Journal Club

Teaching medical students the important connection between communication and clinical reasoning. Windish DM, Price EG, Clever SL, et al. J Gen Intern Med 2005; 20:1108 - 1113.

Reviewed by Michael A. Barone, Johns Hopkins University

Training in clinical reasoning skills and communications often occur separately. Often data gathering and communications training are a "pre-clinical" thing and clinical reasoning skills get developed through the clerkships. A group of general internists explored whether enhanced communication, particularly regarding psychosocial issues, would lead students to have more thorough and accurate clinical reasoning skills.

A curriculum entitled AIME (An Integrated Medical Encounter) was created through a six-step process. It was then administered as a randomized trial to students in a second year clinical skills course. The existing clinical skills course did not have specific training on communication skills or clinical reasoning skills. The AIME curriculum taught these skills using the modalities of role-play, feedback, self-reflection, and review of videotaped standardized patient encounters. An emphasis was placed on how communication strategies impact the quality of data gathered.

One half (n=60) of the class of 121 students was randomized to the AIME curriculum. All intervention and control students underwent baseline self-assessments of their proficiency in communication skills and clinical reasoning. All students completed two standardized patient encounters in which the SP's scored students on communication ability. Fifteen general internists, who were not the investigators, scored the students SP case clinical reasoning on the basis of a generated problem list and differential diagnosis. Student satisfaction with the curriculum was also measured.

At baseline, AIME students had more familiarity with the process of developing a differential diagnosis based on prior health professions training. Other self-assessment measures were equal. AIME and control students showed no differences in data gathered from the SP, numbers of items on the differential diagnosis, and accuracy in predicting the diagnoses of hyperthyroidism and rheumatoid arthritis. AIME students, on average, generated one more problem per patient (8.4 vs. 7.5, P=0.05). Of AIME students, 65% listed at least one psychosocial problem on the list compared to 44% of non-AIME students (P=0.008). Along a 5-point scale scored by the SP, AIME students ranked better in establishing rapport than their control colleagues (4.09 vs. 3.91, P=0.05). 95% of AIME students found it beneficial to learn communication and clinical reasoning strategies simultaneously.

This small study was limited by, among other things, a brief time interval between he intervention and the SP case evaluations, leaving little time for students to practice the skills learned in AIME. In addition, there is not likely to be consistency in what each student learns from his or her preceptor in the clinical skills course, meaning that some non-AIME students may understand the link between the two skills. Despite the under whelming results, many of continue trying to demonstrate that enhanced communication helps the diagnostic process.

(Comment: In our heart of hearts we want to believe that better communication will result in better information and eventually improved patient care. It may be that these findings are too subtle and not easily identified on a standard checklist or differential diagnosis list. - Bill Raszka)