The research, led by Sujal Manohar and Eden Noah Gelgoot with colleagues including Alex Walker, Nora McCarthy and Margaret S. Chisolm, set out to answer a question that has lingered around arts and humanities initiatives in medicine: how exactly do these activities enable learning and reflection? While the value of the arts and humanities in medical education has been increasingly recognized in recent years, with the potential to cultivate important clinical attributes, much of the literature has focused on outcomes rather than process. Less is known about how a processfolio actually functions as a vehicle for learning, and even less about the individual, lived experiences of the learners who create one. The Johns Hopkins team designed their study to close that gap, treating the students not as subjects to be measured but as narrators of their own educational journey.

Methodologically, the study took a deliberately qualitative approach. The researchers employed a cross-sectional design anchored in Interpretative Phenomenological Analysis, or IPA, a methodological framework that aims to uncover how individuals make sense of their personal and social world. IPA is well suited to questions of lived experience because it asks researchers to engage in a double hermeneutic: participants are interpreting their own experiences, and the researchers are then interpreting those interpretations. In this case, the data came from three sources. First, the researchers analyzed the completed processfolios themselves, the summative course artefacts in which students had assembled their work. Second, they examined the students’ final written reflections. Third, they conducted individual semi-structured interviews with each participant, allowing them to elaborate on what the processfolio had meant to them.

The sample was small but remarkably complete. All five fourth-year medical students who finished the museum-based course chose to participate in the research study. That total participation is significant in qualitative research of this kind, because it means the findings capture the full cohort rather than a self-selected fragment of it. It also reflects the voluntary, trust-based nature of the study, which was reviewed by the Johns Hopkins University Institutional Review Board and deemed exempt research under reference number IRB00365270. Because the study was classified as exempt, the institutional review board determined that it did not include informed consent procedures or fall under specific guidelines for research with human subjects. The exemption also signals the educational, non-interventional character of the work: the researchers were studying artefacts and reflections that already existed as part of the course.

From their analysis, the researchers distilled four Group Experiential Themes, the shared patterns of meaning that emerged across the five participants’ accounts. The first theme, contemplating the journey of reflection, growth and insight, speaks to the processfolio’s core function: it makes learning visible over time. Rather than submitting a single polished product at the end of a course, students accumulate artefacts that trace how their thinking evolved week by week. Looking back across that accumulation, participants could see their own intellectual and emotional trajectory in a way that conventional assessments rarely allow. The processfolio became, in effect, a mirror held up to the learning process itself, letting students contemplate not just what they had learned but how they had learned it.

The second theme, exploring personal and emotional growth, points to a dimension of medical training that is often squeezed out by the demands of scientific coursework. Medical students are routinely taught to compartmentalize emotion, yet the capacity to recognize and process one’s own emotional responses is increasingly understood as central to physician wellbeing and patient care. In the museum-based course, engagement with art opened a space where emotional responses were not only permitted but expected to be examined. The processfolio gave students a private, structured repository for that examination, and the act of assembling it encouraged them to connect their experiences in the gallery to their emerging identities as physicians. Participants reflected on their development as medical students and future physicians, a conclusion the authors highlight as central to the study’s purpose.

The third theme is perhaps the most clinically resonant: communicating in clinical contexts, with attention to the importance and complexity of both verbal and non-verbal communication. Art museums are, in a sense, laboratories of observation. Standing before a painting or sculpture, students must describe what they see, tolerate ambiguity, and recognize that others may perceive the same object differently. These are precisely the skills that translate to the bedside, where a physician’s reading of a patient’s posture, expression and silence can matter as much as any laboratory value. The processfolio documented this translation, capturing how students moved from describing artworks to thinking about how they describe patients, and how much of clinical communication happens without words at all.

The fourth theme, acknowledging the complex history of medicine and advocating for better practices, reveals a critical, even activist dimension of the experience. Museums and medicine share entangled histories, and engagement with artistic and historical material prompted students to confront uncomfortable truths about how their profession has treated patients, particularly those from marginalized communities. Rather than treating the arts and humanities as a decorative supplement to clinical training, this theme shows them functioning as a lens for professional critique. Students did not simply absorb the history of medicine; they interrogated it, and the processfolio preserved that interrogation as a record of their evolving ethical commitments. The authors frame this as learners advocating for better practices, a striking outcome for a course that takes place far from any hospital ward.

The study is candid about its limitations and about the fact that the processfolio is not a frictionless tool. Learners shared challenges related to its use, an acknowledgment that matters for educators considering adoption. A processfolio demands sustained reflective labor across a course, and students accustomed to the metrics of biomedical assessment may find the open-ended, self-documenting format unfamiliar or burdensome. The authors also emphasize that the research was conducted at a single institution with a small sample size, which constrains how far the findings can be generalized. Five students at one medical school cannot speak for all learners everywhere, and the authors explicitly call for future research in this area to test and extend what they observed.

Even with those caveats, the study offers a rare, granular look inside an arts and humanities intervention that is often praised in the abstract but seldom examined from the learner’s point of view. By combining analysis of the processfolios and written reflections with in-depth interviews, and by interpreting that material through the lens of Interpretative Phenomenological Analysis, the researchers have shown how a single pedagogical artefact can carry a student through contemplation of their own growth, exploration of their emotional life, refinement of their communicative instincts and confrontation with their profession’s history. The work was published open access on 1 October 2026, received on 11 April and accepted on 10 September of that year, with Manohar and Gelgoot serving as co-first authors. Chisolm’s contribution was supported through her direction of the Paul McHugh Program for Human Flourishing at Johns Hopkins. As medical schools worldwide continue to weave the arts and humanities into their curricula, this study suggests that the humble processfolio, a folder of artefacts and reflections assembled over four weeks in a museum, may be one of the most quietly powerful instruments for shaping the physicians of tomorrow.

Subject of Research: Use of processfolios in arts and humanities-based museum education for reflective learning in medical students

Article Title: Exploring the use of processfolios in a museum-based course for medical students

Article References: Manohar, S., Gelgoot, E. N., Walker, A., McCarthy, N., & Chisolm, M. S. (2026). Exploring the use of processfolios in a museum-based course for medical students. BMC Medical Education. https://doi.org/10.1186/s12909-026-10394-5

Image Credits: AI Generated

DOI: 10.1186/s12909-026-10394-5

Keywords: medical education, arts and humanities, processfolio, museum-based education, reflection, Interpretative Phenomenological Analysis, medical humanities, qualitative research, Johns Hopkins, experiential education, pedagogy, communication skills

The study was a descriptive qualitative investigation built on a retrospective review of complaint records. The researchers retrieved all patient complaints associated with residents that were registered at a large Dutch teaching hospital over a five-year window, from 2017 through 2021. In total, 602 complaints were linked to residents during that period. Rather than treating each complaint as an isolated incident, the team coded them against a well-established competency framework known as CanMEDS — the Canadian Medical Education Directives for Specialists — which describes the roles a competent physician must play: Medical Expert, Communicator, Collaborator, Leader, Health Advocate, Scholar and Professional. This framework is used across many training programmes worldwide, which makes it a natural lens for translating raw complaints into educational targets.

The headline finding is striking for how concentrated it is. The Communicator role accounted for 35 percent of all complaints against residents, with the Medical Expert role close behind at 34 percent and the Professional role contributing 21 percent. In other words, roughly two-thirds of everything patients complained about fell into just two buckets: how information was conveyed, and the clinical care itself. The remaining CanMEDS roles — Collaborator, Leader, Health Advocate and Scholar — made up the residual share. For educators, that distribution is actionable intelligence. It suggests that if training programmes want to reduce complaints, the highest-yield investments lie in communication skills and clinical decision-making, not in the more abstract organizational competencies.

Digging into the Communicator category, the authors highlight problems with correct and complete information as a recurring theme. Patients complained when they felt they had not been properly informed about their diagnosis, treatment plan, procedures or what to expect next. This is a subtle but important distinction from simply being rude or dismissive. A resident can be polite, empathetic and well-intentioned and still leave a patient confused about whether a medication should be taken with food, when a follow-up appointment will happen, or what a surgical complication means for recovery. The complaint data suggest that the completeness and accuracy of information transfer — not just the tone of the conversation — is where many resident-patient interactions break down.

The Medical Expert complaints, the second-largest cluster, relate to the core clinical competencies: diagnostic reasoning, treatment choices and technical performance. That residents attract complaints in this domain is not necessarily alarming — they are, by definition, still learning — but the volume is instructive. It signals that patients perceive gaps in clinical judgement or execution often enough to formalize grievances, and it gives programme directors a concrete signal about where supervision, simulation training and graduated autonomy might need reinforcement. The Professional category, at 21 percent, captures issues of conduct, responsibility and ethical behaviour, including attention to patients’ expectations, which the authors specifically flag as an area deserving more attention in postgraduate curricula.

What makes this study methodologically interesting is the framing of complaints as educational data rather than purely as a quality-assurance or medico-legal artifact. Healthcare complaints analysis tools, including the HCAT referenced in the paper, have been developed to code complaint narratives in a structured way, and pairing such coding with the CanMEDS roles creates a bridge between the patient’s experience and the competency framework that already structures residency training. In principle, a programme director could take an anonymized, aggregated complaint profile for their department and map it directly onto learning objectives, simulation scenarios and workplace-based assessments. A cluster of complaints about incomplete discharge instructions, for example, becomes a targeted communication exercise rather than an abstract exhortation to communicate better.

The context matters too. Residents occupy an awkward position in hospital hierarchies: they perform a substantial proportion of frontline clinical work, yet they are learners with variable experience and incomplete autonomy. Patients interact with them constantly — at the bedside, during rounds, in clinics and on the phone — which means residents are disproportionately the face of the hospital. The authors note that patient complaints against residents are growing, and that despite this trend, research specifically focused on complaints against residents has been lacking. Most complaint analyses pool all clinicians together, which obscures the training-specific signal. By isolating resident-linked complaints, this study gives educators a cleaner read on where the learning needs actually sit.

The implications run in both directions. For patients, a well-designed complaint-to-education pipeline promises a hospital system that learns: the next resident on the ward should be better prepared to explain a procedure fully, manage expectations honestly and follow through on commitments. For residents, the framing matters because complaints can be demoralizing and even career-damaging when handled punitively. Analysed constructively, they become formative feedback — uncomfortable, perhaps, but specific and grounded in real patient experience. The authors argue that good postgraduate medical education programmes can result in fewer complaints, which reframes complaint reduction as an outcome measure for educational quality rather than a disciplinary metric.

There are, of course, limits to what a single-centre retrospective analysis can establish. The data come from one large Dutch teaching hospital, and complaint patterns may differ across countries, cultures, complaint systems and specialties. Complaints also represent a skewed sample of patient experience: they capture the dissatisfied minority who took the trouble to file a formal grievance, not the silent majority, and coding narratives into competency categories inevitably involves interpretive judgement. The study was approved by the Medical Ethical Committee of Zuyderland Hospital, with informed consent waived for the retrospective record review, and it was conducted without external funding. Those are standard safeguards, but they do not erase the inherent constraints of qualitative complaint analysis.

Even so, the core message is likely to travel well beyond the Netherlands. Teaching hospitals everywhere sit on archives of complaint files that are consulted mainly by risk managers and lawyers. This study demonstrates a practical alternative: code them against a shared competency framework, identify the dominant failure modes — here, incomplete information, clinical expertise and professionalism — and route those findings into curriculum design, supervision practices and feedback for trainees. The Communicator role’s top ranking is a particularly portable lesson, because communication failures are consistently among the most common root causes of patient dissatisfaction and litigation worldwide. If the path from complaint to change becomes routine, the 602 grievances in this dataset will have done something no individual complaint could: taught an entire generation of doctors-in-training how to care for patients a little better.

Subject of Research: Analysis of patient complaints against medical residents to improve postgraduate medical education

Article Title: From complaint to change: analysing patient complaints against residents to enhance postgraduate medical education

Article References: van Montfoort, A., van der Baaren, L., van der Baan, N., Sosef, M., & Heyligers, I. (2026). From complaint to change: analysing patient complaints against residents to enhance postgraduate medical education. BMC Medical Education. https://doi.org/10.1186/s12909-026-10450-0

Image Credits: AI Generated

DOI: 10.1186/s12909-026-10450-0

Keywords: patient complaints, residents, postgraduate medical education, CanMEDS, communication skills, medical professionalism, patient safety, teaching hospital, medical education, qualitative analysis, clinical training, healthcare quality

The study focused on the Objective Structured Clinical Examination, or OSCE, a cornerstone of medical training in which trainees rotate through stations and interact with standardized patients — trained actors portraying realistic clinical scenarios. In this case, 126 first-year internal medicine residents at NYU completed six communication-focused OSCE cases between 2019 and 2023, with 82 assessed in person and 54 assessed virtually. In each case, the standardized patients rated resident performance across three core communication domains: information gathering, relationship development, and patient education. Crucially, the ratings used a behaviorally anchored scale — “not done,” “partially done,” or “well done” — meaning each rating level corresponded to observable clinical behaviors rather than a vague global impression. This design choice mattered enormously for the analysis that followed.

Most studies comparing virtual and in-person OSCEs have stopped at overall performance scores, concluding broadly that the two formats produce similar results. The NYU team, led by Christine P. Beltran and Colleen Gillespie, argued that such aggregate comparisons can mask important differences. Two exams might yield identical average scores while individual checklist items behave differently across formats — for example, if a particular behavior is easier to demonstrate, or easier to notice, over video. To detect these hidden discrepancies, the researchers turned to the graded response model, a form of item response theory that estimates what they call item-level thresholds. Each threshold represents the amount of underlying communication proficiency a resident needs to move from one rating category to the next — from “not done” to “partially done,” or from “partially done” to “well done.” If a threshold is lower in one modality, that means residents need less actual skill to earn the same rating there.

The technical machinery is worth unpacking, because it represents a meaningful methodological advance for medical education assessment. In a graded response model, every checklist item is characterized by a discrimination parameter, describing how well the item distinguishes between residents of different ability levels, and a set of threshold parameters, marking the points on the latent proficiency continuum where the probability of achieving each successive rating crosses 50 percent. By fitting the model separately to virtual and in-person data and then comparing threshold estimates with Wald tests — a standard statistical procedure for testing whether estimated parameters differ significantly — the researchers could ask, item by item, whether “partially done” or “well done” meant the same thing in both settings. This stands in contrast to traditional approaches that compare mean scores, which assume that identical numbers imply identical underlying constructs.

The headline results were, in most respects, reassuring. Most residents demonstrated sufficient skill to receive “partially done” or “well done” ratings on the majority of communication items, regardless of format, and overall communication performance appeared broadly similar across modalities. For program directors worried that the pandemic-era pivot to virtual assessment diluted their exams, the message is largely encouraging: the global picture of resident communication competence looks comparable whether the encounter happens in an exam room or on a screen. But the item-level analysis told a subtler story. One specific behavior — “using words the patient understood and explaining jargon” — showed a statistically significant difference between modalities. Residents required a lower level of underlying proficiency to receive a “partially done” rating on that item in virtual encounters compared with in-person ones, with a Wald test statistic of z = 3.92 and an adjusted p-value of 0.001.

Why would explaining medical jargon in plain language be easier to credit over video? The authors are careful to lay out several non-exclusive explanations. It may reflect genuine modality-related variation in the skill itself: residents might consciously simplify their language when they cannot rely on physical props, printed materials, or the full repertoire of in-person cues, making plain speech more prevalent on screen. Alternatively, the difference may lie in rater scoring — standardized patients evaluating a video encounter may attend differently to language, or may be more generous when communication is constrained by technology. Both mechanisms could produce the same statistical signature, and the study design cannot fully disentangle them. What the finding does establish, however, is that at least one checklist item does not function equivalently across formats, which means raw scores from virtual and in-person exams are not perfectly interchangeable, even when their averages look the same.

The broader context makes the study timely. Telehealth has evolved from a pandemic stopgap into a permanent fixture of American medicine, and organizations such as the Association of American Medical Colleges have published telehealth competency frameworks urging training programs to teach and assess virtual care skills deliberately. Previous studies of virtual OSCEs — spanning physical medicine and rehabilitation residencies, pediatric high-stakes exams, dental education, and systematic reviews of implementation across the health professions — have generally reported acceptable feasibility and comparable overall performance, but few have probed whether individual rating categories mean the same thing across formats. Earlier psychometric work had already applied item response theory to OSCE data to explore rater effects and item discrimination, and researchers had documented differences in how satisfied patients feel about physician communication during telemedicine visits. The NYU study ties these threads together, using threshold analysis as a diagnostic for format comparability.

For the assessment community, the practical implications are concrete. Programs running mixed-modality OSCEs — increasingly common as telehealth training becomes standard — can use graded response modeling as a routine quality-assurance step, flagging items whose thresholds drift between formats before those items contaminate pass-fail decisions. The one flagged behavior in this study, avoiding jargon, is itself a natural candidate for targeted curriculum revision: if residents earn partial credit for plain language more easily online, virtual encounters may need explicit prompts or rubric anchors that distinguish genuine skill from modality-driven simplification. The authors also note that their sample, drawn from a single internal medicine program across six cases, limits generalizability, and that the modest virtual cohort of 54 residents constrains statistical power. The project, funded through the AAMC Competency-Based Education in Telehealth Challenge Grant, was reviewed by NYU’s institutional process and classified as educational quality improvement using fully anonymized, de-identified data, with the informed consent requirement waived accordingly. The work was previously presented as a poster at the 2025 Society of General Internal Medicine Annual Conference.

Perhaps the most durable contribution of the study is conceptual: it reframes what “equivalence” means in clinical skills assessment. Averages alone, the authors argue, can lull educators into false confidence, because two formats can converge on the same totals while individual behaviors are weighted differently by raters or expressed differently by trainees. Threshold analysis offers a way to interrogate whether an observed rating reflects the same level of underlying communication proficiency across settings — essentially asking not just whether residents score the same, but whether the same score certifies the same competence. As telemedicine cements its place in routine care, ensuring that the exams certifying tomorrow’s physicians measure what they claim, in every modality, is no longer a technical nicety. It is a patient-safety question, and this study provides a template for answering it one checklist item at a time.

Subject of Research: Item response theory analysis of internal medicine residents' OSCE communication skill ratings in virtual versus in-person examinations

Article Title: When “Well-Done” Is Not the Same: Item Response Theory Analysis of Medicine Residents’ OSCE Communication Ratings Across Modalities

Article References: Beltran, C. P., Nallamaddi, S., Wilhite, J. A., Hardowar, K., Hanley, K., Altshuler, L., Zabar, S. R., & Gillespie, C. (2026). When “Well-Done” Is Not the Same: Item Response Theory Analysis of Medicine Residents’ OSCE Communication Ratings Across Modalities. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10798-5

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10798-5

Keywords: OSCE, item response theory, communication skills, medical residents, telehealth, virtual assessment, standardized patients, internal medicine, graded response model, medical education, assessment comparability, patient communication

The research team conducted individual semi-structured interviews with thirty-four clinicians spanning the entire training continuum, from medical students to postgraduate year one through five residents in internal medicine, and on to attending physicians in internal medicine and critical care medicine at McGill University-affiliated academic hospitals. The interviews were interpreted using applied thematic analysis, a rigorous qualitative method that allows researchers to identify recurring patterns in how participants describe their experiences. What emerged was a developmental arc, a story of how understanding of goals-of-care discussions transforms as clinicians gain experience and seniority.

The analysis organized its findings into four central themes that map the trajectory from novice to expert. The first traces a shift from concrete to abstract conceptualizations of what a goals-of-care discussion actually is. Less experienced trainees frequently conflated goals-of-care conversations with code status discussions, reducing a rich, patient-centered dialogue to a narrow question about resuscitation preferences. For these novices, the task was often perceived as a form to be completed, a checkbox in the admission paperwork rather than an exploration of what matters most to a patient facing serious illness. More senior clinicians, by contrast, described goals of care in abstract and contextual terms, framing these conversations as ongoing negotiations that integrate prognosis, patient values, family dynamics, and clinical uncertainty.

The second theme captures a parallel movement from performative to organic approaches. Early trainees described following scripted frameworks, reciting standardized phrases, and treating the conversation as a performance to be evaluated by a supervising attending. This performative orientation, while a reasonable starting point, left them rigid and easily thrown when a patient or family member deviated from the expected script. Experienced physicians described something fundamentally different: an organic, responsive conversation that flexes to the emotional and informational needs of the moment. They spoke of reading the room, pacing the disclosure of difficult information, and weaving goals-of-care discussions naturally into the fabric of clinical care rather than isolating them as discrete, formulaic events.

The third theme, from follower to leader in shared decision-making, addresses one of the most consequential differences between junior and senior clinicians. Novices were markedly less comfortable offering guidance and tended to position themselves as passive facilitators, presenting options without direction and hoping the patient would choose. This hesitation, the researchers suggest, may reflect both a lack of clinical confidence and an incomplete understanding of prognosis. Attending physicians, drawing on years of accumulated judgment, demonstrated a greater willingness to make recommendations, to share their expert opinion while still honoring patient autonomy, and to steer the conversation toward medically appropriate and patient-aligned decisions. This evolution from deference to directed guidance represents a core component of what experts mean by clinical judgment in serious illness communication.

The fourth theme concerns how learning itself happens, described as scaffolding between formal and informal development. Participants agreed almost universally that goals-of-care skills develop as a career-long endeavor, shaped far more by observation, feedback, and lived clinical experience than by structured instruction. Formal training on this topic was described as limited, fragmented, and often arriving too late. Trainees reported watching senior colleagues conduct these conversations, debriefing afterward with attendings when circumstances allowed, and gradually building competence through repetition and reflection. Yet the study found that many trainees were expected to lead goals-of-care discussions independently early in their training, before adequate scaffolding had been established, raising pointed concerns about patient care and trainee distress.

The implications of this developmental mismatch are significant. Internal medicine is, by the nature of its patient population, a specialty where goals-of-care conversations are frequently required. Hospitalized patients with advanced illness, uncertain prognoses, and complex family situations present these dilemmas daily. If junior physicians are being sent into these encounters with a conceptualization limited to code status and a performative, script-dependent approach, both patients and trainees are being underserved. Prior research cited by the authors, including studies of residents’ code status discussion skills and randomized trials of simulation-based communication training, has shown that these skills can be taught, but the new findings suggest that isolated interventions may not be enough. What is needed, the authors argue, is a structured, stage-specific, longitudinal curriculum that meets learners where they are in their development.

Such a curriculum would look markedly different at each stage. For medical students and early residents, the priority would be building accurate conceptual foundations, decoupling goals of care from code status, and introducing frameworks that emphasize eliciting patient values before discussing interventions. For mid-level residents, deliberate practice with simulated patients and observed conversations with structured feedback could accelerate the shift from performative to organic approaches. For senior residents and early attendings, coaching on recommendation-giving and prognostic communication would support the transition to leadership in shared decision-making. The study’s participants themselves called for exactly this kind of sequenced, longitudinal design, echoing broader movements in medical education such as competency-based frameworks and longitudinal coaching programs that have been adopted in Canada and elsewhere.

The study also carries a broader message about the nature of expertise in medicine. Communication skills are often treated as soft skills, assumed to be absorbed along the way rather than rigorously taught. This research demonstrates that the growth from novice to expert in goals-of-care discussions follows a describable, predictable developmental progression, one that can be anticipated and supported rather than left to chance. The differences in conceptualization, approach, and decision-making role between junior and senior clinicians are not merely matters of personality or confidence. They reflect distinct cognitive and professional stages, each with its own learning needs. Recognizing this progression allows educators to design training that is developmentally attuned, rather than one-size-fits-all lectures delivered at a single point in training.

As populations age and chronic serious illness becomes an ever-larger share of medical practice, the ability to conduct skillful, compassionate goals-of-care conversations will only grow in importance. This study, funded by the Fédération des Médecins Résidents du Québec Research Grant and presented in preliminary form at the International Conference on Residency Education in Ottawa, provides a roadmap for how the medical education community might respond. By treating goals-of-care communication as a career-long developmental arc with structured support at every stage, training programs can ensure that physicians arrive at these pivotal bedside moments not as anxious novices clutching a script, but as confident, nuanced clinicians capable of guiding patients and families through the most consequential decisions of their lives.

Subject of Research: How internal medicine physicians develop goals-of-care discussion skills across the training continuum

Article Title: How Internal Medicine Physicians Learn to Conduct Goals-of-Care Discussions: A Qualitative Study Across the Training Continuum

Article References: Lee, C. B., Snell, L., Li, K. X., Jayaraman, D., & Nugus, P. (2026). How Internal Medicine Physicians Learn to Conduct Goals-of-Care Discussions: A Qualitative Study Across the Training Continuum. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10696-w

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10696-w

Keywords: goals of care, internal medicine, medical education, communication skills, qualitative study, shared decision-making, code status, residency training, palliative care, clinical judgment, longitudinal curriculum, physician development

Nursing teaching ward rounds sit at the heart of clinical education, particularly in demanding specialties such as obstetrics. During these bedside teaching sessions, students present cases, discuss care plans, and practice the professional routines they will one day perform independently. Yet the researchers behind the new trial argue that conventional ward-round teaching tends to privilege technical knowledge and procedural competence while giving short shrift to two qualities that patients notice most: empathy and patient-centered thinking. A student may master the mechanics of a labor assessment but remain oblivious to the anxiety, fear, or loss of control experienced by the woman on the other side of the conversation.

To close that gap, the research team designed an integrated model that fuses empathy mapping with the BOPPPS framework, a six-stage instructional structure widely used in health professions education. BOPPPS stands for Bridge-in, Objectives, Pre-assessment, Participatory Learning, Post-assessment, and Summary. The sequence opens with a hook that captures attention, states clear learning goals, checks what students already know, then immerses them in active, participatory learning before closing the loop with post-assessment and a summary that consolidates key lessons. The structure is attractive to educators because it imposes discipline on teaching sessions that might otherwise drift, but critics have long noted that BOPPPS by itself says nothing about the emotional and perspectival dimensions of clinical care.

That is where empathy mapping enters. An empathy map is a visual tool, borrowed originally from design thinking, that organizes what a patient might be thinking and feeling, seeing and hearing, saying and doing, along with the pains they suffer and the gains they hope for. In the intervention arm of the trial, students first attended a 45-minute empathy-mapping workshop where they learned to construct these maps from clinical vignettes. They then carried that skill into three 70-minute nursing teaching ward rounds delivered over four weeks, each following the full BOPPPS sequence and each incorporating explicit exercises in which students populated empathy maps for real or composite obstetric patients. A standardized lesson plan, a Gibbs Reflective Journal form, and a detailed empathy-mapping guide with a completed example based on a fictional composite case ensured that every session unfolded with high fidelity across instructors.

The trial’s design reflects a growing sophistication in education research. Rather than randomizing individual students—an approach that risks contamination as classmates share notes and compare experiences—the investigators enrolled 100 nursing interns in 20 naturally formed clinical rotation clusters and randomized the clusters one-to-one to either the integrated model or routine nursing teaching ward rounds. Both arms received an identical 45-minute communication-skills session and the same three 70-minute ward rounds over four weeks, isolating the empathy-mapping workshop and its ward-round integration as the only meaningful difference between groups. The primary outcome was critical-thinking disposition, a stable inclination to engage in purposeful, self-regulated, analytical judgment, measured at baseline and within one week after the intervention. Secondary outcomes included empathy, self-reported communication skills, self-directed learning, and satisfaction with the ward rounds, with satisfaction assessed after the third session.

The statistical architecture was equally careful. All analyses used mixed-effects models that included a random intercept for rotation cluster, correctly accounting for the fact that students within the same rotation group are more alike than students chosen at random. The four repeat-measured outcomes were additionally adjusted for their baseline scores, and p values across the five outcomes were Holm-adjusted to guard against the inflated false-positive risk that comes with testing multiple endpoints. The analysts also ran multiple-imputation and cluster-robust sensitivity analyses to confirm that missing data or clustering assumptions had not distorted the picture.

The results were striking in both magnitude and consistency. In the primary analysis, which included all 20 randomized clusters and 93 interns with complete outcome data—46 in the intervention arm and 47 in the control arm—every outcome favored the integrated model. Adjusted mean differences were 15.85 points for critical-thinking disposition, 4.43 points for empathy, 4.55 points for self-reported communication skills, 2.38 points for self-directed learning, and 6.54 points for satisfaction, with confidence intervals that excluded the null in every case and Holm-adjusted p values at or below 0.005. The largest effect, on critical-thinking disposition, is particularly noteworthy because disposition—the habitual willingness to think critically—is considered a harder target than critical-thinking skill itself, and because it is often assumed that empathy training and analytical rigor trade off against each other. This trial suggests the opposite: explicitly rehearsing the patient’s perspective may sharpen, rather than soften, a student’s analytical posture.

Why might a visual tool as simple as an empathy map move so many needles at once? The researchers point to a mechanistic synergy between the two components. BOPPPS supplies scaffolding—clear objectives, pre-assessment that surfaces misconceptions, participatory learning that demands engagement, and post-assessment that cements learning—while empathy mapping injects a concrete cognitive task into that scaffolding. Constructing a map forces students to articulate what a patient sees, hears, thinks, fears, and hopes, converting an abstract exhortation to ‘be empathetic’ into an actionable exercise with a tangible output. When that exercise is threaded through participatory learning on a live ward round, students must defend their inferences about the patient’s inner world in front of peers and instructors, which arguably exercises exactly the evidentiary reasoning and perspective-checking that define critical thinking.

The authors are appropriately measured about the limits of their findings. All outcomes except satisfaction were self-reported within one week of the intervention, so it remains unknown whether the gains persist over months or translate into observable clinical performance measured by examiners, standardized patients, or patient-reported outcomes. The study took place at a single tertiary teaching hospital in China and focused on obstetric nursing, leaving open questions about generalizability to other specialties, cultures, and training systems. The sample, though adequate for the detected effects, is modest, and the trial’s reliance on naturally formed rotation clusters means cluster sizes and instructor effects—documented in the supplementary analyses of intracluster correlations and design effects—introduce variance that larger multicenter trials would need to model explicitly.

Even with those caveats, the trial arrives at a moment when nursing educators worldwide are grappling with burnout, depersonalization, and the erosion of patient trust in high-volume clinical environments. If a 45-minute workshop plus three structured ward rounds can move critical-thinking disposition by more than fifteen points on a standardized scale, the cost-effectiveness of the approach becomes compelling. The study was supported by Teaching Reform Project grants from Central South University, and its full lesson plans, empathy-map templates, reflective-journal forms, and satisfaction questionnaires are published as open supplementary materials, lowering the barrier for other institutions to replicate the model. The authors call for longer-term follow-up and performance-based assessments to determine whether the observed differences endure and change what students actually do at the bedside. In the meantime, the trial makes a persuasive case that the future of clinical teaching may belong to models that refuse to choose between rigor and compassion—and instead build both into the same hour of a student’s education.

Subject of Research: A cluster-randomized controlled trial of a nursing teaching ward-round model integrating empathy mapping into the BOPPPS framework in obstetric clinical education

Article Title: Evaluating a nursing teaching ward-round model integrating empathy mapping into a BOPPPS framework: a cluster-randomized controlled trial

Article References: Evaluating a nursing teaching ward-round model integrating empathy mapping into a BOPPPS framework: a cluster-randomized controlled trial. (n.d.). https://doi.org/10.1186/s12909-026-10462-w

Image Credits: AI Generated

DOI: 10.1186/s12909-026-10462-w

Keywords: BOPPPS, empathy mapping, nursing education, nursing teaching ward rounds, critical-thinking disposition, cluster-randomized controlled trial, obstetric nursing, nursing students, self-directed learning, communication skills, medical education, patient-centered care

The study, conducted by Marcelo Leonel Peluso, Angela Donato Oliva, and Luiz Fellipe Dias da Rocha at the State University of Rio de Janeiro, describes the construction and content validation of the Therapist Communication Skills Inventory – Patient Version, abbreviated in Portuguese as the IHCT-P. Rather than asking therapists to rate themselves or relying on expert observers watching recorded sessions, the instrument puts the evaluation in the hands of the people with the most ecologically valid vantage point: the patients themselves. This choice reflects a growing consensus in the field that patient reports are less biased than therapist self-perceptions or observer judgments, particularly when the goal is to understand the interpersonal fabric of therapy.

The theoretical foundation of the work rests on the concept of social skills, and more specifically communication skills, which psychologists define as the linguistic and paralinguistic behaviors that make clear, positive, and attuned interpersonal relationships possible. The researchers adopt a competence-based view of psychotherapy, one that sees effectiveness not as loyalty to a theoretical tradition but as the therapist’s ability to enact specific, observable interpersonal behaviors that facilitate change. Within this framework, communication skills are not a stylistic flourish; the authors argue they are foundational mechanisms of therapeutic action, tied to the strength of the therapeutic alliance, the expression of empathy, and ultimately to treatment outcomes.

To give the construct a measurable structure, the team organized therapist communication skills into three dimensions. Verbal skills cover the therapist’s choice and structuring of words: asking and answering questions, requesting and providing feedback, opening and closing sessions, and making empathic verbalizations. Non-verbal skills encompass facial expressions, posture, gestures, eye contact, and other bodily cues that signal presence and emotional resonance. Paraverbal skills, the third dimension, involve the features of speech that sit outside the literal content: tone, pace, volume, rhythm, latency, and fluency. These channels are distinct but complementary, and empirical work on clinical communication has consistently treated them as separable yet interacting routes through which therapists convey attunement and intent.

The construction of the inventory began with a narrative review of the literature, drawing on Portuguese and English-language books and articles indexed in SciELO and Google Scholar, searching for concepts linking communication, skills, and therapy while excluding work focused on patient-directed communication or non-clinical settings. From seven reviewed sources, the authors identified recurring skill clusters and translated them into items. The preliminary version of the IHCT-P contained 40 items, with 17 covering verbal skills, 13 covering non-verbal skills, and 10 covering paraverbal skills. Each item then went through internal discussion among the authors regarding clarity, spelling, length, adequacy, and scope before facing external scrutiny.

That scrutiny came in two phases. In the first, five professionals with clinical and empirical expertise in the topic evaluated every item on three criteria: language clarity, practical pertinence, and theoretical relevance, each rated on a five-point scale. The researchers computed a Content Validity Coefficient for each criterion, applying a widely used threshold requiring values above 0.8. The results were strong across the board: 0.945 for practical pertinence, 0.930 for theoretical relevance, and 0.927 for language clarity. Even so, the judges’ comments drove substantial refinement. Three items were cut, fourteen were revised to sharpen clarity and precision, and two new items were added, leaving the instrument with 39 items. For its response format, the judges unanimously favored a five-point Likert scale ranging from ‘it does not apply at all’ to ‘it applies almost all the time.’

The second phase tested whether ordinary people, including those with limited formal education, could actually understand what the items were asking. Thirty adult participants, evenly split between women and men and aged between 19 and 42, with an average age of 28.3, assessed each item for clarity and comprehension rather than answering it. Here the coefficients were even higher: 0.980 for language clarity and 0.981 for comprehension. No items were removed at this stage, though three items fell below a 90 percent approval threshold on the need for change and were reworked in line with participants’ suggestions, while two others were modified based on feedback from both phases. The instrument’s instructions, rated at the maximum for both language and understanding, survived unchanged. The study received ethics approval from the State University of Rio de Janeiro, and informed consent was obtained from all participants.

The authors are candid about the limitations of what they have built. Although the scale was designed to be usable by people with lower educational attainment, the pilot sample was predominantly well-educated, with 63.3 percent holding complete higher education, a mismatch that could limit generalizability. Patient-reported measures also inherit the quirks of the respondent: individuals with personality disorders may struggle to form a stable alliance, coloring their judgments of the therapist’s communication, and the stage of therapy at assessment may shape perceptions. To blunt these biases, the team plans to have at least two patients per therapist complete the questionnaire in future studies, averaging out idiosyncratic views.

Why does this matter beyond psychometrics? The researchers position the IHCT-P as a practical tool with several clinical applications. Therapists can use it for self-assessment by inviting patients to complete it, gaining a window into how their communication actually lands with each individual. Because the instrument itself models a core communication skill, requesting feedback, its use reinforces collaborative empiricism and gives patients a structured, potentially less intimidating channel for critical or negative feedback than face-to-face conversation. In psychotherapy supervision, particularly during clinical internships, the scale can help trainees monitor their own practice and help supervisors spot gaps, while its items can serve as prompts for reflective discussion. It could also anchor intervention studies, since social skills training programs typically require pre- and post-intervention measurement to demonstrate gains.

The work is explicitly a first step rather than a finished product. The authors state that upcoming studies will pursue additional sources of validity evidence under the Standards for Educational and Psychological Testing, including exploratory and confirmatory factor analyses of the internal structure, convergent and divergent validity against established measures of therapeutic alliance and outcomes, and internal consistency and test-retest reliability. They also plan to develop and validate a therapist-report version, enabling comparisons between how therapists see themselves and how patients perceive them. Those studies are already underway, with completion expected within 18 to 24 months. If they succeed, the field will gain something it has long lacked in Brazil: a validated, patient-centered yardstick for one of the quiet but decisive ingredients of effective psychotherapy, the everyday communicative craft of the person in the therapist’s chair.

Subject of Research: Development and content validation of a patient-report psychometric inventory assessing therapists' communication skills in psychotherapy.

Article Title: Therapist’s Communication Skills Inventory – Patient Version: Construction and Content Validity

Article References: Peluso, M. L., Oliva, A. D., & Rocha, L. F. D. D. (2026). Therapist’s Communication Skills Inventory – Patient Version: Construction and Content Validity. Trends in Psychology. https://doi.org/10.1007/s43076-026-00531-w

Image Credits: AI Generated

DOI: 10.1007/s43076-026-00531-w

Keywords: psychotherapy, communication skills, psychometrics, content validity, therapeutic alliance, patient-reported outcomes, test construction, social skills, verbal communication, non-verbal communication, clinical psychology, Brazil

The scale of the dataset sets this study apart from much of the existing literature. Liu examined records of 15,077 youth under community supervision, a sample that was 49 percent Black, 16 percent Hispanic, and 16 percent female. Such a large, diverse sample allowed the researcher to detect patterns that smaller studies of incarcerated or clinical populations might miss. The participants were drawn from a statewide juvenile justice system, meaning the findings reflect the everyday realities of youth living at home, attending school, and navigating their neighborhoods while under supervision, rather than the artificial conditions of residential facilities.

Methodologically, the study employed multivariate logistic regression alongside marginal effect analyses, a combination that lets researchers estimate not just whether an association exists but how large it is across different subgroups. Crucially, Liu controlled for a battery of potential confounders that could otherwise masquerade as skill effects: childhood abuse, neglect, exposure to violence, substance use, impulsivity, and delinquent history. This matters because justice-involved youth frequently carry heavy burdens of adverse childhood experiences, and failing to account for them could distort any estimate of how communication skills operate. By holding these factors constant, the analysis isolates the specific contribution of interpersonal competence and its interaction with social context.

The central finding is both intuitive and radical. Communication skills did significantly reduce aggression across the sample, confirming decades of research linking verbal and social competence to lower rates of hostile and violent behavior. But the magnitude of that reduction was not uniform. Youth who primarily associated with delinquent peers, or who reported having no close friends, saw substantially weaker protective benefits than those embedded in prosocial peer groups. In other words, a skill that acts like a shield in one social environment can behave like a modest filter in another. The protective power of communication is not a fixed property of the individual but a property of the individual-in-context.

This interaction effect has deep theoretical roots. Social learning theory has long argued that behavior is learned and reinforced within networks of significant others, meaning that deviant peer groups can actively reward aggression and punish conciliatory communication. Ecological models of human development similarly hold that individual competencies only translate into outcomes when the surrounding microsystems support them. The new findings give these classic frameworks a sharp, quantitative edge: they demonstrate empirically that individual-level protective factors require compatible social contexts to achieve their optimal impact. A teenager may possess excellent conflict-resolution abilities, but if every social cue in their circle signals that toughness pays and de-escalation is weakness, those abilities may rarely be deployed.

The role of social isolation emerged as equally consequential. Youth with no close friends experienced diminished benefits from their communication skills, a finding that aligns with a growing body of research on loneliness and social threat. Lonely children show heightened hypervigilance for social rejection, and adolescents without friendships lose the everyday practice ground where communication skills are typically refined and reinforced. Skills that go unused can atrophy, and in the absence of trusted peers, even well-developed verbal abilities may not translate into de-escalated conflicts. For youth professionals, this suggests that simply assessing a young person’s skills tells only half the story; mapping their social world is equally essential.

Beyond peers, the study found that engagement with prosocial nonparental adults also moderated the relationship between communication skills and aggression. Mentors, coaches, teachers, and other caring adults appear to provide an audience and reinforcement structure in which skilled communication is valued and rewarded. This finding carries practical weight for juvenile justice systems, which often emphasize family engagement but may overlook the developmental importance of nonparental prosocial ties during adolescence, a life stage when youth naturally orient toward people outside the home. Programs that deliberately connect supervised youth with committed adults may therefore amplify the returns on any skills-based intervention they deliver.

The implications for intervention design are profound. Aggression replacement training and related curricula, which teach prosocial skills to aggressive youth, have shown mixed results across settings, and this study offers a compelling explanation for that inconsistency: skills taught in isolation from environmental change may not survive contact with delinquent peer networks. Liu’s conclusion is that communication-skills training should be explicitly paired with efforts to expand youths’ access to prosocial peers, adults, and structured activities. Doing so creates the reinforcement ecosystem in which newly learned behaviors can be practiced, rewarded, and consolidated, rather than extinguished the moment a young person returns to their usual circle.

For juvenile justice policy, the findings argue against one-size-fits-all supervision. Case plans that focus exclusively on individual deficits, such as poor communication or impulsivity, may systematically underperform, particularly for the large share of supervised youth whose social networks are dominated by delinquent peers or marked by isolation. The data suggest a dual-track approach: build the skill and build the setting. Structured prosocial activities, mentorship programs, and deliberate peer-network interventions become not optional extras but core components of effective aggression reduction among high-risk youth. Systems that ignore the environmental half of the equation may be spending resources on skills that never get the chance to work.

The study also carries a message about resilience that resonates far beyond the juvenile justice system. Human capabilities are context-dependent, and the environments young people inhabit can either amplify or mute the protective factors they carry within them. For the thousands of justice-involved youth striving to desist from aggression, the path forward is not only internal transformation but external opportunity, the chance to belong to circles where better communication is met with connection rather than contempt. As this research demonstrates, skills need compatible environments to take root, and society’s willingness to cultivate those environments may determine whether its most vulnerable young people flourish or falter.

Subject of Research: How social circles moderate the effect of communication skills on aggression among justice-involved youth

Article Title: Skills Need Compatible Environments to Take Root: How Social Circles Shape the Effects of Communication Skills on Aggression Among Justice-involved Youth

Article References: Liu, L. (2026). Skills Need Compatible Environments to Take Root: How Social Circles Shape the Effects of Communication Skills on Aggression Among Justice-involved Youth. American Journal of Criminal Justice. https://doi.org/10.1007/s12103-026-09942-y

Image Credits: AI Generated

DOI: 10.1007/s12103-026-09942-y

Keywords: justice-involved youth, communication skills, aggression, delinquent peers, prosocial peers, social circles, juvenile justice, community supervision, mentoring, social learning theory, peer influence, resilience