Essential elements of communication in medical encounters: the Kalamazoo consensus statement

Views of new internal medicine faculty of their preparedness and competence in physician-patient communication

BACKGROUND

We sought to assess self-rated importance of the medical interview to clinical practice and competence in physician-patient communication among new internal medicine faculty at an academic medical center.

METHODS

Since 2001, new internal medicine faculty at the Mayo Clinic College of Medicine (Rochester, Minnesota) have completed a survey on physician-patient communication. The survey asks the new faculty to rate their overall competence in medical interviewing, the importance of the medical interview to their practice, their confidence and adequacy of previous training in handling eight frequently encountered challenging communication scenarios, and whether they would benefit from additional communication training.

RESULTS

Between 2001 and 2004, 75 general internists and internal medicine subspecialists were appointed to the faculty, and of these, 58 (77%) completed the survey. The faculty rated (on a 10-point scale) the importance of the medical interview higher than their competence in interviewing; this difference was significant (average +/- SD, 9.4 +/- 1.0 vs 7.7 +/- 1.2, P < .001). Similar results were obtained by sex, age, specialty, years since residency or fellowship training, and perceived benefit of training. Experienced faculty rated their competence in medical interviewing and the importance of the medical interview higher than recent graduates (ie, less than one year since training). For each challenging communication scenario, the new faculty rated the adequacy of their previous training in handling the scenario relatively low. A majority (57%) said they would benefit from additional communication training.

CONCLUSION

Although new internal medicine faculty rate high the importance of the medical interview, they rate their competence and adequacy of previous training in medical interviewing relatively low, and many indicate that they would benefit from additional communication training. These results should encourage academic medical centers to make curricula in physician-patient communication available to their faculty members because many of them not only care for patients, but also teach clinical skills, including communication skills, to trainees.

End-of-life care: a retreat format for residents

BACKGROUND

The challenge of teaching end-of-life care involves finding ways to incorporate both the science and the art of medicine.

OBJECTIVES

To develop a curriculum so that internal medicine residents could more effectively (1) elicit patient's values, goals, and preferences for health care at the end of life, (2) communicate "bad news," (3) discuss patient preferences for nutrition and hydration, ventilator withdrawal, and cardiopulmonary resuscitation, (4) prescribe opioids using different routes of administration and, (5) recommend appropriate treatment of symptoms common at the end of life.

DESIGN

The daylong retreat utilized case presentations and problems for presenting scientific content and the film Wit to convey information related to communication, whole-patient assessment, and the palliative care approach. Materials from the Education for Physicians on End-of-Life Care (EPEC) project and the film Wit provided the main educational resources.

SETTING

All second-year internal medicine, and family medicine residents, and geriatric fellows from a community hospital in South Carolina attended.

RESULTS

The residents positively evaluated the seminar content and format. Pretests and posttests revealed that residents significantly improved their knowledge regarding pain management (p<0.001), symptom management (p<0.001) and whole-patient assessment (p<0.014). Scores on the pretest and posttest related to communication skills did not significantly change (p=0.092). Yet, qualitative postretreat evaluations showed that residents perceived that the retreat would affect their communication with patients and other less easily quantifiable factors.

CONCLUSION

Quantitative methods that work well for documenting scientific principles and learning may not apply as well in assessing the art of medicine.

Hello, stranger: building a healing narrative that includes everyone

The authors use the concept of "samaritan medicine" to tie together papers by Klitzman, by Wear and colleagues, and by Branch appearing in this issue of Academic Medicine on the physician-patient relationship. Practicing physicians and trainees alike must confront the challenge of acknowledging and connecting to otherness or difference in patients and in themselves, and practice based in "samaritan medicine" can help to bridge the gaps between self and other. The authors present three vignettes that highlight physicians' and patients' differing perspectives on the stories in which they are mutually involved. The authors then suggest three approaches that operate at the organization as well as the individual level and that speak to establishing and sustaining health-supporting relationships between patients and doctors: video review and replay, Appreciative Inquiry, and self-disclosure. The aim of such approaches is that physicians and physician-trainees be able to ask-and answer-questions about the "narratives" they are enacting, such as "In this story, where am I? Where is the other? Where is the common good? What, then, should I do?" in order that they may develop a robust appreciation of patient interactions and understanding of self that fosters the practice of "samaritan medicine."

Teaching and learning consultation skills for paediatric practice

Effective consultations with patients and their families are important for patient satisfaction, adherence to treatment, and recovery from illness. Communication problems among health professionals are common. Fortunately, the skills of effective communication can be taught and learned. This paper highlights evidence based approaches to teaching these skills with minimal resources.

Commentary: communication skills: how simulation training supplements experiential and humanist learning

The Viewpoint article in this issue by Drs. Michael Hanna and Joseph Fins, "Power and Communication: Why Simulation Training Ought to Be Complemented by Experiential and Humanist Learning," is provocative on several levels. This Commentary focuses on three interrelated questions that emerge from the article's consideration of power dynamics in encounters with simulated patients: (1) To what extent do medical students "perform" (i.e., put on an act) in the context of teaching and assessment that involves simulated patients?; (2) How might medical educators increase the likelihood that students will apply to subsequent practice the core skills and strategies learned in their communication skills training?; and (3) How can different learning modalities complement one another in communication skills training? The Commentary articulates important differences in the application of simulated patients (i.e., teaching versus assessment), elaborates on the issue of power and authority, and then addresses each question noted above. In the process, it outlines some of the avenues through which interpersonal and communication skills are learned--or unlearned--in medical education.

Using patient-generated cases to teach students skills in responding to patients' emotions

Responding to patients' emotions has been identified as a core skill in medical interviewing. To give medical students realistic practice in responding to patients' emotions, an exercise was initiated in which simulated patient (SP) cases were developed in collaboration with SPs. Small groups were visited by two SPs, who portray emotional scenarios based on symptoms for which they had previously sought a doctor's care or considered seeking care. SPs also identified circumstances that would provoke emotional reactions for their case. Students and facilitators rated this activity highly. Benefits included more realistic case portrayals, less training time for SPs and more efficient use of SPs.

The potentially somatizing effect of clinical consultation

Many patients who present physical symptoms that their doctors cannot explain by physical disease have persisting symptoms and impairment. An influential view has been that such symptoms are the somatization of emotional distress, but there has also been concern that medical practice contributes to shaping these presentations. Analysis of patients' accounts indicate that they approach these consultations with a sense of being the expert on the nature and reality of their symptoms and, in primary care at least, they seek convincing explanations, engagement, and support. They often describe doctors as doubting that their symptoms are real and as not taking their symptoms seriously. Observational research has demonstrated that patients presenting idiopathic symptoms in primary care generally provide cues to their need for explanation or to psychosocial difficulties. Their doctors tend to provide simple reassurance rather than detailed explanations, and often disregard psychosocial cues. Patients seem to intensify their presentation in consequence, elaborating and extending their accounts of their symptoms, perhaps in the effort to engage their doctors and demonstrate the reality of their symptoms. When doctors propose physical investigation and treatment in response to such escalating presentation, they thereby inadvertently somatize patients' psychological presentation. Consultations, therefore, have elements of contest, whereby patients seek engagement from doctors who seek to disengage. Although provision of a medical label, such as a functional diagnosis, can legitimize patients' complaints and avoid contest, this is at the risk of indicating that medicine can take responsibility for managing the symptoms. More collaborative relationships rely on doctors recognizing patients' authority in knowing about their symptoms, and providing tangible explanations that make sense to the patient and allow them to tolerate or manage the symptoms. Researchers need to study how doctors can best achieve these aims within routine consultations.

Factors associated with patients' perceptions of health care providers' communication behavior

We examined patients' ratings of communication with health care providers by sociodemographic characteristics, health care access, and health status. Data were from a national, population-based survey, the 2003 Health Information National Trends Survey (HINTS). The survey was administered to 6,369 adults from a representative sample of U.S. households. Linear regression analysis was conducted using SUDAAN. None of the sociodemographic variables were significantly associated with patients' ratings of providers' communication behavior in the linear model. Ratings of health care providers' communication behavior, however, were significantly higher among respondents with health insurance (p = 0.007) and those with a usual source of health care from whom they consistently sought care (p < 0.001). Ratings of provider communication were significantly lower among respondents who perceived their general health to be fair or poor (p < 0.001) and among those respondents with greater depressive symptoms (p < 0.001). Differences in patient ratings of health care providers' communication by health care access and health status suggest the potential for disparities in health outcomes.

A model for educational feedback based on clinical communication skills strategies: beyond the "feedback sandwich"

BACKGROUND

Feedback is an essential tool in medical education, and the process is often difficult for both faculty and learner. There are strong analogies between the provision of educational feedback and doctor-patient communication during the clinical encounter.

DESCRIPTION

Relationship-building skills used in the clinical setting-Partnership, Empathy, Apology, Respect, Legitimation, Support (PEARLS)-can establish trust with the learner to better manage difficult feedback situations involving personal issues, unprofessional behavior, or a defensive learner. Using the stage of readiness to change (transtheoretical) model, the educator can "diagnose" the learner's stage of readiness and employ focused interventions to encourage desired changes.

EVALUATION

This approach has been positively received by medical educators in faculty development workshops.

CONCLUSIONS

A model for provision of educational feedback based on communication skills used in the clinical encounter can be useful in the medical education setting. More robust evaluation of the construct validity is required in actual training program situations.

The influence of information technology on patient-physician relationships

Interpersonal relationships and information are intertwined as essential cornerstones of health care. Although information technology (IT) has done much to advance medicine, we are not even close to realizing its full potential. Indeed, issues related to mismanaging health information often undermine relationship-centered care. Information technology must be implemented in ways that preserve and uplift relationships in care, while accommodating major deficiencies in managing information and making medical decisions. Increased collaboration between experts in IT and relationship-centered care is needed, along with inclusion of relationship-based measures in informatics research.

Content of communication by pediatric residents after newborn genetic screening

BACKGROUND

Newborn screening saves lives, but psychosocial complications after genetic screening have led to doubts about expanding programs. Because complications have been blamed on ineffective communication of results, a population-scale system to ensure communication quality may improve outcomes. The objective of this study was to develop and evaluate a method to assess the content of communication after newborn genetic screening.

METHODS

We abstracted content data and calculated quantitative scores for 3 communication quality indicators (key content, early placement of good news, and excessive background content) for 59 transcribed conversations between pediatric residents and simulated parents of an "infant" who was found via newborn screening to carry either cystic fibrosis or sickle cell hemoglobinopathy.

RESULTS

Only 8.5% of transcripts contained the key content items that were thought to be necessary for parental understanding; 27.1% included reassuring news about carrier status within the first 10% of content. Scores for 3 quality indicators fell in the low performance range in 35.6%, 30.5%, and 27.1% of transcripts, respectively. The most common topic was background about the disease (22% of content statements) even though the infant did not have the disease. Surprisingly, 50% of sickle trait transcripts included counseling about a possible risk for sudden death.

CONCLUSIONS

Assessment of the content domain of communication quality identified some high-quality communication interspersed with many missed opportunities. If integrated into newborn screening, our method may help to alleviate some of society's ethical concerns about benefit and risk after newborn and other genetic screening.

Teaching Communication Skills on the Surgery Clerkship

BACKGROUND

Physician communication skills, linked to important patient outcomes, are rarely formally addressed after the pre-clinical years of medical school. We implemented a new communication skills curriculum during the third year Surgery Clerkship which was part of a larger curriculum revision found in a controlled trial to significantly improve students' overall communication competence.

DESCRIPTION

In three 2 hour workshops students, learned to address common communication challenges in surgery: patient education, shared decision-making, and delivering bad news. Each 2 hour, surgeon facilitated session was comprised of a 30 minute introductory lecture, a 15 minute checklist driven video critique, a 15 minute group discussion, a 45 minute standardized patient (SP) exercise with feedback from the SP, peers, and faculty member, and a 15 minute closing summary. To date, over 25 surgery faculty have been trained to conduct these sessions. In an end-of-clerkship survey, students reported on skill changes and assessed the curriculum's educational effectiveness.

EVALUATION

A survey was completed by 120 of the 160 (76%) third year students who participated in the curriculum. Fifty-five percent of students reported improvement in their communication skills and ability to address specific communication challenges. Students were satisfied with the amount and quality of teaching.

CONCLUSIONS

Communication skills teaching can be implemented in the surgery clerkship, and surgeons are particularly well suited to teach about patient education, discussing informed consent and shared decision making, and delivering bad news. Structured case-based sessions are acceptable to, and improve the self-assessed skills of, surgery clerkship students. Faculty development geared toward such sessions has added benefits to educational activities in a clinical department overall.

Women's satisfaction with physicians' communication skills during an infertility consultation

The purpose of this study was to assess women's satisfaction with the communication of medical residents, in a university tertiary service in Brazil. The follow-up visits of 124 women consulting with 7 physicians were observed. An exit interview was performed to assess women's perception of their interaction with physicians. Factor analysis was used to build a satisfaction score, which was then studied according to the presence or absence (yes/no) of physicians' communicative behaviors observed by the researcher during consultation. Median satisfaction score was 9.4 in a 0-10 scale. Four physicians' communicative behaviors showed significant differences in the general satisfaction score: introducing oneself, setting the main reason for the visit, providing information about treatment procedures and asking whether patient had other issues or concerns. No significant differences were found in satisfaction scores for women's socialdemographic characteristics, reproductive history or duration of consultation. These results are important in the development of educational strategies for doctors and patients.

Recipients' perspective on breaking bad news: how you put it really makes a difference

OBJECTIVE

The goal of this study was to show that physician communication style of breaking bad news affects how the physician is perceived, how satisfied recipients of bad news are with the consultation, and how they feel after the consultation.

METHOD

Female participants (students, N=159) were asked to put themselves in the shoes of a patient receiving the bad news of a breast cancer diagnosis. Participants were randomly assigned to watch one of three prototypical physician communication styles of breaking bad news on videotape: patient-, disease-, or emotion-centered communication.

RESULTS

Results showed that these three prototypical communication styles were perceived very differently and they determined how satisfied participants were with the consultation and how they felt after the consultation. Participants exposed to the patient-centered communication perceived the physician as most emotional, least dominant, most appropriate when it comes to conveying information, most available and most expressive of hope. Also, they reported to be most satisfied with the visit and they showed the least increase in negative emotions.

CONCLUSION

A patient-centered communication style has the most positive outcome for recipients of bad news on a cognitive, evaluative, and emotional level.

PRACTICE IMPLICATIONS

Results of this study provide guidelines to physicians on how to convey bad news.

Core assumptions and research opportunities in clinical communication

OBJECTIVE

Contemporary clinical communication teaching and research reflect the axiomatic importance of building a clinical relationship and of empowering patients as partners. The apparent moral unassailability of these principles has inhibited their scientific scrutiny. By questioning this current hegemony in communication teaching and research, our objective is to identify research opportunities that remain to be fully exploited.

METHOD

We identify assumptions in current communication literature and evaluate them from the perspective of relevant empirical and theoretical literature.

FINDINGS

The view that the clinical relationship is an objective thing which needs to be 'built' can lead researchers to neglect factors within patients that influence their subjective sense of the relationship. The model of partnership is hard to reconcile with patients' vulnerability and associated dependency needs. The widespread use of the term 'communication skills' emphasises processes at a skill level at the expense of those at levels of cognition, emotion, and value.

CONCLUSION

Research is needed into: the extent to which patients' sense of relationship arises from factors outside the relationship; the implications of their vulnerability and dependency for clinical relationships; and the processes at the level of cognition, emotion and value, as well as skill, that are entailed in clinical communication and in communication teaching. RESEARCH AND PRACTICE IMPLICATIONS: Pursuing the research opportunities that we have identified will enhance the theoretical validity and practical relevance of clinical communication research and teaching.

Discussing health care costs with patients: an opportunity for empathic communication

Escalating health care costs are affecting patients across the country. As employers and insurance companies face higher expenses, they may move to a cost-sharing strategy, which potentially increases financial burdens on patients. In this situation, physicians may find themselves serving as both medical and financial advisors for their patients. Clinical encounters in which patients experience financial hardship can be awkward and frustrating for both parties. Physicians must learn to discuss issues of affordability in a manner that builds, rather than detracts, from a therapeutic alliance. This article describes our experiences using several communication skills that can help in the discussion of health care costs with patients. The primary skill, empathic communication, which includes "we" statements and "I wish ..." statements, serves to create a platform for shared decision-making, negotiation, and a search for alternatives. In addition, it is helpful if physician offices have resource materials available and strategies identified to assist patients facing financial hardship.

Enhancing clinician communication skills in a large healthcare organization: a longitudinal case study

OBJECTIVE

This article describes the approach taken over the past 16 years by one large healthcare organization, Kaiser Permanente (KP), to enhance the clinical communication and relationship skills of their clinicians.

METHODS

The centerpiece of KP's approach has been the creation and dissemination of a unifying clinician-patient communication (CPC) framework for teaching and research called the Four Habits Model.

RESULTS

The Model has served as the foundation for a diverse array of KP programs. Sustained improvement in patient satisfaction scores has been demonstrated. Clinician-patient communication training has become a well-established component of professional development in KP.

DISCUSSION

Enhancing clinicians' communication with patients is a complex task requiring planning and organizational commitment. Factors that have contributed to the success and lessons learned from incorporating clinician communication skills across the organization are described.

CONCLUSION

The KP experience attests to the feasibility of bringing the vital skills of effective communication to large numbers of busy clinicians.

PRACTICE IMPLICATIONS

Healthcare practices wishing to enhance clinician-patient communication skills should consider using a consistent teaching model, ensuring strong sponsorship from leaders, and emphasizing clinician satisfaction in the design of programs.

Perspectives of Elderly Veterans Regarding Communication with Medical Providers about End-of-Life Care

OBJECTIVE

To explore patients' perspectives concerning communication with medical providers about end-of-life (EOL) care.

DESIGN

Cross-sectional survey involving semistructured interviews.

SETTING

Outpatient primary care clinic of a large, urban Veterans Affairs (VA) Medical Center.

PARTICIPANTS

Male and female veterans who were 60 years or older, ambulatory, able to speak and read English, residing in the community, receiving outpatient care from the VA, not acutely ill (i.e., not hospitalized or in obvious distress), and not cognitively impaired.

METHODS

During audiotaped interviews to assess understanding of advance directive concepts, all 30 participants were asked what advice they would give medical students or trainees about how to discuss EOL care with patients. The audiotapes of their open-ended responses were transcribed, coded, and examined using qualitative content analysis, a systematic and replicable technique to uncover meaning by detecting commonalities and regularities of speech.

RESULTS

Seven essential elements of advice for medical providers emerged: engage in strategies to ensure patient understanding (mentioned by 30% of participants), communicate honestly and truthfully (27%), develop a compassionate bedside manner (27%), treat others as you would want to be treated (20%), provide empathic care (20%), take the time needed to communicate (20%), and determine patient information and decision-making preferences (17%).

CONCLUSIONS

Effective EOL discussions with patients require attention to the content, process, and perception of patient-provider communication.

In their own words: presenting the patient's perspective using research-based theatre

INTRODUCTION

In this paper we describe the development of a performance piece based on patients' stories of interacting with health care providers, its introduction into the curriculum to dramatise the patient's perspective on health care, and the evaluation of student responses.

METHODS

The piece, entitled In Their Own Words, was created from transcripts of interviews with authors who wrote about their experiences of illness. Over the past 4 years, students have performed the piece as a dramatic reading as part of a required course for Year 1 medical students.

RESULTS

Analysis of the students' written reflections identified 5 major themes describing what students learned from the performance piece. These themes were: illness evokes emotions and providers must address both the physical and emotional needs of their patients; patients want health care providers to listen well and to understand patients' perspectives; providers' words and gestures profoundly affect patients; patients do not want to be defined, identified or treated as only their symptoms or illnesses, and information and conditions that clinicians consider routine can be very distressing for patients.

DISCUSSION

These themes identified in the students' comments represent critical concepts that health care providers must understand so that they can build therapeutic relationships with their patients. Thus, In Their Own Words is an effective tool for increasing students' awareness of patients' experiences of illness, which is a key aspect of learning to provide effective patient-centred care. Presenting patients' stories through dramatic readings represents an innovative approach to incorporating the patient's perspective into medical education.

RADPED: an approach to teaching communication skills to radiology residents

BACKGROUND

The Accreditation Council for Graduate Medical Education mandates that radiology residency programs teach communication skills to residents.

OBJECTIVE

The purpose of this paper is to present a mnemonic, RADPED, that can be used to enhance communication in the radiology setting. It reminds the resident of the salient points to address during an imaging encounter with pediatric patients and their families for the purpose of enhancing communication.

MATERIALS AND METHODS

Recent history and research in medical communication are reviewed. Various communication guides used by primary care physicians, such as SEGUE, and the Kalamazoo consensus statement are discussed. This methodology was adapted into a format that could be used to teach communication skills to radiology residents in the context of an imaging encounter.

RESULTS

RADPED reminds the resident to establish rapport with the patient, ask questions as to why the patient and family are presenting for the study, discuss the exam, perform the procedure, use exam distractions, and discuss the results with the referring physician and family when appropriate.

SUMMARY

This simple memory aid promotes the key points necessary to optimize the radiology resident's encounter with pediatric patients and their families.

Talking about the unthinkable: perinatal/neonatal communication issues and procedures

Clinician-parent conversations in perinatology and neonatology are demanding. They take place over a period of time and ask much of the clinician. Many parents insist that they want thorough explanations so they can understand the medical information and its impact on them. These cases involve copious amounts of medical and resource information and parents cannot assimilate it all at one time; thus, these conversations are extended dialogs. Conversational skills that seem essential for clinicians in this work include giving bad news, sharing information, and expressing empathy. Underlying the conversational skills are those habits that form the complete physician: curiosity that leads one to learn the parents' values; the skill to help parents apply these values as they make difficult decisions; patience to listen to and stick with these suffering people who are full of strong emotions; and finally, the courage and endurance to confront these difficult situations day after day.

Teaching inpatient communication skills to medical students: an innovative strategy

At the University of Washington, a group of medical educators defined a set of communication skills, or "benchmarks," that are expected of second-year medical students conducting history and physical examinations on hospitalized patients. In order to teach the skills listed in the communication benchmarks, an educational strategy was devised that included training sessions for 30 medical teachers and the development of an innovative videotape tool used to train the teachers and their students. The benchmarks were designed in 2003 for the developmental level of the students and were based on key communication concepts and essential elements of medical communication. A set of five short videotaped scenarios was developed that illustrated various segments of a student history and physical examination. Each scenario consisted of an "OK" version of communication and a "better" version of the same scenario. The video scenarios were used in teaching sessions to help students identify effective communication techniques and to stimulate discussion about the communication benchmarks. After the training sessions, teachers and students were surveyed to assess the effectiveness of the educational methods. The majority of students felt that the educational design stimulated discussion and improved their understanding of communication skills. Faculty found the educational design useful and 95% felt that the curriculum and videotape contributed to their own education. The development of communication benchmarks illustrated with short videotaped scenarios contrasting "OK" with "better" communication skills is a useful technique that is transferable to other institutions.

Can words hurt? Patient-provider interactions during invasive procedures

Patients are often prepared for procedural discomforts with descriptions of pain or undesirable experiences. This practice is thought to be compassionate and helpful, but there is little data on the effect of such communicative behavior. This study assesses how such descriptions affect patients' pain and anxiety during medical procedures. The interactions of patients with their healthcare providers during interventional radiological procedures were videotaped during a previously reported 3-arm prospective randomized trial assessing the efficacy of self-hypnotic relaxation. One hundred and fifty-nine videos of the standard care and attention control arms were reviewed. All statements that described painful or undesirable experiences as warning before potentially noxious stimuli or as expression of sympathy afterwards were recorded. Patients' ratings of pain and anxiety on 0-10 numerical scales (0=No Pain, No Anxiety at All and 10=Worst Pain Possible, Terrified) after the painful event and/or sympathizing statement were the basis for this study. Warning the patient in terms of pain or undesirable experiences resulted in greater pain (P<0.05) and greater anxiety (P<0.001) than not doing so. Sympathizing with the patient in such terms after a painful event did not increase reported pain, but resulted in greater anxiety (P<0.05). Contrary to common belief, warning or sympathizing using language that refers to negative experiences may not make patients feel better. This conclusion has implications for the training in medical communication skills and suggests the need for randomized trials testing different patient-practioner interactions.

Characterizing the patient-centeredness of hidden curricula in medical schools: development and validation of a new measure

PURPOSE

The "hidden curriculum" has a powerful influence in shaping medical students' attitudes and behaviors toward patient care. The purpose of this project was to develop and test a tool (the C(3) Instrument) to help educators characterize and understand the hidden curriculum at their own institutions.

METHOD

In 2000, the authors developed survey items to measure three content areas of the hidden curriculum with respect to patient-centered care. These content areas include role modeling, students' patient-care experiences, and perceived support for students' own patient-centered behaviors. The survey was distributed to third- and fourth-year students at ten medical schools in the United States. Using factor analysis, the authors selected items for the final version of the C(3) Instrument. To examine validity, they compared instrument scores to results of a poll of members of two organizations devoted to teaching patient-centered care.

RESULTS

A total of 890 students completed the survey. The mean age of students was 27 (SD 3). Fifty-two percent of students were women, and 70% were white. Twenty-nine items were selected for the C(3) Instrument, with internal consistency measures ranging from .67 to .93 for instrument subdimensions. In the validation analysis, summary scores for all three content areas of the C(3) Instrument were consistent with results of the poll of patient-centered organizations.

CONCLUSION

Despite some issues that still need to be resolved, the C(3) Instrument proved to be a reliable and valid tool that characterizes a medical school's hidden curriculum with respect to patient-centered care. It can be used to guide educational interventions by addressing the context that exists around formal teaching activities. It also makes possible the study of hidden curricula across multiple medical schools. Further research on the hidden curriculum should be aimed at developing a greater understanding of the dynamics between formal teaching activities and school culture.

Examining empathy in medical encounters: an observational study using the empathic communication coding system

Educators, researchers, clinicians, and patients often advocate empathy in the physician-patient relationship. However, little research has systematically examined how patients present opportunities for physicians to communicate empathically and how physicians respond to such opportunities. The Empathic Communication Coding System was used to investigate empathic opportunity-response sequences during initial visits in a general internal medicine clinic. This study focuses on 100 visits during which patients created at least 1 explicit empathic opportunity. Overall, patients presented 249 empathic opportunities in these 100 visits; physicians most often responded by acknowledging, pursuing, or confirming the patient's statement. The mean length of empathic opportunity-response sequences was 25.8 sec; sequences tended to be longer in duration when the physician used a more empathic response. Positively valenced empathic opportunities generated a more empathic response than did negatively valenced empathic opportunities. However, there was no relation between the emotional intensity of empathic opportunities and the level of empathy in subsequent physician responses. Further research should examine patient preferences and outcomes associated with varying levels of empathic responses.

Good communication in pediatric cancer care: a culturally-informed research agenda

Communication affects people's factual understanding of the situations they are in. This in turn affects consent to be treated and adherence. Although a growing body of literature concerns cancer communication, it generally concerns adult patients; pediatric-specific knowledge is limited. Furthermore, most research focuses shortsightedly on physicians rather than providers who have more patient contact, favors studying the single visit instead of encompassing the cycle of cancer care, does not take the child into account, and ignores the importance of provider-provider communication. Moreover, cultural issues are only narrowly conceived. In exploring culture's role in pediatric cancer care communication, this article demonstrates that culture cannot be defined as just ethnicity or race. Professions also have cultures and resultant differences in communication patterns that can lead to communication failures. It also shows that there is a crucial need for more applied research as well as more qualitative research that can enrich our understanding of the complicated context-related factors facilitating or barring successful pediatric cancer communication.

Integrating communication training into a required family medicine clerkship

Persistent evidence suggests that the communication skills of practicing physicians do not achieve desired goals of enhancing patient satisfaction, strengthening health outcomes and decreasing malpractice litigation. Stronger communication skills training during the clinical years of medical education might make use of an underutilized window of opportunity-students' clinical years-to instill basic and important skills. The authors describe the implementation of a novel curriculum to teach patient-centered communication skills during a required third-year, six-week family medicine clerkship. Curriculum development and implementation across 24 training sites in a five-state region are detailed. A faculty development effort and strategies for embedding the curriculum within a diverse collection of training sites are presented. Student and preceptor feedback are summarized and the lessons learned from the curriculum development and implementation process are discussed.

Use of the Roter interaction analysis system to analyze veterinarian-client-patient communication in companion animal practice

OBJECTIVE

To identify specific components of veterinarian-client-patient communication during clinical appointments in companion animal practice.

DESIGN

Cross-sectional descriptive study.

SAMPLE POPULATION

A random sample of 50 companion animal practitioners in southern Ontario and a convenience sample of 300 clients and their pets.

PROCEDURE

For each practitioner, 6 clinical appointments (3 wellness appointments and 3 appointments related to a health problem) were videotaped, and the Roter interaction analysis system (RIAS) was used to analyze the resulting 300 videotapes. Statements made during each appointment were classified by means of a communication framework reflecting the 4 essential tasks of the appointment (ie, data gathering, education and counseling, relationship building, and activation and partnership).

RESULTS

57% of the veterinarians contacted (50/87) and 99% of the clients contacted agreed to participate in the study. Mean duration of the appointments was 13 minutes. Typically, veterinarians contributed 62% of the total conversation and clients contributed 38%. Fifty-four percent of the veterinarian interaction was with the client, and 8% was with the pet. Data gathering constituted 9% of the veterinarian-to-client communication and was primarily accomplished through closed-ended questioning; 48% of veterinarian-to-client communication involved client education and counseling, 30% involved relationship building, and 7% involved activation and partnership (the remaining 6% constituted orientation).

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggest that the RIAS was a reliable method of assessing the structure, process, and content of veterinarian-client-patient communication and that some veterinarians do not use all the tools needed for effective communication.

Satisfying the patient, but failing the test

Communication experts convened in Kalamazoo, Michigan, in 2002 to assess current tools that evaluate physician communication skills. They noted occasional discrepancies between a patient's impression of a physician's skill and the physician's performance as measured by current checklists. The authors explore the reasons for this discrepancy and propose a research agenda to resolve it. They maintain that the patient's evaluation of physician communication skills depends upon the degree to which the patient's reason for seeking care is satisfied. Since current evaluation tools do not incorporate information to which only the patient has access, they can assess neither the meaning of the interview nor the success of the physician from the patient's point of view. The authors conclude that physicians' understanding of how well they are meeting patients' needs may require competencies that are unmeasured or only partially measured by current assessment tools, such as "flexibility" or "improvisational skills." These competencies likely reside in the nonverbal domain. The authors suggest that (1) a new tool must be developed that measures the essence, or meaning, of the visit from the patient's perspective; (2) this tool must incorporate information derived directly from the patient; and (3) research is needed to define those physician and patient behaviors that facilitate meaningful encounters.

Assessing competence in communication and interpersonal skills: the Kalamazoo II report

Accreditation of residency programs and certification of physicians requires assessment of competence in communication and interpersonal skills. Residency and continuing medical education program directors seek ways to teach and evaluate these competencies. This report summarizes the methods and tools used by educators, evaluators, and researchers in the field of physician-patient communication as determined by the participants in the "Kalamazoo II" conference held in April 2002. Communication and interpersonal skills form an integrated competence with two distinct parts. Communication skills are the performance of specific tasks and behaviors such as obtaining a medical history, explaining a diagnosis and prognosis, giving therapeutic instructions, and counseling. Interpersonal skills are inherently relational and process oriented; they are the effect communication has on another person such as relieving anxiety or establishing a trusting relationship. This report reviews three methods for assessment of communication and interpersonal skills: (1) checklists of observed behaviors during interactions with real or simulated patients; (2) surveys of patients' experience in clinical interactions; and (3) examinations using oral, essay, or multiple-choice response questions. These methods are incorporated into educational programs to assess learning needs, create learning opportunities, or guide feedback for learning. The same assessment tools, when administered in a standardized way, rated by an evaluator other than the teacher, and using a predetermined passing score, become a summative evaluation. The report summarizes the experience of using these methods in a variety of educational and evaluation programs and presents an extensive bibliography of literature on the topic. Professional conversation between patients and doctors shapes diagnosis, initiates therapy, and establishes a caring relationship. The degree to which these activities are successful depends, in large part, on the communication and interpersonal skills of the physician. This report focuses on how the physician's competence in professional conversation with patients might be measured. Valid, reliable, and practical measures can guide professional formation, determine readiness for independent practice, and deepen understanding of the communication itself.

Teaching communication in clinical clerkships: models from the macy initiative in health communications

Medical educators have a responsibility to teach students to communicate effectively, yet ways to accomplish this are not well-defined. Sixty-five percent of medical schools teach communication skills, usually in the preclinical years; however, communication skills learned in the preclinical years may decline by graduation. To address these problems the New York University School of Medicine, Case Western Reserve University School of Medicine, and the University of Massachusetts Medical School collaborated to develop, establish, and evaluate a comprehensive communication skills curriculum. This work was funded by the Josiah P. Macy, Jr. Foundation and is therefore referred to as the Macy Initiative in Health Communication. The three schools use a variety of methods to teach third-year students in each school a set of effective clinical communication skills. In a controlled trial this cross-institutional curriculum project proved effective in improving communication skills of third-year students as measured by a comprehensive, multistation, objective structured clinical examination. In this paper the authors describe the development of this unique, collaborative initiative. Grounded in a three-school consensus on the core skills and critical components of a communication skills curriculum, this article illustrates how each school tailored the curriculum to its own needs. In addition, the authors discuss the lessons learned from conducting this collaborative project, which may provide guidance to others seeking to establish effective cross-disciplinary skills curricula.

Doctors' communication of trust, care, and respect in breast cancer: qualitative study

OBJECTIVE

To determine how patients with breast cancer want their doctors to communicate with them.

DESIGN

Qualitative study.

SETTING

Breast unit and patients' homes.

PARTICIPANTS

39 women with breast cancer.

MAIN OUTCOME MEASURE

Patients' reports of doctors' characteristics or behaviour that they valued or deprecated.

RESULTS

Patients were not primarily concerned with doctors' communication skills. Instead they emphasised doctors' enduring characteristics. Specifically, they valued doctors whom they believed were technically expert, had formed individual relationships with them, and respected them. They therefore valued forms of communication that are currently not emphasised in training and research and did not intrinsically value others that are currently thought important, including provision of information and choice.

CONCLUSIONS

Women with breast cancer seek to regard their doctors as attachment figures who will care for them. They seek communication that does not compromise this view and that enhances confidence that they are cared for. Testing and elaborating our analysis will help to focus communication research and teaching on what patients need rather than on what professionals think they need.

Development and implementation of a nurse-managed anticoagulation program

Nurse-managed anticoagulation is an emerging trend in primary care with the potential to improve the quality, efficiency, and responsiveness of outpatient anticoagulation services. Research indicates that specially trained nurses, using portable international normalized ratio (INR) monitors and decision-support systems, safely and effectively perform independent warfarin-dose adjustment. This article describes the development, implementation, and preliminary evaluation of a nurse-managed anticoagulation program as well as key lessons learned in the process. Factors for success included (a) availability of portable INR monitors, (b) designation of specially trained anticoagulation nurses, (c) use of an effective decision support system, and (d) support from staff and management.

Improving anaesthetists' communication skills

The attitude, behaviour and communication skills of specialised doctors are increasingly recognised as important and they have been identified as training requirements. We designed a programme to teach communication skills to doctors in a University Department of Anaesthesia and evaluated its effect on patient outcomes such as satisfaction and anxiety. The 20 h programme was based on videotaped reviews of actual pre-operative visits and role-playing. Effects on patient satisfaction and pre-operative anxiety were assessed using a patient questionnaire. In addition, all participating anaesthetists assessed the training. We provide evidence that the training increased patient satisfaction with the pre-operative anaesthetic visit. Training also decreased anxiety associated with specific aspects of anaesthesia and surgery, but the effect was rather small given the intense programme. The anaesthetists agreed that their interpersonal skills increased and they felt better prepared to understand patients' anxieties. Communication skills training can increase patient satisfaction and decrease specific anxieties. The authors conclude that in order to better demonstrate the efficacy of such a training programme, the particular communication skills of anaesthetists rather than indirect patient outcome parameters should be measured.

Comprehensive assessment of professional competence: the Rochester experiment

BACKGROUND

A required 2-week comprehensive assessment (CA) for 2nd-year medical students that integrates basic science, clinical skills, information management, and professionalism was implemented.

DESCRIPTION

The CA links standardized patients (SPs) with computer-based exercises, a teamwork exercise, and peer assessments; and culminates in student-generated learning plans.

EVALUATION

Scores assigned by SPs showed acceptable interrater reliability. Factor analyses defined meaningful subscales of the peer assessment and communication rating scales. Ratings of communication skills were correlated with information gathering, patient counseling, and peer assessments; these, in turn, were strongly correlated with the written exercises. Students found the CA fair, with some variability in opinion of the peer and written exercises. Useful learning plans and positive curricular changes were undertaken in response to the CA results.

CONCLUSION

A CA that integrates multiple domains of professional competence is feasible, useful to students, and fosters reflection and change. Preliminary data suggest that this format is reliable and valid.

Thirty-five voices in search of an author: what focus groups reveal about patients experiences in managed care settings

Surprisingly little direct information from patients is available in the medical literature. Focus groups, which came into use in the 1940s, provide a simple, cost effective way of exploring attitudes and values within market segments or targeted groups. In healthcare, focus groups are being used to track patients' experiences, expectations and satisfaction in order to optimize quality and cost effectiveness. This study reports on a collaboration of three upstate New York Health Maintenance Organizations (HMOs) that used the same focus group format and questions to identify' best practices' and opportunities for improvement. Participants across groups reported similar experiences despite differences in geography and plan organization. Members' most positive comments were about costs, preventive services, ease of paper work and access to sick care, all administrative functions of the health plans. The most negative focused on retaining one's physician, telephone access, providers' medical skills, provider behavior and notification of results, all related to interpersonal/communication issues. We conclude that focus groups are useful for understanding and responding to the 'voice of the customer'. They also have some distinct advantages over forced-choice questionnaires, especially in trying to discover the range of patients' experiences and expectations, though they are not without their challenges.

Assessing residents' competency in care management: report of a consensus conference

BACKGROUND

Residency programs must prepare physicians to practice in the current health care environment. This mandate is reflected in 3 of the 6 competency domains now required by the Accreditation Council for Graduate Medical Education: systems-based practice, interpersonal skills and communication, and practice-based learning and improvement.

SUMMARY

An invitational conference was convened, with experts in clinical practice, managed care administration, and education to identify and recommend optimal and promising assessment methods for 4 target areas: physician-patient communication, ethics, teamwork and collaboration, and practice management. Working in small groups, participants considered a range of resident assessment methods and identified current or future methods for each area, based on reliability, validity, use of behaviorally oriented outcomes, feasibility, and cost. Preferred methods of assessment varied by domain and include written examinations, computer-based patient management problems, standardized patients, objective structured clinical examinations, portfolios, 360-degree evaluations, and patient satisfaction surveys.

CONCLUSIONS

The use of several practical, scientifically sound, and specific methods for assessing residents' competency in care management are recommended. Assessment instruments will need to be flexible enough to adapt to the rapid changes in the health care delivery system and terminology.

Doctors' strategies when breaking bad news to terminally ill patients

Breaking bad news to patients with a terminal disease is a difficult task for physicians. The aim of this study was to study how doctors perceive their strategies when giving information to cancer patients about discontinuing active tumour treatment. Thirty doctors with different demographic characteristics working with patients with cancer in Sweden participated. Semistructured interviews were conducted and analyzed using a qualitative phenomenographic method. The goal when giving this information was described as making the patient understands while being as considerate as possible. However, the strategies for reaching this goal were different: (1) explaining and convincing information, (i.e., giving a long explanation about why treatment has to be discontinued); (2) softening the impact of the information, with the doctor recommending discontinuation of treatment; (3) and preparing either the patient or the physician himself/herself for the information; (4) adapting or tailoring the information to the patient, with the doctor actively seeking knowledge about the patient in order to be able to adapt the information to the patient's level, or with the doctor briefly describing the situation and then remaining silent, allowing room for the patient's reactions and questions (i.e., letting the patient take an active part). When giving information, the doctors' goal was to make patients understand, but the strategies differed depending on the context.

Realizing Engel's vision: psychosomatic medicine and the education of physician-healers

Many of the exciting conceptual and scientific advances in the field of psychosomatic medicine are not taught in United States medical schools. This article, based on the Presidential Address given at the Annual Meeting of the American Psychosomatic Society in Phoenix, Arizona in March 2003, reviews the rationale for integrating psychosomatic medicine into medical curricula, identifies educational needs, proposes a core curriculum, and suggests how American Psychosomatic Society members can be instrumental in curriculum development and implementation.

Interacting with cancer patients: the significance of physicians' communication behavior

A diagnosis of cancer typically results in patients experiencing uncertainty about and loss of control over their situation, which in turn has a negative influence on their health outcomes. Cancer treatment further disrupts patients' quality of life. Throughout their cancer journey patients often rely on their physicians to provide them with social/interpersonal, informational, and decisional support. A growing body of research shows that physicians' communication behavior does indeed have a positive impact on patient health outcomes. Thus, the patient-physician interaction assumes great significance in the cancer care delivery process. It is encouraging to note that research in this area, largely dominated by studies conducted in primary care, is attracting the attention of cancer researchers. In an attempt to encourage and aid future research on patient-physician communication in cancer care, this paper presents a critical evaluation of existing literature on key elements of physicians' communication behavior (i.e., interpersonal communication, information exchange, and facilitation of patient involvement in decision-making). Different approaches to assessing physician behavior are discussed followed by a review of key findings linking physician behavior with cancer patient health outcomes. Finally, potential limitations of existing research are highlighted and areas for future research are identified.

The interplay between education and research about patient-provider communication

Attention to providers' communication skills is likely to increase, given the confluence of forces that have highlighted the importance of communication in healthcare. In the United States, interpersonal and communication skills have been explicitly identified as a priority throughout the continuum of medical education and practice. Ideally, theory and research inform teaching and assessment efforts by suggesting how communication behavior affects outcomes and by providing a conceptual framework for learning skills. This article illustrates the interplay between education and research by discussing examples of useful concepts (models of communication, issues of perceived control, and patterns of non-verbal communication) and understudied topics (physician verbalizations during patients' initial narratives, the mundane aspects of communication in healthcare, conceptual and operational definitions of empathy, and the effect of patient narratives on both patients and providers). Given the breadth and depth of experience, from screening and prevention to treatment and support, the context of cancer offers a promising laboratory for enhancing both education and research about provider-patient communication.

Two words to improve physician-patient communication: what else?

The medical interview is the physician's initial and perhaps most important diagnostic procedure, but physicians vary in their abilities and skills in physician-patient communication. Information gathering, relationship building, and patient education are the 3 essential functions of the medical interview. A physician-centered interview using a biomedical model can impede disclosure of problems and concerns. A patient-centered approach can facilitate patient disclosure of problems and enhance physician-patient communication. This, in turn, can improve health outcomes, patient compliance, and patient satisfaction and may decrease malpractice claims. Physicians can improve their communication skills through continuing education and practice.