Barriers for teaching communication skills in Spanish Medical Schools: a qualitative study with academic leaders


 Background: In recent years, Spanish medical schools (MSs) have been incorporating training in communication skills (CS), although how this is being carried out has not yet been evaluated. Objective: to identify the barriers to the introduction and development of CS teaching in Spanish MSs.
Methods: Based on participation in a previous study, 34 (83%) MSs (34) were invited to participate in a previous study that explored factual aspects of teaching CS in these schools. Person responsible for the teaching this domain were contacted at each school and asked to respond to a single open ended question. Two researchers independently conducted a thematic analysis of the responses.
Results: We received responses from 30 MSs, (85.7% of those contacted and 73% of all MSs in Spain). Five main thematic areas were identified, each with different sub-areas: negative attitudes of teachers and academic leaders, type of organisation, structure and presence in the CS curriculum, negative attitudes of students, lack of trained teachers and problems linked to teaching methods and necessary educational logistics.
Conclusions: The barriers and problems identified indicate there are areas for improvement in the teaching CS in most Spanish MSs. There seem to be a vicious circle in the dynamic relationship and interdependence of all these problems, that should be faced with different strategies but, at the same time, requiring a significant cultural shift as well as decisive institutional support at the local and national level. This represents a major challenge that must be addressed in order for students to learn these skills more effectively and avoided negative attitudes toward learning CS.

communication skills can be learned by students, doctors and other healthcare professionals [4,5]. As a result, communication skills (CS) training has for some time been incorporated into undergraduate medical studies in a number of different countries where published guidelines set out the most appropriate and efficient strategies for developing CS within course curricula [6][7][8][9]. These guidelines are based on the available scientific evidence and recommendations indicate that teaching: 1) must be longitudinal sustained throughout the curriculum in order to improve content retention [10,11] given that these skills tend to decrease over time and over the course of clinical training; 2) must include "experiential" teaching methods (role-playing, practice with simulated patients, observation, feedback, and small group discussions), which have been demonstrated to be effective in changing or acquiring new behaviour [12,13]; 3) must be integrated within the general medical curriculum and practical activities of medical specialties [14,15]; 4) must focus on the quality of training, both in simulation scenarios where all students have the opportunity to practice these skills and receive feedback, and in medical clerkships where there are opportunities for informal and opportunistic learning. In order to be effective, explicit learning and training objectives must be established allowing teachers to conduct directed observations and provide relevant feedback. In Spain, the National Agency for Quality Assessment and Accreditation (ANECA) referred to CS in its white book as a specific competence to be taught in MSs [16]. Furthermore, two years later, an Order by the Ministry of Education and Science, establishing the requirements for certifying an official university degree in Medicine, defined CS as one of seven competencies medical students must acquire in order to obtain a medical degree [17]. Both documents provide a generic, declarative perspective on the subject, leaving accredited schools free to organise their CS curricula, teaching methods and assessments.
In 2017, a study was conducted by our group with the participation of 83% (34) of Spanish MSs to explore the current circumstances of CS teaching in Spanish MSs [18]. The study concluded that while almost all MSs had formally incorporated some content relating to CC in their curricula, the evidence suggested that, in the vast majority of cases, CS teaching did not follow many of the main recommendations of the aforementioned bodies. As a result, while debate continues about many aspects of CC training, efforts to incorporate it into undergraduate studies may not be effective for Spanish medical students to acquire these CS. Thus, the study showed that a very significant percentage of these MSs (64.7%) only offer CS training during preclinical years, and that it is taught separately from other clinical skills and alongside the more theoretical subjects of humanities, ethics, history and, above all, psychology. It was also noted that there were no structured CS training programmes at any stage of the curriculum, that is, programmes with clear learning objectives and formative and summative assessment strategies. In 29.5% of the MSs, this "training" is considered a part of medical clerkships with no clear learning objectives. The predominant teaching method was a traditional class format or seminars in smaller groups where the use of role play or SP (simulated patients: a scarcely used resource) was carried out in a predominantly demonstrative manner. Thus, the majority of students did not get the opportunity to practise individually and receive structured and constructive feedback on their performance. The study also revealed that although the majority of teachers are clinicians, they lack specific training in this subject while a significant number of teachers had no clinical experience or were had no specialities outside of standard clinical practice, especially in psychology. Finally, CS were generally assessed using the traditional method of a written exam with very little structured assessment of student performance in simulated or actual settings.
As a result, and further to the study, we proposed a new exploration of current realities of CS training in Spanish MSs, inviting the same academic leaders that participated in the previous study to offer their opinions on the problems and barriers to incorporating and implementing CS training in their own MS. The aim of this second survey was to analyse the current situation of the training subject to the previous study, identifying the main problems faced by schools as well as the priority areas for future action to make training more effective.

Materials And Methods
This is a qualitative study that aims to explore the principal problems and barriers to the development of CC training in Spanish medical schools, in based on the opinions of the professors responsible for teaching this domain in the curriculum.
In the preliminary study, 41 medical schools (MSs) were invited to participate, drawn from the official list of Spanish medical schools according to the Ministry of Health in 2017 [19]. Some 34 medical schools or 83% of those contacted replied (28 public and 6 private schools), providing information on their curriculum (credits, subject/s and year/s in which it is taught, methodology, etc), characteristics of the faculty and the teaching and assessment methods used in the CC training [18]. Two researchers (CGL and ACP) contacted the schools three times over a period of three months (from Analysis: All results were codified thematically and independently by two researchers, RR and AC. The results were sorted into thematic categories and subcategories, with a high degree of agreement between categories. There was a discrepancy in the allocation of subcategories but this was resolved through discussion in order to illustrate varying opinions, perspectives and agreements. The most relevant themes emerging from the results are presented below, including the number of times they appeared with statements that best illustrate the opinions of the staff.

Results
Out of the 34 MSs which participated in the previous study and were contacted, we received responses from 30 (85.7% of those contacted and 73% of all MSs in Spain; 5 private schools). Five main thematic categories were identified, each with different subcategories. Table 1 provides a list of the barriers identified: Incorporated as a theoretical subject in an ad-hoc style during preclinical periods In a fragmented way (in different subjects) Part of a subject with other non-clinical content (humanities ethics, history of medicine, psychology) No transversal structure with coherent teaching aims Negative student attitudes (as a result of opinions such as...) (11 comments) They do not understand its use Reductionist and scientific epistemological interpretations It is not important because it is not assessed It is not useful in the MIR (medical intern) exam It is not important because it is of a marginal or secondary nature in the curriculum It is innate, subjective and cannot be learnt Limited and ill-trained teaching staff (13 comments) There are no teachers with an appropriate academic status The clinicians use a weak or negative model They have no training in CS or teaching methods Teaching and assessment methods needed (21 comments) They do not use experience-based teaching methods Experience-based methods are expensive It needs more time It needs continuity and the commitment of teaching staff It needs a relatively sophisticated infrastructure It needs complex assessment systems that are no necessarily well known

Negative attitudes of the university professors and academic leaders
These comments illustrate that the principal barrier is the negative attitudes of academic leaders and university professors who teach traditional subjects and their influence on the way the CS curriculum is incorporated and structured.
Those responsible for curricula felt that CS are not very useful: "the inclusion of CC as an interdisciplinary subject or skill was outlandish and unnecessary taking time away from real teaching" (U-5) "teachers of unrelated subjects or content believe it to be "superfluous", "not very serious", "lacking content", etc" (U-11) Those responsible for the curricula felt that there is no scientific (biomedical) evidence to support teaching CS: Those responsible for the curricula felt that CS are learned by modelling: "The undergraduate degree administrators don't forcefully or confidently support training in these skills... as they consider it to be something that you learn through imitation" (U-10)

Type of organisation, structure and presence in the CC curriculum
These are the most frequent and repeated comments by key respondents, noting that these skills would primarily be included as a legal obligation and therefore implemented without an adequate teaching plan: Incorporated in an ad-hoc, theoretical way during preclinical periods: Need to be incorporated into curriculums in a structured and transversal way from a supradepartmental level: "An institutional or structural barrier is that curricula do not incorporate the subject in an obvious way. In general, they recognise the need for it but do not explain how it will be carried out and where the necessary credits will come from" (U-23)

Negative student attitudes
They identify student attitudes to clinical communication as a major barrier. The respondents link these attitudes to a number of different causes.
Negative attitudes towards CS because of a lack of understanding as to why they are useful: Negative attitudes towards CS because of how it is included and taught in curricula: "By including it as something secondary within other subjects, generally pre-clinics, using inadequate teaching method, if any, and with no thought as to how it is assessed, students see it as something that is not very important or related to their own personality" (U-26)

Lack or absence of trained teachers
There were comments that made reference to the lack or absence of trained teachers, not only when it comes to adequately teaching the content (offering feedback, etc.) but also in terms of adequately planning it in the curriculum:

"There aren't enough trained associate teachers involved in this subject area to be able to establish proper parameters for communication skills, teaching objectives and teaching methods" (U-4)
"There aren't enough trained teachers to teach it properly. It is left "in the hands" of the teaching clinicians in charge of clerkships. The psychologists don't generally have trained teachers that know the clinic" (U-5)

Problems linked to teaching methods and the necessary educational logistics for it to be taught
These comments consider the teaching method designed specifically for teaching CC to pose a significant barrier to its assessment.

Discussion
In this qualitative study, those responsible for CS in their MS offer their personal opinions on the most significant problems or barriers to incorporating and developing these skills. These key informants agree on the principal problems: the negative attitudes of teachers and academic leaders who regard these skills as marginal, little investment in educational methodologies and evaluative structures, and limited training and promotion on the part of faculty, in addition to the negative attitude of students regarding these skills. This has resulted in a teaching approach based on traditional teaching methodologies (lectures and workshops) and assessment strategies (written exams) as well as poor curricular integration, a theoretical approach often detached from clinical practice and taught by nonclinical professors. Although surveys show that educational input generally improves communication skills among trainees [13], teaching methods classified as 'experiential' [20], including role-play, simulated patients, supervised practical training, self-assessment and peer feedback are more effective [4,12,21,22]. Experiential learning is a structured cyclical learning process through awareness, practice, reflection and feedback (individually or as a group) delivered in a structured way by experienced professionals [20, 23,24]. A focus on learning tasks and skills improves student acquisition of useful communication strategies for use with patients [4,12,21,22]. In recent decades these educational strategies have being incorporated with varying scope and depth in the curricula of many medical schools around the world. However, most schools have encountered barriers and problems similar to those identified by our key informants [25][26][27][28][29].
The general opinions offered and similarity of statements by key informants offer a perspective on the educational context where the biomedical paradigm is hegemonic, revealing the effect these barriers and dynamics have on the educational environment. In Figure 1 we present these barriers in context, giving us a better understanding of their dynamics and the opportunity to explore possible strategies to improve and progress towards a more efficient approach to teaching CS.
To varying degrees, many of the barriers have been identified in recent years. The belief that communication is innate, lacking academic credibility, subjective and unscientific, are notions that have been identified elsewhere [30,31] and are found not only among academic leaders and teachers of other subjects but also in many students [32]. This interpretation reveals the influence of the biomedical paradigm on academic medicine in Spain that determines what is appropriate and what is inappropriate to research, teach and, of course, practice. Several studies show the extent to which the introduction of humanities and social sciences in medical curricula is hindered by such hegemonic thinking [33][34][35][36]. This study highlights how, according to key respondents, this ideological hegemony is a determining factor in the incorporation of CS in MS curricula in Spain. Figure 1 shows the dynamics that link the different barriers as a vicious circle within the framework of this ideological influence. In effect, when taken as a whole, these barriers form a coherent and revelatory picture of the problem: in an educational environment dominated by biomedicine, the negative attitudes of teachers and academic leaders towards this subject are primarily due, according to respondents, to their belief that CS are "not scientific" and are innate skills. Other factors are also at work, including the position of universities within the political power structure of Spain. Thus, the legal requirement for the introduction of CS into medical school curricula, as per the ministerial order of 2008, would appear to be temporary, peripheral or otherwise secondary, included within other pre-clinical subjects and without an integrated and coherent teaching plan. Furthermore, when CS are taught as a preclinical subject or in a theoretical way by teachers who are not clinicians, the tacit message to students is that clinicians know the fundamentals of medical practice while others specialise in less scientific, psychosocial topics [37]. It also implies CS are an objective in themselves rather than a tool for better patient care [38]. All of this dismisses the fact that CS enhance the clinical encounter, facilitating the sharing of clinical information, negotiation and decision making between doctor and patient.
Additionally, the absence of sophisticated (experiential) teaching methods and appropriate assessment strategies also represents a barrier as learning appears to have little impact on students. This is evident both in the lack of trained and in the difficulty and disinterest in investing the required resources. The absence of practical training based on observation and feedback is not, however, something exclusive to the Spanish education system [39][40][41], nor is having an "informal" CS training plan "without structure, sufficient time or defined objectives" [42]. Even well-structured programs can have negative student perception if adequate teaching methods are not used [43]. It has been observed that students who receive less experiential CS training are less likely to consider communication a skill to be learned and used to improve clinical results [44]. The use of experiential training methods is recommended (role play, simulations, feedback, etc) for both teachers and students [45]. However, students may view these experiential sessions negatively if they are not conducted in a safe, trusting and prejudice-free environment [32,45].
The study shows that teacher training is the key and that a lack of qualified or experienced teachers is a major barrier. In fact, clinicians interested in CS complain they receive little training and are reluctant to teach and assess skills they themselves have not fully mastered [29]. Furthermore, this lack of teacher training also limits the skills which can be taught [46]. Teaching CS in clinical practice requires teachers who believe in it and can demonstrate it [47]. This is particularly important since CS training will remain deficient if supervisors do not believe these skills to be essential for a clinician and/or that they cannot be taught [47]. Additionally, clinical supervisors tend to teach CS using role modelling in a very irregular and rarely explicit manner [48]. When clinical supervisors address communication problems with residents and students they generally intervene as corrector, clinician or trainer rather than as a teacher [29]. Many hope that by simply watching and listening, young doctors will recognise, accept and imitate desirable behaviour [49]. The risks of entrusting CS training to role modelling during internships has been observed by clinical supervisors who have noted that models often lack the required skills [50]. Respondents also note the absence of teachers in influential posts to champion CS training and push for changes to the curriculum.
With regards to the weighting accorded to CS in the Spanish system and the way in which clinical communication is assessed, this has proven to be counterproductive. In general, Spanish MSs do not always assess CS in a specific way or do so by using a written exam with multiple choice questions, a list of skills to be completed by the supervisor at the end of the internship or by using unsuitable checklists. These assessment methods give students the impression that these skills are unimportant or secondary and are not usually well received [51,52].
Finally, students and young doctors are described as having negative attitudes towards CS and fail to learn them. While some believe that communication is something innate and subjective that cannot be taught [30,31], personal factors also play a role. Students with the most positive attitude towards CS are generally women, whose parents are not doctors or who believe that their CS need improving [53]. Student attitudes also vary according to their level of experience. Younger doctors with less experience tend to be more stressed and less open to communication problems than those with more experience because they are still concerned about providing accurate diagnoses and providing quick and effective care [29]. Poor knowledge of biomedicine, clinical reasoning or a lack of skill in using technical procedures (electronic medical registers) [50,54] can also hinder communication. However, while these factors no doubt contribute to the failure to see the benefits of CS in medicine, they may also confirm negative attitudes towards these skills while also reaffirming reductionist conceptions of medicine and clinical communication, creating a vicious circle difficult to break (figure 1).
However, despite everything, and particularly the negative attitudes of professors and academic leaders towards communication skills training, studies show that young doctors and students value CS when they are taught experientially using a student-centred approach and when clinical supervisors take a more active role in observing them and offering feedback [55,56]. These have also come to expect training in clinical communication skills in MSs and residence programmes [57][58][59]. Student representatives in Spain have made these requests explicit [60].

Conclusions
Those responsible for introducing and developing CS in Spanish MSs identify a set of barriers that would make it difficult for students to effectively learn these skills, representing a set of interrelated problems that largely explain the way in which CS are being introduced and the real priority for them to be taught in many of the Spanish medical schools. Effectively incorporating CS teaching into MS curricula is a challenge which will require a significant culture change and support from all local and national academic and institutional levels as a prerequisite for introducing new educational models that are more in line with new teaching and clinical practice trends. internal medicine ward rounds: a cross-sectional study. BMC Med Educ. 2010;10:53.