Medical students’ concerns about communicating with adolescents prior to workshops
Prior to workshops, medical students reported that they did not feel comfortable because of their own lack of practical experience in talking with adolescents, and because proactive screening necessitated asking about sensitive topics.
‘I guess I haven’t spoken to many adolescents, I don’t feel comfortable at this stage asking… or broaching those conversations’. (Medical student 1, male)
They expressed concerns about asking ‘intrusive’ questions. In this they appeared to believe that their duty was chiefly to be reactive (responding to the presenting problem) rather than proactive (conducting an opportunistic screening).
‘It depends on how important you think it is to bring it up, if it’s relevant to the presentation, how badly you need to know…if it’s not relevant to the symptoms they present, why would I ask about it?’ (Medical student 3, female)
Yeah, like ‘do I really need to know about this?’ It would seem strange to them, I think. Like, ‘why are they asking me this!’ (Medical student 6, female)
Many thought that it would be easier to initiate questions about mental health than sex because mental health would be something young people would ‘expect’ to discuss with their doctors:
‘If there wasn’t a presentation of symptoms, mental health would be a bit easier [than discussing sexual health]’. (Medical student 3, female)
‘I’d find it easier [asking about mental health], you can ask something like ‘have you been feeling down’. Asking that is easier’. (Medical student 1, male)
Some were concerned that initiating questions around sexual health might seem ‘a bit creepy’ unless there was a presenting complaint, and unless the patient understood why the questions were being asked, believing that it may be better to respond than to initiate.
Prior to workshops, young people in this study were asked what they thought the ‘most personal’ issue for young people would be out of sexual health, mental health or issues with drugs or alcohol (for a more detailed discussion of findings relating to young people in this study see Author 2013). Most of the school students said they thought mental health was the ‘most personal’ issue and that it would be more difficult to talk about than sexual health .
‘With mental health stuff, it’s really personal. And it’s not something you’d tell a doctor, it’s more something you’d tell friends…you wouldn’t trust them enough like you would a friend’. (School Student 2, year 9, male)
Evaluating learning partnerships
Survey data shows that the medical students found the workshops valuable in improving their skills in communicating with young people and understandings of adolescent health needs. Respondents ranked the usefulness of the workshops out of 10 (1 = not at all useful, 10 = extremely useful) across areas such as skills and understanding, value of learning activities and overall value of the workshop. The mean was 7.72 or higher for all ‘skills and understanding’ items on the survey, with ‘Understand importance of informing young people about confidentiality’ (mean 8.41), ‘Knowledge of how to apply the HEADSS psycho-social screening tool’ (mean 8.41) and ‘Understand the challenges adolescents can encounter in disclosing experiences relating to drugs or sex’ (mean 8.38) as the mostly highly rated items. The highest rated learning activities were ‘Trying out techniques in role-play’ (mean 8.58), ‘Getting feedback and advice from the school students’ (mean 8.52) and ‘Discussion following the activity’ (mean 7.99). The items relating to the overall value of workshop were also highly rated. ‘Provided opportunities to improve capacity to communicate well with adolescents’ had a mean score of 8.43; ‘Increased confidence about the possibility of building positive relationships with adolescent patients’ scored a mean of 8.29, and ‘Provided better insight into the needs of adolescent patients’ scored a mean of 7.95. The survey data shows that the workshops were rated by medical students as highly useful in enhancing their skills and confidence initiating conversations with adolescents about sensitive issues, and for providing them with greater insight into the needs that young people had for adults to take the lead in initiating these conversations.
The focus groups conducted with medical students (n = 39) immediately after the workshops provided an opportunity to explore their experiences in greater depth. Respondents explained that they particularly valued the supportive and experimental learning space which provided opportunity to try out different communication strategies, and to re-play after receiving coaching.
‘It was useful learning to think on your feet. Learning different phrases, if they don’t work, ask again, try something else…you couldn’t do that with a real patient in a real situation’. (Medical student 17, female)
‘I thought it was great to see what all the different Jo [character] reactions were – it was great to figure out and practice how to respond to their emotions. Like, one shut down when I was asking about sex, but we were able to talk about other things for a while and then she opened up more’. (Medical student 1, male)
‘We got to have a go and make a mistake, it was ok to get it wrong because we were in such a supportive environment, to work out what works and what doesn’t (Medical student 5, female)
Medical students described that the immediacy and rapid feedback within the face-to-face interaction heightened their sense of accountability for their communication style as it became obvious that the patients would withhold information or ‘shut down’ if they did not ask suitably framed questions or if their manner was perceived as judgmental. The students gave emphatic feedback about the importance of non-judgmental style, use of proactive and educative questioning, as well as reassurances about confidentiality. The structure of authentic coaching was designed to heighten the medical students’ acceptance of the need to use a screening tool rather than to confine their attention to the presenting complaint, which in the case of this character was a spike in frequency and severity of asthma attacks following initiation into smoking.
It’s the subtleties that we learnt, little bits to learn how to be more sensitive about issues, and I think a lot of medical students needed those creases ironed out’. (Medical student 20, female)
‘The workshop helps you understand your own strengths and weaknesses and focus on ways of improving the overall experience for both parties involved. It will definitely help with real life situations!’ (Medical student 15, female)
The medical students valued the way in which the workshops provided a link between theory and practice. The practice helped to build their confidence in initiating and persisting with the screening conversation.
‘I feel a lot better actually. Getting the individual feedback from the students, as well as the actual practice – we do so much theory but we don’t ever get to put it into practice like that’. (Medical student 6, male)
‘It’s confidence building. I felt that getting experience will make me more confident’. (Medical student 8, male)
The medical students particularly valued the adolescent feedback provided to them following the role-plays. This provided an authentic, personalised and immediate feedback loop.
‘I liked the feedback from students. I got told ‘you probably need to smile more!’ I don’t think that’s something a patient would tell me, I wouldn’t get that feedback from anywhere else!’ (Medical student 14, male)
‘It’s helpful that they say ‘I would feel better if you asked it in this way’ or ‘if you’d said it like this, this would make me more comfortable’, but also the positive stuff like ‘you asking it this way was good’… it’s good to have that opportunity so that when we start GP practice we’ve been given some practice so you’re not thrown in there and like ‘this is the first adolescent I’ve talked to, how do I do this?” (Medical student 35, female)
‘Apart from these sorts of things [the workshop] there’s no other opportunity for feedback of this type’. (Medical student 38, female)
Survey data shows that the school students also found the workshops valuable for increasing their understanding and trust of doctors and their confidence that doctors could be a useful source of help on problems relating to sex, drugs and mental health. The mean for items in the ‘skills and understandings’ ranged from 6.92 to 8.70, with ‘Learn about confidentiality at the doctors’ (mean 8.70), ‘Get a better understanding of how to handle problems if they come up in the future’ (mean 8.17) and ‘Understand the doctor’s job in helping teenage patients with problems to do with sex, drugs or mental health’ (mean 8.15) as the top three highest rated items. The most highly rated learning activities for school students were ‘Discussion with the doctors’ (mean 8.35), ‘Giving feedback and advice to the doctors’ (mean 8.23) and ‘The coaching and replay in fishbowl activity conducted by facilitator’ (mean 8.03). The highest rated ‘overall outcome’ was the item ‘Increase your confidence that doctors may be useful when young people have personal health problems’ (mean 8.13).
In focus groups following the workshops, school students said the experience made doctors seem more ‘human’ and more approachable, and thus became more likely sources of help.
‘Now we know they are just there to help us; it’s not like they’re going to judge you’. (School Student 5, female)
‘Now you know how they learn it, so it’s not as intimidating’. (School Student 28, female)
‘They’re just as nervous as we are about talking about what’s wrong’. (School Student, 29, female)
Overall, the school students and medical students described that the encounters and activities in workshops gave them a greater understanding of each other, and more confidence in the possibility of relating effectively with each other.