Medical student (and patient) attachment-orientation and clinical communication skills in the simulated and clinical (primary care) setting.

Abstract Background: Doctor-patient communication influences patients’ health through direct and/or mediated routes, with clinical communication integrated into the teaching and assessment of medical students at the University of Liverpool. Despite this, the field lacks a strong theoretical framework. Attachment theory is psychological theory that offers insight into why some students struggle with clinical communication in the objective structured clinical examination (OSCE) and in patient consultations. There has also been a lack of research examining the relationship between medical students’ clinical communication skills outside the OSCE and across contexts. The aim of this thesis was therefore twofold. Aims: (1) To explore the relationships between medical students’ attachment-orientation and their clinical communication skills in the OSCE and the clinical setting (primary care). (2) To explore longitudinally medical students’ clinical communication skills in the OSCE and in the clinical setting (primary care). Procedures: Two empirical studies were conducted. The first study (OSCE study) investigated the influence of fourth year medical students’ (n = 508) attachment-orientation on their communication ratings in the OSCE. Attachment was assessed using the Relationship Styles Questionnaire. Examiner communication ratings were also collected. The second study (exploratory study) comprised three phases (OSCE; primary care, and longitudinal) and provided an in-depth analysis of the influence of attachment-orientation on clinical communication with a sample of medical students (n = 37) in the OSCE and the clinical setting (primary care). This also allowed for longitudinal analysis of medical students’ clinical communication skills from the simulated setting (OSCE) to the clinical setting (primary care). Medical students were videoed in the OSCE and in several consultations each in primary care (n =138). The purpose of this videoing was to code simulated patients’ and patients’ expressions of emotion and medical students’ associated responses using the Verona Coding Definition of Emotional Sequences (provide space responses); and to obtain medical students’ communication ratings. Patients completed the Relationship Styles Questionnaire and the Communication Assessment Tool. Results Attachment-orientation (especially attachment-avoidance) influenced medical students’ clinical communication. Attachment-avoidance was negatively associated with communication ratings and responses to simulated patient (SP) and patient emotion (provide space responses) in the OSCE and clinical setting (primary care). Stronger relationships between attachment-avoidance and clinical communication were found in the clinical setting (primary care) compared with the OSCE. Outcomes were more influenced by medical students’ attachment-orientation than by that of patients. No relationship was found between attachment-orientation and patient satisfaction. Longitudinal analysis found a large, significant, and positive relationship between medical students’ communication ratings in the simulated setting (OSCE) and the clinical setting (primary care), and between medical students’ responsiveness to emotion (provide space responses) in the simulated setting (OSCE) and the clinical setting (primary care). Conclusions/Implications: Attachment-orientation was more likely to be influential and activated in authentic clinical environments such as primary care. It is important that medical students develop an understanding of attachment theory in undergraduate medical education to foster understanding of individual differences in clinical communication. Longitudinal analysis indicated that medical students’ clinical communication skills effectively transferred from the simulated OSCE setting to patient encounters in primary care. This supported the validity of the current training and assessment of clinical communication at the University of Liverpool.