Counselling skills play an important role in the relationship between the patient and the doctor. 

Since 1979, there has been a growing realization amongst medical professionals, and even as high as the US Congress, that clinical medical practice should be supported by well-developed interpersonal skills (IPS), and that these should include counseling skills (Kahn 1979).  Other studies have indicated a positive impact of counselling on patient response to treatment.  For example, Cox et al 2011 showed that, when physicians used counselling techniques and empathy, patients reacted positively with health-related attitudes and behaviors.

Simultaneously, as a result of the Information Age, today’s patients (often referred to as e-patients (Masters et al. 2010)) are more knowledgeable of their diseases than before, and there is a growing awareness of the need for doctors and patients to work together to achieve effective treatment.  For patients to participate fully, however, it is crucial for them to understand their role in that treatment.  Proper counseling that respects the patient’s emotional, psychological and physical needs can provide a platform on which to build effective medical treatment.  This is especially so because of population growth, population longevity and the increase in chronic diseases.

Because of the importance of counselling in medical care, there has been a corresponding increasing awareness that medical training without counselling skills is not “effective and comprehensive.” (Stillman 1990).  As a result, in addition to competencies of standard history taking, physical examination, and diagnostics skills, third and fourth year medical students need to be taught and assessed on their skills of patient education and counselling. 

Setting

At the College of Medicine & Health Sciences, Sultan Qaboos University, Sultanate of Oman, medical training follows the traditional pre-clinical basic sciences training, following by clinical training.  Between these two phases is a “Pre-clerkship,” five-month semester which is aimed at preparing medical students for their clinical phase. 

Until 2014, medical students were taught few counseling skills on an ad hoc basis late in their clinical training.  In 2013, the College appointed a full-time student counsellor (BB) whose prime role is to counsel students with their challenges that face them during their university experience.  Having this counsellor provided an ideal opportunity to teach the pre-clerkship students the fundamentals of patient counselling.

The aim of this exercise was to set up contact sessions with pre-clerkship students in order to expose them to the principles of counseling so that 1) they may be open to receiving counseling from a counselor, and 2) that they may be able to utilize the counseling skills that they have learnt to enable more effective medical practice.

Results

General

Of the 114 registered students, 76 (46 (60.5%) female) attended the workshops, and all students (100% response rate) completed the evaluation. 

Quantitative Data

Of these, 71 (93.4%) answered “Agree” or “Strongly Agree” on finding the workshop valuable (Mean: 4.3/5); 70 (92.1%) on learning new counseling skills (Mean: 4.4/5), and 73 (96.1%) on the belief that they would use the counseling skills with their patients (Mean: 4.5/5).   There were no statistically significant differences between male and female responses.

Figures 1 to 3 show the plots of the figures.

Qualitative Data

The qualitative data were themed into broad themes.  As expected from the quantitative results, the comments are almost exclusively positive, with some students showing great insight into the broader role of counselling.  The most commonly-occurring themes were (data given below are unedited) :

Student Responses

Theme1: Students wanted extra workshops

• We need extra workshop about counseling.
• Very useful workshop we hope to have more than one workshop.
• We need more workshops in this skills.
• I think we need more sessions in this
• More hours should be assigned for this course, because it's v.important for future work.
• Any other habits!? Great session :)
• We need to do more senarios to get more trained and learn more.
• I hope to have more workshops. Not only once.
• Specify counseling sessions in every week to learn.

Theme2: Workshop should be longer

• Time for practicing is not enough
• give more time to this session, it helps a lot.

Theme3: Students recognized the need for understanding a lot more about counselling

• the workshop was good, but we need to spend more time to learn the basic of caunseling and to practice more.
• More detailed in the way of speaking and acting in counseling
• I need more of counseling teaching! I think it is extremlly important
• Was good, but reality I think it's difficult.

Theme 4: Overall, students were pleased with the exercise

• Interesting workshope will help us in future work
• Excellent well done!
• Most session sould be like this. It interactive and we learn some new skills.
• Love the workshop. I will try to use all what I learned from the session. Learned how to counsel is important, for me as a future Doctor. Not only with my patients, but also with anyone in need
• interesting session
• It was useful session.
• very useful workshop, it is the first time I interset in counselling and ethics lecture….. THANKS
• Excellent idea to have such counselling skills to be schedulled in timetable especially if it's for small group cuz it help us to understand & practice it in real situation. Thanx a lot dr.Buthaina for this useful& wonderful lecture.. God bless you :)
• What is great in the workshop is the interaction between the lecturer and students and this makes the person enjoy and gain the information more [translated] .
• Thank you a lot
• I found it useful, many thanks to you doctor

Theme 5: Students liked the role-play

• Thanks a lot…Iloved the ideaof learning how to counsel by using " the role play" method… :) Best of luck
• Good idea to give chance for the students to act the scenarioes.

Theme 6: Students wanted more interaction

• I hope more interaction bw the student

Theme7: Students wanted contact with real patients

• Next time I hope that we can try counseling real people with real problems
• It's better to have a real counselling session, instead of role playing because untill you really live the situation and feel it you cant play it.
• Do the counseling with real smoker or even do it in the OPD

Theme 8: Students wanted to see real cases

• Better to see videos and real stories.
• examples form students problem are totally different from cases of smoking
• It is good if the doctor do a counseling in front of us. Or at least we saw a video

Theme 9: Students recognized that currently-practising doctors could benefit from the workshops

• Doctors need counseling workshop of prepheral hospitals

Theme 10: Students saw the larger picture of the need for Communication Skills to be taught

• Communication skills are a must to be a good doctor. For Oma[n] "lovely country" we must be perfect. That’s from my deep heart.

Theme 11: For exam purposes, student wanted a PowerPoint or other presentations

• Better to have a presentation to study for exam.

Sometimes, their enthusiasm for the workshop got a little out of hand, and the situation needed to be controlled.  One student made the comment: The doctor was a little angry :)  

Methods

In preparation for the design of the contact sessions, the counsellor attended hospital rounds with the consultants and students, and also attended some classes.  This gave her added insight into the overall environment in which the students were working, and would be working as doctors.

Based on this experience and further conversations with medical staff, role-play workshop scenarios were developed.  These scenarios resembled real and typical cases without exposing patient identity.

Student contact sessions were in two formats:

The workshops were conducted by the College counselor in the College’s Skills Laboratory.  The skills laboratory was selected because it has the necessary audio-visual equipment and small rooms required for the role-play.

One video was made of a student interaction. 

After each workshop, students completed a three-question evaluation form with a Likert Scale (Strongly agree to strongly disagree).  An additional question for further comments was included.  Data were placed into an MS-Excel spreadsheet and descriptive statistics were obtained.

Discussion

Student experience

Clearly, the students’ comments and the figures given in Figure 1 indicate that the workshop was informative and of value, and may be useful in their future practice.  This provides confirmation for a need to repeat the exercise.

Although this was a very basic introduction to the core conditions of counselling, and the brief application of the core conditions using role play, the results in Figure 2 indicate that students had little or no previous exposure to counselling skills, and were able to learn basics skills through the workshop.

Figure 3 indicates their awareness of the value of counselling skills and their preparedness to use the skills in their practice.  Some of the qualitative comments also reflect their awareness of the impact of such skills on practicing medicine in Oman.

The students’ comments strongly support the need for workshops on counselling skills.  The students’ comments suggest that they were pleased with the role-play component, as it gave them a chance to understand the patient’s perspective in counselling.

Finally, the repeated requests for real patients does underscore the students’ overall enthusiasm for, and belief in, such a program; direct exposure to actual patients at this early stage, and on sensitive issues would, however, be logistically and ethically difficult.

Wider perspective

With even this brief exposure to counselling, the students’ recognition of it as important in the clinical environment mirrors current thought as described in the literature.  As early as 1979 (Kahn et al 1979), there was a concern at the US Congress level about complementing doctors’ technical competencies with well-developed interpersonal skills; this was in recognition of the need to treat the patient as a whole and also enhance the overall patient-doctor relationship.  More recently, as Cox et al. state, training that does not include counselling does not equip doctors to properly counsel patients and fulfil their role as doctors to achieve the desired results with patients’ weight loss program.  

The students at the College of Medicine and Health Sciences (CM&HSc) at SQU are members of the global health care community also recognize the importance of having in depth training in counselling to equip them to use the skills needed in their practice. Their enthusiasm and willingness to apply the skills is apparent from their verbal as well as written comments.  

The future

In light of this experience, there are plans to further develop the counselling workshops to include some more structured techniques that are used in some clinical settings.  In addition, while we do not wish to over-burden students with theory, we will be incorporating theoretical concepts (e.g.  BATHE (Stuart & Lieberman) and DIG) into the workshop.

Limitations

This was a single set of workshops with one set of students at one university.  This exercise will need to be repeated before more positive conclusions can be drawn.

In addition, because this has been the first run of the workshop, very early in the students’ training, we do not know of the long-term impact.  Many questions are, as yet, unanswered.  These include: How much of this will be remembered by the time these students graduate, and how much of what has been learned will actually be practiced?

A future study in later years, and, if possible, when they are practicing professionals will answer these questions: for now, even this small intervention appears successful.

Conclusion

Clinical practitioners’ counselling skills in a clinical setting has been a growing concern globally. This concern has been pointed out in early and recent literature. It covers various spectrums of professionals including health care professionals to the US Congress in addition to other healthcare educators.   

Although the component is two hours of exposure to counselling only, it is better than nothing. This exposure would probably be a start for the new practitioners to consider the patient’s true consent as opposed to written consent which may only be a formality. 

The results and the reactions of the students after the workshops were over expressed how they appreciated the information and skills taught to them and the usefulness to them in the clinical setting. 

This pilot study is a good indicator of the willingness of the young doctors to learn these skills which could make them effective doctors of the future.