Medical Education Initiatives in Communication Skills Cancer Prevention & Control 3, 1999; 3(1): 37-45.
S. Kurtz, University of Calgary Medical School
T. Laidlaw, Faculty of Medicine, Dalhousie University
G. Makoul, Northwestern University Medical School
G. Schnabl, Faculty of Medicine, University of Manitoba
Despite longstanding recognition of the importance of communication in medicine 1-3, there remains tremendous variation in the extent to which communication skills are taught and evaluated.4-5 Still, it is clear that the apprenticeship model and a conception of communication as 'bedside manner' or 'history taking' is giving way to more formalized instruction and a reconceptualization of communication as an essential clinical skill. Attention to communication skills in North American medical schools is likely to increase dramatically, given a resolution adopted in 1995 by the Liaison Committee on Medical Education (LCME), which reviews and accredits medical schools in the United States, and the Committee on Accreditation of Canadian Medical Schools (CACMS):
Communication skills are integral to the education and effective function of physicians. There must be specific instruction and evaluation of these skills as they relate to physician responsibilities, including communication with patients, families, colleagues and other health professionals.
In addition, the Association of American Medical Colleges, which represents all of the accredited medical schools in North America, highlighted communication skills in its 1998 Medical School Objectives Project report, Learning Objectives for Medical Student Education.6 Other high-profile reports indicate that significant interest in communication skills is neither limited to medical schools nor to North America. In 1996 The Royal College of Physicians and Surgeons of Canada issued a report referred to as CanMEDS 2000,7 which clearly states the importance of communication skills for specialists. Perhaps the most influential document published outside of North America is Tomorrow's Doctors, an agenda-setting collection of recommendations for undergraduate medical education, including the teaching of communication skills, issued by the Education Committee of Britain's General Medical Council in 1993.8
The growing interest in communication skills teaching and assessment may be most evident in the exchange of resources and information stimulated by international conferences on the topic. In 1996, the Program in Communication & Medicine at Northwestern University Medical School and the Practice Skills Programme at Oxford University Medical School convened the Teaching about Communication in Medicine Conference, for which 200 people from 21 different countries traveled to Oxford. The Netherlands Institute for Primary Care (NIVEL) held a conference on Communication in Health Care in 1998, and several of the sessions in Amsterdam focused on communication education in medical schools, residency programs and continuing medical education courses. Northwestern's Program in Communication & Medicine is currently working with The Oxford Institute for Ethics and Communication in Health Care Practice to host a Communication in Medicine Conference, scheduled for July 1999 in Chicago. Another conference is planned for Barcelona in October 2000.
Assumptions and evidence base
A number of assumptions underlie the teaching of communication in medicine.9 These assumptions and the evidence behind them form an important part of the rationale for promoting the development of communication curricula.
- Effective clinician-patient communication results in numerous significant benefits, in areas such as patient recall and understanding, adherence, symptom resolution and physiological outcomes, patient and physician satisfaction, and malpractice claims9,43.
- Communication is one of the core clinical skills, and developing it to a professional level of competence is as important as developing competence regarding cognitive knowledge, physical examination, and problem solving .10-11
- Communication is a series of learned skills which can be taught; it is not just a personality trait or a single global ability.12-18
- Experience alone can be a poor teacher of communication skills. That is, without guidance and reflection, experience tends to reinforce communication styles and habits regardless of whether they are good or bad.19-22
- Changes resulting from communication training can be retained.23-25
Constructing an effective communication training program requires attention to knowledge and attitudes, as well as skills. Knowledge of basic communication concepts (e.g., communication models, direct and indirect messages, types and functions of non-verbal communication, perception and attribution) gives learners a context and vocabulary that provide a basis for skill-building efforts.9,26 Incorporating a focus on attitudes into training programs facilitates discussion of learners' anxieties about their role and about particular patients or situations. Relevant attitudes include appreciating the importance of effective communication, the need to see patients as people rather than as cases and the contribution of different players on the health care team.
In addition, communication skills teaching and assessment should be based on a coherent framework, emphasizing tasks that enable doctors to meet the needs of their patients. For examples of specific skills organized within task-based frameworks, see Kurtz and coauthors' "Calgary-Cambridge Observation Guides,"9,43 Makoul's SEGUE Framework,27 and Pendleton and colleagues' "Consultation Tasks."27 Focusing on tasks provides a sense of purpose for learning communication skills. In addition, the task approach recognizes that individual learners will need a repertoire of communication skills and strategies that work for them and their patients. This built-in flexibility with respect to the skills and strategies required to accomplish relevant tasks reflects the reality and individuality of human communication.27
Just as is the case in other educational areas,29 communication skills teachers and learners will benefit from a clear statement of goals and objectives regarding relevant knowledge, attitudes and skills, a plan for teaching and learning, and a description of how the education is related to learners' needs and experiences at the time. It is essential that key messages and topics be introduced and reinforced at appropriate stages of medical training. Teachers of medical ethics in the United Kingdom have found it helpful to work together in developing a list of key topics that can be used as a basis for discussion and development of individual programs.30 Communication skills teachers might find this approach useful as well.
Specific strategies for teaching communication skills
There are a number of ways to teach communication skills, but effective approaches tend to include the following components:9,18,31,32
- Dissemination of knowledge about communication
- Demonstration of communication skills
- Practice of specific skills
- Observation with feedback and self-assessment
- Repeated practice with feedback and self-reflection
- Supportive and reinforcing role-models
- Continuing development of advanced skills integrated with curriculum
- Evaluation of communication skills
Dissemination of knowledge about communication
Learners need a conceptual framework for understanding communication within the doctor-patient relationship. Assigned reading and discussion can assist learners to develop or reinforce appropriate attitudes, acquire evidence about the value and impact of effective communication, and of course, focus on the specific skills they will be learning. For this component of a curriculum, didactic approaches complement relevant reading and group discussion.
Demonstration of communication skills
It is very helpful for learners to observe demonstration interviews, whether live or videotaped. They can then discuss aspects that work well, areas that need improvement, and alternate ways to approach the encounter. Effective examples provide learners with models and give them actual sample language that is especially beneficial at this stage. This component can be taught in large groups but small groups provide a facilitator with more opportunity to guide observation and generate group discussion.
Practice of specific skills
Learners do not learn effective communication skills by only reading, viewing others and discussing; they must have the opportunity to practice specific or component skills in a supportive environment. Practice may involve role plays with peers or interviews with standardized patients or actual patients in teaching or practice settings.9,33 Role playing with peers can present some challenges of authenticity but the process is improved with preparation and assignment of roles and by briefing and debriefing of the learners. At both early and later stages of learning, the role-play format can be effective and is financially attractive.
Standardized or simulated patients (SP's) are a particularly valuable resource for teaching communication skills.9,23,33,34 Learners can practice skills in a 'safe' environment, where they cannot harm a real patient by initial awkwardness or an incorrect approach. They can take 'time outs' to consult with colleagues or the teacher, 'redo' their performance, and obtain feedback from the SP at the conclusion of the encounter. Cases can be developed to reflect desired content and SP's can be trained to respond and portray affect as required. Ultimately, learners need to see actual patients, but, even then, observation and feedback (discussed in the next section) can continue to assist their learning.
Small group formats work best for the practice of skills and encourage learners to be more involved in the learning process than large groups. Sometimes learners may work independently with SP's, videotaping their interviews and receiving immediate SP feedback and later feedback from a preceptor. Videotaping provides an excellent opportunity for learners to assess their own performance.
Observation with feedback and self-assessment
This component is a cornerstone of any effective communication skills teaching. Feedback can be anxiety-producing, but these sessions work best when they are learner centred and when there is some structure to the process. Depending on the context, the learner may be observed by other learners, a standardized patient, by himself or herself on video-tape and by a teacher. Learners should first be given the opportunity to make a self-assessment and to identify areas where they feel they did well and areas where they want help.9 As well as reducing natural defensiveness, self-assessment is an acquired skill that enables learners to continue development of communication skills even after they are in practice. Others may then become involved in providing feedback, but care must be taken that feedback is balanced, focused on behaviour and is descriptive. Observation and feedback needs to continue throughout a learner's education, in undergraduate and postgraduate years, and is also critical as learners develop skills of communicating with patients in more complex or challenging situations, such as sharing bad news, informed consent or cross-cultural interviews.
Repeated practice with feedback and self-reflection
Learners need repeated opportunities to practice reinforcing and refining their skills, and to be observed and to receive feedback on their performance. A helical model has been used to represent how learners can revisit previous learned skills, build on their experience and develop greater sophistication.35 As learners proceed beyond the beginning skills, periodic sessions that encourage learners to reflect on their interviews with patients provide the opportunity to examine, challenge or consolidate values and attitudes that may be explicit or implicit in their interactions.
Supportive and reinforcing role-models
Whereas learners can develop skills in communicating with patients, we know that respected role models can make the difference as to whether these skills are retained, enhanced or lost over time.24,36 Many experienced clinical faculty have not received any training in communication skills; some may not value this aspect of the doctor-patient interaction, others may actively discourage students from using skills they have been taught. Therefore, it is important that efforts are also undertaken to provide faculty development in communication skills. There needs to be a critical mass of faculty who support the use of effective communication with patients and themselves model these skills for learners.
Continuing development of complex skills integrated with curriculum
Communication skills are not skills taught only at the beginning of one's medical education but must naturally be integrated with the ongoing curriculum. However, it is not enough to assume that this will occur without specific intent and planning. Because such skills are still often seen as "soft" at best or a "frill" at worst, they can be easily subverted or overlooked, given the proverbial time pressures. The appointment of a designated curriculum communications coordinator can help to ensure that communication skills teaching is included appropriately and where relevant.
Evaluation of communication skills
Evaluation of communication skills validates their inclusion in the curriculum, supports their acquisition by learners and reinforces their importance to faculty.37 The Objective Structured Clinical Examination (OSCE) which asseses clinical performance using a standardized format has been used for a number of years. The evaluation of communication skills in these examinations may be done by examiners or by SP's depending on the format. These examinations are carried out both within faculties of medicine and by licensing or certifying bodies.38-40 Case development for these examinations does take time and, depending on the "stakes" involved, there may be considerable reluctance to share this resource between one medical school and another.
Inclusion of communication skills teaching in any medical school or residency curriculum requires faculty development initiatives. In this discussion, we consider faculty development in a very broad sense and will refer to formal teaching preceptors, role models, champions and point people. Because teaching communication skills is a relatively new addition to curricula, the development of skills in faculty who will formally teach undergraduate and postgraduate learners is frequently required.9,41 The small group format necessitates more faculty than may be needed for teaching in some other subject areas. Even those faculty members who are effective communicators may not have the conceptual framework at hand to describe what they do or to pass this onto others.
Beyond these preceptors, there are many other faculty who supervise students or residents and convey directly or indirectly what is important about encounters with patients. Raising the awareness of such role models about the components and benefits of effective communication increases the likelihood that communication is addressed as part of their ongoing discussions with learners. Faculty development for this group can be more challenging to institute and needs to be a long term and continuing activity.
Other individuals, both within faculties of medicine and without, can make a difference if communication skill teaching programs are effective. Deans and respected clinicians can act as champions for the inclusion of this teaching and for providing financial and other support. Provincial and national professional societies through both policy statements and certifying and licensing requirements also lend support for the teaching of communication skills within medical education programs.7
The appointment of individuals within faculties of medicine as point people for communication skills is a great advantage when programs are being set up or in the early years. Such individuals are able to take the lead and work with others to identify and implement appropriate curricula, to institute faculty development where needed, lobby for funding when necessary, and generally heighten the awareness of the institution and its members about the importance of communication skills.
Table 1: Resources for communication skills training
The following compilation offers a sample of the wide range of resources available. The resources cited are not intended to represent a comprehensive listing in the area.
| Resources for Communication Skills Training Resource Example(s)
||Enhancing Communication Skills in Your Practice. (1997). Public Works & Government Services Canada, Health Canada.
||A Practical Guide to Communication Skills in Clinical Practice. (1998). A Four CD-Rom Set for Healthcare Professionals. Medical Audio Visual Communication Inc.
||Patient-centred Interviewing and Information Sharing, Sharing Bad News, and Pregnancy Loss. A three video set. (Prof. G. Schnabl, Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, R3E 0W3).
Patient Narrative Series: Personal Documentaries of the Illness Experience. (Dr. G. Makoul, Director, Program in Communication & Medicine, Northwestern University Medical School, 303 East Chicago Ave. (Tarry 2-718) Chicago, Illinois, 60611).
|| Hodges B, Robb A, Tabak D, Turnbull J. (1995). Communication Challenges: Standardized Patient Scenarios for Teaching and Assessing Interviewing Skills. (A. Robb, Department of Family & Community Medicine, University of Toronto, Toronto, Ontario, M5S 1A8).
Stimmel B. Editor. (1998). Utilizing Standardized Patient Protocols to Improve Clinical Skills in Identifying Tobacco, Alcohol and Other Drug Use: A Manual of Cases. (NY: Josiah Macy Jr. Foundation, 44 East 64th Street, New York, New York, 10021).
||Bayer Communication Skills Programs. CME programs including Choices and Changes: Clinician Influence and Patient Actions, Difficult Clinician-Patient Relationships, Coaching for Improved Performance and Teaching Communication Skills in Academic Settings. (Bayer Institute for Health Care Communication, 77 Belfield Rd., Etobicoke, Ont., M9W 1G6).
Cancer Care Ontario Communication Skills Program for Health Professionals. An initiative that has linked the regional cancer centres of Cancer Care Ontario in a concerted and onging CME program to improve communication between health professionals and patients in all eight Ontario cancer centres; an approach for improving communication through institutional collaboration. (Dr. J. Laidlaw, Cancer Care Ontario, 620 University Avenue, Toronto, Ontario M5G 2L7).
CMQ and CFPC (Quebec Chapter) Joint Programs on the Physician-Patient Relationship. Workshops include: An Expectation of Understanding: An Understanding of Expectations, focussing on better patient-physician communication; The Right Distance, focussing on the limits of intimacy; and, Approaches to a Difficult Relationship. (Dr. J. Frenette, Director, Family Medicine Program, Faculty of Medicine, University Laval, Quebec, PQ G1K 7P4).
||Communication in Medicine, Northwestern University, Chicago, July 20-23, 1999. (G. Makoul and T. Schofield, Conference Coordinators, e-mail: firstname.lastname@example.org).
International Conference on Health and Communication, Barcelona, Spain, September 20-22, 2000. (Dr. F. Borrell, Chairman, e-mail: email@example.com).
||Dalhousie Medcom Collection. A yearly updated information management system consisting of over 2000 articles, manuals and teaching resources on medical communication skills. (Dr. T. Laidlaw, Division of Medical Education, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, B3H 4H7).
||Patient-Physician Communication Assessment Instruments: 1986 to 1996 in Review. A compendium of 44 instruments which have been used to assess patient-practitioner communication. (Dr. H. Boone, Faculty of Medicine, University of Western Ontario, London, Ontario, N6A 5C1).
||Canadian Breast Cancer Initiative. A Health Canada program that has linked health care professionals, researchers and women with breast cancer in a variety of high profile initiatives including annual conferences on enhancing patient-physician interaction. (Health Promotion and Programs Branch, Health Canada, Jeanne Mance Building, Room 1044B, Tunney's Pasture, Ottawa, Ontario, K1A 1B4).
||Talking Tools I and II: Better Physician-Patient Communication for Better Patient Outcomes. Interactive presentations for practising physicians developed by the Professional Education Strategy of the Canadian Breast Cancer Initiative, Health Canada. Includes a video, resource material, exercises and guides for session leaders about effective communication with patients. (Health Promotion and Programs Branch, Health Canada, Jeanne Mance Building, Room 1044B, Tunney's Pasture, Ottawa, Ontario, K1A 1B4).
Violence Against Women Empower Education Program: A Practical Guide for Health Professionals. A four module program including videos, slides, print and resource material, interactive exercises and guides for session leaders (Health Professionals Network, c/o Dr. B. Lent, Victoria Family Medical Centre, 60 Chesley Avenue, London, Ontario, N5Z 2C1).
||Chugh U and Lockyer J. (1995). How to Impact and Change Communication Behaviour of Physicians. A Literature Review. 38 page report for the Canadian Breast Cancer Initiative. (Faculty of Medicine, University of Calgary, Calgary, Alberta, T2N 4N1).
Ong LM, de-Haes JC, Hoos AM, Lammes FB. (1995). Doctor-patient communication: A review of the literature. Soc. Sci. Med. 40(7), 903-918.
Stewart MA, Brown JB, Weston WW, McWhinney CL, Freeman TR. (1995). Effective patient-physician communication and health outcomes: A review. Can. Med. Assoc. J. 152(9), 1423-1433.
|Medical School Surveys
||Association of American Medical Colleges and Northwestern University Medical School's Program in Communication & Medicine (G. Makoul). A survey of current communication skills teaching and assessment at US and Canadian medical schools. To be published upon completion.
Cowan DH, Laidlaw JC , Russell ML. (1997). A Strategy to Improve Communication Between Health Care Professionals and People Living With Cancer, Part 11: Follow-up of a workshop on the teaching and assessment of communication skills in Canadian Medical Schools. J. Cancer. Educ. 12(3), 161-165.
Hargie O, Dickson D, Boohan M, Hughes K. (1998). A Survey of Communication Skills Training in UK Schools of Medicine: present practices and prospective proposals. Medical Education 32, 25-34.
Novack DH, Volk G, Drossman DA, Lipkin M, Jr. (1993) Medical interviewing and interpersonal skills in teaching in US medical schools: Progress, problems and promise. JAMA. 269(16), 2101-2105.
Whitehouse CR. (1991). The teaching of communication skills in United Kingdom medical schools. Med. Educ. 25(4), 311-318.
||The Standardized Patient Program, Faculty of Medicine, University of Calgary (Dr. Brian Gromoff, Director). A bank of standardized patients and cases developed for teaching and evaluating clinical skills (communication, physical examination, problem solving).
Many medical schools including the University of Manitoba, the University of Toronto, and Dalhousie University, have well developed standardized patient programs such as the one described above.
|Texts for Teaching Communication
||Kurtz SM, Silverman JD, Draper J. (1998). Teaching and Learning Communication Skills in Medicine and its companion book, Skills for Communicating With Patients. Abingdon, Oxon: Radcliffe Medical Press.
Stewart M. (1995). Patient-Centred Medicine: Transforming the Clinical Method. Thousand Oaks, California: Sage Publications.
||Association of American Medical Colleges (AAMC). The AAMC is a nonprofit association comprising the 125 accredited U.S. medical schools; the 16 accredited Canadian medical schools; more than 400 major teaching hospitals and health systems, including 70 Department of Veterans Affairs medical centers; nearly 90 academic and professional societies representing 75,000 faculty members; and the nation's medical students and residents. www.aamc.org
Association of Canadian Medical Colleges (ACMC). The Association of Canadian Medical Colleges (ACMC) groups sixteen medical schools, and provides the national voice for academic medicine in Canada. www.acmc.ca
Medical Interview Teaching Association (MITA). A website that includes a chat room available to anyone interested in teaching medical interviewing. www.mita.soton.ac.uk
National Board of Medical Examiners (NBME). The NBME prepares and administers qualifying examinations, provides information and services including the research and development program, computer-based testing, standardized patients, and evaluation services. www.nbme.org
Program in Communication & Medicine. This program, based at Northwestern University Medical School, facilitates exchange of information about communication in medicine via an international network of approximately 1,000 educators and practitioners. Interested people can join the network through the website. www.pcm.nwu.edu
Most of the resources we have described above, and indeed most existing communication programs, focus primarily on one-to-one patient-physician communication and/or on the communication issues which surround such interactions. This is a logical starting point for several reasons: a substantial research base supports this area, core skills here form the foundation for improving communication in all other health care contexts, and interest and advocacy regarding communication between physician and patient is currently widespread. Recent research and experience support a number of next steps for enhancing communication skills teaching and learning:
- Focusing greater attention on communication with third parties, for example, with parents of children, family members of elderly patients or significant others assisting in their care, those involved with the care of chronically ill patients and interpreters helping with language differences.
- Developing programs for enhancing patients' communication skills that can be implemented in doctors' offices, clinics and hospitals, as well as through patient advocacy and support groups.
- Promoting further development regarding communication issues such as prevention, delivering bad news, death and dying, cross-cultural communication, gender, spirituality, and ethics.
- Developing programs to enhance the use of various communication technologies, such as telephones, electronic medical records, computer-assisted consultations, telemedicine, databases, e-mail and Web sites.
Moving beyond the domain of doctor-patient communication, another focus for program development might include working on curricula to enhance communication between health care professionals (e.g., primary and tertiary care doctors, doctors and nurses or allied health professionals, health care teams, administrators in health care). Improving presentation and group leadership skills is another aspect of this area (e.g., in the areas of prevention and health promotion). A third tier of program development might focus on enhancing physicians' skills regarding communication via the mass media and improving their ability to influence health policy through communication with representatives from private and public agencies, government, health care institutions, and communities.9
Two recent studies that surveyed Canadian medical schools confirmed that the lack of well-trained faculty is one of the most significant impediments to developing communication programs in medicine.41,42 Therefore, at all levels of medical education, an essential next step toward improving communication in health care involves focusing on both the content of the programs themselves and the development of better approaches for training faculty to teach and model effective communication. The success of efforts at this fundamental level will, ultimately, determine the degree to which medical education initiatives such as those described in this article will benefit learners and their patients.
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- Association of American Medical Colleges. Learning objectives for medical school education. 1998.
- The Royal College of Physicians and Surgeons of Canada. CanMeds 2000 Project: Skills for the new millenium: report of the societal needs working group. Sept. 1996.
- Education Committee of Britain's General Medical Council. Tomorow's Doctors; 1993.
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Address for Correspondence:
Dr. Suzanne Kurtz
Faculties of Education and Medicine
University of Calgary
Education Tower 1130
2500 University Drive, NW
Calgary, AB T2N 1N5