DISCIPLINE
Health Sciences; particularly Medicine.

DURATION
One learning session (e.g. small scope of contiguous time such as: one tutorial, one week of the subject/unit/course)

ICT USED
Multimedia CD-Rom, using extensive QuickTime® audio and video.

DELIVERY CONTEXT
The general context of implementation is a problem-based medical curriculum. The Computer Facilitated Learning program is used as a self-directed learning resource within the Introduction to Clinical Medicine (ICM) component of first semester. It is designed to complement the communication and consulting skills learning that occurs in weekly tutorials throughout the semester. These tutorials use role-play with colleagues and interviewing of simulated patients who are trained to provide feedback to students. Tutorials are facilitated by clinical tutors.

TARGET AUDIENCE
Predominantly first year undergraduate medical students enrolled in a problem-based medical curriculum.

As the program is designed for first-year students and as a self-directed learning resource, users are not expected to have extensive prior computing experience or skills.

The program would be suitable for other health science students as the material presented incorporates microskills of communication in a psychosocial context. This would be applicable for any health science student if it is used within a communication skills subject (although designed specifically for medical students).

COHORT
The program is designed to be used by students alone. As the program is a self-directed learning resource, the size of the cohort able to use the resource will be determined by the delivery environment (i.e. number of computers hosting the program and/or the number of program copies available for student loan).

BROADER CONTEXT
Communicating with the Tired Patient was designed to be used with first-year medical students at the University of Melbourne. In 1999, the University of Melbourne introduced a new medical curriculum incorporating problem-based learning, self-directed learning and educational technology. In the new curriculum, students are presented with a weekly clinical problem which they are required to investigate using self-directed learning resources, including text books, journal articles, web sites and computer facilitated learning modules. Introduction to Clinical Medicine is a face-to-face subject stream which runs in parallel to the problems of the week, reflecting the integration of biomedical and clinical components of the course. An emphasis on clinical skills at an early stage in the course and a philosophy of self-directed learning were two attributes of the new curriculum which led to the development of Communicating with the Tired Patient.

Identifying a patient's problems in a clinical interview is a complex skill that health professional students must acquire. Too frequently health professional students fix on the biological aspects of a patient and ignore social and psychological factors that may be contributing to the patient's problems. Communicating with the Tired Patient aims to alert students to the need to consider all facets of the patient's history in an integrated biopsychosocial approach.

A second aspect of a clinical interview, or any interpersonal interaction, is the communication microskills used by the participants. Microskills refer to the interviewing strategies that are used to help facilitate a successful interview and to establish rapport between the interviewer and the interviewee. Microskills may be verbal or non-verbal. Verbal strategies include using different types of questions (open, closed or focused), reflecting and following skills (such as clarification, probing, summarising, confronting), voice tone and style. Non-verbal strategies include posture and facial expressions, and "encouragers" such as nods, eye contact and the timely use of silence. A skilled clinician listens to verbal responses and observes the non-verbal behaviour of the patient and is able to monitor how comfortable and forthcoming a patient is and alter his or her interview accordingly.

Thus, the program Communicating with the Tired Patient had two overarching aims:

• First, it aims to help students develop an understanding of the need to consider biological, psychological and social factors when conducting a clinical interview and ultimately in their identification of a patient's problems.
• Second, the package challenges students to reflect on an array of microskills used and a range of verbal and non-verbal behaviours exhibited, by both the doctor and the patient, in a clinical interview.

IMPLEMENTATION OF ASSESSMENT STRATEGIES
Assessment in Introduction to Clinical Medicine is formative via regular feedback from the tutor, and summative, through a video-taped interview of a simulated patient which is marked by observing examiners. The self-directed CD-ROM learning resource allows the student the opportunity to practise in an interactive tutorial, which requires them to listen to the questions and observe the patient's response before making a choice as to their next action. This allows them to practise in an environment with an element of uncertainty - a virtual testing/assessment session where they can "reflect-in-action".

IMPORTANCE OF ASSESSMENT STRATEGIES USED
Students are asked to reflect on their clinical interviewing skills within the program and this is a form of self assessment. The program is designed specifically for this type of self evaluation.

A range of clinical skills is assessed each semester from semester one to five, using videotaped interviews which are also observed and, in later semesters, through formal OSCE (Objective Structured Clinical Examinations). These activities are integrated with the Body Systems component of the curriculum. The communication and consulting skills students have encountered, used and hopefully learned in semester one continue to be assessed each semester. This recognises the importance of effective communication skills and rapport building to quality clinical care.

WHY ICT IS USED
Students traditionally focus on the biological aspects of patients' problems and largely ignore social and psychological factors. Moreover, students in an integrated medical curriculum need to become familiar with skills that help facilitate a successful clinical interview. While role-plays with actors or other students are an excellent way to support students' development in this area, not all students reflect on their own skill level in this setting. The use of multimedia - specifically audio and video - represented an attractive solution to this problem. By designing a program which simulated an interview, students were able to play the role of a doctor with a number of patients and were challenged to reflect on their performances with these patients; students were supported in this process by a "virtual" expert.

HOW ICT USE HELPS
It should be noted that a similar learning experience could be provided without the use of technology; it would, however, be costly in both time and resources. A clear advantage of the program is that it allows students to repeat an interview, selecting alternative pathways and reflecting on how changes in their interview technique can alter the outcome. The program also provides a uniform interviewing experience for a cohort of students; that is, the whole class has the opportunity to interview the same patients.

MOST IMPORTANT ICT CONTRIBUTION TO LEARNING DESIGN
Integrating the use of high quality audio and video in a simulated patient encounter is the most important aspect of the learning design. Providing students with an opportunity to reflect on stages of their interview is also critical.