Clinical communication is a core skill that is essential for providing correct diagnostic evaluation and treatment, for symptom resolution, and for patients’ satisfaction.^1-4 Studies have revealed that teaching communication skills to medical students can have positive effects on empathy, taking medical histories, and interpersonal communication in medical consultations.⁵ Early introduction of communication skills training that runs longitudinally throughout the medical curriculum, has been shown to be effective in improving the students’ psychosocial skills and confidence in clinical settings. ^6-9

Communication skills training that includes personalized feedback seems to have the strongest positive impact on medical students’ skills.^5,10 Role-playing with simulated patients or peers in small groups is the most common pedagogical method, while observing senior physicians or other students as they interview patients is the most common methods in clinical settings.^5,11 Patient-centered approaches aim to ensure efficient communication and shared decision-making, by empowering patients to take a more active role in their care.¹² This is increasingly recognized as an important topic in health care education, as it may have a positive influence on patients’ health and treatment compliance.^{13, 14}

Nevertheless, some studies have suggested that medical students’ attitudes towards learning and using skills in clinical communication, patient-centeredness, and empathy may decline as they progress through medical school.^15-18 This adverse trend has partially been assigned to the effect of the “hidden curriculum”, that is, the informal processes within a curriculum that are often taught unintentionally.^19-21 Another theory is that certain methods of communication skills training, such as role-playing with simulated patients in front of peers and teachers, may be a source of stress and anxiety that eventually leads to self-doubt and negative attitudes.²²

One way to integrate communication skills training and patient-centeredness in medical education, and to mitigate declining empathy among students, is to establish mentorship programs. ^{7, 23-25} Many mentorship programs aim to offer support and stimulate professional development, and they focus on empathy, collaboration, ethical decision-making, and patient-centered approaches.^26,27 At the medical school at the UiT The Arctic University of Norway (UiT), a new mentorship program was established in 2012, as part of a curricular reform. The overall goal of the revised medical curriculum is to educate physicians with a holistic academic and professional competence that will enable them to treat illness and promote health through patient-centered work.²⁸ The new curriculum aimed to use more problem-based learning involving early patient contact and practical training in both general practice and hospital settings, and it implemented a longitudinal group-based mentorship program.

Mentoring in a group-based format can provide rich opportunities for medical students to reflect on social and relational abilities and share experiences with their peers and mentors, resulting in professional development.^{23, 29} It has been shown that in a group environment, if students can actively compare and build on their own experience alongside their peers, their understanding of knowledge can be enhanced.³⁰

To the best of our knowledge, there is little evidence regarding how mentorship programs influence medical students’ attitudes towards professional attributes, especially when compared to students who are not offered such mentoring throughout medical school. The aim of this study was to explore whether the group-based mentorship program within the new curriculum could significantly enhance medical students’ self-assessed clinical preparedness and shift their attitudes towards communication skills and patient-centeredness in a positive direction.

In the following comparisons between NC- and the OC-students, the results from the Mann Whitney U-test are reported. The NC-students (Mdn=4) scored significantly higher than the OC-students (Mdn=3), when asked how they thought the first four years of the medical curriculum had prepared them for clinical practice (Table 3) (U=828.5, p=.003, r=0.35).

Additionally, the NC-students scored significantly higher than the OC-students when asked how the curriculum had prepared them for communicating with patients (Mdn=4 for both groups, U=748.5, p<.001, r=0.35), and on how the curriculum had prepared them for ethical reflections in clinical practice (Mdn=4 for both groups, U=951.5, p=.043, r=0.20). The OC-students (Mdn=4) felt more prepared to collaborate with other health care professionals than the NC-students (Mdn=3), but this finding was not significant (U=1297.5, p=.584, r=0.05). Figure 1 provides boxplots visualizing the NC- and the OC-students’ responses to these items.

The NC-students were asked how the mentorship groups and PROFCOM had prepared them for clinical practice. The median scores were 4 (IQR = 1) for both items. Further, these students were asked about the extent to which they thought each of the 10 mentorship activities had prepared them for clinical practice. Most activities had a median score of 3, and the lowest median score was 2 (Table 4).

When analyzed individually, the scores on five of the 22 items in the CSAS differed significantly between the NC- and OC-students. The NC-students scored significantly higher on three items that were positively worded and lower on two that were negatively worded (Table 5). Figure 2 visualizes the responses of NC- and OC-students on these five items. On the items regarding patient-centeredness, the NC-students had higher scores on all five statements, though none of these differences were statistically significant (Table 6).

One crucial test for the relevance and efficiency of a teaching program for medical students is whether students feel that the program is helpful in preparing them for working with real patients in everyday clinical settings. Students at UiT spend most of their fifth year training with real patients in small hospitals and in general practice, giving them abundant opportunities to experience how they personally feel prepared for real life medical practice. In this study, we found that the first cohort of students enrolled in the new curriculum (NC-students) felt better prepared for clinical practice during their fifth year than did the OC-students. Specifically, the NC-students felt more prepared for ethical reflections and for communicating with patients in clinical practice.

They also expressed positivity towards the mentorship groups and the professionalism program that they were a part of, and felt that that it had adequately prepared them for clinical practice. Another significant finding was that the NC-students reported more positive attitudes towards learning clinical communication skills. Additionally, they scored higher on all survey questions related to patient-centeredness than the OC-students, although these differences were not statistically significant.

Surprisingly, we found a median score of 3 among NC-students for several of the specific mentorship group activities, even though they responded positively about how the program in general had prepared them for clinical practice. Most of these activities involved recording and watching videos of role-playing or students’ own encounters with simulated or real patients. Possible reasons for this discrepancy include students feeling uncomfortable and lacking experience in role-playing and video recording, and in receiving and giving structured feedback on communication skills in group settings. The use of video-cameras can generate technical challenges, and if relied on repeatedly, this can lead to frustration. Furthermore, experiential learning, such as patient interviews that peer students and mentors observe, has been shown to cause stress, tension, and feelings of embarrassment.^{22, 36} This could be especially prominent in inexperienced students, that is, those just starting medical school.³⁷

Despite the relatively low scores on several of the mentorship activities, the NC-students reported a high median score on the question regarding how the mentorship groups in general had prepared them for clinical practice. They scored the mentorship groups slightly higher than the overall curriculum regarding their preparedness for clinical practice. One explanation for this is the potential positive effect of the “hidden curriculum”, in that role- and behavior modelling can transmit values that are important in clinical practice, such as ethical thinking, responsibility and patient-centeredness.^38,39 Previous studies have shown that well-functioning group mentorships can be an effective way to provide students with beneficial role models to learn from and emulate, and can allow them to evolve professionally in the company of peer students.^23,40 Both mentors and peer students may act as important role models in these settings. ⁴¹

Another interesting finding in our study was that both the NC- and the OC-students rated every positively worded CSAS items relatively high. At the time of the study, the NC-students were in their fifth year and the OC-students were in the sixth and final year. Other studies have reported that medical students tend to develop more negative attitudes towards patient-centeredness and communication as they progress through medical school,^15,17 so one may expect that the attitudes to be negatively skewed. However, a Norwegian study at two universities showed that medical students’ attitudes towards learning communication skills at the end of medical school had improved over a 12-year period.

The authors suggest that this may illustrate the increasing expectation for physicians to have higher levels of communication skills, hence leading to greater motivation among the students.⁹

Attitudes motivate behavior, and positive attitudes are well known to contribute to obtaining specific skills. ⁴² In the same way, experiencing unprofessional behavior and poor role modelling can have a strong impact on students’ attitudes and further behavior.^{43, 44} Overall, the NC-students had more positive attitudes towards learning communication skills and towards patient-centeredness. They highly rated the items stating that learning communication skills is interesting, and that it has helped or will help them respect their patients. This finding aligns well with previous knowledge, as it has been shown that discussions in small groups and constructive feedback on students’ patient encounters were associated with improvement in student performance, compared to other teaching approaches (e.g. lectures).⁴⁵

Previous studies have reported that longitudinal and integrated training in medical school can improve psychosocial skills, such as communication skills and empathy.^9,24,46 Participating in reflective discussions with peers, particularly if accompanied by positive role models, helps students in developing psychosocial skills.^47,48 Based on existing knowledge, this study proposes that a decline in attitudes may not necessarily be solely attributed to changes in students’ cognitive attitudes. Poor learning experiences may also contribute to the development of less positive attitudes.^25,32 The consistently positive attitudes among NC-students towards communication skills and patient-centeredness calls for a deeper exploration of the factors that influence positive learning environments in medical education.

The findings of this study offer insights into the potential of a group-based mentorship program in medical education to foster positive attitudes towards important interpersonal skills. Hopefully, our findings can highlight the importance of incorporating elements that specifically prepare students for real-world clinical practice, patient communication, and ethical decision-making to better equip future physicians for the complexities of clinical practice.

Medical students who followed a longitudinal group-based mentorship program felt better prepared for clinical practice than students in a traditional curriculum. The findings also revealed a positively shift in the students’ attitudes towards communication skills and patient-centeredness. This indicates that group-based mentorships can be a valuable teaching resource. Hopefully, our findings can highlight the importance of incorporating elements that specifically prepare future physicians for clinical practice, patient communication, and ethical decision-making. More research is needed to further explore influences on students’ professional attitudes, and how students with and without a longitudinal group mentorship perform in clinical practice.