communication skills assessment: the perceptions of medical students at the university of nottingham
TRANSCRIPT
Communication skills assessment: the perceptions of medicalstudents at the University of Nottingham
Charlotte Rees,1 Charlotte Sheard2 & Amy McPherson2
Introduction Despite the wealth of literature surround-
ing communication curricula within medical education,
there is a lack of in-depth research into medical stu-
dents’ perceptions of communication skills assessment.
This study aims to address this gap in the research
literature.
Methods Five focus group discussions were conducted
with 32 students, with representatives from each of the
5 years of the medical degree course at Nottingham
University. Audiotapes of the discussions were tran-
scribed in full and the transcripts were theme analysed
independently by 2 analysts.
Results Two assessment-related themes emerged from
the analysis: namely, students’ perceptions of formative
assessment and students’ perceptions of summative
assessment. While students seemed to value formative
methods of assessing their communication skills, they
did not appear to value summative methods like
objective structured clinical examinations (OSCEs).
Students had mixed views about who should assess
their oral communication skills. Some students pre-
ferred self-assessment while others preferred peer
assessment. Although students appeared to value med-
ical educators assessing their communication skills,
other students preferred feedback from patients. Al-
though summative methods like OSCEs were criticized
widely, students suggested that examinations were
essential to motivate students’ learning of communica-
tion skills.
Discussion This study begins to illustrate medical stu-
dents’ perceptions of communication skills assessment.
However, further research using large-scale surveys is
required to validate these findings. Medical educators
should provide students with feedback on their com-
munication skills wherever possible. This feedback
should ideally come from a combination of different
assessors. Over-assessment in other subject areas
should be minimized to prevent students being dis-
couraged from learning communication skills.
Keywords Education, medical, undergraduate ⁄ *stand-
ards; *communication; students, medical; attitudes;
educational measurement; England.
Medical Education 2002;36:868–878
Introduction
The General Medical Council (GMC)1 has stated that,
by the end of their undergraduate education, medical
students should have acquired and demonstrated their
proficiency in communication. In terms of acquiring
proficiency in communication, much has been written
about the various methods of teaching and learning
communication skills2 and the effectiveness of those
methods.3,4 In addition, several papers have discussed
how medical students can best demonstrate their
proficiency in communication by talking about the
assessment of communication skills.
When contemplating communication skills assess-
ment, 3 different but related issues must be taken into
consideration. The first issue concerns whether the
assessment is formative or summative. Some medical
educators have focused on formative assessment meth-
ods like direct observation of communication skills with
feedback,5 while others have concentrated on summa-
tive methods like objective structured clinical examina-
tions (OSCEs)6,7 or written reflective portfolios.8
The second issue concerns the aspects of communi-
cation skills that should be assessed. For example, some
medical educators have focused on assessing medical
students’ verbal communication skills by direct
observation.6,7,9–11 Other medical educators have con-
centrated on assessing students’ knowledge of commu-
nication skills theory6,7,12 and still others have focused
1Peninsula Medical School, Plymouth, UK2Behavioural Sciences Section, Division of Psychiatry, University of
Nottingham, UK
Correspondence: Dr Charlotte Rees, Peninsula Medical School, ITTC
Building, Tamar Science Park, Davy Road, Plymouth PL6 8BX, UK.
Tel.: 00 44 1752 764261; Fax: 00 44 1752 764226; E-mail:
Students and tests
868 � Blackwell Science Ltd MEDICAL EDUCATION 2002;36:868–878
on students’ self-assessment and their abilities to reflect
on their communication skills.8,13,14 Humphris and
Kaney6 suggest that the measurement of observable
behaviours has been welcomed by medical educators
due to the unknown association between performance
on written tests and actual communication skills with
patients.
The third issue about communication skills assess-
ment concerns the assessor. In terms of direct obser-
vation of medical students’ communication skills, many
authors discuss the medical educator as the asses-
sor.5,6,9–11 Other authors discuss patients,15 students’
peers16 or the students themselves as assessors.13
Aspegren’s review3 suggested that students’ self-ratings
of their communication skills correlated poorly with
external independent ratings, with both over-rating17
and under-rating18 on the part of the students. In
addition, Cooper and Mira15 found that academic
teachers’ assessments of students’ communication skills
correlated poorly with simulated patients’ assessments,
with lay people giving students higher scores than
academic teachers. The authors concluded that the
communication skills emphasized by academic teachers
did not reflect the skills considered important by
simulated patients.
Although papers have discussed communication
skills assessment, there is a lack of in-depth exploration
into students’ perceptions of communication skills
assessment. In order to address this gap in the research
literature, this study aims to answer the following
research questions:
1 What are students’ views on how communication
skills are assessed?
2 What do students like about communication skills
assessment?
3 What do students dislike about communication skills
assessment?
Methods
Design
This study employed a qualitative design in order to
explore in depth medical students’ perceptions of
communication skills assessment. Focus group meth-
odology19 was used for 3 reasons. Firstly, focus
groups are extremely useful for carrying out explor-
atory research.20 Secondly, the interaction among
group members often produces data unobtainable
using other qualitative methods such as individual
interviews.21 Finally, the interaction between group
members replaces the interaction between participants
and the interviewer, thus minimizing interviewer
bias.21 In the present study, 5 focus group discus-
sions, lasting between 1Æ5 and 2 hours each, were
convened with students from each of the 5 years of
the medical degree course at the University of
Nottingham.
Sampling and recruitment
After receiving ethical approval, all students registered
at the University of Nottingham’s Medical School in
the academic session 2000–01 were invited to parti-
cipate in this study. Three different methods were
used to recruit students to this study. Initially, all stu-
dents were sent an invitation pack by post in October
2000. This pack included a covering letter, an
information sheet, a research consent form and a
Freepost envelope. The same information was also
e-mailed to students. Students were asked to read the
information sheet and, if interested in participating,
encouraged to return the research consent form to
the researchers. However, because this recruitment
method led to a poor response (11 ⁄965 ¼ 1Æ1%),
additional students were recruited using 2 other meth-
ods. The first method involved teaching staff asking
students in seminars whether they would like to
participate in the study. The second method involved
the authors contacting student year representatives to
ask them whether they or any of their peers would
like to participate in the discussions. Having submit-
ted consent forms, respondents were contacted by
phone or e-mail to arrange convenient dates, times
and locations for their focus groups to take
place. Those who gave their consent to participate
Key learning points
While students seem to value formative methods
of assessing their communication skills, they do
not appear to value summative methods such as
OSCEs.
Students have different opinions about who should
assess their oral communication skills.
Despite student criticism of OSCEs, students
suggest that summative assessment is necessary to
motivate students to learn communication skills.
These qualitative data are not intended to be
generalized to a wider population of medical
students; therefore further research using large-
scale surveys is required to validate these study
findings.
Perceptions of communication skills assessment • C Rees et al. 869
� Blackwell Science Ltd MEDICAL EDUCATION 2002;36:868–878
electronically or verbally were asked to sign a consent
form on the day of the focus group discussion.
Materials
Personal details questionnaire
The personal details questionnaire collected demogra-
phic and education-related details from the partici-
pants. Demographic items included age, gender, ethnic
origin, the employment histories of the participants’
parents (to calculate socioeconomic group) and first
languages. Education-related items included year of
study.
Discussion guide
Although the discussions were relatively unstructured,
the discussion guide contained a number of distinct
sections: welcome, introduction, anonymity, ground
rules, warm-up, clarification question, key questions,
concluding question and conclusion.18 The primary
purpose of this guide was to serve as an aid to memory
for the moderators. An adaptation of this discussion
guide was used successfully in a pilot study carried out
by the first author to explore medical students’
attitudes towards communication skills learning.22
Focus group procedure
The moderators welcomed participants and informed
them that the purpose of the discussion was to
determine their perceptions of communication skills
learning. The issue of anonymity was discussed and
participants were asked to give their consent to the
discussion being audiotaped. In order to manage
the group discussions, ground rules were outlined to
the participants. They were informed that only one
person should speak at a time, there were no right or
wrong answers, they did not have to speak in any
particular order and they did not have to agree with
others but needed to state their points of view without
making negative comments about the views or experi-
ences of other group members. The participants were
also informed that they could be interrupted and their
conversation re-directed. The participants were invi-
ted to ask questions before the discussion began
properly.
Participants introduced themselves by saying their
names to the group. Participants were asked to con-
template the words �communication skills� and express
what the words meant to them, thereby drawing them
to the specific topic of inquiry. The participants were
given a non-threatening forum in which they could
discuss issues they felt were important. However, they
were interrupted if they digressed to such an extreme
that they no longer focused on issues relevant to the
study. In these cases, they were brought back to the
topic of inquiry using key questions such as �How are
communication skills assessed?� �What do you like
about communication skills assessment?� and �What
do you dislike about communication skills assessment?�Finally, participants were asked what they thought were
the most important issues concerning communication
skills learning. After taking part in the discussion,
participants were thanked for their time and asked to
complete the demographic questionnaire before they
left the meeting.
Data analysis
All the discussions were audiotaped and transcribed in
full. The transcripts were analysed using a manual cut-
and-paste method of theme analysis,19 which is an
adaptation of naturalistic inquiry23 and the constant
comparative method.24 Analysis followed an iterative
process composed of several stages. The first analytic
stage involved the identification of strong themes
running through the data. The second stage involved
the identification of information units, i.e. �the smallest
amount of information that is informative by itself�.19
The third stage involved the categorization of the infor-
mation units.
Stages one to 3 were carried out independently by 2
analysts (either CS and CR or CS and AM) for each
focus group discussion. The fourth stage involved the
analysts comparing their themes, which allowed for
determination of interrater reliability. Any differences
were then negotiated. This process was conducted
separately for each of the 5 focus group transcripts.
Data were then coded across all 5 focus groups. The
level of agreement between the 2 analysts for each of
the 5 focus group discussions were j ¼ 0.500 (year
1), j ¼ 1.000 (year 2), j ¼ 0.467 (year 3),
j ¼ 1.000 (year 4) and j ¼ 0.588 (year 5). These
levels of agreement were moderate (year 1), perfect
(year 2), moderate (year 3), perfect (year 4) and
moderate (year 5), as indicated by Landis and Koch.25
Finally, corresponding verbatim quotations were used
to support all themes. An adaptation of these analytic
procedures has been used successfully in previous
research.22
Responses to the demographic questionnaire were
analysed using SPSS Version 10Æ0. First, exploratory
data analysis was carried out to determine the distri-
bution of the continuous variable �age�. A median and
interquartile range was established for this non-nor-
mally distributed variable. Secondly, the frequencies
Perceptions of communication skills assessment • C Rees et al.870
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and percentages of categorical variables (e.g. gender)
were determined. Socio-economic class was established
following existing guidelines on standard occupational
classification.26
Validity was established by participant evaluation of
the findings. All 32 medical students were sent a copy
of the results with an evaluation sheet. A total of 17
(53Æ1%) students, comprising representatives from each
of the 5 discussion groups, returned the evaluation
sheet. All of them (100%) stated that the results were a
fair interpretation of the discussions in which they had
participated.
Results
Participant characteristics
Of the 965 students invited to participate in this study,
32 took part, giving a response rate of 3Æ3%. Their ages
ranged from 19 to 27 years (median ¼ 20, interquar-
tile range 19Æ25–22Æ0 years). The majority were white
(n ¼ 28, 87Æ5%), female (n ¼ 22, 68Æ8%) and came
from socio-economic classes I and II (n ¼ 31,
96Æ9%).26 All spoke English as their first language.
Seven (21Æ9%) of the participants were first year
students, 7 (21Æ9%) were second year, 10 (31Æ3%)
were third year, 5 (15Æ6%) were fourth year and 3
(9Æ4%) were fifth year students.
Themes
Two distinct assessment-related themes emerged as a
result of the 5 focus group discussions:
1 students’ perceptions of formative assessment, and
2 students’ perceptions of summative assessment.
Students’ perceptions of formative methods
of assessing communication skills
Students’ communication skills were most commonly
assessed formatively using a method in which a student
would be observed conducting an interview with a
simulated patient. They would then receive immediate
feedback from medical educators and their peers. (All
names attached to the following excerpts have been
changed for the purposes of anonymity.)
Penny: You did it [the interview] on your own in a
room and it was videotaped and then they [peer
group] all watched you and then you had to come
back in and sort of everyone criticized you and said,
�You should have done it like this.�
Clara: Very similar to what we did in the first year.
Penny: But more difficult scenarios.
(Penny and Clara, year 4 students.)
This method of formative assessment seemed to be
valued by students. Not only did they think that the
simulated interviews helped them practise their com-
munication skills, but they also considered the imme-
diate feedback they received helped them develop these
skills:
It’s a true learning experience and you don’t feel
you’re being given a mark out of 10 and I felt that’s
the best assessment for communication skills that
we’ve done.
(Margaret, year 5 student.)
A third year student insisted that all students should
receive feedback on how they could improve their
communication skills:
What we want is how we can improve and that
should be told to everyone who’s teaching these
things, and especially assessing these things, that you
should give feedback.
( Jane, year 3 student.)
However, students had mixed views about who
should assess communication skills formatively.
Self-assessment
Some students suggested that it was important to be
able to assess themselves and identify what they did well
and which aspects of their communication they could
improve. A first year student suggested that self-assess-
ment was the key to formative assessment, largely
because different assessors have different views about
what constitutes good communication:
I think it is quite difficult [to assess communication],
because everyone’s different, and everyone has a
different view of what good communication skills are.
The most important thing is self-assessment.
( Will, year 1 student.)
Although students found it useful and reasonably
straightforward to assess a videotape of themselves
communicating with a patient, they found it difficult to
reflect more globally on their communication skills,
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� Blackwell Science Ltd MEDICAL EDUCATION 2002;36:868–878
particularly if their communication skills had not been
captured on video or audiotape:
Trying to reflect on what you’ve done yourself when
you’ve got nothing to reflect… it’s going to be better
for the other years �cause they can video themselves,
they can sit down with a piece of paper and say �I did
that badly, look at me there, that was really bad�, but
this year we can’t do that.
(Claire, year 2 student.)
Peer assessment
Some of the older clinical students valued peer assess-
ment, suggesting that it was useful for them to get
feedback from people who were similar to themselves
and who could truly empathize with their feelings about
interviewing patients:
I valued what they [peers] said as much, if not a bit
more sometimes than what the other person [GP],
because they knew exactly what I was going, you
know, you’re going through the same things, so for
them to say something which is good, you know, it was
quite good, you had to say something positive first or
whatever and then, but then even like the things they
said you could improve on you actually took on board.
(Stuart, year 5 student.)
In addition, some older clinical students thought that
peer assessment offered them opportunities to compare
their communication skills with the skills of other
students:
It was quite interesting to be able to compare how
well you thought you were with the rest of the people
in your group because otherwise you have no sort of
standard apart from the doctors to measure yourself
against, because obviously you’re not going to be as
good as doctors.
(Penny, year 4 student.)
Two second year students stated that peer assess-
ment was a useful learning experience for the assessor
too:
Sandra: I think you pick up probably on things you
might do yourself and see perhaps that you shouldn’t
and also you can learn from them, like you can think,
�Oh, they dealt with that really well, so I could use
that.� Like I wouldn’t really have known how to deal
with that but now I’ve seen them it’s like helped me.
John: They’ve done that and I wouldn’t do that, or
that was bad and it makes you aware.
Sandra: You learn from each other, don’t you?
(Sandra and John, year 2 students.)
While some older students enjoyed receiving feedback
from groups of peers, younger preclinical students
seemed more dissatisfied with group peer observation.
Two first year students criticized group peer observation
because they felt it was unfair to receive feedback in front
of a group and thought that their peers were often too
polite to offer constructive criticism in a group setting:
Kathryn: I think peer assessment in a big group is a bit
mean but if you’re with a partner, no-one else knows
how you’ve done apart from that one person…if you
make a pact with each other that you’ll be brutally
honest.
Anna: People can be too polite, because they’re too
worried about hurting people’s feelings, like �you did
really, really well�, when actually they’re thinking �no
you didn�t’ but they’re not going to say that if it’s a
big group.
(Kathryn and Anna, year 1 students.)
A second year student stated that it was difficult to be
objective about friends’ communication skills:
It’s hard to be objective because they’re your friends
or whatever and they’re going to mark you as well, so
you scratch my back, I’ll scratch yours.
(John, year 2 student.)
Other younger preclinical students felt it was difficult
to give feedback because they did not feel expert
enough to comment on other students’ communication
skills:
It’s very difficult for the ones observing to know, well,
�are they doing this right?� Because they don’t know
themselves what’s right and what’s wrong and what’s
the best way to talk to someone.
(Claire, year 2 student.)
When asked why they thought older students valued
peer assessment more than younger students, fifth year
students thought it was because they were more
mature, had more clinical experience and knew their
peers much better than first and second year students:
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Interviewer: A lot of students have said that they’d
rather have feedback from teachers rather than peers.
David: That’s �cause we�re older. Second years and
fourth years are miles apart in terms of what you
know, what to expect.
Stuart: There are 2 things about the fifth year.
You’ve gone through clinicals together to start with,
so I think you know each other better but also you’ve
had to do, you do more communicating with patients
in your first clinical attachment than you’ve done in
your first 3 years…and secondly, you know, you’re
that much older.
(David and Stuart, year 5 students.)
Teacher assessment
Some students seemed to place more value on medical
educators than peers as assessors of their communica-
tion skills, largely because educators were thought to be
better able to pick up on faults than peers. Some
students valued feedback from non-clinical lecturers
such as psychologists:
They can say, �You�re fidgeting all the time or your
body language is aggressive’, which is useful.
(John, year 2 student.)
However, despite witnessing many examples of poor
communication skills from qualified doctors, clinical
students appeared to value feedback from clinical edu-
cators more than non-clinical educators:
You [psychologists] are experts in communication
skills even more so perhaps than GPs, who have the
medical knowledge but might not be good commu-
nicators… My GP videoed me and then we sat and
watched the video and I thought that was really
good…I found that was good because it was a real
doctor who was saying, �Well, you should do this, you
should do that� and you don’t mind criticism from a
doctor.
(Clara, year 4 student.)
Some students received useful feedback from their
clinicians regarding their communication skills:
What he [the GP] did was there was a patient
asking why he was breathless when he laid down, so
he said, �You can explain it. You tell it to me and
then when the patient comes in you explain it� and
he told me what I did right or wrong and that was
really useful.
(Sam, year 2 student.)
However, some students criticized the feedback they
received from their clinicians, either stating that it was
very harsh or that the feedback wasn’t particularly
constructive:
I mean, he [consultant] ripped everyone apart while
you were presenting it and it took like an hour to do a
presentation, 2 people, and you got torn to shreds
but it was worthwhile because you learnt what they
were looking for, what you hadn’t said, but it was
scary.
(Lauren, year 3 student.)
There’s 2 or 3 sentences for feedback, and she [stu-
dent] went and she said �You know, I was wondering
how can we improve on this for next time?� and the
guy [doctor] was just absolutely so blase, and he
basically said something like �Oh, you know, you
can�t expect to get an �A� all the time’ and didn’t tell
her anything about it.
(Jane, year 3 student.)
Another criticism of the feedback from medical edu-
cators was that feedback in GP-led seminars seemed
unnecessarily drawn out:
It got to the stage where you, it was a bit drawn out,
you were trying to carry on analysing the interview
when everything had been said, and you know, trying
to draw out some criticism from somewhere when the
person on the video had done perfectly well.
(Derek, year 4 student.)
Students’ perceptions of summative methods
of assessing communication skills
Students’ verbal communication skills were most com-
monly assessed summatively by communication stations
within OSCEs. Other summative assessments included
written coursework, tapping either students’ knowledge
of communication skills theory or their abilities to
reflect on their communication skills.
The summative assessment of communication skills
did not appear to be valued by the students. Although
one fifth year student did state that the OSCE was a fair
assessment, students mainly criticized OSCEs:
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To come back to the whole OSCE thing, it’s the most
ridiculous assessment I have ever had to go through
in my life.
(Sally, year 3 student.)
OSCEs were criticized because they were thought to
be artificial and because the assessment failed to match
communication skills learning and teaching:
You look at the mark sheet and think �I�ve got to [do]
some empathy’, you know the mark sheets, so you
think of what you’ve got to put in. It’s a bit false.
(Clara, year 4 student.)
It bears no relation to anything we’ve been taught
before and if you pray, if you’re really lucky you get in
the afternoon group, so you can ask the morning
group what they had to do…because it’s honestly,
some of the assessment you didn’t have a hope in hell
of passing unless you’d spoken to somebody who’d
already done it.
(Sally, year 3 student.)
OSCEs were also criticized because there were limi-
ted opportunities for students to receive feedback to
help them improve their communication skills:
You don’t get any feedback because it’s so quick
and you’re moving on to the next one and you get
a brief �Oh, you said this, you missed this out�, you
don’t get �Yeah, that was good, you were talking to
them at the right level or perhaps you could think
about doing this�, because in that situation, it’s all,
you know, time, and you haven’t got time for better
feedback.
(Caroline, year 3 student.)
A fourth year student questioned the appropriateness
of summatively assessing first and second year students’
communication skills when they had received limited
learning opportunities in communication with real pa-
tients. This student felt that it was problematic to fail
first and second year students for their communication
skills:
But how are they going to improve? You’ve failed
your communication skills, �Shit, what am I going to
do?� Like, it’s not going to get people any better
necessarily because they’ve got no opportunity to
practise. Like, you can’t just revise it. You can’t say,
�I�ll go and read my book a bit more and then I’ll be
okay afterwards’. If you fail your whatever, I can’t
remember any of our courses, say your biochemistry,
you can go back to your book and re-learn it. You can
re-do your exam, but if you fail your communication
skills exam you’re telling an 18, 19-year-old that
they’re not capable of being a doctor and that’s not
true and it’s not really fair.
(Penny, year 4 student.)
Finally, OSCEs were also criticized because students
felt that their communicative performance often failed
to match what their communication skills were really
like. A fourth year student suggested that it would be
more appropriate for students to receive marks from an
individual who knew them well and had seen them
communicating on many separate occasions rather than
an individual who simply assessed their communication
skills in a 5-minute OSCE:
The GP gives you your grade that you’ve attained in
that attachment and I think it’s actually one of the best
ways to do it because you spend a month with this
doctor and he knows what you’re like by the end of it
and how willing you are to work and how good your
communication skills are. So, I think it’s better that he
assesses your communication skills rather than maybe
aGPwho’s justmetyou thatdayandseenyouonavideo.
(Anne, year 4 student.)
However, despite students’ criticisms of OSCEs,
students thought that the assessment of their practical
skills was far more appropriate than the assessment of
their knowledge of communication skills theory:
Anna: Cause you could learn the theory, you could
sit there and learn your notes. But it’s whether you
can actually apply it, that’s what’s important…
Tony: Yeah. I think that the theory should be
completely ignored in the assessment.
(Anna and Tony, year 1 students.)
Students had different opinions about who should
assess their communication skills in an OSCE. Some
students felt that patients should assess their commu-
nication skills rather than medical educators:
The particular lecturer just said �Right, you did this,
that and the other, and this and that�…and the
patient’s sat there and I thought, �Well, why don�tyou give the patient the form and let the patient mark
it’ and that’s how I think you should do it.
(Jake, year 3 student.)
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A second year student explained that patients’
assessment of medical students’ communication skills
would have more validity:
The examiner could be sitting thinking, �Oh yeah,
they said that and that put them [the patient] at ease�but it might not have put the patient at ease. It’s…the
examiner’s view, �Oh, they said good morning, so
that�s put them nice at ease’. �Good morning?�The guy could be sitting there thinking, �Ask me
what�s wrong, ask me what’s wrong’ and is tense
as anything.
(Claire, year 2 student.)
However, other students criticized patients’ assess-
ments of their communication skills because they were
too generous and failed to give them any constructive
criticism:
In the communication block we had to get patients to
tell us how well we communicated and, you know,
they just gave us a mark, you didn’t get much
feedback on it but it was really silly and a complete
waste of time because I know my communication
skills aren’t 10 out of 10 for like 10 patients and they
were all 10 out of 10…so I don’t think you learn very
much from their feedback.
(Margaret, year 5 student.)
Communication skills learning is dependent on summative
assessment
Some students suggested that the summative assess-
ment of communication skills motivated students to
learn communication skills:
I don’t think people do the interviews for fun, they
do it because they have to do it, you know, it’s an
exam.
(John, year 2 student.)
A first year student suggested that students only learn
communication skills if they know they are being
examined on it:
I think you need to examine it though, in some way,
to make people go and do it. Just a small piece of
coursework, nothing major, you know, like the piece
we did wasn’t that strenuous, but it made you go and
interview the patient, if you’ve got a few bits of work,
people are more likely to go and do it.
(Liam, year 1 student.)
Another student suggested that one way to motivate
students to attend communication skills sessions would
be to award them marks for their attendance:
Making people come to the sessions, like saying, �Part
of your mark will be rewarded on whether or not
you�ve attended all of the sessions’. That’s the only
way to get people to go.
(Sally, year 3 student.)
A fourth year student suggested that over-assessment
in other subject areas, particularly in the first 2 years,
inhibited students’ learning of communication skills:
I think half the problem with our course is that it’s so
focused on learning and everyone has this like focus
towards exams at the end of the course. So, that’s
basically what we do, and we don’t think, �Oh, let�sdo this to become better communicators’…because
like it’s not going to be assessed, so it doesn’t matter.
I think that’s because particularly during the first and
second year we have so many intense exams at the
end of each semester, that’s all that everybody really
focuses on.
(Emily, year 4 student.)
Discussion
To our knowledge, this is the first study to explore
medical students’ perceptions of communication skills
assessment in depth. Two related but different themes
emerged from the analysis of the 5 focus group discus-
sions: students’ perceptions of formative assessment
and their views regarding summative assessment. With
regard to formative assessment, students received
feedback from their peers and medical educators on
their communication skills while interviewing simulated
patients. Students valued this feedback and felt that it
helped them to develop their communication skills, a
finding supporting earlier work27 showing that experi-
ential methods were more effective than instructional
methods in learning communication skills.3 In addition,
it supports GMC28 recommendations that students
should be provided with regular and consistent infor-
mation about their development and progress.
Students had different views about who should assess
their communication skills formatively. Some students
preferred self-assessment, although this has been found
to correlate poorly with external independent ratings in
previous studies.13,17,18 Other students, particularly
those in their clinical years, preferred peer assessment,
either because they felt their peers could empathize
Perceptions of communication skills assessment • C Rees et al. 875
� Blackwell Science Ltd MEDICAL EDUCATION 2002;36:868–878
with their feelings about interviewing patients or
because assessing their peers’ communication skills
was a useful learning experience. On the other hand,
non-clinical students seemed to be more dissatisfied
with peer assessment, either because they felt students
were too polite to criticize or were unable to offer
constructive criticism due to a lack of knowledge and
experience. Some clinical students suggested that diff-
erences in views between themselves and preclinical
students might have resulted from their having more
clinical experience and therefore more experience in
communicating with patients. Aspegren3 suggests that
communication skills training in clinical clerkships may
be more effective than in preclinical courses, which
could influence students’ perceptions of peer assess-
ment. Finally, other students preferred receiving feed-
back from medical educators, as has been indicated in
previous research.29 Interestingly, although some stu-
dents had observed clinicians with poor communication
skills, clinical students seemed to prefer receiving feed-
back from clinical educators rather than from non-
clinical educators. This finding contradicts previous
research29 which found that students rated social
scientists higher than doctors as teachers in small group
communication skills training. This contradictory find-
ing may be due to the different samples used in these 2
studies. For example, Quirk and Letendre’s study29
surveyed first year medical students only and the
present finding was associated with the views of clinical
students. Indeed, while preclinical students may be
satisfied with communication skills teaching from social
scientists, clinical students may prefer communication
skills teaching from qualified doctors.
Unlike formative assessment methods, some students
did not value summative assessment methods for com-
munication skills. In particular, students criticized
OSCEs for being artificial, for failing to represent what
they had learned during the course and for failing to
provide them with opportunities for feedback to
enhance their learning. Nevertheless, the summative
assessment of students’ oral communication skills was
valued more highly than the assessment of their
knowledge of communication skills theory, a view
that is consistent with the educational shift from
written assessments of communication skills to the
assessment of observable behaviours.6 As mentioned
previously, the measurement of observable behaviours
has been welcomed by medical educators because of
the unknown association between performance on
written tests and actual communication skills with
patients.6
Students had different opinions regarding who
should assess their oral communication skills
summatively. On the one hand, some students felt
that patients should mark their communication skills
within OSCEs and other students criticized patients’
assessments because they over-estimated students’
communication skills, as has been found in previous
research.15
Some students suggested that summative assessment
motivates students to learn communication skills.
However, over-assessment in other subject areas, par-
ticularly in the first 2 years, was thought to inhibit
students’ learning of communication skills. This finding
is consistent with the worries expressed by the GMC,1
which stated that students were reluctant to afford time
to explore areas in which they were not examined.
This study has one major limitation that must be
taken into consideration when interpreting the results.
Although all medical students registered at the Univer-
sity of Nottingham were invited to participate in this
study, only 32 students eventually took part. Although
this sample size is satisfactory for a qualitative research
project, the response rate was very low (3Æ3%). There
are 2 possible reasons for this low response rate. Firstly,
students may not have been able or prepared to give up
2 hours of their time to participate in a group discus-
sion. Secondly, students may not have been motivated
to discuss communication skills learning, possibly
because they did not have particularly strong views
concerning such learning. Certainly, the students who
did take part in the focus group discussions appeared to
possess strong views (either very positive or very
negative) regarding communication skills learning.
However, because the response rate was so low, we
cannot be sure that responders were similar to non-
responders. In fact, the demographic characteristics of
our sample were different from those of Nottingham
University medical students as a whole (n ¼ 1016 in
the academic session 2001–02). For example, students
in our sample were more likely to be female (n ¼ 22,
68Æ8%) compared with Nottingham medical students
overall (n ¼ 635, 62Æ5%). Students in our sample
were also more likely to be white (n ¼ 28, 87Æ5%)
compared with Nottingham medical students overall
(n ¼ 729, 73Æ7%). It is possible, therefore, that non-
responders may have possessed different perceptions of
communication skills assessment to responders.
Although qualitative research is not meant to be
generalized to a wider population, the low response
rate in this study indicates that the fullest spectrum of
views may not have been elicited.
Despite this methodological limitation, the data
analysis for this study was reliable (see kappa values)
and the participants thought that the results were a
fair interpretation of the discussion, thus giving
Perceptions of communication skills assessment • C Rees et al.876
� Blackwell Science Ltd MEDICAL EDUCATION 2002;36:868–878
evidence for the validity of the study. The study does
begin to illustrate medical students’ perceptions of
communication skills assessment and the findings have
implications for both further research and educational
practice. Large-scale surveys are needed to quantita-
tively establish medical students’ perceptions of com-
munication skills assessment and how perceptions may
change during the course of medical training. This
quantitative data may then be generalized to a wider
population of medical students. In educational prac-
tice, medical educators should continue to use experi-
ential methods of teaching communication skills rather
than instructional methods. Wherever possible, med-
ical educators should provide students with feedback
on their communication skills, even in summative
assessments like OSCEs and a combination of differ-
ent assessors would probably provide the richest
feedback. Finally, medical educators should reduce
over-assessment within the medical curriculum, so
that students are not discouraged from learning
communication skills.
Contributors
All authors contributed to the data collection, data
transcription, data analysis and writing of this paper.
CR designed and secured funding for the study. CS and
AM recruited participants.
Acknowledgements
We would like to thank all the students who partici-
pated in this study.
Funding
This study was funded by a grant awarded to CR by the
Teaching Enhancement Office at the University of
Nottingham (Ref. 99TL ⁄179).
References
1 General Medical Council. Tomorrow’s Doctors. Recommenda-
tions on Undergraduate Medical Education. London: General
Medical Council; 1993.
2 Hargie O, Dickson D, Boohan M, Hughes K. A survey of
communication skills training in UK Schools of Medicine:
present practices and prospective proposals. Med Educ
1998;32:25–34.
3 Aspegren K. BEME Guide No. 2: Teaching and Learning
Communication Skills in Medicine: A Review with Quality Gra-
ding of Articles. Dundee: Association for Medical Education in
Europe; 1999.
4 Hulsman RL, Ros WJ, Winnubst JA, Bensing JM. Teaching
clinically experienced physicians communication skills. A
review of evaluation studies. Med Educ 1999;33:655–68.
5 McKinley RK, Fraser RC, van der Vleuten C, Hastings AM.
Formative assessment of the consultation performance of
medical students in the setting of general practice using a
modified version of the Leicester Assessment Package. Med
Educ 2000;34:573–9.
6 Humphris GM, Kaney S. The Objective Structured Video
Examination for assessment of communication skills. Med
Educ 2000;34:939–45.
7 Humphris GM, Kaney S. Assessing the development of
communication skills in undergraduate medical students. Med
Educ 2001;35:188–90.
8 Rees CE, Garrud P. Encouraging medical students’ reflective
practice in communication skills learning: an evaluation of a
new course. Presented at the Annual Scientific Meeting of
ASME, Royal College of Surgeons in Ireland, Dublin, 11–13
July; 2001.
9 Ram P, Grol R, Rethans JJ, Schouten B, van der Vleutan C,
Kester A. Assessment of general practitioners by video
observation of communicative and medical performance in
daily practice: issues of validity, reliability and feasibility. Med
Educ 1999;33:447–54.
10 Rowland-Morin PA, Burchard KW, Garb JL, Coe NP.
Influence of effective communication by surgery students on
their oral examination scores. Acad Med 1991;66:169–71.
11 Edwards A, Tzelepis A, Klingbeil C, Melgar T, Speece M,
Schubiner H, Burack R. Fifteen years of a videotape review
programme for internal medicine and medicine-paediatrics
residents. Acad Med 1996;71:744–8.
12 Winefield HR, Chur-Hansen A. Evaluating the outcome of
communication skill teaching for entry-level medical students:
does knowledge of empathy increase? Med Educ
2000;34:90–4.
13 Tamburrino MB, Lynch DJ, Nagel R, Mangen M. Evaluating
empathy in interviewing: comparing self-report with actual
behaviour. Teaching Learning Med 1993;5:217–20.
14 Kidd J, Nestel D. Development of a feedback process for
reflective assignments on communication skills. Presented at
the Annual Scientific Meeting of ASME, Royal College of
Surgeons in Ireland, Dublin, 11–13 July; 2001.
15 Cooper C, Mira M. Who should assess medical students’
communication skills: their academic teachers or their
patients? Med Educ 1998;32:419–21.
16 Hughes IE, Large BJ. Staff and peer-group assessment of oral
communication skills. Studies in Higher Education
1993;18:379–85.
17 Marteau TM, Humphrey C, Matoon G, Kidd J, Lloyd M,
Horder J. Factors influencing the communication skills of
first-year clinical medical students. Med Educ 1991;25:127–
34.
18 Farnhill D, Hayes SC, Todisco J. Interviewing skills: self-
evaluation by medical students. Med Educ 1997;31:122–7.
19 Vaughn S, Schumm JS, Sinagub J. Focus Group Interviews in
Education and Psychology. Thousand Oaks, CA: Sage; 1996;
pp. 106.
Perceptions of communication skills assessment • C Rees et al. 877
� Blackwell Science Ltd MEDICAL EDUCATION 2002;36:868–878
20 Stewart DW, Shamdasani PN. Focus Groups Theory and
Practice. Applied Social Research Methods Series Vol. 20.
Thousand Oaks, CA: Sage; 1990.
21 Morgan DL. Focus Groups as Qualitative Research. Qualitative
Research Methods Series 16. Thousand Oaks, CA: Sage; 1988.
22 Rees CE, Garrud P. Identifying undergraduate medical stu-
dents’ attitudes towards communication skills learning: a pilot
study. Med Teacher 2001;23:400–6.
23 Lincoln YS, Guba EG. Naturalistic Inquiry. California: Sage;
1985.
24 Glaser BG, Strauss AL. The Discovery of Grounded Theory:
Strategies for Qualitative Research. New York: Aldine de
Gruyter; 1967.
25 Landis JR, Koch GG. The measurement of observer agree-
ment for categorical data. Biometrics 1977;33:159–74.
26 Office of Population Censuses and Surveys. Standard Occu-
pational Classification Vol. 3. London: HMSO; 1991.
27 Evans BJ, Stanley RO, Burrows GD, Sweet B. Lectures and
skills workshops as teaching formats in a history-taking skills
course for medical students. Med Educ 1989;23:364–70.
28 General Medical Council. Draft Recommendations on
Undergraduate Medical Education: Consultation Copy July
2001. http://www.gmc-uk.org/med_ed/tomorrowsdoctors/
guidance.htm; visited 3 August 2001.
29 Quirk M, Letendre A. Teaching communication skills to first
year medical students. J Med Educ 1986;61:603–5.
Received 28 August 2001; editorial comments to authors 2 November
2001; accepted for publication 1 March 2002
Perceptions of communication skills assessment • C Rees et al.878
� Blackwell Science Ltd MEDICAL EDUCATION 2002;36:868–878