4.1.5.2 Problem based
In the seventies some medical schools such as McMaster University in Hamilton, Canada, and the Maastricht University in the Netherlands, developed a problems based curriculum with small group tutoring and skills training. Communication skills training (CST) including small group sessions with videoed demonstrations, role play exercises, feedback and reflection, acquired a firm place in these curricula [Baumal 2008, Silverman 2009]. However, CST programmes have traditionally concentrated on the first, diagnostic half of the consultation. Patient education issues were less addressed [Irwin 1989, Joesbury 1990, Wouda 1992, Frederikson 1992, Hargie 1998, Silverman 2011]. Several factors promoted this attention to the diagnostic part. First, the curricula still suffered from the historically grown imbalance, reflected by clinical practice, between the teaching of "diagnosis" and "problem management" [Metcalfe 1983]. Second, medical education adopted much of social sciences curricula which already contained social skills programmes based on the ideas of Carl Rogers [Rogers 1957] and Allen Ivey [Ivey 1971], with much attention to listening skills and to a lesser extent to the skills of conversational control. Third, the CST programmes prepared students for their main task during their internships which is questioning patients about their complaints and health status. Interns were not supposed to educate patients. Thus, students were not taught patient education skills with one curious exception: breaking bad news. Although breaking bad news is regarded as one of the most challenging consultations, many CST programmes contained one or two small group sessions with role play exercises in breaking bad news, while students still lacked basic patient education knowledge and skills.
The problems based curricula and CST programmes also required new assessment procedures and instruments. Next to knowledge assessment, skills assessment was needed. The Objective Structured Clinical Examination (OSCE) was developed in order to reliably assess clinical skills in standardised conditions [Brannick 2011]. For the teaching and assessment of communication skills several guidelines and accompanying assessment instruments were developed [Kraan 1995, Boon 1998]. Nearly all guidelines and assessment instruments were based on the concept of patient-centredness and used checklists or rating scales of required communication behaviors ordered according to the different consultation phases. The instruments differed in their empirical validation. However, these instruments lacked a theoretical basis which clarified the shifting consultation goals and the physician's tasks with matching communication skills to attain these goals, nor did they predict clinical outcomes [Epstein 2002, Hulsman 2009, Veldhuijzen 2011].
Although most instruments contained items concerning patient education issues such as explaining and shared decision making, patient education skills were hardly assessed in undergraduate OSCE's since communication skills training and assessment of students focused on history taking.