In this article we describe the initial use of an educational innovation consisting of a teaching objective structured clinical examination (OSCE) used as “sensitizing practice,” followed by personal, guided, and group reflection. This approach provides a forum for mindful practice and reflection concerning challenging communication topics between physicians and patients. Sensitizing practice allows learners to encounter a patient without knowing the educational intent, which means that they can explore the patient’s full biopsychosocial context and organically experience the challenging communication interaction without any cues to alert them to any particular aspect of that context. As learners engage with the patient and then later, after learning the educational intent, reflect on the encounter, they are better able to identify their own practices and potential biases.
The aim of the initial use, carried out in 2012, was to prompt learners to engage in mindful practice with patients who identified religion and/or spirituality (R/S) as part of their biopsychosocial contexts. We reasoned that an OSCE incorporating topics of R/S was an opportunity to teach medical learners the skills needed to engage in challenging conversations.
Medical education has implemented the OSCE for more than 30 years,1 and it has become the standard for evaluation2 for a wide range of clinical skills.3 The traditional model of the OSCE provides educators an opportunity to assess learners’ performance in clinical situations4; it is also a useful method of appraising learners’ interpersonal and communication skills in challenging clinical scenarios.5,6 Whereas standardized patients (SPs) have long been partners in teaching specific clinical skills,3 such as giving musculoskeletal exams or Pap smears, the OSCE has only occasionally been used as a teaching tool.7,8 Previous applications have prepared health care professionals for challenging communication scenarios,9 including ethical dilemmas.10
Challenging communication scenarios can emerge when there are conversations about inherently personal topics. Such topics have the potential to complicate clinical communication. Both patient and provider may have anxieties about bringing up a personal topic out of fear of judgment, fear of offending the other party, or fear of a difference in values that could lead to interpersonal tension or even conflict. Thus, patient and provider may withhold information about values in an effort to avoid discord.
One strategy to deal with this problem is the incorporation of patient-centered communication (PCC). PCC is associated with higher levels of patients’ perceived satisfaction with communication and the health care provided to them11,12 and increased adherence to self-management behaviors.13 Through PCC, physicians seek the patient’s perspective to under stand the patient within his or her biopsychosocial context.14
One component of the patient’s perspec tive may be R/S, but the appropriate role of R/S in clinical practice is some times debated.15,16 Many patients have the desire to discuss R/S with their physi cians, and this desire is magnified when patients face a grim diagnosis.17 Luckhaupt et al18 found that almost half of primary care residents felt they should engage in discussions about their patients’ R/S. Despite the findings of one study that a majority of physicians agreed that they should pursue R/S when prompted by the patient, another study19 reports that physicians rarely reported talking to patients about spiritual topics and cited numerous barriers to engaging in religious conversations. The major obstacles of engaging in R/S conversations appear to be lack of time, lack of experience taking a spiritual history, difficulty identifying patients who wanted to discuss spiritual issues, and the belief that addressing spiritual concerns is not part of the physician’s role.15 Moreover, physicians’ reports of patient R/S communication behavior have been linked to physicians’ amplitude of religious beliefs and observances.20 For all these reasons, we thought that an OSCE incorporating R/S topics would be an opportunity to teach medical learners the skills needed to engage in challenging conversations.
Our experience has shown that following a sensitizing OSCE with prompted steps to encourage reflection can magnify learning opportunities and enable learner maturation. For the purposes of this article, we define reflection as the cognitive and affective exploration of experience to create new understanding. The reflection in our innovation (described in the next section) was primarily reflection on action, which occurs following an experience.21 Additionally, in the context of R/S, reflection activities incorporate emotional reactions to experience. In this iterative process, the learner returns to the experience, attends to feelings, reevaluates the experience, and develops a resolution.22 This reflective process helps individuals clarify their understanding of experiences, which can alter their perspectives and behavior.23 However, students do not generally reflect without prompting.24 Reflective exercises allow relationships between the content, process, and assumptions underlying the experience to emerge.25
The educational innovation
The initial use of the innovation that we describe below provided learners the opportunity to engage in a potentially challenging conversation about R/S through the use of an OSCE. The innovation consists of a teaching OSCE followed by personal, guided, and group reflection. Written, dyadic, and group reflection add value to such an OSCE by allowing participants to reflect on difficult learning objectives over time.26 The aim of the innovation was not to equip learners with a particular tactic to introduce or discuss R/S but, instead, to prompt learners to engage in mindful practice27 with patients who identify R/S as part of their biopsychosocial contexts. Mindful practice includes active listening and discussion but does not require personal disclosures from the physician. The OSCE sensitizes learners to the organic experience of a challenging communication context, in this case R/S. The instructional design of the innovation is based on adult learning theory28 and social cognitive theory.29 Sensitizing practice followed by reflection uses the learner-centered approach, allowing learners to delineate insight, promoting learners’ participation in setting goals and priorities, encouraging sharing of personal and professional experiences related to the context, fostering a supportive learning climate that promotes risk taking, engaging learners to have interactive experiences, and fostering relationship building between faculty and participants and among participants.30,31 Specifically, from social cognitive theory, the innovation relies on observational learning in group reflection that occurs when a learner sees the actions of another person and the reinforcement responses that person receives.29 See Table 1 for a description of this educational innovation.
The initial use of the innovation
The initial use of the innovation occurred in an unopposed family medicine residency at a suburban community hospital in Virginia in August 2012. There were 28 participants: 27 staff and resident physicians and 1 medical student. They volunteered to participate in an activity regarding personal topics. We designed and carried out the innovation with the assistance of three outside researchers from the communication department of a local university.
The innovation began with a teaching OSCE that provided a forum for practice in engaging in challenging communication. Learners had not received training on R/S communication within the residency, and the topic of the clinical case was intentionally concealed to prevent participants from individually preparing to talk about R/S. The simple nature of surprise can generate reflection.26 Before the encounter, learners were given two minutes to review the case presentation of a 63-year-old female SP who had been diagnosed with hypertension in an emergency department and was presenting to primary care for follow-up. In the clinic room, the SP reiterated information from the case presentation but also reported that her mother had had hypertension and had died at age 63. The OSCE encounter was limited to 10 minutes.
In her state of uncertainty regarding her new diagnosis, the SP introduced R/S into the clinical discussion. For example: “[My diagnosis] scares me and I just resorted to prayer and I’m just praying that it’s not my time to go”; “I guess what I’m asking is, Do you believe in God?” The SP was given a script and participated in three hours of training to ensure that the same prompts were used for each encounter. The same SP served as the patient in all 28 encounters.
Following the OSCE, individual learners were directed to an empty clinic room where they completed demographic information and recorded initial reactions to the encounter in handwritten journals. Instructions directed each learner to record whatever reactions he or she chose to, allowing for immediate, private, open personal self-reflection, for up to 10 minutes. Following the self-reflection, learners were asked to not discuss the experience with residency peers until all participants had completed the process.
After completing journal entries, participants used a separate document to indicate their availability for a short follow-up interview. Interviews were scheduled according to learners’ preferences. Within a week, using the journal as a recall aid, learners engaged in guided reflection in individual, semistructured interviews with one of us (M.R.C., who was unaffiliated with the residency). Interviews took place in a private office in the residency. Questions were about such issues as reflection on feelings about the encounter, reflection on performance during the interaction, learners’ recommendations for how to handle challenging communication, and learners’ perceptions of the utility of an OSCE for teaching. Interviews were scheduled for 15 minutes; however, the interviewer allowed the learner to reflect as long as he or she chose. (The longest interview was 25 minutes.) Interviews were audio-recorded and transcribed.
Finally, during a 30-minute morning report two weeks after the initial OSCEs, one of us (C.J.W.L.) led a group reflection, which facilitated reflective thinking,26 among both learners who had completed the OSCE and other resident and faculty physicians in attendance. Learners discussed the sensitizing practice, instructional objectives, and lessons learned. Faculty and resident physicians who had not participated in the educational innovation also contributed to the group discussion, sharing experiences of when R/S had emerged in their own clinical discussions with actual patients.
The educational intervention received an institutional review board exemption from the Fort Belvoir Community Hospital Department of Research Programs.
Of the 28 learners who completed the OSCE, 27 also completed the personal reflection activity, and the same 27 completed the guided reflection activity. See Table 2 for characteristics of the 28 participants.
The program evaluation was based on a behavior-change perspective, using the transtheoretical, or stages of change, model (TTM),32 which segments populations by individual readiness to adopt a targeted behavior.32,33 Whereas TTM has been used extensively to test interventions focused on health behaviors,33–36 we found this approach to be conceptually applicable to targeting physicians’ willingness to implement communication behaviors. The target behavior here was physicians’ willingness to engage in mindful practice with patients who identify R/S as part of their biopsychosocial contexts.
Two of us (C.J.W.L., L.A.C.) developed a set of change-assessment codes* based on TTM37,38 and applied these codes to the journals and interview transcripts. Unique identifiers linked journals and transcripts for coding. The unit of analysis for the journals was each sentence or bulleted phrase. The average number of units per journal was 5.15 (SD 3.57), with a range of 1 to 18 units. For the 27 journals, interrater reliability (IRR) was outstanding, κ = 0.937, P < .001.39 The unit of analysis for interviews was the topical “turn” (i.e., change of topic) as guided by the interviewer. The average number of units per interview was 18.24 (SD 3.85), with a range of 11 to 31 units. For the 27 interviews, IRR was also outstanding, k = .869, P < .001.39 When coders disagreed, one of us (M.R.C.) was engaged to provide context, and consensus was reached on the final code. See Table 3 for the coding scheme with example quotes.
Ordinal stages of change were coded with corresponding numerals 1 to 5. We calculated a paired t test to detect effects of intervention reflection activity. Quantitative analyses were conducted using SPSS version 19.0 (Armonk, New York).
In personal reflection, no journals were coded as precontemplation; 15 were coded as contemplation, 7 as preparation, 1 as action, and 4 as maintenance. (See Table 3 for explanations of these categories.) In guided reflection, no interview transcripts were coded as precontemplation or contemplation; 17 were coded as preparation, 4 as action, and 6 as maintenance. A significant effect was detected for intervention activity, t(25) = −4.37, P < .001, with participants indicating a progression along the stages of change through guided reflection (M = 3.62, SD 0.85) as compared with the stage of change evidenced in personal reflection (M = 2.73, SD 1.08). Additionally, all participants provided evidence of at least the preparation stage at the time of guided reflection.
The group reflection reinforced the progression in stages of change evidenced between personal reflection and guided reflection. Validating the intent of sensitizing practice, learners shared first their initial surprise at the R/S context. Through discussion, learners then shared the emotions they felt within the OSCE context and talked through their responses to the challenging communication scenario. Experienced physicians then contributed their own accounts of R/S conversations with patients, prompting the group to recognize the presence of R/S and other challenging communication topics in the clinic. Group reflection culminated in strategies for managing R/S conversations with patients.
Discussion and Conclusions
The innovation in medical education presented here extends the OSCE from a testing tool to one that fosters an educational experience. Whereas the OSCE reported here focused on R/S, the results of this use of the innovation replicate those from other successful teaching OSCEs7–10 and provide a model for other challenging communication topics, such as breaking bad news.40 By following the OSCE with personal, guided, and group reflection, learners were enabled to, first, recognize the need for willingness to engage in mindful practice and, second, reflect on practiced strategies for potentially challenging conversations. Through sensitizing practice, learners examined individual assumptions and comfort levels regarding the topic, identified strategies they practiced in the interaction, and critically reflected on how they address patients’ biopsychosocial needs. Learners identified divorce, prenatal issues (abortion, genetic testing, and miscarriage), and end-of-life care as challenging communication topics they had encountered previously. This educational innovation can be applied to other similar challenging conversations that physicians encounter.
Our use of this innovation provides a model for preparing physicians to willingly engage in R/S discussions with patients.41 In our demonstration of this, reflection allowed physicians the opportunity to explore their views regarding their role in R/S clinical discussions and initiated critical thinking regarding R/S as part of the patient’s biopsychosocial context. Learners also reflected on strategies that they used in the OSCE, but this innovation did not prescribe specific strategies for that discussion. Sensitizing practice followed by reflection was intended to allow physician learners to develop and refine their own strategies that fit within their own psychosocial contexts. Our use of the innovation allowed learners to practice skill-level competencies, such as listening attentively, having a compassionate presence, and providing spiritually-integrated care.42 Specific tools are cited elsewhere15,43 to provide physicians with specific R/S assessment and discussion tactics to support patients through listening, document spiritual preferences, incorporate patient beliefs into treatment plans, and recommend other R/S resources, including hospital chaplains, to patients.
This educational innovation blended formal and informal curriculum strategies, adapting a traditional technique with individualized interpersonal tactics. Collaborating with outside researchers allowed teaching to span organizationally and culturally influenced boundaries that may contribute to the “hidden curriculum.”44 Success of the intervention could be linked to this participation of outside researchers (in planning, recruitment, data collection, and analysis), allowing for more openness regarding personal, potentially socially divisive topics such as abortion, genetic testing, and sexuality.
There are barriers to implementing such training into residents’ education. Time and space must be set aside for the learner and educator. Also, SPs must be well trained and can be expensive. These barriers can be mitigated by scheduling several learners to perform the OSCE during a block of time. The educational innovation we used integrated the OSCE into established schedules without overburdening physician or resident learners. This maximized the efficient use of the SP.
In future interventions, reflection could be further developed through viewing OSCE video recordings with the interviewer.45 Reflective viewing could increase the participant’s recall and help the participant deconstruct his or her critical thinking in the encounter. Future efforts could also increase the role of group learning, incorporating Balint groups46 or team-based learn ing.47 The evaluation was designed to assess individual change; however, the concept of sensitizing practice pre cluded the use of a pre–post design or a control group. Future interventions could include each of these design conditions to assess individuals’ change, potentially using Balint groups as a control condition.
Our initial use of the educational innovation was limited to one training site, with a single SP encounter; thus, our findings may not generalize to other programs. Additionally, the participants were almost all white; however, the demographic of interest—religious affiliation—was diverse. Also, because the SP was white, ethnic dissonance presents less of a threat to the findings.48 The findings should also be considered within the potential limitations of the Hawthorne effect on observed behavior.49,50
We hope that our initial use of the educational innovation reported here will encourage others to use it to help learners become more aware of and skillful in dealing with difficult physician–patient communication topics.
Acknowledgments: The authors wish to recognize Dr. Melinda Villagran and Dr. Joseph Huang for their role in planning and execution of the OSCE process reported here.
* We are performing inductive coding of the data to identify communication strategies for a future manuscript.
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