Patient–Provider Communications

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ORIGINAL RESEARCH

The effect of communication training using standardized patients on nonverbal behaviors in medical students Kyung Hye Park1 and Seung Guk Park2

1Department of Medical Education, Yonsei University Wonju College of Medicine, Wonju and 2Department of Family Medicine, Inje University College of Medicine, Busan, Korea

Purpose: Nonverbal communication (NVC) is important in the patient-physician relationship, but the effect of NVC education is not well kown. In this study, we try to identify if students’ NVC abilities are improved through communication training. Methods: First-year medical students conducted medical interviews, which were performed with standardized patients (SPs) before and after communication skill education, and recorded in video. Fifty-one students were enrolled for this study. Two researchers used the NVC checklist, which consists of 12 nonverbal behaviors, to analyze and compare the students’ nonverbal expressions in the interviews recorded before and after the education. Results: After the students participated in communication training, open body position and adequate facial expression were increased while unnecessary silence, un-purposive movements, and giggling were decreased. These results can be interpreted as positive effects of the education. However, hand gesture was increased as a negative effect of the education. The total NVC score of the 12 nonverbal behaviors in the NVC checklist improved significantly, rising from 8.56 to 10.03. Conclusion: Communication skill education using SPs can improve nonverbal behaviors of medical students, especially facial expression, un-purposive movement, body position, unnecessary silence, and giggle, but not hand gesture. Further research is needed on a variety of teaching methods to improve NVCs.

Key Words: Nonverbal communication, Medical students, Medical education, Simulation, Patient, Feedback

Received: November 6, 2017 • Revised: March 21, 2018 • Accepted: April 16, 2018 Corresponding Author: Seung Guk Park (https://orcid.org/0000-0002-2986-3729)

Department of Family Medicine, Inje University Haeundae Paik Hospital, Inje University College

of Medicine, 875 Haeun-daero, Haeundae-gu, Busan 48108, Korea

Tel: +82.51.797.3220 Fax: +82.51.797.0589 email: [email protected]

Korean J Med Educ 2018 Jun; 30(2): 153-159. https://doi.org/10.3946/kjme.2018.90 eISSN: 2005-7288 Ⓒ The Korean Society of Medical Education. All rights reserved. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Introduction

Communication is important in the patient-physician

relationship. Doctors with good communication skills

can improve diagnostic capability, reduce frustration or

stress caused by difficult patients, and increase job

satisfaction. It is also known that patients’ satisfaction

and compliance are increased when working with a

physician with good communication skills [1].

Communication is composed of verbal and nonverbal

communication (NVC). Verbal communication plays a

major role in information delivery, while NVC is known

to play an important role in conveying emotions and

contexts involved in verbal communication between

physician and patient [2].

According to previous studies, people tend to judge a

person through nonverbal behaviors in relation to others.

Nonverbal behaviors are known to reflect personality trait,

type of social relationship, what their the intensions or

Kyung Hye Park and Seung Guk Park : The effect of communication training on nonverbal behaviors

154 Korean J Med Educ 2018 Jun; 30(2): 153-159.

motivates, and what they think or feel, and so forth [3].

This also applies to physician-patient relationships.

Clinical studies have reported that a physician’s ability

to understand the information contained in the nonverbal

behaviors of a patient can help improve decisions in

diagnosis and treatment [3]. In addition, physicians’

nonverbal behaviors when working with patients are also

known to affect patients’ satisfaction, compliance, and

clinical outcomes [2,4].

The results of these clinical studies reveal the necessity

of educating NVC as well as verbal communication educa-

tion in medical schools. Students can develop, through this

education, the ability to be sensitive to nonverbal expres-

sions presented by the patient and to perform appropriate

nonverbal behaviors in the interview process.

There are studies that investigate what factors are

associated with students’ sensitivity to the nonverbal

expressions of standardized patients (SPs) [5] and whether

communication education affects that sensitivity [6].

Previous research on students’ nonverbal behaviors is

mainly dedicated to the effects of the students’ specific

nonverbal expressions on the patient-physician relation-

ship [7,8]. However, only a few studies have examined

whether nonverbal behaviors can be changed through

education [9,10].

The purpose of this study is, therefore, to investigate

whether nonverbal behaviors of students are improved

through communication training using SP.

Methods

1. Participants

This study was conducted using 102 first-year medical

students enrolled at Inje University as of March 2016.

Although 102 students participated in the study, a

number of results were excluded: 34 students were

obstructed by the SP’s back in the video footage, 15

students’ videos had unusable sound quality, and two

students failed to perform either the medical interview

or the objective structured clinical examination (OSCE).

In total, 51 subjects (29 males, 22 females) were analyzed

through the recorded video.

2. The medical communication course

The medical communication course was based on the

Calgary-Cambridge guide to the medical interview [11]

and consisted of medical interview experience, five

topics, and OSCE. The topics were agenda setting,

attentive listening, empathy, medical interview with

pediatric patients, and patient education.

During the medical interview experience session, every

student conducted a 5-minute, one-to-one medical

interview with SPs. Male SPs played the role of a

mid-fifties patient attending a regular check-up. These

medical interviews were video-recorded. Each topic

took 4 hours to cover: a 1-hour lecture, a 2-hour

exercise with SPs and formative feedback, and a 1-hour

discussion with the instructor. During the 2-hour

exercise with SPs, six to seven students met one SP.

Each student then took turns practicing a 5-minute

medical interview with the SP. Feedback by the SP and

the student’s peers was given to each student im-

mediately after each interview.

In the OSCE scenarios, 44-year-old female SPs played

a role of a patient attending a regular, 5-minute health

check-up. As students do not learn clinical medicine in

the first year, a regular checkup case was developed by

the Medical Communication Committee at the College of

Medicine, Inje University. The communication skill tests

were recorded using a video camera and a microphone.

This record could be used to retrain the students who

score lower in the test (Fig. 1).

Kyung Hye Park and Seung Guk Park : The effect of communication training on nonverbal behaviors

155

Fig. 1. Communication Course and Study Design

SPs: Standardized patients, NVC: Nonverbal communication, OSCE: Objective structured clinical examination.

There was no formal NVC lecture in this medical

communication course. Instead, students were educated

on NVC through experienced SPs’ formative feedback.

All SPs were recruited through our medical college’s

homepage announcement, and employed after interview.

SPs who participated in the communication course had

over 5 years of experience. In order to participate, they

were required to have had training every 2 years in

OSCE concepts, acting, physical examination, and

feedback for medical students.

3. Study design

Informed consents were taken from the students and

standardized patients for agreement of video recordings,

which can be used for research and feedback. Video

recordings were used for our study after approval by the

Institutional Review Board of Inje University (IRB

approval no., 2017-01-008-002). The medical interview

process was recorded using a fixed video camera and a

microphone in the room. The two researchers checked

NVCs in five video samples of medical interview

experiences and confirmed their observations with NVC

checklists. After the students received communication

training, OSCE was performed again. The two re-

searchers then reviewed all video files and compared the

students’ NVCs before and after the lesson.

4. Measurement

We developed an NVC checklist by reviewing previous

studies [7,8] and monitoring the sample videos of

medical interview experiences. Our NVC checklist is

based on the checklist of Collins et al. [8], which

consists of eight items: body lean, body position,

postural change, facial expression, eye contact, affirma-

tive gestures, self-touching or un-purposive movements,

and hand gestures. In addition, as sound analysis was

possible with our video data, two items from the

checklist of Ishikawa et al. [7] were added to our check-

list: speech rate and voice volume, and matching voice

tone with verbal content. Also, while monitoring the

sample videos, we found some nonverbal behaviors of

students that we thought could affect physician-patient

Kyung Hye Park and Seung Guk Park : The effect of communication training on nonverbal behaviors

156 Korean J Med Educ 2018 Jun; 30(2): 153-159.

Table 1. Coding of Nonverbal Factors

Category Bad (score=0) Good (score=1) Examples Facial expression Blank or mismatched Adequately expressive Eye contact More likely when talking Equal when talking and listening Affirmative gestures Infrequent Adequately frequent Head nodding, smiling Hand gestures Frequent Few or none Self-touching or un-purposive

movements Frequent Few or none Touching the face, twirling a pen,

manipulating objects Postural change Yes No If a student shifted body lean or posture

at the point of the communication challenge issued by the standardized patient.

Body lean Backward Neutral or forward Body position Closed Open Closed: crossed arms angled away from the

patient Speech rate and voice volume Not accorded Accorded Patient-doctor accordance of speech rate and

voice volume Match of voice tone with verbal

contents Flat Adequate Match of voice tone and intonation with the

verbal contents Unnecessary silence, pauses of

conversation Frequent None

Giggle Frequent None

relationships and added them to our checklist: unneces-

sary silence or pauses of conversation, and giggle. Con-

sequently, we have a checklist of twelve NVC items

which can be categorized into two groups: bad and good

behavior. Each bad behavior was rated at zero points and

each good behavior was rated at one point. We defined

the sum of the twelve items as the NVC score (Table 1).

5. Statistical analysis

We examined the effectiveness of the education by

subtracting the percentage of good nonverbal behaviors

in medical interview experience from in OSCE. The

Wilcoxon signed-rank test was used to compare the

differences in NVC between the medical interview

experience and OSCE but did not include the NVC score.

The NVC score was averaged by dividing the sum of the

scores of each of the 12 NVC items by the number of

participants and compared using a paired t-test.

Statistical analysis was done using STATA ver. 13.0

(Stata Corp., College Station, USA) with 2-sided p<0.05 considered statistically significant.

Results

The inter-rater reliability between two researchers, in

terms of gamma coefficient, was 0.871 on average (range,

0.546–1.0). When comparing the frequency differences of the 12 NVC items before and after education, open body

position, adequate facial expression, and hand gestures

were increased to 23.53%, 21.57% and 17.65%, respec-

tively. Although the frequency of hand gestures was

increased, it means the negative effect of education.

Because we defined few or none hand gesture as good NVC.

In addition, unnecessary silence, un-purposive move-

ments, and giggle were decreased to 49.02%, 19.61%, and

37.26%, respectively. With the exception of hand gesture,

the change in frequency of these NVCs can be inter-

preted as positive effects of the education. On the other

hand, no significant change was found in eye contact,

affirmative gestures, postural change, body lean, speech

rate and voice volume, or match of voice tone with

verbal contents (Table 2). The total NVC score of the 12

Kyung Hye Park and Seung Guk Park : The effect of communication training on nonverbal behaviors

157

Table 2. Compared NVC between Medical Interview Experience and OSCE

Variable No. of experience (%) No. of OSCE (%) % Change p-value Facial expression: adequately expressive 39 (76.47) 50 (98.04) 21.57 0.001 Eye contact: equal when talking and listening 35 (68.63) 38 (74.51) 5.88 0.513 Affirmative gestures: adequately frequent 46 (90.20) 49 (96.08) 5.88 0.257 Hand gestures: few or none 15 (29.41) 6 (11.76) -17.65 0.013 Un-purposive movements: few or none 13 (25.49) 23 (45.10). 19.61 0.025 Postural change: no 51 (100.00) 50 (98.04) -1.96 0.317 Body lean: neutral or forward 51 (100.00) 51 (100.00) 0 - Body position: open 35 (68.63) 47 (92.16) 23.53 0.003 Speech rate and voice volume: accorded 48 (94.12) 50 (98.04) 4.28 0.317 Match of voice tone with verbal contents: adequate 51 (100.00) 51 (100.00) 0 - Unnecessary silence, pauses of conversation: none 22 (43.14) 47 (92.16) 49.02 <0.001 Giggle: none 31 (60.78) 50 (98.04) 37.26 <0.001

NVC variables were calculated by Wilcoxon signed-rank test. ‘% Change’ was calculated by subtracting the percentage of good nonverbal behaviors in medical interview experience from in OSCE. OSCE: Objective structured clinical examination, NVC: Nonverbal communication.

nonverbal behaviors improved from 8.56 (0.20) to 10.03

(0.13) significantly.

Discussion

In this study, we investigated whether communication

training using SPs influenced the delivery of NVC. It

was found that, among the NVC types, facial expression,

involuntary movement, body position, unnecessary

silence, and giggle could be positively changed through

the education. However, hand gesture could be nega-

tively influenced.

In a similar study, 268 medical students were divided

into two groups. One group performed online telecon-

sultation and the other group did not. The telecon-

sultation group of students who received overall feedback

from SPs as well as feedback on their nonverbal behaviors

analyzed by computer recorded a higher communication

score in a subsequent medical interview. In particular, the

group receiving feedback on nonverbal behavior received

the highest score [10]. This is consistent with our results

that SP feedback has a positive impact on NVC.

In the study of Ishikawa et al. [9], when comparing a

group that received three hours of NVC classes to

another group that did not, the NVC-trained group was

more interested in NVC as a goal in the OSCE than the

non-trained one. In practice, however, there was no

meaningful difference between the groups in NVC during

the OSCE.

The students in our study had been educated about the

concept of NVC several times even though there was no

available class that only covered NVC. In addition, they

had received feedback on their NV behaviors from SPs

during repeated practice on each topic. Education using

SPs can give accurate assessment and formative feedback

on various behaviors and attitudes to students in

designed medical interview situations [12]. In particular,

students can become better aware of how their behaviors

influence the SP’s affective domains [13]. Additionally,

the formative feedback given by SPs for 2 hours on five

topics seems to be effective in our educational curri-

culum as a repetitive practice.

Among the NV behaviors, the greatest changes were

reported in unnecessary silence and giggle. It is known

that too much silence during medical interviews

indicates that a physician is scared, lacks knowledge, or

is under stress [14]. Because the subjects of our study

Kyung Hye Park and Seung Guk Park : The effect of communication training on nonverbal behaviors

158 Korean J Med Educ 2018 Jun; 30(2): 153-159.

were first-year students who had not yet learned about

clinical medicine, unnecessary silence and giggles were

frequently observed in their medical interview experi-

ences prior to education. However, such behaviors

decreased through familiarity and repetition of classes.

We expected that hand gestures would be decreased

after education, but the result revealed that the students

showed more hand gestures than before. The previous

research results regarding hand gestures are inconsistent:

Collins et al. [8] reported that students who use fewer

hand gestures get higher scores from SPs while Griffith

et al. [15] showed the positive relationship between the

frequency of hand gestures and patients’ satisfaction. In

Sloane et al. [16], hand gestures were divided into simple

movements and movements for emphasis or illustration.

SPs gave higher ratings to the latter. In our study,

students are thought to use more hand gestures after the

education in order to explain themselves more actively.

In further research, it will be necessary to distinguish

between meaningless gestures and intentional gestures

for explanation.

The eye contact rate in our study was 68.63% was

lower than the study of Collins et al. [8] (100%) but was

similar to the study of Ishikawa et al. [7] (68.5%).

Although the figure was relatively high, it did not

significantly improve after education. Physicians’ proper

eye contact helps to increase patients’ satisfaction

[15,17]. Therefore, more attention should be given to eye

contact in NVC education.

There was no significant difference in postural change,

body lean, speech rate and voice volume, and match of

voice tone with verbal contents before and after

education. This might be because these NVC types had

already scored very high before the training. It is

possible that these NVC types could have shown dif-

ferent results had the subjects been in a clinical

environment rather than a testing situation.

This study cannot be free from the limitation that NVC

was evaluated in a testing environment, so it will be

different from the types of NVC that appear in an actual

clinical encounter. Secondly, there could be qualitative

and quantitative differences in feedback by SPs.

However, the data gathered was supplemented by the

repeated SP practice. Third, the sample size is small.

Despite these limitations, this study was the first to

compare NVC changes before and after training,

specifically of first-year students who had not yet

received clinical education, in order to demonstrate the

change in NVC through effective communication

education.

This study confirms that communication education

using SPs can positively change the nonverbal behaviors

of medical students, especially facial expression,

un-purposive movements, body position, unnecessary

silence, and giggle. Therefore, it is necessary to activate

the NVC education using the SP feedback. Also, In SP

training program, it is needed to emphasize the SPs

about the importance of nonverbal behaviors and inform

them about appropriate feedback methods. In addition,

further research is also needed on a variety of teaching

methods to improve the NVC types that are important

for physician-patient relationships.

ORCID:

Kyung Hye Park: https://orcid.org/0000-0002-5901-6088;

Seung Guk Park: https://orcid.org/0000-0002-2986-3729

Acknowledgements: None.

Funding: None.

Conflicts of interest: No potential conflict of interest

relevant to this article was reported.

Author contributions: Conception or design of the work,

data collection, data analysis and interpretation: SGP,

KHP; drafting the article: SGP; critical revision of the

Kyung Hye Park and Seung Guk Park : The effect of communication training on nonverbal behaviors

159

article: KHP; and final approval of the version to be

published: SGP, KHP

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