This study demonstrated that there is no significant difference between ASP and SRP in global communication skills evaluated by the CCG questionnaire. However, students’ communication skills were more appropriate when interacting with a professional actor rather than with a student colleague, in terms of gathering information in order to discover the biomedical perspective, background information and context but also in terms of closing the session with forward planning. When raters evaluated the items ‘gathering information’ in order to discover the biomedical perspective, background information and context, they evaluated if students: (1) tended to facilitate patient’s responses verbally or non-verbally, (2) paid more attention to the verbal and non-verbal cues (body language, facial expression, affect), (3) clarified patient’s statements that were unclear, (4) periodically summarized to verify own understanding of what the patient had said, (5) used concise, easily understood questions and comments, avoided or adequately explained jargon, (6) established dates and sequence of events. All the items before cited are linked to known valuable actor contributions like the higher authenticity and realism of the ASP situation as well as to the actors’ lack of medical knowledge, an important asset for the medical experience [18]. The actors’ flexibility in verbal and non-verbal communication as well as their emotional commitment seemed to generate more concentration/attention from the learner as well as a more adapted language. While colleagues know what to anticipate and have comparable clinical knowledge, actors are highly improvisational. There may be certain strategies and even protocols to approach challenging conversations, but the reality is that no two clinical conversations are the same. A successful approach in one setting may be inadequate or even problematic with another patient or family. Relational proficiency in medical interviews necessitates recognition of, and flexible response to, variable patient and family cues [25]. In the ASP context, this relational flexibility seems to be higher and learners have better suited communication skills for gathering information.
However, an interesting observation is that no difference was observed between the SRP and ASP groups for the item ‘Gathering information exploration of the patient’s problems to discover the patient’s perspective’. This item requires a more empathic approach for gathering information. In order to respond to this item, raters paid attention if the learner explored patient’s ideas, patient’s concerns regarding each problem, patient’s expectations, how each problem affects the patient’s life and if he/she encouraged the patient to express feelings. This result is in accordance with the fact that no differences were observed between the SRP and ASP groups concerning the ‘Building relationship’ CCG main task or empathy, as evaluated with the CARE score. During the SRP training, the learner who played the doctor role had not also played the role of the patient. In order to make the access to an empathic approach easier for the peer role play-group, students have to switch roles (doctor and patient), but it was not the case for the SRP training in this study [17, 26]. HM Bosse et al showed that having role-played both the doctor and patient in the exercise is a key to the success of peer role play and creates a heightened awareness for the ambiguity of roles of the partners in communication, facilitating a more empathic approach [17]. The ability to sense and appreciate patients’ views, as well as the empathic approach towards the patients represent the basis for a functioning and safe patient–physician relationship [27]. It improves patient adherence and supports patient safety which are increasingly important issues in physicians’ daily work [28, 29]. Most certainly, switching roles in peer role play should be mandatory during our CST in order to allow learners to experience both biomedical and patient perspectives.
With respect to non-verbal behaviour items, nervousness was significantly higher in the ASP group compared to the SRP group. The most frequent signs of nervousness observed by the raters were self-touching (rubbing one’s face, grooming the hair), frequent postural shift, manipulation of objects (mostly the pen) and inappropriate facial display such as smiling or laughing. The deeper authenticity of the ASP situation and the emotional commitment of the professional actors pushed learners at more important levels of emotion depth, which could explain the higher nervousness [18]. Self-touching or unpurposive movements are signs of anxiety, tension and preoccupation and these non-verbal behaviors are known to accompany a poorer quality of the medical interview [7, 30]. Repeating the ASP exercise could diminish nervousness, increase auto-control and improve learner’s performance. Concerning the inappropriate facial display, namely smiling or laughing at inappropriate moments during the medical interview, in the European culture, it appears to cover embarrassment [31]. Embarrassment is a feeling of concern with one’s public image and with the reactions from others to inappropriate behaviour [31]. Therefore learners in the ASP group present more embarrassment signals compared to the SRP group, as a sign of failure to present a desired image to the actors, whom they seem to regard as evaluators of their performance. The embarrassment signals have a disruptive effect upon social interaction therefore, repeating the ASP exercise could also diminish these signals and improve students’ performances.
Concerning the gender specific differences in CCG scores, female students performed significantly better for the task ‘Building the relationship - Using appropriate non-verbal behavior’ and ‘Initiating the session – Identifying the reasons for the consultation’. Our results are consistent with several studies showing that female physicians interact differently with the patients, compared to their male counterpart by showing more empathy, using more positive statements and more affective behavior when communicating diagnosis-specific information [32–37].
Several limitations to our study should be noted in interpreting these findings. First, its representativeness is weighed down by the small sample of students who participated in the study. However, the fact that all 20 students were evaluated independently by 3 raters increased the accuracy of the results. Second, the communication skills assessment was based on several different scenarios. It has been previously suggested that the feasibility of a communication skills assessment would depend on the difficulty of the contents of the medical interviews [38]. We consider that even though we used different scenarios, they were similarly challenging for the students. Third, the students from the ASP group were one year older than those from the SRP group. The more adequate skills of ASP group in terms of gathering information in order to discover the biomedical perspective, background information and context, but also in terms of closing the session with forward planning could also be due to their supplementary year of medical education. Forth, although non-verbal behaviors, like nervousness, are under less conscious control than verbal behaviors, and are generally irrepressible, students may have acted differently than in real-life situations because of the simulated nature of the consultation and because they were also being filmed and observed by their colleagues [7, 20]. However, the SRP and ASP workshops took place under the same conditions, therefore, if non-verbal behavior results were biased by these conditions, they were equally biased in both groups.