The impact of assessing simulated bad news consultations on medical students' stress response and communication performance.

Seventy second-year medical students volunteered to participate in a study with the aim of evaluating the impact of the assessment of simulated bad news consultations on their physiological and psychological stress and communication performance. Measurements were taken of salivary cortisol, systolic and diastolic blood pressure, heart rate, state anxiety and global stress using a Visual Analogue Scale. The subjects were asked to take three salivary cortisol samples on the assessment day as well as on a quiet control day, and to take all other measures 5 min before and 10 min after conducting the bad news consultation. Consultations were videotaped and analyzed using the information-giving subscale of the Amsterdam Attitude and Communication Scale (AACS), the Roter Interaction Analysis System (RIAS), and the additional non-verbal measures, smiling, nodding and patient-directed gaze. MANOVA repeated measurements were used to test the difference between the cortisol measurements taken on the assessment and the control day. Linear regression analysis was used to determine the association between physiological and psychological stress measures and the students' communication performance. The analyses were restricted to the sample of 57 students who had complete data records. In anticipation of the communication assessment, cortisol levels remained elevated, indicating a heightened anticipatory stress response. After the assessment, the students' systolic blood pressure, heart rate, globally assessed stress level and state anxiety diminished. Pre-consultation stress did not appear to be related to the quality of the students' communication performance. Non-verbal communication could be predicted by pre-consultation physiological stress levels in the sense that patient-directed gaze occurred more often the higher the students' systolic blood pressure and heart rate. Post-consultation heart rate remained higher the more often the students had looked at the patient and the more information they had provided. However, the heart rate appeared to diminish the more often the students had reassured the patient. These findings suggest that in evaluating students' communication performance there is a need to take their stress levels into account.