3A.06 Problem based

In the 1970s, some medical schools such as McMaster University in Hamilton, Canada, and Maastricht University in the Netherlands, developed a problem-based curriculum with small-group tutoring and skills training. Communication skills training (CST), including small-group sessions with videoed demonstrations, role play exercises, feedback, and reflection, acquired a fixed place in these curricula [63,64]. However, CST programs have traditionally concentrated on the first, diagnostic half of the consultation. Patient-education issues were less often addressed [65-70]. Several factors promoted this attention to the diagnostic part. First, the curricula still suffered from the historically developed imbalance, reflected in clinical practice, between the teaching of "diagnosis" and "problem management" [71]. Second, medical education adopted much of the

social sciences curricula, which already contained social skills programs, based on the ideas of Carl Rogers [72] and Allen Ivey [73], with much attention paid to listening skills and, to a lesser extent, to the skills of conversational control. Third, the CST programs prepared students for their main task during their internships, which is questioning patients about their complaints and health status. Interns were not supposed to educate patients. Thus, students were not taught patient-education skills with one curious exception: breaking bad news. Although breaking bad news is regarded as

one of the most challenging consultations, many CST programs contained one or two small-group sessions with role-play exercises in breaking bad news, while students still lacked basic patienteducation knowledge and skills [70]. The problem-based curricula and CST programs also required new assessment procedures and instruments. In addition to knowledge assessment, skills assessment was needed. The Objective

Structured Clinical Examination (OSCE) was developed in order to reliably assess clinical skills in standardized conditions [74]. For the teaching and assessment of communication skills, several guidelines and accompanying assessment instruments were developed [75,76]. Nearly all guidelines and assessment instruments were based on the concept of patient-centeredness and used checklists or rating scales featuring required communication behaviors, ordered according to the different phases of a consultation. The instruments differed in their empirical validation. However, these

instruments lacked a theoretical basis that would clarify the shifting consultation goals and the physician's tasks along with matching communication skills, to attain these goals, nor did they predict clinical outcomes [14,42,77]. Although most instruments contained items concerning patient-education issues, such as explaining and shared decision-making, patient-education skills were hardly assessed in undergraduate OSCE's, since communication-skills training and assessment of students focused on history-taking.