Why Effective Communication Skills for Medical Students Needed in the 21st Century

INTRODUCTION Effective communication is crucial for quality healthcare delivery, involving verbal and nonverbal skills, active listening, empathy, and conveying complex medical information in an understandable manner.[1] Communication in healthcare is often overlooked in teaching, leading to young doctors with inadequate skills. Poor communication can lead to decreased trust, patient satisfaction, medical errors, and suboptimal treatment adherence. Assessing and improving communication skills is crucial for patient-centered healthcare. However, little data exists on teaching communication skills to medical students in developing countries. Healthcare delivery is influenced by economic, technical, political, social, and cultural factors, necessitating practical training with a humanistic aspect.[2] The curriculum for teaching communication skills varies, with role playing being a common method. However, educators face challenges in incorporating these skills due to inconsistencies in terminology, content, methodology, and expected competencies. Problem-based learning is a helpful tool, but small group training can create the workloads. Effective communication is crucial for patient-centered medicine and empathic behavior, leading to better patient outcomes. Medical students develop: Communication and consultation skills (CCS) alongside other skills, with empathy being easier to teach than problem-oriented CCS.[3] Understanding medical students’ attitudes toward communication skills training is crucial for improving clinical communication behaviors and enhancing the effectiveness of communication skills training programs, particularly in medical education. Language is crucial for communication, socialization, and understanding culture. Cuban Medical University’s training model emphasizes four essential skills. However, communication skills decline over time due to negative attitudes, insufficient structured training, poor role models, and organizational constraints. Optimizing learning requires modifications, field extension, and regular structured trainings.[4] The National Medical Commission (NMC) introduced the Competency-based Medical Education (CBME) Undergraduate Curriculum in 2019, emphasizing communication skills for Indian Medical Graduates. However, the curriculum lacks specific specialty competencies for each module. The NMC also introduced a PG CBME curriculum for postgraduate and postdoctoral degrees, emphasizing empathy and communication.[5,6] Effective communication skills are crucial in the medical profession, especially during clinical clerkships, and Indian doctors need formal training to avoid common communication mistakes.[7] HISTORY OF COMMUNICATION Communication technologies have evolved over time, with the origin of speech dating back to 100,000 BCE. Symbols, such as cave paintings, petroglyphs, pictograms, and ideograms, have been used since 30,000 BCE. The first calendar may have been created 15,000 years ago, and linguistics reveals a connection between drawing and writing in Ancient Egypt and Greece. The history of communication is a relatively young field of historical research, encompassing transport, traffic, communication, media, and information techniques. The 1970s saw new questions and combinations regarding the revolution in communication, including computation, multimedia, and the Internet. The shift in medicine from doctor-centered care to patient-centered care has been driven by the changes in the accessibility of medical information. Medical students can design patient education to benefit both patients and students, enhancing their understanding of patients’ information needs and self-efficacy in patient encounters.[8] FUNDAMENTALS OF EFFECTIVE COMMUNICATION Communication is exchanging information, ideas, or feelings between the sender and receiver through the channel offered with some sort of encoding, transmission, decoding, and feedback, while possible barriers present themselves due to noise, language differences, cultural differences, and so on. Communication can be verbal (spoken or written), nonverbal (body gestures and facial expressions), visual (charts and diagrams), or para-verbal (tone, pitch, and volume); for communication to take place successfully, clarity, conciseness, completeness, courtesy, appropriate medium, and above all, active listening, are imperative. Some would say communication begins with an idea, and then much of it is formed in a process called encoding. This encoded message is then sent by associating it with some medium, with a goal that someone on the other side would decode it and interpret it. Now, just the interpretation itself does not complete the process; rather, some feedback shall be provided by the receiver to the sender. Being a good communicator involves listening, maintaining eye contact where appropriate, body language, confirming understanding, adjusting to pace, and tone for an audience.[1,2,8] What to communicate? Doctors must understand patients’ health literacy, prior knowledge, and attitudes to design effective patient education, ensuring it effectively conveys the intended message.[1,7] Purpose and outcome The purpose and intended outcome of patient education is crucial. Health information can inform patients about their illness, provide instructions for medication use, or encourage participation in disease-screening programs. The intended outcome of online health information can be to comfort patients, empower them to use medicine correctly, or urge them to act in certain ways.[1,7] Prior knowledge To effectively implement an online health information program, it is crucial to assess the prior knowledge and health literacy of the target audience. This knowledge is often integrated with the new information and depends on the factors such as education, health literacy, age, and experience. Chronically ill patients may have more knowledge about their disease than recently diagnosed ones. It is essential to identify and understand the target audience’s perspective and background to design online health information that fits their needs. Misconceptions, such as the belief that vaccinations cause autism, can influence the audience’s attitude and perception of online health information about vaccinations, which may not have the intended effect.[2,7] Perspective of the target audience The target audience’s social, political, and cultural background is crucial when determining the content or purpose of an informational message. A negative attitude towards the information may require adjustments to the content or purpose. The cultural background can influence the audience’s attitudes, such as strong religious or political beliefs, making it essential to assess these factors before delivering the message.[2,4] How to communicate? To ensure effective online health information, a balance between accessibility and accuracy is crucial. Content should be correct, informative, and comprehensible while also being accurate. To make online health information accessible to patients with different levels of health literacy, it is important to reduce cognitive load, which is the capacity to process new information. Mayer’s Cognitive Theory of Multimedia Learning suggests several ways to avoid cognitive overload, such as using images and text in combination, matching images with text, presenting images and corresponding text simultaneously, removing distracting additions, and replacing written text with narration in an informal style.[9] ATTITUDE, ETHICS, AND COMMUNICATION AETCOM stands for Attitude, Ethics, and Communication. It is a module for medical students in India that helps them develop professional skills. The Medical Council of India (MCI) (NMC) created the AETCOM module to improve the quality of medical education.[7] The AETCOM module was introduced in India by the National Medical Council (NMC) in 2019–2020. The module was implemented across all medical schools in the country.[7] How it all started? The MCI decided to implement AETCOM to improve the attitudinal, ethical, and communication skills of medical graduates The MCI created AETCOM modules for each year of the MBBS course The MCI hoped that AETCOM would lead to a competency-based undergraduate medical education program.[7] What does attitude, ethics, and communication do? Helps students develop professional skills Improves communication skills Helps students develop the right attitudes Helps students learn medical ethics Helps students learn how to counsel patients Helps students learn how to obtain informed consent.[7] How does attitude, ethics, and communication work? The NMC created AETCOM modules for each year of the MBBS course The modules are integrated into the regular teaching program The modules emphasize self-directed learning The modules include case-based learning The modules include competency logbooks The modules include assessments of students’ professional development.[7] What is the goal of attitude, ethics, and communication? To produce medical graduates who are caring, compassionate, and committed to serving patients To prevent malpractices and litigations against doctors.[7] Practical Implementation of attitude, ethics, and communication in medical curriculum While its theoretical premises are well documented, for effective implementation in day-to-day medical education requires strategic planning and structured implementation. The following are key suggestions for practical implementation: Vertical and horizontal integration AETCOM should be integrated with preclinical and clinical disciplines such as anatomy, pathology, internal medicine, and surgery, and use cases in which the clinical problem also requires communication and ethical considerations.[7] Skills-based training modules Simulation labs should be created by various institutes for communication role-plays, OSCEs, and dealings with standardized patients.[7] Faculty development Faculty should be continuously trained with periodic workshops for them to properly model and teach AETCOM competencies. Such faculty development ensures consistency between the hidden curriculum role modeling and intended learning outcomes.[7] Feedback mechanisms Reflections-assessments by students after patient encounters Patient feedback surveys to rate student performance on empathy, clarity, and respect 360-degree feedback involving peers, faculty, and patients.[7] Assessment tools Rubrics can be employed to assess the communication in clinical confines. Communication can be assessed as one of the formative and summative assessments.[7] Learning portfolios and logbooks Students should be able to develop longitudinal portfolios that capture their AETCOM milestones, reflections, and challenges.[7] For AETCOM to be fully integrated into daily medical education programs and clinical practice, all the academic staff, concerned with undergraduate medical education, must integrate AETCOM concepts side by side into all basic science and clinical subjects. A template for the educators to plan a nested session of 3–6 min focused on AETCOM skills relevant to the core-topic of a 60-min lecture or a tutorial session is attached along with a worked-out example of a nested communication skills role-play in a biochemistry lecture on bilirubin metabolism. If all the educators who conduct teaching sessions could adopt this principle of embedding in their sessions one or more AETCOM skills relevant to the biomedical core knowledge, then in the 4½ years of MBBS curriculum we can truly achieve the vision of the Indian Medical Graduate who is fully equipped with AETCOM skills in a holistic and wholesome manner. HEALTH LITERACY IN ATTITUDE, ETHICS, AND COMMUNICATION Health literacy is defined as the ability to obtain, process, and understand basic health information by a patient. With literacy and multiple language barriers in India, medical students need to be sensitized to customize their communication accordingly.[10] Some ways by which health literacy can be intertwined into AETCOM include: Training on literacy assessment by utilizing simple assessment tools such as the “teach-back” method, wherein the patient repeats the instructions in his or her own words Use visuals and translate into regional languages during patient counseling Medical jargon should be simplified while taking consent, discharge, and disclosing diagnosis. There should be a module on health literacy under the AETCOM framework for educators to ensure that patient education is fair, inclusive, and effective.[10] CONCLUSION AETCOM should henceforth become an organic and reflective activity on actual clinical experiences, intervened by faculty trained on this aspect, and thereby continuously improved on the basis of feedback. The conceptualization of its implementation should not be thought of as some sort of ancillarium or add-on but as one of the very foundational plinths on which the conception of the Indian Medical Graduate stands. That would inculcate a truly transformed healthcare professional, skilled yet humane and ethically grounded. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.