Education Research: The medical student perspective on challenging conversations

Medical students experience difficult conversations with patients during clinical clerkships. This study aimed to characterize barriers to and opportunities for learning in the setting of challenging conversations.

Neurology clerkship medical students were enrolled prospectively in a concurrent nested mixed methods study. Qualitative data were collected using a postclerkship survey and semi-structured focus groups. Students were asked to reflect on challenging conversations they experienced with patients and to identify the top reasons why conversations were challenging. Responses were analyzed using directed content analysis.

A total of 159 medical students were enrolled (MS2: n = 35 [22%]; MS3: n = 97 [61%]; MS4: n = 27 [17%]). Three themes of difficulty were identified in survey and focus group data: (1) tough clinical realities: how the clinical environment makes conversations challenging; (2) communication skill needs: the difficulty of finding the words to say; and (3) navigating emotions: of patients, clinicians, and students themselves. Tough clinical realities were cited by over two-thirds of students in all years (MS2: n = 30 [86%]; MS3: n = 74 [76%]; MS4: n = 23 [85%]). Communication skills needs were cited most frequently by third-year students (MS2: n = 15 [43%]; MS3: n = 55 [57%]; MS4: n = 10 [37%]). Students early in training were more likely to cite difficulty navigating emotions (MS2: n = 28 [80%]; MS3: n = 71 [73%]; MS4: n = 19 [70%]).

Medical students frequently observe and participate in challenging conversations with patients. Here, students identified what makes these conversations most difficult. Communication curricula should leverage clinical communication encounters, prepare students for inherent clinical realities, and help students navigate emotions in the health care setting.