Response to “Medical students’ attitudes toward communication skills learning: comparison between two groups with and without training” [Letter]

Dear editor

We read with great interest the study by Ruiz Moral et al regarding medical students’ attitudes toward communication skills (CS) teaching.¹

Of particular interest were the findings that “affective” attitude scores, which reflect feelings toward the delivery of CS teaching, were lower in fourth-year students than first-year students. The fourth-year students also scored lower for “positive attitudes” toward CS training.¹ The authors concluded that “students’ attitudes toward CS could decline as a result of CS training”.¹

Multivariate analysis demonstrated a statistically significant difference between the scores of first- and fourth-year students. However, the difference was as little as 2.0 for the affective dimension and 2.2 for positive attitudes. It is unclear whether this represents a tangible difference in attitudes between the two groups.

Furthermore, reported baseline characteristic data for the included populations were limited to gender, parent–doctor status, and education fees. Other important variables including, but not limited to, overall satisfaction with the medical course and prior CS teaching were not assessed.

Analysis was based on a cross-sectional design with unpaired comparisons performed. It is unclear whether fundamental baseline differences existed between the two populations which could explain the differing scores. Therefore, the study cannot validly conclude that attitudes decline due to previous exposure to CS as comparisons were made using two distinct populations with little adjustments for baseline characteristics. Although costly and timely, a prospective cohort study with paired comparisons of the same group of students in their first and fourth year would be enlightening and increase the validity of the conclusions.

The authors proposed that medical students’ changes in attitude toward CS may be due to the pressure of performing in small groups and under the scrutiny of peers. This is supported by current evidence. Nilsen and Baerheim investigated the opinions of students on video-based feedback in a focus-group based qualitative study and commented on the importance of carefully designing CS programmes to reassure and support students (eg, effective debriefing).²

Nevertheless, the conclusion that a decline in attitude toward CS is directly due to negative training experiences does not account for the complex interplay of students’ experiences throughout medical school. Students’ clinical and life experiences between their first and fourth year will no doubt shape their attitudes toward CS in the curriculum and in clinical practice. Changes to students’ attitudes and perceptions throughout medical school are well documented in the literature, and have been described as a decline in empathy and increased cynicism.³ Reasons for this change are undefined, but Woloshuck et al suggested “a ceiling of high attitude scores at entry, loss of idealism and the impact of the unintended curriculum”.⁴

Attitudes toward CS are multifaceted and may be shaped by medical education and an individual’s life experiences. CS are important in clinical practice and we should ensure that trainees have a positive attitude toward CS courses. This study highlights an important issue in our approach to ensuring CS is delivered in an effective format.