Limitations

There were various limitations to our study. First, there was no control group at 1 year, and there was no significant difference at 1 year between the scores of all three groups. We therefore cannot confidently assume that the significant improvements in the students’ scores at 1 year compared with their scores at the beginning were due to the effects of the SPS or Balint groups, and not other influences they have been subject to having completed a year of clinical medical studies, such as specific curriculum factors or the frequent observation of clinician-patient contacts. An important component of the medical school curriculum at the UCL School of Medicine is the professional development spine, which was developed in line with the recommendations of Tomorrow’s Doctors ²⁰ and emphasises the importance of patient-centred medicine. There is also a preclinical communication skills teaching component, but this is more behavioural than reflective, focusing on issues such as the value of open v. closed questions, eye contact and body language, rather than emotional and relational aspects of communication.

An alternative explanation for the significant increase in scores in all the groups in our study at 1 year could be maturation of the students over time rather than the effect of any teaching programme. However, such a hypothesis is not supported by the literature, which suggests a diminution of communication skills in medical students without some formal input. ^{Reference Humphris and Kaney21} One interesting result in our study was the decrease in scores from baseline at 3 months in the partial control group of students who had as yet received no intervention. Other researchers have noted a worrying decline in communication skills, patient-centred attitudes and empathy in medical students as they progress through medical school, which has been attributed to the dominant medical culture promoting biomedical mechanisms of disease rather than psychosocial determinants. ^{Reference Haidet, Dains, Paterniti, Hechtel, Chang and Tseng22-Reference Shapiro25} Students may lose their idealism and wish to help others, becoming disillusioned and cynical and developing coping mechanisms of distance and detachment at the expense of their awareness of patients’ concerns and emotions.

A second limitation of our study was the small number of students involved and the low number of questionnaire returns at 3 months. The numbers of students that we could include in this research project were limited by the number of places that we had available on the SPS, which was originally ten, and we did not anticipate that two of the students would drop out at the beginning. The poor return rate at 3 months may have been caused by students’ reluctance to fill out the same questionnaire they had only completed 3 months before.

Another limitation was that we did not use a pre-existing validated measure of communication skills, but devised a measure ourselves. Most measures of communication skills require trained raters to assess videotaped encounters between students and standardised patients, which are costly, time consuming, and often have poor interrater reliability. ^{Reference Lurie, Mooney, Nofziger, Meldrum and Epstein26} Empathy and patient-centred attitudes have been identified as key aspects of the doctor-patient relationship. ^{Reference Balint, Ball and Hare27} However, empathy and related concepts such as emotional intelligence, psychological mindedness and reflective function are complex constructs that reflect a range of cognitive, emotional and behavioural phenomena that reflect a person’s personality and are difficult to measure. Empathy and emotional intelligence in medical students have been measured in previous studies by instruments such as the Bar-On Emotional Quotient Inventory, ^{Reference Fletcher, Leadbetter, Curran and O'Sullivan28} and patient-centred attitudes by the questionnaires such as the Patient-Practitioner Orientation Scale ^{Reference Humphris and Kaney21,Reference Nogueira-Martins, Nogueira-Martins and Turato23} and the Doctor-Patient Communication Inventory. ^{Reference Schneider and Tucker29} However, we felt that these existing measures did not address knowledge of the doctor-patient relationship from a psychodynamic viewpoint, that is considering an understanding of the unconscious processes involved in emotional communication or the importance of a patient’s prior attachment experiences in influencing their relationship to the doctor. We therefore decided to design our own questionnaire that would meet all those requirements. The questionnaire is, of course, testing students’ knowledge at a theoretical level, and so we do not know whether, and how, such acquired knowledge translates into actual behavioural change in the form of improved communication skills with patients. Our ideal answers to the questionnaire may also have assumed a greater potential in the students for learning about the doctor-patient relationship than was possible with so short an exposure to these psychodynamic teaching approaches, and may explain why the changes in the three groups were relatively small.

The interrater reliability was not perfect, with the observers having different overall mean scores, and less than ideal correlation between the scores. If the observers had been masked, any biases should not have affected differences seen between groups at 3 months. Since only one person commented that they were not masked when making assessments, the analysis was repeated with their results omitted. Results were essentially unchanged, with magnitudes of differences among groups being very similar to those reported. Indeed, the lack of reliability would have tended to mask true effects of the intervention, so we believe the poorer performance for the control group at 3 months is likely to be real.

Implementing psychotherapy teaching methods on a wider scale - benefits

The results of our study suggest that psychotherapy teaching and Balint groups could help medical students to learn about the doctor-patient relationship and as such could be useful additions to the undergraduate curriculum. Running a student psychotherapy scheme requires considerable expertise and resources, as well as involving complex clinical governance and ethical issues, and will therefore only be available to a small proportion of students in any year group. A similar scheme has recently been established at the University of Bristol (R. Brown, personal communication, 2009). Balint group teaching also requires experienced group leaders, but is able to accommodate many more students owing to the shorter duration of the course. Balint groups have been used as a teaching method for medical students and have been reported in the literature in several countries, including Germany, ^{Reference Sollner, Maurer, Mark-Stemberger and Wesiack30} Italy, ^{Reference Castiglioni and Bellini31-Reference Luban-Plozza33} South Africa, ^{Reference Levenstein34} Poland, ^{Reference Jugowar, Skommer, Salinsky and Owen35} Finland ^{Reference Torppa, Makkonen, Martenson and Pitkala36} and the USA. ^{Reference Brazeau, Boyd, Rovi and Tesar37} However, although Balint-style case discussion groups are now a compulsory part of the postgraduate curriculum for junior psychiatrists in the UK, to our knowledge there have been no published reports of Balint groups for medical students in the UK since Balint himself experimented with medical student discussion groups at UCL. ^{Reference Balint, Ball and Hare27}

Although the aim of both interventions is to teach the student about the doctor-patient relationship, inevitably the students doing the SPS will learn a lot about psychodynamic psychotherapy, whereas in the SPS and the Balint groups the students will have contact with psychiatrists supervising their patients or running the Balint group. In a retrospective study of the career choices of 200 students who did the SPS between 1982 and 1992 and who were compared with 200 randomly selected control students in the same period who did not do this scheme, we found that the students who participated in the SPS, even if they were not originally planning a career in psychiatry, were significantly more likely to choose psychiatry as a career than those who did not do the SPS. ^{Reference Yakeley, Shoenberg and Heady16} This finding is important given the current recruitment crisis in psychiatry. As the Balint groups at UCL have only been running for the past 6 years, we have not had a chance as yet to follow up these students’ career pathways. Nevertheless, we might hypothesise that the experience of participating in a Balint group, in which the students are exposed to thinking about psychological issues in an innovative way, might foster the students’ curiosity in considering psychiatry as their potential chosen specialty. In the meantime, we are encouraged that we are oversubscribed every year thanks to the immense popularity of both of these teaching opportunities, which we hope to develop further.