Can you really teach clinical communication virtually? Evaluating new methods in the time of Covid-19

Adam Montgomery, Faeez Ramjan, Alistair Cannon, Sae Kohara, Chloe Saunders, Deekshitha Umasankar, Lois Zac-Williams & Sophie Butler

Abstract

Introduction

“PsychED Up” is an extracurricular clinical communication course, with a focus on Psychiatry, for third year undergraduate medical students at King’s College London. Students have large group teaching on a weekly topic, then perform three clinical scenarios with simulated patients based on the topic, with peer feedback administered throughout. Due to the Covid-19 pandemic, one session of PsychED Up was organised virtually, via Zoom™, in June 2020. This provided an opportunity to evaluate novel approaches to teaching, and to evaluate a live clinical communication course being delivered virtually.

Methods

Twelve students and ten faculty members participated in the online session, performing live clinical scenarios with simulated patients, over a two-hour period. Pre-and post-course questionnaires were designed with quantitative measures of confidence and qualitative questions about participants’ experience. Eight students completed both questionnaires. Questionnaire answers were analysed using a mixed-methods approach, with themes identified from the qualitative long answers, and statistical analysis of quantitative answers was also performed.

Results

Students found the session beneficial, with all indicating that they would sign up for a full online course. Based on answers to the quantitative questions, 50% of students felt more prepared for their clinical examinations. (p=0.046).  However, all participants noted a reduction in their ability to read non-verbal cues and body language. Returning students found they were less attentive during the session compared with the original face-to-face teaching (p=0.05). Actors and faculty members found that the online course was feasible, acceptable and effective, but most preferred face to face teaching.

Discussion

The majority of students and faculty found the session both beneficial and enjoyable but felt face-to-face sessions would be more helpful in teaching clinical communication. Student attentiveness and awareness of non-verbal cues were highlighted as concerns. However, students generally responded positively to the online course, particularly the quality and diversity of peer feedback. Teaching clinical communication virtually has the potential to be successful, and has implications for future undergraduate medical teaching.

Introduction

The ongoing Covid-19 pandemic has caused major disruption to education provision worldwide [1, 2] with many educational institutions seeking to continue teaching via online methods [3, 4]. Social restrictions have necessitated changes to teaching the undergraduate medical curriculum, for example through delivering more lectures and workshops virtually. Whilst teaching the purely biomedical aspects of medicine have been shown to be effective when conducted online [5], it is less obvious whether clinical communication, which is a core skill [6], can be taught effectively in this manner. Previous evaluations of multimedia-based learning resources show that they may promote deeper learning as well as assist students in becoming self-sufficient learners [7, 8]. Video-based online tutorials may provide flexibility that promotes access [9]. The online nature of learning resources allows asynchronous learning, where the student can engage, in their own time at their own pace with the ability to manipulate the resources (e.g., rewind or speed up) [10].

However, such sessions do not give students the ability to ask questions or access real-time feedback from teachers, and as such offer limited information on the benchmark of performance that may assist students in overcoming barriers of self-assessment of clinical skills [11]. There is a perception that multimedia and web-based education resources are a less appropriate medium for teaching clinical skills such as communication [12-15]. In this way, these techniques are often used as a supplement rather than an alternative to traditional teaching methods. These perceptions however, are based on pre-recorded online modules with an absence of a live tutor.

Literary studies of online communication skills with a focus on Psychiatry are scarce, and to our knowledge there has yet to be a clear evaluation of the efficacy of live, web-based teaching of clinical communication skills, particularly with a Psychiatry-specific focus.

“PsychED Up” is an innovative, Psychiatry focused, voluntary, extra-curricular medical education programme for Year Three King’s College London (KCL) medical students. It aims to deliver high-quality and authentic teaching about clinical communication via Objective Structured Clinical Examination (OSCE) style simulation.  Experiential learning opportunities are provided through role plays with simulated patients. Each session features large-group teaching focused on a clinically relevant topic followed by three simulations in smaller groups. Each group has a Small Group Teacher (SGT; a Psychiatry trainee) and a Peer Facilitator (PF; a senior medical student) to guide the scenarios and facilitate feedback. A student volunteers to act in a clinical scenario with a simulated patient, while others provide feedback using an adapted “feedback sandwich” model [16] which is then discussed after the scenario. Individuals with lived experience are invited to join the session in an observational capacity, reflecting research on the importance of their unique contribution to mental health education [17] with their feedback supporting the improvement of roleplay and session content.

The final session of Term 2 of PsychED Up was cancelled due to advice issued in March 2020 by the UK Health Secretary against all unnecessary contact and social travel [18]. A decision was made to run the final session of PsychED Up via Zoom™ on 2nd June 2020, with Term 2 students invited to participate, as well as new students, recruited from King’s College London (KCL) third-year medical students.

Methods

Setting up the session

Faculty members were surveyed and expressed sufficient interest to run an online session. Email invitations were sent to the 32 students who were enrolled in PsychED Up’s Term 2, and 12 students responded. An email invitation was also sent out to all KCL third year medical students (a total of 334) who had not participated in PsychED Up via the KCL Undergraduate medical education department.  A total of five students responded.  Students were allocated teaching groups. Returning students were matched to their original group where possible and students unfamiliar with the PsychED Up model were grouped together.

Zoom™, an online videoconferencing software, was used to host these sessions. Students and faculty members were given instructions on how to join the virtual-classroom and how the session was planned to run. This included instructions on how and when to give feedback using a specifically designed PsychED Up feedback sheet and included a request to turn microphones and cameras off when they were not actively participating. Role plays were adapted to be relevant to a virtual setting. 

Statistical Analyses

A mixed-methods approach was used with an ethical framework based on it being an evaluation.

Questionnaires were designed for three groups: returning students, new students and faculty members. All students and faculty were asked via email to complete online pre-session and post-session questionnaires which included both open and closed ended questions.

Closed ended questions asked all students to rate their confidence in communication skills, preparedness for exams, and ability to give feedback to peers using a five-point Likert scale (1 = strongly disagree to 5 = strongly agree). Returning students were asked to rate their level of attentiveness, interpretation of non-verbal communication, ability to offer empathy, and willingness to speak up during sessions delivered face-to-face and online. All students were also asked to write free-form answers to questions further exploring their attitudes and experiences.  A full list of these questions can be found in Table 1.

Table 1: Free-form questions for students  

Pre-course free-form questions (returning students)
• What do you think was the critical component of PsychED Up that helped you to improve your communication skills (if it did)?
• If you agreed to the above question (I feel that PsychED Up supported me to give constructive feedback to my peers), how do you feel that PsychED Up supported you in this way?
• What did you like most about the delivery of the face-to-face sessions?
• What did you like least about the delivery of the face-to-face sessions?
• What are your thoughts regarding the upcoming online delivery of PsychED Up? (E.g. potential benefits and limitations, your feelings, group dynamics etc.)
• How do you feel about practising scenarios and learning communication skills, through an online format?
• Based on your expectations for the online version of PsychED Up, would you sign up to a full 7-week course of sessions if they were to be delivered online? Please share your reasons.
Pre-course free-form questions (new students)
• What were your reasons for signing up to a place for the upcoming online session of PsychED Up?
• What are your thoughts regarding the upcoming online delivery of PsychED Up? (E.g. potential benefits and limitations, your feelings, group dynamics etc.)
• How do you feel about practising scenarios and learning communication skills, through an online format?
• Based on your expectations for the online version of PsychED Up, would you sign up to a full 7-week course of sessions if they were to be delivered online? Please share your reasons.
Post-course free-form questions (returning and new students)
• What skills do you think you have gained from participating in PsychED Up delivered online?
• If the online delivery of PsychED Up has helped you to feel prepared for the OSCE, how has it done so?
• How does feedback compare in this online session to when you have face-to-face feedback?
• What did you like most about the delivery of the online session?
• What did you like least about the delivery of the online session?
• How was your experience of the online delivery of PsychED Up? (E.g. benefits and limitations, your feelings, group dynamics etc.)
• How do you think the online session could have been improved?
• Having experienced PsychED Up online, how do you now feel about practising scenarios and learning communication skills, through an online format?
• Based on your experience of the online version of PsychED Up, would you now sign up to a full 7-week course of sessions if they were to be delivered online? Please share your reasons.

Faculty rated various items related to their confidence in the delivery of teaching and answered free-form questions (Table 1b) designed to elicit attitudes about the online teaching experience. All subjects (new students, returning students and faculty members) were asked pre-session and post-session whether they would participate in a full 7-week online course.

Table 1b: Free-form questions for contributors

Pre-course free-form questions (contributors)
• Is there anything that you paid particular attention to when giving feedback face-to-face?
• If you agreed to the above question (I predict that my teaching of communication skills will change between face-to-face teaching and online teaching), how do you think your teaching will change?
• What were your initial thoughts regarding the delivery of PsychED Up online?
• In your role, what do you anticipate will be the challenges of delivering the sessions online?
• In your role, what are the benefits of delivering the sessions online?
• Based on your expectations for the online version of PsychED Up, would you deliver a full 7-week course of sessions online? Please share your reasons.
Post-course free-form questions (contributors)
• Is there anything that you paid particular attention to when giving feedback online?
• If you agreed to the above question (My teaching of communication skills changed between face-to-face teaching and online teaching), how do you think your teaching changed?
• How do you think the students’ familiarity or unfamiliarity with the group impacted the experience?
• How do you think the students’ familiarity or unfamiliarity with the PsychED Up model impacted the experience?
• How do you now feel about teaching communication skills, through an online format and why?
• In your role, what were the challenges of delivering the session online?
• In your role, what were the benefits of delivering the session online?
• How do you think the delivery of the online session could have been improved?
• Based on your experience of the online version of PsychED Up, would you now deliver a full 7-week course of sessions online? Please share your reasons.

Pre- and post-session Likert responses were described using medians and ranges and analysed using the Wilcoxon signed-rank test. Statistical software SPSS (IBM Corp. Released 2017. IBM SPSS Statistics for Windows, Version 25.0. Armonk. NY: IBM Corp) was used. Free-text answers were analysed thematically [19]. Inductive, data-driven approach was used to identify and code semantic themes through which patterns in the responses could be organised and described. Throughout the process of analysis, methods and investigator triangulation occurred. Before coding, DU, LZW and AC read and discussed the transcripts. The responses were split between the three researchers. After coding, the themes were discussed and LZW and DU grouped the codes into themes according to content. Definitions, descriptions and the focus of each theme were developed. Through triangulation, the reliability and validity of the results is increased, by ensuring that the themes are accurate and representative of the data set. Multiple researchers were used for analysis to reduce bias risk.

Results

On the day of the session, a total of 12 students attended: nine returning students and three new students. The demographic details of these students are displayed in Table 2. Some initial responders emailed to cancel with short notice. The three new students formed one group, with the nine returning students split into two separate groups of four and five students respectively. Each group was co-ordinated by a Small Group Teacher and Peer Facilitator, with four actors moving between groups, for a total of ten faculty members actively participating in the session; two other faculty members and one service user virtually observed the groups throughout the session. 

Table 2: Demographic details of students

Demographics Returning students (n=9) New students (n=3)
Gender Male 1 2
Female 8 1
Ethnicity White 1 0
Mixed/Multiple ethnic groups 2 1
Asian/ Asian British 4 2
Black/ African/ Caribbean/ Black British 2 0
Age 18-20 0 1
21-23 7 2
24-26 2 0

Eight students completed both the pre and post-course questionnaires and were, therefore, included in the full analysis. For the qualitative analysis of the long-form answers, 42 responses from: pre and post returning students, new students, and contributors were analysed.

Returning students reported a significant reduction in their attentiveness and focus through the online format, in comparison to the face-to-face format (p=0.05) (Table 3c). They also reported feeling less able to offer verbal and non-verbal empathy to the simulated patients through the online format. However, no significant differences were found in their ability to interpret non-verbal communication, and how comfortable they felt speaking up to ask questions or contribute to discussion, outside of the role-plays.

Table 3c: Questionnaire results for specific OSCE skills and engagement in the session.

Question Course delivery Strongly disagree Disagree Neutral Agree Strongly agree P value
During the role-plays, I was able to pick up on non-verbal communication (e.g. body language, facial expression). Face-to-face 0% (0) 0% (0) 0% (0) 50.0% (3) 50.0% (3) 0.317
Online 0% (0) 0% (0) 0% (0) 83.3% (5) 16.7% (1)  
During the role-plays, I was able to offer verbal empathy. Face-to-face 0% (0) 0% (0) 0% (0) 50.0% (3) 50.0% (3) 0.414
Online 16.7% (1) 0% (0) 0% (0) 50.0% (3) 33.3% (2)  
During the role-plays, I was able to offer non-verbal empathy. Face-to-face 0% (0) 0% (0) 0% (0) 66.7% (4) 33.3% (2) 0.257
Online 0% (0) 0% (0) 33.3% (2) 50.0% (3) 16.7% (1)  
I felt comfortable speaking up during the sessions (e.g. asking questions, contributing to discussions). Face-to-face 0% (0) 0% (0) 0% (0) 50.0% (3) 50.0% (3) 1.000
Online 0% (0) 0% (0) 0% (0) 50.0% (3) 50.0% (3)  
I was fully attentive and focused in the sessions. Face-to-face 0% (0) 0% (0) 0% (0) 50.0% (3) 50.0% (3) 0.046
Online 0% (0) 0% (0) 33.3% (2) 50.0% (3) 16.7% (1)  

Comparison of pre- and post-course responses suggested a significant increase in students’ confidence in their ability to give meaningful feedback on communications skills to their peers (p=0.05) as compared to having no teaching. 50% of students also reported feeling more prepared for OSCE examinations (p=0.05), with no significant changes in the other 50% (Table 3a). There was no significant change in the students’ confidence ratings for interacting with people with mental health conditions. 

Table 3a: Questionnaire results for communication skills

Question Questionnaire Strongly disagree Disagree Neutral Agree Strongly agree P value
I feel confident in my communication skills for interacting with people with mental health conditions. Pre 0% (0) 0% (0) 25% (2) 62.5% (5) 12.5% (1) 0.564
Post 0% (0) 0% (0) 0% (0) 100% (8) 0% (0)  
I feel prepared for the objective structured clinical examinations (OSCE). Pre 0% (0) 25.0% (2) 37.5% (3) 37.5% (3) 0% (0) 0.046
Post 0% (0) 12.5% (1) 12.5% (1) 75.0% (6) 0.% (0)  
I feel confident in being able to give meaningful feedback on communication skills to my peers. Pre 0% (0) 0% (0) 12.5% (1) 75.0% (6) 12.5% (1) 0.046
Post 0% (0) 0% (0) 0% (0) 50.0% (4) 50.0% (4)  

Of the 15 contributors who attended the session, 12 responded to the pre-session questionnaire and ten responded to the post-session questionnaire. On average the ratings were comparable between the face-to-face and online sessions regarding contributors’ confidence in supporting students to give meaningful feedback. Following delivery of the course, faculty expressed greater willingness to teach a full 7-week online course (p=0.03) (Appendix 3b).

Table 3b: Questionnaire Results for the question “Would you sign up to a 7 week online course?”

Question Questionnaire Yes No Maybe P value
Sign up to 7 week online course? Pre 75% (6) 12.5% (1) 12.5% (1) 0.655
Post 87.5% (7) 0% (0) 12.5% (1)  

Qualitative Analysis from online questionnaires – long answer

As illustrated in Figure 1, three key themes, with nested sub-themes were identified:

(1) Attitudes towards learning communication skills online;

(2) Perceived ability to fulfil a role in the group;

(3) Perceptions of learning and teaching.

Figure 1: Key themes extracted from long answer questionnaire data

1. Attitudes towards learning communication skills online

Student feedback

In the pre-course questionnaire, returning students voiced fears about being out of practice with history-taking due to lack of patient contact during lockdown. Other concerns included how the online format would affect group cohesion and the ability to read body language. New students were less apprehensive about the delivery of teaching, welcoming the opportunity to practice clinical communication. Technical issues, such as audio/visual lag, were concerns expressed by both student sets. The majority of students expressed that running the session online would likely be a suitable alternative only during the current pandemic, preferring the idea of face-to-face sessions for the future.

Post-course, many returning students expressed surprise at the similarity between virtual and face-to-face teaching. The general consensus was that it was enjoyable, however there were certain limitations, with some comments that it was harder to conduct the consultation online compared with face-to-face. New students spoke positively of the experience, praising the quality and diversity of feedback. Both student groups felt that running a virtual patient consultation felt “inauthentic.”  Despite the pre-session concerns, a few technological issues arose. Most issues related to group dynamics, such as when to turn off video or sound functions on Zoom™.  All new students, plus some returning students, stated they would sign up for an online course, although some returning students felt face-to-face teaching would still be preferable.

Post-course, both returning and new students felt that this experience had taught them how to adapt their communication skills, and felt that the online environment was not as detrimental to learning, compared to face-to-face teaching, as was expected.

Faculty Feedback

The faculty expressed excitement at the online format but shared concerns about technological difficulties and authenticity of interaction. Post-course, the contributors were less enthusiastic than the students. Some felt that they did not perform to the best of their ability due to the virtual setting. The contributors generally liked the online session but most agreed face-to-face sessions would be preferable.

2. Perceived ability to fulfil a role in the group

Returning and new students expressed mixed opinions about being able to give feedback to their peers who acted in the scenarios. Some students reported a diminished ability to pick up on non-verbal cues and read body language due to observing a scenario via a small screen. Some students also noted that the webcam only enabled them to see a small part of the participant’s body. Additionally, new students were more concerned that camera placement affected their ability to assess the patient while performing in the scenarios.

Many faculty members felt they were able to execute their role well, but expressed concerns that the usual group size of eight students would not work as well.

3. Perceptions of learning and teaching

Views on giving and receiving feedback online vs. face-to-face were mixed, with some returning students feeling it was more focused and others feeling that the online platform made it harder to assess interactions due to the camera not allowing students to see the entire patient. Thus, most of the discourse around non-verbal communication skills was limited to facial expressions. New students valued the experience of the teachers and the different viewpoints they brought to the session as working doctors and senior medical students.

Actors particularly missed the human interaction aspect, with one actor feeling they were unable to fully immerse in their character in this format. PFs and SGTs felt more confident after the session about delivering communication skills teaching online. They also found that students engaged with feedback well, with students making appropriate, constructive points for their peers.

Discussion

In this pilot we have demonstrated that it is feasible to deliver experiential teaching about clinical communication using an online platform. A team of ten faculty delivered this pilot to 12 students with no major issues and good student and faculty satisfaction. A recognised advantage of the online format is that it can offer flexibility in access for both students and faculty, potentially making it easier to deliver and attend [9]. This does assume good access to the technology and needs to be balanced with the barriers that technology can pose that will be further discussed.

The online teaching format was also acceptable for both faculty and students. New students, who had not experienced PsychED Up being delivered face-to-face, were in general more receptive to the course than returning students and faculty members. This could be explained by returning students and faculty having to make many adjustments to online work, compared with the unsullied approach of new students. Overall, new and returning students, plus faculty members, were happy with how the session ran, and would participate in a full online course, but unsurprisingly, a return to face-to-face teaching was a preferred option.

The adaptation of clinical communication teaching to an online setup was also effective. 50% of students felt better prepared for their clinical examinations, and many students felt increasingly confident in online learning. New students who had not previously participated in PsychED Up found the session to be consistent and straightforward in structure. Returning students generally found that the sessions translated well into the online format, with four out of six returning students who filled in questionnaires remarking that it was “similar” or had “little difference” compared to the structure of face-to-face sessions.

The importance of technological issues in online learning is self-evident [20] and was a source of anxiety among faculty members and students before the session. In reality, technological issues did not heavily impact the session, perhaps reflecting the preparedness of students in the current climate. The study also supports the importance of good “video etiquette,” such as appropriate camera placement to ensure adequate lighting and sound, maintaining eye contact, and keeping hands and arms in the camera frame to ease detection of non-verbal cues [21]. In any future sessions, we plan to embed more thorough preparation of both faculty and students, and the area of ‘onboarding’ before these sessions is surely an area of research with significant future potential [1].

The subtle ways that technology can impact group dynamics (e.g. impairing the ability to pick up on non-verbal cues and to offer verbal empathy) were identified by students and are consistent with previous studies [22]. Specific concerns also detected in the qualitative data include the authenticity of interactions and a reduced ability to focus during the session. This demonstrates that, while adaptation of face-to-face material for an online setting is possible, it is not straightforward and cannot be directly translated without consideration of some intangible factors. Furthermore, longer-term work delivered online risks increasing the isolation of students and educators alike, leading to an increased psychological burden [23].

Some limitations of the study include recruitment, sampling method and size. Sign-up for the online session was lower than would be expected with face-to-face teaching, with only 9/32 returning students participating in the online session. New student numbers were also limited, with 3/334 invited students attending.  These numbers limited how representative the results were. Poorer student uptake is a known phenomenon in web-based higher education courses [24]. Reasons suggested for this include psychological factors (financial or family pressures, low motivation to engage at home), course-related factors (lack of structure/feedback as compared to face-to-face sessions) and technological issues [20, 25]. These factors, amplified by the disruption caused by the Covid-19 pandemic (e.g. personal or family illness, prioritising more essential activities), are likely to have contributed to the poorer-than-expected uptake in this pilot. As a result, there was a high faculty-to-student ratio. The issue of uptake is a problem that can be overcome through further research into the effect of the above factors on web-based clinical teaching. In such a ‘proof of concept’ pilot as ours, it was not seen as a disadvantage, but the results cannot be extrapolated to larger groups.

Most returning students felt either as confident or more confident in their clinical Psychiatry skills after the course than they did before. There were also no notable differences in their confidence in contributing to feedback and discussion in the online session vs. face-to-face. This may reflect an element of self-selection bias in those who signed up for the online course.

We have demonstrated that clinical communication can be taught virtually in a way that is effective, acceptable and feasible, but largely not preferable to face-to-face communication. With many educational institutions moving to an online teaching platform, further evaluation of clinical teaching is both desirable and essential for understanding the future of clinical education. Potential areas for future research can include assessing teaching with different camera placements, assessing group dynamics and the ability to offer verbal and non-verbal empathy.

Acknowledgements

The authors would like to acknowledge Dr Sean Cross, Dr Roxanne Keynejad and Dr Charlotte Wilson-Jones for their role in the development of PsychED Up and ongoing support.

Funding/support

Since 2018, PsychED Up has been supported by a small grant from Health Innovation Network (HIN) which has been used to support further educational opportunities and faculty development. (HIN. 2018. Health Innovation Network Small Grant [Online]. https://healthinnovationnetwork.com/news/100k-awarded-to-drive-nhs-innovations-across-south-london/.  [Accessed 31/12/18].)

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About the authors

Adam Montgomery is a Higher Trainee (ST4) in General Adult Psychiatry, working at South London and Maudsley NHS Foundation Trust.

Faeez Ramjan is a 4th year medical student, studying at the Faculty of Life Sciences & Medicine, King’s College London.

Alistair Cannon is a Core Trainee (CT2) in Psychiatry, working at South London and Maudsley NHS Foundation Trust.

Sae Kohara is a 5th year medical student, studying at the Faculty of Life Sciences & Medicine, King’s College London.

Chloe Saunders is a Core Trainee (CT3) Psychiatry, working at South London and Maudsley NHS Foundation Trust.

Deekshitha Umasankar is a 4th year medical student, studying at the Faculty of Life Sciences & Medicine, King’s College London.

Lois Zac-Williams is a 4th year medical student, studying at the Faculty of Life Sciences & Medicine, King’s College London.

Sophie Butler is a Higher Trainee (ST6) in General Adult Psychiatry, working at South London and Maudsley NHS Foundation Trust.

Research conducted at Institute of Psychiatry, Psychology and Neuroscience (IOPPN), 16 De Crespigny Park, London, SE5 8AF