Since the mid-1990s, the demographics of the medical student population at the University of Melbourne have undergone a radical transformation with respect to both the proportion of medical students originating from outside Australia (international students) and the proportion of Australian-born students from a non-English speaking background. By 2001, the University of Melbourne was the primary destination for international students studying medicine in Australia, attracting 30% of all Bachelor of Medicine and Surgery (MBBS) enrolments (352 students), compared to 21% in 1996 (204 students). By March 2003, international student enrolments in the School of Medicine had climbed to an unprecedented 619 (1). Malaysia, Singapore and Indonesia predominate as source countries for international students so that the great preponderance of international students at the University of Melbourne are Asian-born.
The contemporary Australian undergraduate medical teaching environment comprises a high proportion of Asian-born students encountering Australia’s public hospital patient base of primarily British-Australian, Italian, Greek, and Yugoslavian origin. In addition, the fact that Melbourne has one of the most ethnically diverse populations in the world means that the communication issues arising from ethnic and linguistic mismatch applies to Australian-born students as well as international students. Nevertheless, ethnic and linguistic mismatch leads to particular challenges for Asian-born medical students on clinical attachment (2) just as it does for Australia’s nursing workforce, a high proportion of which are Asian-born (3). Asian-born Australian medical students report feeling significantly less confident interacting with public hospital patients than their British-origin counterparts (4). From our experience, student confidence in interacting with patients is especially problematic in the field of psychiatry where communication and cross-cultural awareness is so central. Similarly, it has been found to be an important issue for the many overseas-trained psychiatrists employed in the Australian state of Victoria (5).
On clinical psychiatry attachment all University of Melbourne students are expected to learn how to confidently but sensitively pose questions of a personal and intimate nature to patients, and, in clinical vivas, are assessed on their skills in this area. The following case studies illustrate examples of difficulties experienced by international students during observed clinical interviews.
Student KS was observed taking a history from a patient who had admitted himself to the psychiatry ward for psychiatric care and assistance in finding new accommodations. The patient, who had a withered left arm and was approximately 50 years old, had been an itinerant rural worker in the past. Difficulties began when KS did not understand what an itinerant worker was and did not ask for clarification. It became obvious to the patient that KS did not have any local or geographical knowledge, and the patient became increasingly frustrated and aggressive in response. In addition, though the patient explained he was once a good sportsman in the country town where he had lived until he had contracted poliomyelitis (which had resulted in him losing feeling in his left arm), this discussion appeared to be ignored, as was the impact that the disability had had on the patient’s life (including loss of local sporting status). The student appeared to lack empathy, and his inability to explore the situation in a subtle way caused the patient to become both angry and aggressive, resulting in the interview being prematurely aborted.
HC took a history from a young patient on the psychiatry ward, who had been an outstanding student. The patient’s studies resulted in selection for an educational exchange program in Europe where he had become dependent on illicit drugs. On returning to Australia, the patient had continued to use a variety of substances and on one occasion, in a drug induced stupor, had been surfing on the balcony of a third floor flat when he had fallen off and sustained serious head injuries. The patient demonstrated grandiose delusions about unrealistic job expectations. The student appeared dismissive, frustrating the patient. The patient used terminology about drugs that HC did not understand—for example, "acid trip," "bongs," "smack," "kava," "dealing." He also used additional colloquial language that the student failed to clarify—for example, "closet gay," "pushing up daisies," "so many pills I was rattling," "went on the wagon." A communication breakdown ensued, resulting in HC failing to obtain a clear history. A feedback session involving the hospital psychiatrist demonstrated that important issues had not been addressed due to the student’s difficulty communicating effectively with the patient.
These case studies illustrate common difficulties international students encounter: limited skill in colloquial English; the use of nonverbal communication cues, which are unfamiliar to the mainstream Australian patient; sketchy local, social, and geographical knowledge; and discomfort when asking personal questions, which would be regarded as highly disrespectful from the context of the students’ background. Our plan was to develop a program that would 1) increase students’ self-awareness of their own communication style; 2) increase students’ awareness of differences in patients’ communication styles; and 3) engage all students, regardless of background, in the challenge of improving their clinical communication skills.
A teaching intervention was designed to encourage all medical students to improve their repertoire of techniques for putting patients at their ease, establishing good rapport, and obtaining a thorough history while negotiating sensitive areas of inquiry tactfully and diplomatically: in particular in the areas of religious and cultural beliefs and practices, sexual history, drug use, past psychiatric illness, childhood abuse and other traumatic experiences, suicidal feelings and acts of self-harm. The intervention was designed as part of the introductory week to the 9 week psychiatry rotation taking place in the fifth year of the 6-year MBBS course. An actor was used to portray different psychiatric clinical assessment dilemmas.
Sessions began with a discussion led by a communications skills expert who described strategies for effective communication in psychiatry settings. Among issues raised were the importance of paying attention to both the verbal and nonverbal cues, which students may unconsciously give patients when they are finding a clinical interview challenging or discomforting. The students were offered techniques and strategies designed to enhance communication with patients and were encouraged to draw on their own experiences from previous clinical attachments.
An informal tutorial-style atmosphere was encouraged but led and directed by the academic psychiatrist acting as session facilitator to enhance the participation of students from diverse cultural backgrounds within the group. Groups varied greatly in the mix of students and some adaptation of style was required on the part of the psychiatrist in view of recognized differences in students’ willingness to speak up and comment on proceedings and to feel comfortable to directly participate. The clinical scenarios were based around consultation-liaison psychiatry settings, which have been described as uniquely well suited to teaching medical students about important nuances in the doctor-patient relationship in a compelling way (6).
The three clinical scenarios (all female as only female actors were available) depicted included:
1. A third-generation Anglican Australian widow, who is in her 50s and from a rural area in Victoria, recently nursed her husband until he died of cancer. Now she fears that she too may have cancer and has expressed suicidal ideas to nursing staff
2. A newly married woman from the Middle East in her 20s on a temporary resident’s visa is refusing to consent to urgent investigations until her husband returns from a business trip in another city
3. A second generation agnostic single woman in her 30s brought to the emergency department by police in an intoxicated state and acting in a bizarre and overfamiliar manner is demanding to be certified fit for discharge by psychiatry personnel
The session facilitator introduced each scenario and acted as a model psychiatric interviewer for the first scenario. Four to five students took turns acting as psychiatric interviewers for the second and third scenario with the facilitator fielding comments from the student group on each student’s interview segment. The actor participated, in character, in aspects of the discussion.
In mid-2003 sixth year medical students from across the three University of Melbourne hospital clinical schools were anonymously surveyed about their recollections of, and reactions to, the communication skills sessions held at the commencement of their psychiatry rotations during 2002 (8 to 18 months previously). Participation in the survey was entirely voluntary as is mandated with student surveys of this nature at The University of Melbourne. On the advice of clinical school academic staff, the questionnaires were distributed at the commencement of what were anticipated to be well-attended lectures where material relevant to important up-coming final examinations was to be presented. Clinical school staff stressed to the student group the value of providing feedback via the survey.
Eighty-eight students responded to the survey. This represented 33% of the 269 students enrolled in that year level of the medical course. Of the respondents 48 (55%) were female; 71 (81%) were aged 20—24 years and 17 were aged 25—34 years (none was older than 34 years); 32 (37%) were from Australia, 28 (32%) from Malaysia, 4 each (5%) from China, and India/Sri Lanka respectively and 16 (18%) from other Asian countries. Regarding their residential status in Australia, 32 (37%) were Australia-born; 24 (28%) were overseas-born but with Australian citizenship or permanent resident status; and 31 (36%) were international students. The 31 international students (assuming they reported their status accurately) represented 49% of the 63 international students enrolled in that year level according to faculty records.
The communication session was very clearly recalled by 57% of all respondents, and 42% reported they had a very good or excellent opinion of the session. Eighty percent reported that it was helpful or very helpful regarding psychiatric challenges, and 53% reported that the discussion with the psychiatrist was helpful or very helpful. The cross-cultural discussion was helpful or very helpful according to 48% of respondents, while 64% reported that it had been helpful or very helpful with their communication skills. Finally, 52% reported that it was helpful or very helpful with interview strategies. In short, the majority of student respondents from all backgrounds clearly recalled the session and reported favorably on it. None of the Asian-international students were among those who reported difficulty recalling the sessions.
With the increasing number of international students studying medicine in Australia, concerns have been raised regarding the lower levels of confidence in dealing with interactions with patients reported by Asian students in particular (4). This may be a consequence of English language disadvantage and/or cultural differences. We believe the intervention described has enhanced the role the psychiatry attachment in the University of Melbourne MBBS course plays in improving medical students’ communication skills and confidence in interacting with patients from a wide range of language and cultural backgrounds.
We have described what we believe is an innovative teaching program designed to enhance the communication skills and cross-cultural awareness of medical students undertaking their psychiatry attachment. The program was designed particularly with the needs of international students in mind and was intended to highlight for these students the central role that language and cultural issues play in the forming of an effective doctor/patient relationship. We have found this approach to be useful in teaching our students, including the international students, and the results of our survey of students’ recollections of the program have been encouraging.
This program has been popular with the students who responded to the survey and has had a lasting impact on most of them. Such educational interventions clearly need further refinement and more thorough, preferably prospective, evaluation in the future. With a trend toward increasing international enrolments in medical courses across Australia and in other Western countries, we believe this type of program could be usefully employed by other institutions.
The authors thank Wilma Beswick, Jacqueline Walters, and Bruce Singh in developing and expanding this teaching initiative at The University of Melbourne and its affiliated Clinical Schools.