Efficacy of a one-month training block in psychosocial medicine for residents: a controlled study

Communication skills training for healthcare professionals working with people who have cancer

BACKGROUND

This is the third update of a review that was originally published in the Cochrane Library in 2002, Issue 2. People with cancer, their families and carers have a high prevalence of psychological stress, which may be minimised by effective communication and support from their attending healthcare professionals (HCPs). Research suggests communication skills do not reliably improve with experience, therefore, considerable effort is dedicated to courses that may improve communication skills for HCPs involved in cancer care. A variety of communication skills training (CST) courses are in practice. We conducted this review to determine whether CST works and which types of CST, if any, are the most effective.

OBJECTIVES

To assess whether communication skills training is effective in changing behaviour of HCPs working in cancer care and in improving HCP well-being, patient health status and satisfaction.

SEARCH METHODS

For this update, we searched the following electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 4), MEDLINE via Ovid, Embase via Ovid, PsycInfo and CINAHL up to May 2018. In addition, we searched the US National Library of Medicine Clinical Trial Registry and handsearched the reference lists of relevant articles and conference proceedings for additional studies.

SELECTION CRITERIA

The original review was a narrative review that included randomised controlled trials (RCTs) and controlled before-and-after studies. In updated versions, we limited our criteria to RCTs evaluating CST compared with no CST or other CST in HCPs working in cancer care. Primary outcomes were changes in HCP communication skills measured in interactions with real or simulated people with cancer or both, using objective scales. We excluded studies whose focus was communication skills in encounters related to informed consent for research.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials and extracted data to a pre-designed data collection form. We pooled data using the random-effects method. For continuous data, we used standardised mean differences (SMDs).

MAIN RESULTS

We included 17 RCTs conducted mainly in outpatient settings. Eleven trials compared CST with no CST intervention; three trials compared the effect of a follow-up CST intervention after initial CST training; two trials compared the effect of CST and patient coaching; and one trial compared two types of CST. The types of CST courses evaluated in these trials were diverse. Study participants included oncologists, residents, other doctors, nurses and a mixed team of HCPs. Overall, 1240 HCPs participated (612 doctors including 151 residents, 532 nurses, and 96 mixed HCPs).Ten trials contributed data to the meta-analyses. HCPs in the intervention groups were more likely to use open questions in the post-intervention interviews than the control group (SMD 0.25, 95% CI 0.02 to 0.48; P = 0.03, I² = 62%; 5 studies, 796 participant interviews; very low-certainty evidence); more likely to show empathy towards their patients (SMD 0.18, 95% CI 0.05 to 0.32; P = 0.008, I² = 0%; 6 studies, 844 participant interviews; moderate-certainty evidence), and less likely to give facts only (SMD -0.26, 95% CI -0.51 to -0.01; P = 0.05, I² = 68%; 5 studies, 780 participant interviews; low-certainty evidence). Evidence suggesting no difference between CST and no CST on eliciting patient concerns and providing appropriate information was of a moderate-certainty. There was no evidence of differences in the other HCP communication skills, including clarifying and/or summarising information, and negotiation. Doctors and nurses did not perform differently for any HCP outcomes.There were no differences between the groups with regard to HCP 'burnout' (low-certainty evidence) nor with regard to patient satisfaction or patient perception of the HCPs communication skills (very low-certainty evidence). Out of the 17 included RCTs 15 were considered to be at a low risk of overall bias.

AUTHORS' CONCLUSIONS

Various CST courses appear to be effective in improving HCP communication skills related to supportive skills and to help HCPs to be less likely to give facts only without individualising their responses to the patient's emotions or offering support. We were unable to determine whether the effects of CST are sustained over time, whether consolidation sessions are necessary, and which types of CST programs are most likely to work. We found no evidence to support a beneficial effect of CST on HCP 'burnout', the mental or physical health and satisfaction of people with cancer.

Psychosocial Factors in Older Patients 'Medical Encounters

This article reviews the literature and presents some new preliminary findings on physician-older patient communication about psychosocial issues in primary care medical visits. The authors examine the importance of psychosocial talk in medical encounters, the barriers to these discussions, and the prevalence and specific content of psychosocial discussions in primary care medical encounters. The research suggests that the preponderance of talk in the medical encounter is biomedical, with little attention to psychosocial topics. The differential attention to the biomedical sphere may be more common and more problematic with the elderly. A research agenda in three areas is proposed. Investigations are needed on: (a) the determinants, outcomes, and nature of physician-older patient communication about psychosocial issues; (b) the psychosocial factors that are problematic in older patients' lives and have relevance for their medical care; and (c) the psychosocial issues that arise when the older patient is sick or disabled.

Communication skills training for healthcare professionals working with people who have cancer

BACKGROUND

This is an updated version of a review that was originally published in the Cochrane Database of Systematic Reviews in 2004, Issue 2. People with cancer, their families and carers have a high prevalence of psychological stress which may be minimised by effective communication and support from their attending healthcare professionals (HCPs). Research suggests communication skills do not reliably improve with experience, therefore, considerable effort is dedicated to courses that may improve communication skills for HCPs involved in cancer care. A variety of communication skills training (CST) courses have been proposed and are in practice. We conducted this review to determine whether CST works and which types of CST, if any, are the most effective.

OBJECTIVES

To assess whether CST is effective in improving the communication skills of HCPs involved in cancer care, and in improving patient health status and satisfaction.

SEARCH METHODS

We searched the following electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL) Issue 2, 2012, MEDLINE, EMBASE, PsycInfo and CINAHL to February 2012. The original search was conducted in November 2001. In addition, we handsearched the reference lists of relevant articles and relevant conference proceedings for additional studies.

SELECTION CRITERIA

The original review was a narrative review that included randomised controlled trials (RCTs) and controlled before-and-after studies. In this updated version, we limited our criteria to RCTs evaluating 'CST' compared with 'no CST' or other CST in HCPs working in cancer care. Primary outcomes were changes in HCP communication skills measured in interactions with real and/or simulated patients with cancer, using objective scales. We excluded studies whose focus was communication skills in encounters related to informed consent for research.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials and extracted data to a pre-designed data collection form. We pooled data using the random-effects model and, for continuous data, we used standardised mean differences (SMDs).

MAIN RESULTS

We included 15 RCTs (42 records), conducted mainly in outpatient settings. Eleven studies compared CST with no CST intervention, three studies compared the effect of a follow-up CST intervention after initial CST training, and one study compared two types of CST. The types of CST courses evaluated in these trials were diverse. Study participants included oncologists (six studies), residents (one study) other doctors (one study), nurses (six studies) and a mixed team of HCPs (one study). Overall, 1147 HCPs participated (536 doctors, 522 nurses and 80 mixed HCPs).Ten studies contributed data to the meta-analyses. HCPs in the CST group were statistically significantly more likely to use open questions in the post-intervention interviews than the control group (five studies, 679 participant interviews; P = 0.04, I² = 65%) and more likely to show empathy towards patients (six studies, 727 participant interviews; P = 0.004, I² = 0%); we considered this evidence to be of moderate and high quality, respectively. Doctors and nurses did not perform statistically significantly differently for any HCP outcomes.There were no statistically significant differences in the other HCP communication skills except for the subgroup of participant interviews with simulated patients, where the intervention group was significantly less likely to present 'facts only' compared with the control group (four studies, 344 participant interviews; P = 0.01, I² = 70%).There were no significant differences between the groups with regard to outcomes assessing HCP 'burnout', patient satisfaction or patient perception of the HCPs communication skills. Patients in the control group experienced a greater reduction in mean anxiety scores in a meta-analyses of two studies (169 participant interviews; P = 0.02; I² = 8%); we considered this evidence to be of a very low quality.

AUTHORS' CONCLUSIONS

Various CST courses appear to be effective in improving some types of HCP communication skills related to information gathering and supportive skills. We were unable to determine whether the effects of CST are sustained over time, whether consolidation sessions are necessary, and which types of CST programs are most likely to work. We found no evidence to support a beneficial effect of CST on HCP 'burnout', patients' mental or physical health, and patient satisfaction.

Interventions for providers to promote a patient-centred approach in clinical consultations

BACKGROUND

Communication problems in health care may arise as a result of healthcare providers focusing on diseases and their management, rather than people, their lives and their health problems. Patient-centred approaches to care delivery in the patient encounter are increasingly advocated by consumers and clinicians and incorporated into training for healthcare providers. However, the impact of these interventions directly on clinical encounters and indirectly on patient satisfaction, healthcare behaviour and health status has not been adequately evaluated.

OBJECTIVES

To assess the effects of interventions for healthcare providers that aim to promote patient-centred care (PCC) approaches in clinical consultations.

SEARCH METHODS

For this update, we searched: MEDLINE (OvidSP), EMBASE (OvidSP), PsycINFO (OvidSP), and CINAHL (EbscoHOST) from January 2000 to June 2010. The earlier version of this review searched MEDLINE (1966 to December 1999), EMBASE (1985 to December 1999), PsycLIT (1987 to December 1999), CINAHL (1982 to December 1999) and HEALTH STAR (1975 to December 1999). We searched the bibliographies of studies assessed for inclusion and contacted study authors to identify other relevant studies. Any study authors who were contacted for further information on their studies were also asked if they were aware of any other published or ongoing studies that would meet our inclusion criteria.

SELECTION CRITERIA

In the original review, study designs included randomized controlled trials, controlled clinical trials, controlled before and after studies, and interrupted time series studies of interventions for healthcare providers that promote patient-centred care in clinical consultations. In the present update, we were able to limit the studies to randomized controlled trials, thus limiting the likelihood of sampling error. This is especially important because the providers who volunteer for studies of PCC methods are likely to be different from the general population of providers. Patient-centred care was defined as a philosophy of care that encourages: (a) shared control of the consultation, decisions about interventions or management of the health problems with the patient, and/or (b) a focus in the consultation on the patient as a whole person who has individual preferences situated within social contexts (in contrast to a focus in the consultation on a body part or disease). Within our definition, shared treatment decision-making was a sufficient indicator of PCC. The participants were healthcare providers, including those in training.

DATA COLLECTION AND ANALYSIS

We classified interventions by whether they focused only on training providers or on training providers and patients, with and without condition-specific educational materials. We grouped outcome data from the studies to evaluate both direct effects on patient encounters (consultation process variables) and effects on patient outcomes (satisfaction, healthcare behaviour change, health status). We pooled results of RCTs using standardized mean difference (SMD) and relative risks (RR) applying a fixed-effect model.

MAIN RESULTS

Forty-three randomized trials met the inclusion criteria, of which 29 are new in this update. In most of the studies, training interventions were directed at primary care physicians (general practitioners, internists, paediatricians or family doctors) or nurses practising in community or hospital outpatient settings. Some studies trained specialists. Patients were predominantly adults with general medical problems, though two studies included children with asthma. Descriptive and pooled analyses showed generally positive effects on consultation processes on a range of measures relating to clarifying patients' concerns and beliefs; communicating about treatment options; levels of empathy; and patients' perception of providers' attentiveness to them and their concerns as well as their diseases. A new finding for this update is that short-term training (less than 10 hours) is as successful as longer training.The analyses showed mixed results on satisfaction, behaviour and health status. Studies using complex interventions that focused on providers and patients with condition-specific materials generally showed benefit in health behaviour and satisfaction, as well as consultation processes, with mixed effects on health status. Pooled analysis of the fewer than half of included studies with adequate data suggests moderate beneficial effects from interventions on the consultation process; and mixed effects on behaviour and patient satisfaction, with small positive effects on health status. Risk of bias varied across studies. Studies that focused only on provider behaviour frequently did not collect data on patient outcomes, limiting the conclusions that can be drawn about the relative effect of intervention focus on providers compared with providers and patients.

AUTHORS' CONCLUSIONS

Interventions to promote patient-centred care within clinical consultations are effective across studies in transferring patient-centred skills to providers. However the effects on patient satisfaction, health behaviour and health status are mixed. There is some indication that complex interventions directed at providers and patients that include condition-specific educational materials have beneficial effects on health behaviour and health status, outcomes not assessed in studies reviewed previously. The latter conclusion is tentative at this time and requires more data. The heterogeneity of outcomes, and the use of single item consultation and health behaviour measures limit the strength of the conclusions.

An effective training to increase accurate recognition of patient emotion cues

OBJECTIVE

For healthcare providers, accurate perception of patients, particularly accurate recognition of patient emotions, is an ability associated with better patient care and more satisfied patients. Despite the importance of accurately recognizing patient cues for provider-patient communication, research on clinically relevant training programs is limited. The effectiveness of a multi-component training program designed to enhance emotion cue recognition ability was experimentally assessed.

METHODS

The comprehensive training included raising awareness about the importance of emotion cues in healthcare interactions, providing instruction on increasing emotion cue recognition accuracy, and practicing emotion recognition while receiving feedback. Undergraduate participants were randomly assigned to one of five training conditions or an untrained control condition to experimentally test the efficacy of the comprehensive training and each training component.

RESULTS

Participants were significantly more accurate on a standardized test of patient emotion cue recognition in the comprehensive condition, as compared to those participants in the control condition, with Practice with Feedback emerging as the most effective component.

CONCLUSIONS

Results suggest that a 30-min emotion recognition training intervention can significantly improve emotion recognition accuracy.

PRACTICE IMPLICATIONS

The results can be used to guide development and implementation of future research and programs aimed at increasing providers' emotion recognition.

Interprofessional education about shared decision making for patients in primary care settings

With an increasingly complex array of interventions facing healthcare professionals and patients, coupled with a potentially diverse number of professionals operating within the primary care team, the adoption of shared decision making (SDM) - with or without patients' decision aids - in an interprofessional manner is essential to ensure the highest quality of care for patients. In this article, we propose a framework for interprofessional education about SDM targeted to primary care settings. Five areas of knowledge and skills were agreed to be essential for all relevant stakeholders for interprofessional education in SDM to be successful: understanding the concept of SDM; acquiring relevant communication skills to facilitate SDM; understanding interprofessional sensitivities; understanding the roles of different professions within the relevant primary care group; and acquiring relevant skills to implement SDM. We suggest a series of teaching methods for the aforementioned areas, using principles from adult learning.

A cohort study assessing difficult patient encounters in a walk-in primary care clinic, predictors and outcomes

BACKGROUND

Previous studies have found that up to 15% of clinical encounters are experienced as difficult by clinicians.

OBJECTIVES

Explore patient and physician characteristics associated with being considered "difficult" and assess the impact on patient outcomes.

DESIGN

Prospective cohort study.

PARTICIPANTS

Seven hundred fifty adults presenting to a primary care walk-in clinic with a physical symptom.

MAIN MEASURES

Pre-visit surveys assessed symptom characteristics, expectations, functional status (Medical Outcome Study SF-6) and the presence of mental disorders [Primary Care Evaluation of Mental Disorders, (PRIME-MD)]. Post-visit surveys assessed satisfaction (Rand-9), unmet expectations and trust. Two-week assessment included symptom outcome (gone, better, same, worse), functional status and satisfaction. After each visit, clinicians rated encounter difficulty using the Difficult Doctor-Patient Relationship Questionnaire (DDPRQ). Clinicians also completed the Physician's Belief Scale, a measure of psychosocial orientation.

KEY RESULTS

Among the 750 subjects, 133 (17.8%) were perceived as difficult. "Difficult" patients were less likely to fully trust (RR = 0.88, 95% CI: 0.77-0.99) or be fully satisfied (RR = 0.78, 95% CI: 0.62-0.98) with their clinician, and were more likely to have worsening of symptoms at 2 weeks (RR = 0.75, 95% CI: 0.57-0.97). Patients involved in "difficult encounters" had more than five symptoms (RR = 1.8, 95% CI: 1.3-2.3), endorsed recent stress (RR = 1.9, 95% CI: 1.4-3.2) and had a depressive or anxiety disorder (RR = 2.3, 95% CI: 1.3-4.2). Physicians involved in difficult encounters were less experienced (12 years vs. 9 years, p = 0.0002) and had worse psychosocial orientation scores (77 vs. 67, p < 0.005).

CONCLUSION

Both patient and physician characteristics are associated with "difficult" encounters, and patients involved in such encounters have worse short-term outcomes.

A controlled trial of a short course to improve residents' communication with patients at the end of life

PURPOSE

High-quality palliative care requires physicians who communicate effectively, yet many do not receive adequate training. Leading efforts to demonstrate the effectiveness of such training have involved time-intensive programs that included primarily attending physicians, which have been conducted outside of the United States. The goal was to evaluate the effect of a short course to improve residents' communication skills delivering bad news and eliciting patients' preferences for end-of-life care.

METHOD

This prospective trial enrolled internal medicine residents at Duke University Medical Center from 1999 to 2001. The course consisted of small-group teaching with lecture, discussion, and role-play. The outcome measure was observed communication skills delivering bad news and eliciting patients' preferences for end-of-life treatment, assessed via audio-recorded standardized patient encounters before and after receiving the intervention.

RESULTS

Thirty-seven residents received the intervention and 19 were in the control group. Residents attending the course demonstrated statistically significant increases in their overall skill ratings in the delivery of bad news, with improvement in the specific areas of information giving and responding to emotional cues. Although cumulative scores for discussions about patient preferences for treatment did not increase, residents demonstrated enhanced specific skills including discussing probability, presenting clinical scenarios, and asking about prior experience with end-of-life decision making.

CONCLUSION

A relatively short, intensive course can improve the end-of-life communication skills of U.S. medical residents.

Teaching personal awareness

Educators rarely consider the attitudes that determine whether a learner will use the clinical skills we teach. Nevertheless, many learners and practitioners exhibit negative attitudes that can impede the use of patient-centered skills, leading to an isolated focus upon disease and impairing the provider-patient relationship. The problem is compounded because these attitudes often are incompletely recognized by learners and therefore are difficult to change without help. We present a research-based method for teaching personal awareness of unrecognized and often harmful attitudes. We propose that primary care clinicians without mental health training can follow this method to teach students, residents, faculty, and practitioners. Such teachers/mentors need to possess an abiding interest in the personal dimension, patience with a slowly evolving process of awareness, and the ability to establish strong, ongoing relationships with learners. Personal awareness teaching may occur during instruction in basic interviewing skills but works best if systematically incorporated throughout training.

Developing communication competency in the context of cancer: a critical interpretive analysis of provider training programs

We conducted a critical interpretive analysis of 47 studies from the Cochrane Review of the communications training literature to capture the empirical indicators used to judge provider communication competency and to describe how the indicators were characterized in the context of a cancer care system. Of the 47 studies reviewed, few showed any resemblance to recommendations from two international consensus conferences of experts in the communication research field. Some of the challenges in moving forward with cancer-related communication skills involve deciding what we want people to learn, providing learning across various experiences, identifying learning models, and finding alternate ways of motivating people to learn. Once core competencies are clearly articulated, we can determine the best approaches for developing cancer-specific training programs.

Communication skills training for health care professionals working with cancer patients, their families and/or carers

BACKGROUND

Research suggests communication skills do not reliably improve with experience. Considerable effort is dedicated to courses improving communication skills for health professionals. Evaluation of such courses is important to enable evidence-based teaching and practice.

OBJECTIVES

To assess whether communication skills training is effective in changing health professionals' behaviour in cancer care with regard to communication/interaction with patients.

SEARCH STRATEGY

We searched CENTRAL (Cochrane Library Issue 3 2001), MEDLINE (1966 to November 2001), EMBASE (1980 to November 2001), PsycInfo (1887 to November 2001), CINAHL (1982 to November 2001), AMED (1985 - October 2001), Dissertation Abstracts International (1861 to March 2002) and EBM Reviews (1991 to March/April 2001). Reference lists of relevant articles were searched. Three further studies were detected in November 2003.

SELECTION CRITERIA

Randomized controlled trials or controlled before and after studies of communication skills training in cancer health professionals, measuring changes in behaviour/skills using objective and validated scales.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trials and extracted data.

MAIN RESULTS

Of 2824 references, 3 trials involving 347 health professionals were included. One provided an intensive 3 day course then assessed oncology doctors interacting with 640 patients; a second provided a modular course then assessed role plays with oncology nurses; the third was modular and assessed outcomes with clinical and simulated interviews and patient questionnaires. In one trial, course attendees used more focused questions (probability < 0.005), focused and open questions (p = 0.005), expressions of empathy (p < 0.005) and appropriate cue responses (p < 0.05) at follow up than non-attendees. No significant differences were found between attendees and non-attendees for leading questions. From baseline to follow up, attendees had significantly different changes in rates of leading questions (p < 0.05), focused questions (p < 0.005), open questions (p < 0.05) and empathy (p = 0.005). The only observed significant difference in the second trial was that trained doctors controlled the follow-up interview more than untrained doctors (p < 0.05). Neither studies found differences in summarising, interrupting and checking. The third trial found trained nurses used more emotional speech than untrained counterparts, particularly regarding anxiety and distress. Patients interviewed by trained nurses used more emotional terms, but no differences emerged in questionnaires.

REVIEWERS' CONCLUSIONS

Training programmes assessed by these trials appear to be effective in improving some areas of cancer care professionals communication skills. It is unknown whether this training would be effective if taught by others, nor the comparative efficacy of these programmes.

Communication skills training for health care professionals working with cancer patients, their families and/or carers

BACKGROUND

Research suggests communication skills do not reliably improve with experience and considerable effort is dedicated to courses improving communication skills for health professionals. The evaluation of such courses is of importance to enable evidence-based teaching and practice.

OBJECTIVES

To assess whether communication skills training is effective in changing behaviour of health professionals in cancer care with regard to communication/interaction with patients.

SEARCH STRATEGY

We searched CENTRAL (Cochrane Library Issue 3 2001), MEDLINE (1966 to November 2001), EMBASE (1980 to November 2001), PsycInfo (1887 to November 2001), CINAHL (1982 to November 2001), AMED (1985 - October 2001), Dissertation Abstracts International (1861 to March 2002) and EBM Reviews (1991 to March/April 2001). Reference lists of relevant articles were searched.

SELECTION CRITERIA

Randomized controlled trials or controlled before and after studies of communication skills training in cancer health professionals, measuring changes in behaviour/skills using objective and validated scales.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data.

MAIN RESULTS

Although 2822 references were considered, only two trials involving 232 health professionals were included. One provided an intensive three-day course then assessed oncology doctors interacting with a total of 640 patients; the other provided a modular course then used role plays with oncology nurses for skill assessment. In one trial, course attendees used more focused questions (34% increase, probability < 0.005), focused and open questions (27% increase, p = 0.005), expressions of empathy (69% increase, p < 0.005) and appropriate responses to cues (38% increase, p < 0.05) at follow up than non-attendees. No significant differences were found between attendees and non-attendees in use of leading questions. From baseline to follow up in the same study, attendees had significantly different changes in rates of leading questions (relative risk 0.72, p < 0.05), focused questions (Relative Risk 1.25, p < 0.005), open questions (RR 1.17, p < 0.05) and empathy (RR 1.50, p = 0.005). The only significant difference in observed communication skills in the second trial was that the trained group were more in control of the follow-up interview than the untrained group (p < 0.05). Both studies investigated differences in summarising, interrupting and checking but found none.

REVIEWER'S CONCLUSIONS

The training programmes assessed by these trials appear to be effective in improving cancer care professionals communication skills. It is not known whether the training would be effective if taught by other educators, nor has any trial compared the efficacy of both programmes.

Physician communication skills training: a review of theoretical backgrounds, objectives and skills

CONTEXT

Significant shortcomings have been noted in the literature in communication skills training for practising doctors. Given the importance of competent communication to the doctor-patient relationship and health care in general, these shortcomings should be addressed in future research.

OBJECTIVE

Research into physician communication skills training is examined with respect to the communication objectives and behaviours that are addressed.

METHODS

A Medline search of literature from 1990 to the present was conducted.

RESULTS

A total of 26 studies of doctor communication skills training were found. The majority of studies included insufficient information about the communication behaviours taught to participants. In several studies, there was a mismatch between stated behaviours and instruments or procedures used to assess them.

CONCLUSION

Three recommendations are suggested. Firstly, future researchers should take greater care in matching assessment instruments with stated communication skills. Secondly, researchers should provide and use a theoretical framework for selecting communication skills to address in interventions, and thirdly, the timing of communication skills within the interview context should be part of the instruction in interventions.

Retention and use of patient-centered interviewing skills after intensive training

PURPOSE

Studies show that residents trained in patient-centered interviewing (PCI) are more effective in handling patients' emotions and are more skillful in gathering patients' data. This study evaluated the long-term use of PCI skills.

METHOD

Fourteen residents received PCI training during internship, and their skills were evaluated before, immediately after, and two years after their training through directly observed patient interviews. A confidential survey evaluated the residents' actual use of PCI two years after the intensive training. Control groups of 14 interns prior to PCI training and 14 residents from another program not trained in PCI were also surveyed.

RESULTS

Residents' use of PCI skills (optimization of setting, establishment of narrative thread, open-to-closed-ended questioning cone, avoid asking more than one question at a time, and (facilitation) were significantly improved, even two years after their training in PCI. The residents who received intensive block training reported using PCI techniques more frequently than did those in the control groups. However, the only significant difference in use of PCI skills between the intervention and control groups was found in reflection of patient's emotions.

CONCLUSION

Medical residents retained PCI skills for two years. Further studies are needed to determine whether successful postgraduate training of physicians in PCI translates into a change in behaviors during their professional lives.

Interventions for providers to promote a patient-centred approach in clinical consultations

BACKGROUND

Communication problems in health care may arise as a result of health care providers focusing on diseases and their management, rather than people, their lives and their health problems. Patient-centred approaches to care are increasingly advocated by consumers and clinicians and incorporated into training for health care providers. The effects of interventions that aim to promote patient-centred care need to be evaluated.

OBJECTIVES

To assess the effects of interventions for health care providers that aim to promote patient-centred approaches in clinical consultations.

SEARCH STRATEGY

We searched Medline (1966 - Dec 1999); Health Star (1975 - Dec 1999); PsycLit (1887- Dec 1999); Cinahl (1982 - Dec 1999); Embase (1985-Dec 1999) and the bibliographies of studies assessed for inclusion.

SELECTION CRITERIA

Randomised controlled trials, controlled clinical trials, controlled before and after studies, and interrupted time series studies of interventions for health care providers that promote patient-centred care in clinical consultations. Patient-centred care was defined as a philosophy of care that encourages: (a) shared control of the consultation, decisions about interventions or management of the health problems with the patient, and/or (b) a focus in the consultation on the patient as a whole person who has individual preferences situated within social contexts (in contrast to a focus in the consultation on a body part or disease). The participants were health care providers, including those in training.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data onto a standard form and assessed study quality for each study. We extracted all outcomes other than health care providers' knowledge, attitudes and intentions.

MAIN RESULTS

17 studies met the inclusion criteria. These studies display considerable heterogeneity in terms of the interventions themselves, the health problems or health concerns on which the interventions focused, the comparisons made and the outcomes assessed. All included studies used training for health care providers as an element of the intervention. Ten studies evaluated training for providers only, while the remaining studies utilised multi-faceted interventions where training for providers was one of several components. The health care providers were mainly primary care physicians (general practitioners or family doctors) practising in community or hospital outpatient settings. In two studies, the providers also included nurses. There is fairly strong evidence to suggest that some interventions to promote patient-centred care in clinical consultations may lead to significant increases in the patient centredness of consultation processes. 12 of the 14 studies that assessed consultation processes showed improvements in some of these outcomes. There is also some evidence that training health care providers in patient-centred approaches may impact positively on patient satisfaction with care. Of the eleven studies that assessed patient satisfaction, six demonstrated significant differences in favour of the intervention group on one or more measures. Few studies examined health care behaviour or health status outcomes.

REVIEWER'S CONCLUSIONS

Interventions to promote patient-centred care within clinical consultations may significantly increase the patient centredness of care. However, there is limited and mixed evidence on the effects of such interventions on patient health care behaviours or health status; or on whether these interventions might be applicable to providers other than physicians. Further research is needed in these areas.

Interventions to improve provider diagnosis and treatment of mental disorders in primary care. A critical review of the literature

The authors conducted a critical review of the literature on interventions to improve provider recognition and management of mental disorders in primary care, searching the MEDLINE database for relevant articles published from 1966 through May 1998 and finding 48 usable controlled studies (27 randomized controlled trials and 21 quasi-experimental studies). Improved diagnosis of mental disorders was reported in 18 of 23 (78%) of the studies examining this outcome and improved treatment in 14 of 20 studies (70%); clinical improvement in psychiatric symptoms or functional status was documented in 4 of 11 and 4 of 8 (36% and 50%, respectively). Considerable study heterogeneity precluded subjecting the literature synthesis to a formal meta-analysis of pooled results; the authors were therefore unable to demonstrate an association between efficacy of an intervention and any specific variables. A variety of interventions and further research may be effective in improving the recognition and management of mental disorders in primary care.

Teaching clinically experienced physicians communication skills. A review of evaluation studies

CONTEXT

Interest in the teaching of communication skills in medical schools has increased since the early seventies but, despite this growing interest, relatively limited curricular time is spent on the teaching of communication skills. The limited attention to the teaching of these skills applies even more to the physicians' clinical years, when attention becomes highly focused on biomedical and technical competence. Continuing training after medical school is necessary to refresh knowledge and skills, to prohibit decline of performance and to establish further improvements.

OBJECTIVE

This review provides an overview of evaluation studies of communication skills training programmes for clinically experienced physicians who have finished their undergraduate medical education. The review focuses on the training objectives, the applied educational methods, the evaluation methodology and instruments, and training results.

METHODS

CD-ROM searches were performed on MedLine and Psychlit, with a focus on effect-studies dating from 1985.

RESULTS

Fifteen papers on 14 evaluation studies were located. There appears to be some consistency in the aims and methods of the training programmes. Course effect measurements include physician self-ratings, independent behavioural observations and patient outcomes. Most of the studies used inadequate research designs. Overall, positive training effects on the physicians' communication behaviour are found on half or less of the observed behaviours. Studies with the most adequate designs report the fewest positive training effects.

CONCLUSION

Several reasons are discussed to explain the limited findings. Future research may benefit from research methods which focus on factors that inhibit and facilitate the physicians' implementation of skills into actual behaviours in daily practice.

A comparison of clinical performance of primary care and traditional internal medicine residents

OBJECTIVE

To compare primary care and traditional Internal Medicine residents in their adherence to preventive medicine guidelines, performance in the management of chronic diseases, and utilization of resources.

DESIGN

Prospective cohort study.

SETTING

Urban Internal Medicine residency program.

PARTICIPANTS

Sixteen primary care and 137 traditional Internal Medicine residents who took care of 6,307 patients (a total of 21,002 patient visits in a 1-year period).

MEASUREMENTS

Adherence to preventive medicine guidelines for the screening of breast cancer, cervical cancer, hypercholesterolemia, and colon cancer; admission rates among patients with asthma, chronic pulmonary disease, and diabetes mellitus; four items in the management of diabetes; and resource utilization including the costs for laboratory and radiology tests and number of consultations.

RESULTS

Primary care residents, as compared with traditional residents, adhered to preventive medicine guidelines for a greater proportion of their patients for the following: breast cancer among women aged 52 to 75 years (61% vs. 54%, respectively, P = 0.05); cholesterol screening among patients aged 20 to 64 years (39% vs. 33%, P = 0.007); colon cancer among patients older than 50 years (49% vs. 31%, P = 0.001); and cervical cancer among women aged 20 to 64 years (36% vs. 31%, P = 0.03). There were no differences in hospital admission rates for patients with diabetes or asthma. Total ambulatory care costs for tests, procedures, consults, and office visits were greater for patients of primary care residents ($1,045 vs. $899, P = 0.0001), although total costs per primary care visit were similar between the two patient groups.

CONCLUSIONS

Primary care residents more closely adhered to preventive medicine guidelines but were similar to traditional residents in their management of chronic diseases. Patients of primary care residents had greater ambulatory care costs that were not entirely attributable to greater adherence to preventive medicine guidelines.

Ethics and teaching the art of emergency medicine

This article discusses the art of medicine as it relates to effective teaching. Valuable contributions to such teaching are made through applying ethical considerations to situations unique to emergency medicine. The author includes several appendices for further information on this vital topic.

Patient-doctor communication in cross-national perspective. A study in Mexico

The authors assessed the cross-national replicability previously used to study medical encounters in the United States by adapting them to Mexico. The main research questions focused on information-giving, gender and social class differences in communication, and attention to socioemotional concerns in primary encounters. Sixty-two primary care encounters were audiotaped. Questionnaires were translated into Spanish, then translated back into English. Coding and transcription techniques were taught to Spanish-speaking researchers. Measures of communication were treated as dependent variables and were related by nonparametric statistical analyses to characteristics of physicians, patients, and clinical settings. Doctors in Mexico spent an average of 2.1 minutes (+/- 1.7 standard deviation [SD]), or 16.7% (+/- 10.7 SD) of total interaction time, in information-giving. Mexican doctors asked an average of 27.3 questions per encounter (+/- 18.0 SD), whereas patients asked an average of 1.5 questions (+/- 2.0 SD). Substantial interphysician variability was observed in total time of interaction (Kruskal-Wallis analysis of variance, chi-square = 27.2, P = 0.000), physician time in information giving (chi-square = 16.4, P = 0.022), and physician questions (chi-square = 36.7, P = 0.000). Patient characteristics associated with physician information-giving included male gender (chi-square = 4.1, P = 0.04) and age (Kendall's tau-b = .17, P = 0.05) but not education (tau-b = .08, P = 0.41). Information-giving in public clinics did not differ from that in private practices (chi-square = 0.0, P = 0.91). A bootstrap approach to multiple nonlinear regression permitted additional analysis of physicians', patients', and situational characteristics in explaining measures of patient-doctor communication; this analysis further demonstrated the importance of interphysician variability in communicative behavior. Previous methods for studying patient-doctor communication can be adapted and replicated in a non-English-speaking society. With certain exceptions, findings from Mexico were similar to those obtained in the United States.

The advanced clinical skills program in medical interviewing: a block curriculum for residents in medicine

OBJECTIVE

This study sought to demonstrate whether an intensive block curriculum would lead to learning of basic medical interviewing skills by first year residents in medicine.

METHOD

Pairs of brief clinical interviews done before and after a four week block program in medical interviewing were rated using the Rhode Island Hospital Interview Checklist (RIC). The data were analyzed using the McNemar Test to look for possible improvement following the course.

RESULTS

Of the nineteen categories measured, fourteen showed statistically significant improvement (p < .05) in Year 1 and twelve in Year 2. Combining the data for the two years gave statistically significant results in sixteen of the nineteen categories.

CONCLUSIONS

An intensive block curriculum in medical interviewing led to a significant degree of learning of basic skills by first year medical residents as judged by interviews done at the end of the block. The intensive approach also allowed for a degree of personal growth and solidification of identity as a physician. These factors can be expected to influence interviewing proficiency as well.

Improving residents' confidence in using psychosocial skills

OBJECTIVE

To evaluate an intensive training program's effects on residents' confidence in their ability in, anticipation of positive outcomes from, and personal commitment to psychosocial behaviors.

DESIGN

Controlled randomized study.

SETTING

A university- and community-based primary care residency training program.

PARTICIPANTS

26 first-year residents in internal medicine and family practice.

INTERVENTION

The residents were randomly assigned to a control group or to one-month intensive training centered on psychosocial skills needed in primary care.

MEASUREMENTS

Questionnaires measuring knowledge of psychosocial medicine, and self-confidence in, anticipation of positive outcomes from, and personal commitment to five skill areas: psychological sensitivity, emotional sensitivity, management of somatization, and directive and nondirective facilitation of patient communication.

RESULTS

The trained residents expressed higher self-confidence in all five areas of psychosocial skill (p < 0.03 for all tests), anticipated more positive outcomes for emotional sensitivity (p = 0.05), managing somatization (p = 0.03), and nondirectively facilitating patient communication (p = 0.02), and were more strongly committed to being emotionally sensitive (p = 0.055) and managing somatization (p = 0.056), compared with the untrained residents. The trained residents also evidenced more knowledge of psychosocial medicine than did the untrained residents (p < 0.001).

CONCLUSIONS

Intensive psychosocial training improves residents' self-confidence in their ability regarding key psychosocial behaviors and increases their knowledge of psychosocial medicine. Training also increases anticipation of positive outcomes from and personal commitment to some, but not all, psychosocial skills.

The efficacy of intensive biopsychosocial teaching programs for residents: a review of the literature and guidelines for teaching

OBJECTIVE

To review research evaluations of intensive biopsychosocial training programs for nonpsychiatry residents, and determine whether this research showed sufficient rigor and consistent beneficial impact to allow initial research-based teaching guidelines.

DATA SOURCES

An English-language literature search used MEDLINE (1966-93), Psychological Abstracts (1967-93), and Educational Resource Information Clearinghouse (1966-93) as well as bibliographic reviews from prominent peer-reviewed articles and consultation with an expert.

STUDY SELECTION

From among several hundred articles about biopsychosocial training, only 12 studies met the selection criteria: at least 100 contact hours of training for nonpsychiatry residents and an evaluation of efficacy.

DATA EXTRACTION

The three authors independently assessed these 12 studies and made a consensus decision based on explicit criteria. Successful and unsuccessful programs were distinguished from among those classified as quasi-experimental or experimental to identify programs of sufficient rigor to meet the study objective; success was defined as learning beyond knowledge and residents' acceptance of teaching.

DATA SYNTHESIS

Four successful quasi-experimental or experimental programs showed the following uniquely beneficial features: 1) protected time for residents; 2) teaching that was required, structured, multidimensional, and balanced between learner-centered and teacher-centered approaches; 3) teaching methods that used normal as well as psychosocially disturbed patients, nonpsychiatrist teachers, and special teaching techniques; and 4) inclusion in the curriculum of interviewing, interpersonal skills, doctor-patient relationship, and patient education. Two unsuccessful quasi-experimental or experimental programs were unidimensional and unstructured, and used predominant or isolated teacher-centered approaches. Features found in both successful and unsuccessful programs were experiential teaching, psychiatrist and other mental health professional teachers, use of disturbed patients, training to manage patients' psychosocial problems, teaching directed toward knowledge acquisition, teaching about treatment, and university affiliation.

CONCLUSIONS

Four rigorously studied, successful programs showed a common pattern of intensive biopsychosocial teaching that produced, in aggregate, improvement in residents' knowledge, attitudes, skills, and self-awareness. Although there is need for more definitive research, these data are sufficiently compelling and consistent to provide initial, research-based teaching guidelines.