the students with an active learning environment.These activities also encouraged the students to learn, and was very favourably received with regard to both content and method [5].The learning environment provided by role playing is very important in allowing the students to feel like doctors.The active participation of the students in their own education is also critical in encouraging them to expand and further their learning experiences.
In another study, the role playing method and the conversation method were employed as two different approaches to provide students with knowledge and practical skills regarding emergency cases.The results of this study demon-strated that role playing was the most effective of these two methods in providing such knowledge and skills.The study also emphasized that direct participation rendered the classes more appealing to the students, and that the more actively the students participated in these classes, the more satisfied they felt about their learning experience [6].The feedbacks that were obtained from the students in the current study were similar.Nowadays, students are less interested in boring and instructor-centred educational methods.These days, there is an increasing emphasis on student-centred education, and role playing methods -such as the one employed in the current study -are becoming more important.
Role playing serves an important function in allowing students to have an experience similar to real-life situations, thus giving them the opportunity to better prepare themselves for such events.In fact, such methods are also described as being effective in reducing the concerns of students towards real-life situations [7].This is because medical faculty students are individuals who will soon interact directly with patients.In this respect, role playing provides students with foresight, and prepares them for real-life situations and the different types of patients they will encounter in their profession.Learning and teaching activities are of crucial importance for instructors.Throughout the history, there has been a continuous need to develop new learning and teaching approaches in education.This, in turn, has led to constant efforts to renew the existing activities and approaches used in education.In other words, there has been a constant search for new methods that would be better suited for the current needs and interests of students.In a previous study, the role playing method was employed within the context of problem-based learning activities.This study described role playing as an effective method for providing students with new experiences, and for facilitating their learning [8].
Role playing allows students to feel like doctors, instructors to enact patients, and other students to see their classmates engage in role playing, thus, role playing activities contribute significantly to developing the students' com- In another study, it was observed that role playing provided the students with a very different experience, enabling the students to communicate very well, without feeling under any pressure.This role playing also allowed them to learn with greater ease [9].
It is important for a patient-doctor communication to be performed adequately.Such communication should be based on mutual respect.Proper communication with the patients is essential for a correct diagnosis, for proper treatment, and for patient compliance to treatment.One of the goals of medical education is to teach students to display professionalism.As such, there is a constant need for doctors who can communicate well with other people.
In certain instances, patient consent should be obtained for certain procedures; and after the benefits and risks of the procedure have been described to the patient, it may be necessary to make joint decisions with the patient, his/her relatives, and sometimes even with other doctors and clinical teams [10].
In the present study, it was noted that the areas in which the students experienced the greatest difficulties in communication were the abilities to, "Address the patient with his/her name, " to "Introduce oneself to the patient, " to "Take notes without interrupting the conversation" and to "Ask the patient whether he/she has any questions." While communicating, the doctor needs to confirm whether a patient correctly understands what he/she, as the doctor, is saying.The doctor also needs to ascertain whether he/she correctly understands what the patient is saying.A doctor must be cautious during his/her conversations with a patient.One study described that negative communication lead to difficulties with patients, and also that whenever patients had negative moods such as stress, the positive attitude of the doctor could easily overcome and remedy such moods [11].
It is imperative for courses on communication to be a part of the curriculum of medical students.Students should learn how to overcome and resolve conflicts in communication.However, students cannot learn how to handle such conflicts based solely on theoretical courses.A review of malpractice suits shows that many of these cases were actually the result of miscommunication.Doctors who are better at communicating with patients face such trials far less frequently.In addition, acting cooperatively towards a patient when communicating with him/her -as if the doctor and patient were both a part of the same team -will serve to create an atmosphere of mutual respect and trust [12].
Medical education generally fails to place sufficient emphasis on doctor-patient communication, and accords more importance to the disease than to the patient.Unfortunately, not enough time is allocated for talking to patients, or to listening and understanding them, despite the fact that such activities represent a fundamental aspect of any treatment [13].Ensuring that patients feel understood when they speak with the doctor will allow them to better express themselves, and will also help reduce their level of stress and concern.Establishing communication based on effective listening, active listening, and body language will allow mutual trust to develop between the patient and doctor.For example, the use of mimics or nodding by the doctor while listening to a patient will allow the patient to feel that the doctor is actively listening.During the activities that were performed with the students, the verbal feedback indicated that doctors who listened to their patients were more appreciated.
In scenarios which the faculty member played the role of a difficult patient, or deliberately caused communicationrelated conflicts, it was observed that the students who assumed the role of the doctor had a really difficult time dealing with such situations.Evidently, the students will not always encounter patients who are polite, respectful, or timid.Consequently, the education programs and courses of students should also include information on what they should do, and how they should behave as doctors, when faced with difficult, rude, disrespectful, or forceful patients.
Teaching communication skills, and assessing whether these skills have been taught successfully, is not an easy task.Patient satisfaction and patient-doctor communication are inextricably correlated with one another [14].It is natural for patients to be more satisfied and pleased with doctors with whom they can better communicate.Conducting patientdoctor communication in such a manner that one of the parties dominates the conversation will also result in poor communication.It is hence recommended for the patientdoctor communication to be conducted in the form of a dialogue between partners.Furthermore, taking the cultural characteristics of the patient into account will assist in allowing the patient-doctor communication to be performed in a more mutual and cooperative way [15].The cultural diversity of present-day Turkey requires doctors who are capable of communicating in such a way.
In conclusion in medical education, it is very important to train doctors in a way that will allow them to communicate effectively with patients.Medical education involves a long and tiresome process.Thus, there is a need to render a lengthy and intensive education process that is more interesting and enjoyable for the student.The researchers of the current study believe that activities involving role playing might fulfil this need.Furthermore, these role playing activities can be used to improve the communication skills of doctors, and also to improve their ability to effectively take patient history within the context of patient-doctor communications.