In the physician–patient interaction, effective communication is critical to achieve accurate history taking and diagnosis, satisfactory discussion of treatment options, meaningful patient education, and better health outcomes.1 While communication depends on a large number of factors, including attitudes and knowledge of the principles of communication, the importance of language cannot be overestimated. Interpreters are often used to bridge language differences between patients and caregivers, but this practice is far from ideal.2,3 Indeed, communication in health care delivery is usually enhanced when the professional speaks in the patient's mother tongue and is familiar with the patient's culture and context. These factors are all the more relevant for minority populations, since their linguistic needs in the delivery of health care services are chronically overlooked by the majority and their cultures often poorly understood. Hence, in order to be socially responsive, medical schools that serve minority populations must find ways to ensure that their medical curricula offer appropriate training for the development of communication skills that specifically address the needs of these populations.
As a minority group, the francophone population of Ontario needs to have physicians who can speak French fluently and who understand the specific context and cultural aspects of their communities. In response to these societal needs, the Faculty of Medicine at the University of Ottawa began developing, in 1995, a French-language stream in its undergraduate program.4 In planning the new stream, program developers realized that there was a need for a structured format to teach communication skills to francophone students in French. In the existing context, all teaching hospitals had English as their working language, and exposure of francophone students to francophone patients and instructors for communication skills' development was haphazard at best. As a solution to this problem, in 1996 a communication skills laboratory was developed for francophone students at the medical school. This constituted one of the three innovations of the new program, the other two being early student exposure to francophone patients in an ambulatory, primary care setting and the development of clerkship rotations in a francophone community hospital. We have written this article in the hope that the methods used in teaching communication skills to French-speaking students at our medical school will be of interest to other institutions that serve linguistic minority populations.
In this article we describe the setting in which the communication skills laboratory was developed, the purpose of the innovation, the specifics of the laboratory, the factors that were considered in its design, and the main outcomes of the educational project.
In the province of Ontario, there are over half a million people who have French as their mother tongue. This group constitutes the largest francophone population in Canada outside the province of Québec. However, at about 5% of the total population, Franco-Ontarians represent a minority group within the province. Most of the communities where Franco-Ontarians are in largest numbers are underserved, and suffer from a chronic lack of health professionals who can deliver services in French.5
As the premier bilingual institution of higher learning in Canada, the University of Ottawa offers programs in French and English, the two official languages of the country. In 1965, the institution received from the government of Ontario the specific mandate “to further bilingualism and biculturalism and to preserve and develop French culture in Ontario.” As part of this mandate, the university had to find ways to develop and provide educational programs in French for Franco-Ontarians who were admitted to the Faculty of Medicine, a medical school where instruction had traditionally been delivered solely in English. In 1992, as part of a curricular reform to a problem-based learning curriculum, the faculty started offering a few hours of small-group learning in French to francophone students. In 1995, following an evaluation of the project, an action plan was developed and adopted by the faculty in order to develop a complete French-language stream for the undergraduate medical program.4 The Office of Francophone Affairs was created: it then consisted of five francophone faculty members, a vice-dean responsible for francophone affairs as director, and a senior administrator. This steering group was given the mandate to plan, develop, and implement the new program. A five-year grant for the project was obtained from the Ministry of Education and Training of Ontario, and financial support was secured from the University of Ottawa for the steering group.
One of the many challenges that program developers were facing was to create an environment where francophone students could learn clinical and communication skills in French. Until then, all students had received clinical skills training in three tertiary care teaching hospitals that operate in English. That environment seldom allowed for teaching activities to be run in French: for the patient–student–resident-faculty team involved in the process, it was a rare event to have all four individuals able to communicate in that language. Therefore, the communication would take place in English if even a single member of the group did not speak French.
“When I am sick, I am not bilingual.” These words, found in the title of a report on health care planning,6 illustrate the need of the francophone population of Ontario to receive services from health professionals who can communicate well in the French language. Although Franco-Ontarians are largely bilingual for day-to-day conversations, they usually depend on their mother tongue for communication in stressful or unfamiliar circumstances such as when seeking help for a health problem. A recent review of French-language health services in Ontario reports that failure to recognize this linguistic need “generates additional referrals, interventions or hospitalizations, as well as excessive or inappropriate medication; they may also be inadequately assessed by health professionals and as a result, receive less appropriate health care.”7 In the case of children, the elderly, and people with mental illnesses, the need for communication in their native language is even more crucial.
Another need of the francophone population is to receive medical care from physicians who know their communities well and who understand their culture. People of Ontario expect their physicians to be their advocates concerning their health care needs, a role that requires a good understanding of psychosocial circumstances and cultural aspects of a given population group.8
Taking into account these societal needs and the existing context, program developers had two goals in mind in developing the communication skills laboratory. First, they wanted to give students the opportunity to learn clinical skills efficiently outside the tertiary care centers where instruction in French was rarely possible. Second, they wanted to expose students to clinical scenarios that reflect the primary care practice of francophone physicians to introduce them to cultural aspects of health care. They felt that these goals would best be achieved by creating a structured learning environment where francophone students could develop effective interviewing and physical examination skills while using French as the language of communication. In the design of this facility, they adapted to local needs the Skillslab developed at Maastricht medical school, University of Limburg, The Netherlands.9
The communication skills laboratory consists of a controlled environment at the medical school where francophone students conduct interviews in French on a regular basis for their two pre-clinical years, starting four weeks into the first year. The laboratory makes use of simulated patients who are trained to play specific roles and to give individualized feedback to students regarding their perceptions of the quality of the communication during the encounter. For each student–patient encounter, a clinician trained in observation and feedback techniques observes the interview and provides constructive comments to the student. Fifteen separate themes (such as “a noncompliant patient,” “a depressed elderly patient,” etc.) are covered during the laboratory sessions in both the first and second years. Four half-day sessions covering the same theme are held over a two-week period, and three student–patient–clinician encounters take place simultaneously every 30 minutes throughout each session, in order to accommodate student scheduling. In addition to doing an interview, students perform physical examination techniques during the laboratory sessions, toward the end of the first year and throughout the second year. Thus, the laboratory allows students to gain some experience in conducting interviews and in performing physical examinations in a nonthreatening environment. In addition, it exposes them to increasingly complex clinical situations under controlled conditions.
During laboratory sessions, all student-simulated patient encounters are run in a systematic fashion. First, the medical student interviews the simulated patient in French in an examining room while a clinician observes and assesses the interaction with the help of a standardized grid. The student–patient interaction lasts 10–15 minutes. Then, the student evaluates his or her own performance. Next, the simulated patient gives feedback to the student in private about his or her perceptions and feelings during the interview. The patient then leaves the room and the clinician gives the student feedback based on notes taken during the encounter. At the end of the activity, which lasts about half an hour, the student describes to the clinician what he or she would do differently in this situation, based on the feedback received. Facilities are in place to film the activity. Students who take advantage of that opportunity are given their videotapes so that they can review their performances and the feedback that they have received. They can also assess their progress over time when they view the tapes at a later date.
Several steps were followed in the design of the communication skills laboratory.
▪ First, program developers identified appropriate situations or incidents that would serve as triggers for the development of relevant scenarios.
▪ Second, they wrote the scenarios for all the laboratory sessions, in sufficient detail to provide guidance for the simulated patients' role plays. For each scenario, they developed instructions about the case for the student and the clinician–supervisor.
▪ In addition, they created a standardized grid that would be used by the clinician–supervisor to assess student performance.
▪ Another step involved the recruitment and training of simulated patients.
▪ They recruited and trained clinicians who would be supervisors in the laboratory.
▪ They organized the cases in order of increasing complexity to optimize student learning.
Inspiration for scenarios that would best teach communication skills came from two sources: francophone community members and community physicians. Information was obtained from the community by means of a needs survey that was conducted as a summer project by two francophone medical students in 1995.10 The project consisted of conducting informal interviews of francophone community members to elicit, from their personal experiences, situations where communication with a physician had been unsatisfactory because of a linguistic problem. Flanagan's critical-incident technique was used to obtain factual data regarding the events, the technique being “a method for collecting behavioral data about the ingredients of competent behavior in a profession.”11 Factual data were obtained from 85 francophone community members of various ages and occupations who came from the regions where francophones are found in largest numbers: eastern and northeastern Ontario. Over 30 critical incidents illustrating communication problems due to a language barrier were described by these patients. Examples of incidents included misunderstanding a physician's orders and taking too much medication, having emergency surgery without understanding the nature of the planned procedure, receiving counseling for contraception through a relative and being labeled as confused when not understanding the meaning of questions. In addition to confirming the importance of the French-language medical program as a whole, these incidents served as triggers in designing appropriate scenarios for the laboratory.
Community physicians were a second source of information in the development of scenarios. In addition to providing instructive clinical situations, these clinicians had to ascertain that the cases were relevant for the training of a generalist physician. A small group of francophone clinicians (family physicians and specialists) and a medical student met regularly for several weeks to identify the medical problems that, from their experience, represented common reasons for patients' visits to a physician. The working group also outlined situations where communication difficulties could arise during physician–patient encounters. Making use of the list of reasons for consultation and of the experience of the working group, program developers created the 30 scenarios needed for the laboratory sessions to run over a two-year period. The information to be gathered by the student and the communication skills to be learned were defined for each case. These expectations were summarized as educational objectives for each encounter. A script was also developed, describing the role to be played by the simulated patient during the encounter: reason for the consultation, personal and family history, attitude to have with the student, symptoms to mention, answers to give to unforeseen questions, etc. Finally, what was expected of the student was translated into observable actions and behavior, and a scoring sheet containing the expected performance was prepared for use by the clinician-supervisor during the encounter.
Recruiting and training personnel
Simulated patients were recruited from the francophone community. Some community members had expressed interest in helping train their future physicians at the time the health services needs-assessment was done by the two francophone medical students in 1995.10 Others were recruited from the practices of the francophone clinicians.
A professional standardized-patient trainer was hired to train simulated patients for their acting role and for their role as evaluators of student performance. This professional was also given the responsibility to coordinate the activities of the laboratory for both first- and second-year students of the program. Simulated patients were expected to play their specified roles four or five times during a given session. Some were trained to play additional roles throughout the academic year.
Clinician–supervisors were recruited mainly from the francophone community physician pool. A smaller number of recruits were faculty members coming from tertiary care teaching hospitals. Each clinician was asked to devote a minimum of two half-days per academic year to the communication skills laboratory.
Program developers organized workshops for the training of the clinician–supervisors. During the one-day workshops, future supervisors received training to do direct observation of the students, to assess the patient–student interaction, and to give constructive feedback to students.
Organizing laboratory scenarios
To optimize learning, laboratory scenarios were organized in a way that requires an increasingly complex set of skills from students. In the first year, the emphasis is on interviewing techniques. During the first two encounters, the student learns to establish rapport with the patient and to explore the reasons for his or her visit. In the several subsequent encounters, the student has to obtain a history from a patient who presents a communication problem (e.g., who is talkative, very quiet, tearful, vague, anxious, disorganized, withdrawn, domineering, or provocative). Two physical examination techniques are included in the second semester of the first year: the cardiovascular examination of an apprehensive patient and the pulmonary examination of an adolescent who fears the visit will be discussed with his or her parents. In the second year, the students are encouraged to expand their interviewing and physical examination skills. To facilitate the integration of theoretical knowledge with clinical skills, the scenarios are related to the multidisciplinary block being taught at the time. For example, during the cardiovascular system block in the first year, one of the cases depicts an anxious patient with chest pain, and during the endocrine system block in second year, one of the cases involves a diabetic patient. A communication difficulty is incorporated into each scenario.
OUTCOMES AND COMMENTS
Now in its seventh year of operation, the communication skills laboratory is among the most popular educational activities of the French-language medical program. The laboratory is an elective activity, yet, in both the first and second years, the majority of francophone students participate in it. Anglophone medical students who have sufficient knowledge of French ask to join the francophone students in this activity and are given that opportunity whenever possible. Favorable evaluations have been obtained from all parties who have participated in the laboratory: students, clinician–supervisors, the professional patient trainer/laboratory coordinator, and the simulated patients. Positive comments have also been made about the program by clinical preceptors who supervise students during clerkships and elective rotations. Finally, the project is of great interest to faculty members in charge of the English-language stream, in part because they find tertiary care hospitals less and less suitable for the teaching of communication skills to students.
At the end of each encounter, students are asked to provide their comments about the activity and to rate it on a scale of 1 (agree completely) to 5 (disagree completely) by filling an evaluation sheet containing a number of statements regarding the quality and relevance of the scenario, the realism of role-playing by the simulated patient, the usefulness of the feedback given by the patient and the supervisor, and the student's perception concerning the acquisition of new communication skills. The responses to the statements are almost always in the most favorable category, i.e., ratings of 1. Student comments are in agreement with the favorable ratings: “Very realistic case”; “Excellent evaluator! Much experience and useful advice”; “Feedback very constructive and pertinent”; “Gives a clinical perspective to our theoretical knowledge”; “Excellent acting”; and, “Dr. G. made me feel comfortable, his constructive comments help me improve my performance.”
The clinician–supervisors also provided positive comments in their evaluations of the laboratory: “Stimulating case, a good challenge”; “Realistic case, very relevant”; “The physical examination techniques of the students were a bit disjointed. We were able to explore a logical structure for the examination”; “Good choice of case—a challenge to the students' ability to interview patients about personal and delicate topics.” Recurring comments by the physicians emphasized the appropriateness of the cases and their close resemblance to actual cases occurring in a primary care clinical practice. Although the students had not yet learned the theory of a particular organ system at times, the laboratory supervisors did not feel this diminished the learning experience of the students. Coming from experienced clinician–educators, these comments are encouraging to the program developers.
The professional in charge of simulated-patient training and coordination of the laboratory was able to appreciate the overall climate of the laboratory sessions throughout the academic year for the two years of medical studies. She noted that students, clinicians, and simulated patients were generally enthusiastic about participating in the communication skills laboratory. Her personal perception was that the sessions were highly educational for students: she could witness changes in their behaviors and demeanors as they became more comfortable in playing the roles required of a physician.
The simulated patients often mentioned their delight in helping to educate their future physicians. They took a genuine interest in giving constructive feedback to students to help them perfect their communication skills. Several have offered to increase their involvement in the program by playing different roles throughout the academic year.
Preceptors who supervise students during clerkship rotations find that francophone students have a greater mastery of communication and physical examination skills when they enter the third year than was the case in the past. Francophone students who participate in the program feel well prepared for their clinical rotations. They are comfortable in communicating with both French- and English-speaking patients and know the medical terminology in both languages. However, at present, the degree to which francophone students have learned communication skills through their laboratory experience is not formally assessed: they are subjected to the same examinations as their peers in the English-language stream. It will be important to develop an objective method to compare the performances, when interacting with patients, of students who have participated in the laboratory and of those who have not.
In view of the popularity of the laboratory, its educational merits, and the difficulties encountered in teaching communication skills in tertiary care hospitals, the faculty considers translating the scenarios and setting up a similar type of program for students in the English-language stream. Although the scenarios were designed to help communication with a linguistic minority group, the faculty believes that there is a universal group of communication skills that can be learned from each of them.
We are pleased with the outcomes of the innovation. We seem to be achieving what we set out to do: to train students to become effective communicators with a linguistic minority group. However, the ultimate reason for setting up the French-language medical program is to provide cohorts of young francophone physicians for the communities where there are chronic shortages of health professionals who can deliver services in French. The program was established too recently to ascertain that students trained in French will set up their practice in these communities. However, by designing educational activities according to the societal needs of that linguistic minority population, we are hopeful that the aims of the program will be fulfilled.
We believe that the training methods that were developed and successfully applied in the communication skills laboratory at our medical school are readily transferable to other socio-cultural contexts. In urban areas that are multilingual and multicultural, a medical school may begin by focusing on the communication skills that address the needs of the predominant minority population group that it serves. The adaptation of these methods to local circumstances could help alleviate the need for using interpreters, could lead to better physician–patient communication, and could improve health outcomes.