The conduct of a medical interview is a challenging skill, even for the most qualified physicians. Several objectives should be achieved in the same time, such as gathering precise and valid medical information, establishing a climate of trust and empathy, and providing diagnostic and therapeutic strategies [1]. A set of interpersonal skills is required during the medical interview to obtain the confidence of the subject. The building of patient confidence is a process called “engagement” and results to what is traditionally called an alliance. In order to succeed the engagement process, the physician will need interpersonal skills that can be trained such as providing empathy, sense of security, authenticity, and competence [1]. It is now established that a good communication between physicians and patients can lead to better patient compliance, and better satisfaction with the care received [2]. However communication skills -defined here as interpersonal skills- need to be trained as other medical skills, as initial but also continuing training for physicians, otherwise they will deteriorated [3].

Since a practice is needed to acquire the necessary skills during the interview with a patient, most medical schools now integrate specialized training to teach communication skills [4]. Training strategies include oral presentation, modeling by watching others (reality or video), small group discussions, peer role-play and role play with standardized patients (SP) [5]. Increasing attention exists regarding SP programs that have proven efficacy in teaching communication skills to students [5-7]. SP can be played by actors, real patients or physicians, who are trained to follow predefined scenarios and to provide standardized responses. SP programs integrate the opportunity of standardization between sessions. The reproducibility of the sessions allows to examine communication skills with a good reliability between students [8].

The use of such interactive trainings have been compared to more conventional didactic methods like learning in a manual, and have proved superiority in the acquisition of communication skills [9]. However, up to date, no studies assessed the efficacy of role-play with SP in teaching communication skills versus a lecture, which is the very most used didactic method [10]. Moreover, such study is expected as the interactive training programs based on role-play and SP are shown to be effective but are more time and cost consuming than conventional lectures [11]. In this context, we decided to develop in our university a simulation-based education program conducted in a dedicated simulation center that promotes simulation in healthcare education. SP programs to train communication skills were developed for undergraduate medical students. We conducted a randomized study to compare role-play with SP training and a conventional lecture for the acquisition of communication skills in undergraduate medical students. Our hypothesis was that students trained with SP would have higher ratings in objective communication skill measures assessed with the Calgary modified guide.

In this randomized controlled study, we report a comparison between conventional lecture and SP session in teaching communication skills to undergraduate medical students. Our results showed that teaching with SP was associated with improved communication skills as compared to a conventional lecture. Moreover, we observed a significant improvement between the first and the second SP sessions, suggesting that despite a daily active bedside teaching, interviews with SP still provided additional training and contribute to the acquisition of relevant communication skills.

Among strengths of our study, the whole promotion of students was included, whereas most studies were based only on volunteers among medical students, which may have led to selection biases [9]. Moreover, students were randomized between groups, and the supervisors were blinded to student’s arms. All these conditions were required to avoid confounding factors such as imbalance between skills of students before starting the program, which are recognized major biases of such pedagogic studies [9].

Previous studies reported that lecture methods were considered too passive to properly develop the acquisition of communication skills, as compared to active methods such as SP [13,14]. In our study, students benefited from teaching with SP in the objective acquisition of skills, but also provided positive feedback about the pedagogical interest of the training. All students were successively interviewers and observers participating in the supervision of the interview. Thus, the trainees were encouraged to analyze their strengths and weakness following the Calgary Cambridge scale, which contributed to the acquisition of skills. Moreover, the availability of graduated physicians as tutors facilitated the interactivity in the groups and the experience sharing between students and tutors. This positive feedback has been linked to effective learning [15] and could contribute to a sustainable retention of skills, although our study did not assess the long term benefit of the program.

Some limits should be acknowledged. First, our data were collected immediately at the end of the SP sessions, and so the sustainability of acquired communication skills can not be assessed from this study. We cannot conclude regarding the longterm benefit from this short-term program. Moreover, some studies suggested that longer training programs (more than one day) would be more effective than shorter [5], and we did not compare different SP trainings according to their duration. The best results were from practical training programs as role play, that combined a didactic component with practical rehearsal and feedback [16]. Probably the best training program would include both lessons and SP session [17]. Moreover, flipped classroom has also demonstrated very interesting teaching results, with growing popularity, and could be combined or compared to SP in future studies [18]. Third, the evaluation of paired students may also have altered the results. Nevertheless, to ensure comparability between groups, even in the smallest group, students were trained by two to avoid confusing factors between arms, and so this may not have impacted the efficacy comparison. Finally, we may wonder whether the SP teaching program would have been more useful if it had been scheduled before reaching a real patient’s bedside (in second year), and if it could be repeated in higher grade students to teach more delicate skills such as teaching bad news. But although the implementation of the SP teaching program has been considered a success, the high cost of running such a program, as well as the necessity to recruit a large number of actors and tutors, may represent a limit to the generalization of this teaching approach.

Regarding cost assessments, significant human resources were necessary to carry out this educational program, but students reacted favorably to the SP training sessions and their learning significantly improved after training. Consequently, we concluded that Kirkpatrick’s level 2 was reached19 (accounting for the acquisition of skills) strongly encouraging us to continue this program in our University. Interestingly, SP training shows efficacy in teaching the communication skills in foreign medical students, too [20]. Future researches are also expected to compare different methods to evaluate reliably communication skills [21-23], as well as assessing the impact of these training on health outcomes [4].

Teaching communication skills with standardized patients programs was more efficient than a traditional lecture in undergraduate medical students. Nevertheless, the long-term sustainability of such acquisition and its consequences in building the patient-physician relationship need to be assessed.