Anders Baerheim

In this study, we wanted to investigate the relationship between background variables, communication skills, and the bio-psychosocial content of a medical consultation in a general practice setting with a standardized patient.

Communication training builds on the assumption that understanding of the concepts related to professional communication facilitates the training. We know little about whether students' knowledge of clinical communication skills is affected by their attendance of communication training courses, or to what degree other elements of the clinical training or curriculum design also play a role. The aim of this study was to determine which elements of the curriculum influence acquisition of knowledge regarding clinical communication skills by medical students.

The Communication Skills Attitudes Scale (CSAS) created by Rees, Sheard and Davies and published in 2002 has been a widely used instrument for measuring medical students' attitudes towards learning communication skills. Earlier studies have shown that the CSAS mainly tests two dimensions of attitudes towards communication; positive attitudes (PAS) and negative attitudes (NAS). The objectives of our study are to explore the attitudes of Norwegian medical students towards learning communication skills, and to compare our findings with reports from other countries.

Our aim was to better understand why inhabitants in a typical Norwegian town use out-of-hours services in primary care, and whether introduction of a patient list system (Fastlegeordningen) in 2001 had any influence on this choice. We analyzed changed use of out-of-hours service in Stavanger, Norway (approx. 110,000 inhabitants) from 1989 to 2002. Changes in the number of consultations and home visits between 4 to 11 pm seven days a week, were assessed in the light of changes in operational presumptions for both the out-of-hours service and the family physicians' day-time service. There was a steady increase in the number of consultations and home visits from 1989 to 1997, except for in 1994. The absolute increase in the proportion of the population who sought this kind of care was 4.6%, i.e. a relative increase of 20%. From 1997 to 2002, there was an absolute decrease in consultations and home visits of 5.3%, or a 19% relative reduction. The percentage of patient encounters in patients' homes, decreased from 25% in 1989 to 11% in 2002. The number of consultations and home visits in the evenings during the first 17 months after the list system was introduced, decreased (absolute value) with 2.2% (1.7-2.6), i.e. a 10% relative decrease, as compared to those during a similar period two years earlier. A 20 % change in the use of out-of-hours service during few years, indicates that patients have used the service for other purposes than the intended emergency care. The demand for out-of-hours service is most influenced by the availability of primary care physicians during daytime. The list system has most likely encouraged both doctors and patients to promote the "personal doctor" to solve everyday health emergencies during the day.

Earth rays are claimed to cause several types of illness and shielding against earth rays to have a therapeutic effect. There have been many reports in the media of the dangers of earth rays and the usefulness of protective shielding. As with several other alternative therapies, the theory of earth rays and its effects is incompatible with modern medicine, chemistry and physical science. We have earlier shown that earth rays can not be consistently detected, and that children sleeping on earth rays are no more ill than other children are. Recently, a randomised, controlled trial has convincingly though hardly surprisingly shown no effect of TX-disc shielding against earth rays. TX-discs are of plastic with rings of copper. Eighty patients with longstanding muscular-skeletal complaints were enrolled. Patients were, after a few weeks, substantially better (20-40%) whether they had received real TX-discs or not. The concept of earth rays lacks any scientific verification. We advocate prudence in taking success stories, whether published or from one's own clinical experience, as proof of any treatment's effectiveness before having it confirmed by research.

Communication training is a central part of medical education. The aim of this article is to explore the positions and didactic functions of the fourth wall in medical communication training, using a role-play model basically similar to a theatrical performance. The empirical data stem from a communication training model demonstrated at an international workshop for medical teachers and course organizers. The model involves an actress playing a patient, students alternating in the role of the doctor, and a teacher who moderates. The workshop was videotaped and analyzed qualitatively. The analysis of the empirical material revealed three main locations of the fourth wall as it moved and changed qualities during the learning session: 1) A traditional theatre location, where the wall was transparent for the audience, but opaque for the participants in the fiction. 2) A "timeout/reflection" location, where the wall was doubly opaque, for the patient on the one side and the moderator, the doctor and the audience on the other side and 3) an "interviewing the character" location where the wall enclosed everybody in the room. All three locations may contribute to the learning process. The theatrical concept 'the fourth wall' may present an additional tool for new understanding of fiction based communication training. Increased understanding of such an activity may help medical teachers/course organizers in planning and evaluating communication training courses.