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Theme: 7II Simulation and Simulated Patients			Currently nan/5 1 1 2 2 3 3 4 4 5 5 Rating: nan/5 (0 votes cast)

Simulated medical consultations with an extended debriefing: students perception of learning outcomes

Authors:

Marcelo Schweller
Silvia Passeri
Marco Antonio de Carvalho Filho

Institutions:

FCM Unicamp - Emergency Medicine

FCM Unicamp - Medical Course

FCM Unicamp - Emergency Medicine

Background

In Brazil, medical students begin to perform supervised consultations since the 4^th-year of their 6-year undergraduate course. As teachers, we often observe their difficulties with the affective dimension of the consultation, even when they are comfortable with technical issues related to diagnosis and treatment. It seems that students sometimes do not feel legitimate in the role of doctors. This contrast between what they know and what they can actually deliver reduces the success of the physician-patient relationship and the beneficial outcomes of the consultation, including students’ own satisfaction.

One possible explanation for this is what happens in the development of their professional identity throughout the medical course. Most medical students in Brazil are young, never worked, and come from small families. In this context, they had few personal experiences associated with illness, loss and failure, and thus fewer opportunities to reflect on these issues. With this background, they come in contact with the suffering related to patients' illnesses and the social inequality of our country. The lack of formal activities directed to reflective practice, the subspecialized and disease-centered medicine, and the contact with negative role models contribute to the affective detachment between the medical student and the patients.

Summary of Work

The authors conducted a simulated medical consultations activity using standardized patients, with an in-depth debriefing based on the feelings of the patient and the student. The clinical cases were developed with a mixture of technical and human challenges related to the doctor-patient relationship, and a particular concern in defining the emotional atmosphere of the consultations. Feedback was conducted in the form of an extended in-depth debriefing, lasting at least 2 hours, with the participation of students, teachers and actors. The structure of the debriefing, especially the availability of time, allowed us to address the students’ and patients’ feelings coming from the simulated consultations, as well as the consequences of this emotional interaction.

Fourth- and sixth-year medical students (n=344) participated and completed an anonymous questionnaire about the activity and the learning outcomes. The purpose of this study was to record the opinions of students about this new kind of training, especially regarding the way they handled a feedback that deals with their feelings and encourages a great deal of personal exposure.

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Summary of Results

The 344 fourth- and sixth-year medical students rated particular elements of the activity, as shown in the table below:

Students reported their perceptions regarding aspects of the activity and its impact on their academic and professional daily lives:

Some sentences written by students seemed most representative of their opinions:

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Conclusion

A safe learning environment, free of judgment and with purely formative goals, allows medical students to start the reflective process that will ultimately place them as protagonists of their professional future. That kind of environment should also prevail between doctor and patient during a consultation, so that the patient feels comfortable sharing their experiences and thoughts, and the doctor has the legitimacy and intimacy required to comment, suggest and make proposals. The teacher, as well as the physician, must be prepared to deal with intense emotional reactions, being available to assist and support.

Take-home Messages

When medical students are encouraged to share what they feel about the doctor-patient relationship in an academic activity, they may feel more comfortable to encourage their patients to share their feelings about the disease and its consequences. Moreover, if we deal with the students’ emotions in a positive way, guiding them and giving legitimacy to what they feel, they will probably do the same with their patients in a consultation.

Acknowledgement

Summary of Work

Standardized Patients (SP's)

We recruited a group of professional actors with experience in education. Before the construction of the characters, we discussed in detail the patients' emotions regarding their disease, and the impact of this new reality in their lifestyle. The characters were developed by the actors through the methods of Realist Theater, with an emphasis on the theories of Constantin Stanislavsky.

After this initial phase, we tested the cases with the purpose of developing the patients’ stories, discussing the themes involved and predicting students’ reactions when facing each situation. The actors were trained to create verbal and nonverbal cues that enabled the identification of the patients’ emotions during the consultations by students. It was essential to refine the emotional atmosphere of the consultations so that different attitudes of students would lead to different outcomes.

Facilitators

During the development phase of this activity, we discussed situations from our real clinical practice, with special attention to the doctor-patient relationship. These discussions were essential in defining the main themes to be approached with the students and attempting to objectively formulate questions that were present in our day-to-day practice.

In this context, it was important to be conscious of our attitudes as teachers. We concluded that, if one of our core messages was to be the importance of avoiding preconceived ideas and judgments with regard to the patient, it would be necessary that we, as teachers, be trained not to make negative or moral judgments towards the students. Thus, it was possible to conduct the discussions with an emphasis on positive reinforcement, which allowed us to approach difficult topics about the doctor-patient relationship and the hidden curriculum.

Simulation of Medical Consultations

The activity was performed in groups of from seven to nine students in four weekly meetings throughout 2011, 2012, 2013 and 2014. In each of the meetings, the SP was seen by two students individually, while the other students and facilitators watched these consultations in an adjoining room through a CCTV system. The facilitators who participated in the activity already worked with the students in the emergency unit and the internal medicine infirmary.

Debriefing

After a brief break, students would share with the group their initial feelings regarding the consultation they had just experienced and would make a summary of the clinical case. The students’ own speech, always rich in clues, worked as a trigger for discussion of the topics that had been planned. Furthermore, other themes frequently came up based on the needs of each student and each group.

The main reflection made in the debriefing revolved around the importance of realizing the frailty of the patient when faced with his or her disease. A diagnosis and its prognosis bring unplanned changes in the life of the patient, possibly setting off emotions like fear, guilt and helplessness. The patients react to these emotions in different ways, showing indignation, sadness or even anger, a feeling that may be directed towards the physician. These reactions may confuse the young physician, who is not always alert to the hidden feelings that lie behind a patient’s negative or even bad attitude.

Facing the patient's diagnosis, the medical student is also more likely to feel similar emotions such as fear, guilt and uncertainty. In addition, the student must deal with the patient’s emotions, even when projected towards the own student, and to have a contextualized approach that enables and encourages the improvement of the patient's emotional state. Because of the complexity of the topics discussed and the reactions of the students, who often became emotional and shared their difficulties, the debriefing lasted, on average, 2 to 3 hours per meeting.

Instrument and Data Analysis

On the last day of the activity, after the debriefing, the students filled out an anonymous questionnaire in which they were asked to score on a scale of 1 to 10 the activity as a whole and specific aspects of it, like the facilities, the realism of the scenes, the acting and the feedback from the facilitators. Moreover, they answered questions about how they felt during the activity and about its impact on their professional and personal lives. These questions had as possible answers “yes”, “no” and “indifferent”, and were recorded and analyzed.

After certain questions, there was space for students to explain their answers or write in comments. These questions were: (1) “did this simulation activity motivate you to study? Study what?”; (2) “Did you feel comfortable during the feedback? Why?”; (3) “Do you think you will use what you have learned in your personal life? How?”.

The students’ answers were read by the authors, categorized and then classified based on most frequent to least frequent. Some complete sentences written by the students which seemed most representative of the opinions as a whole were selected and transcribed.