Vocational trainees' views and experiences regarding the learning and teaching of communication skills in general practice

Doctors' experiences of earlier mandatory postgraduate communication skills training: a qualitative study

OBJECTIVES

This study explored the question: what are doctors' perspectives on and experiences with their earlier mandatory postgraduate communication skills training?

METHODS

The study used a qualitative, exploratory design. We used purposeful sampling based on the principle of maximal variation to ensure different clinical perspectives. Thus, three focus groups were formed with 12 doctors who had attended mandatory postgraduate communication skills training within 1-9 years prior to the study. The doctors were from three specialties: internal medicine, oncology, and general practice. We used a semi-structured interview guide, and the focus groups were video-recorded. Thematic analysis was used to analyze the data material. Through an iterative process, we identified main and sub-themes.

RESULTS

The first-year residency mandatory postgraduate communication skills training provided all participants with skills that had helped them in their ongoing clinical work. In addition, five dominant themes were observed: modes of use, the timing of course, experience with experiential methods, sharing challenges with peers, and need for continuous feedback and follow-up.

CONCLUSIONS

Doctors value early mandatory postgraduate communication skills training even years after attending the course and request similar ongoing initiatives. Their experiences are positive, they found the timing relevant, and they used the learned skills in their ongoing clinical work, even years after the initial course. Our study indicates that more attention should be given to 'early career' postgraduate communication skills training that is tailored to specific clinical contexts, including hospital settings.

Experiences of GP trainees in undertaking telephone consultations: a mixed-methods study

BACKGROUND

Primary care telephone consultations are increasingly used for patient triage, reviews, and providing clinical information. They are also a key postgraduate training component yet little is known about GP trainees' preparation for, or experiences and perceptions of, them.

AIM

To understand the experiences, perceptions, and training of GP trainees in conducting telephone consultations.

DESIGN & SETTING

A mixed-methods study was undertaken of North Central and East London (NCEL) GP trainees.

METHOD

A cross-sectional electronic survey of trainees was performed with subsequent semi-structured interviews. Survey data were analysed using descriptive statistics, and qualitative data using thematic analysis.

RESULTS

The survey response was 16% (n = 100/618), and 10 participated in semi-structured interviews. Trainees felt least confident with complicated telephone consulting, and there was a strong positive correlation between the percentage reporting having received training and their confidence (R ² = 0.71, P<0.0001). Positive experiences included managing workload and convenience. Negative experiences included complex encounters, communication barriers, and absence of examination. Trainees reported that training for telephone consultations needed strengthening, and that recently introduced audio-clinical observation tools (COTs) were useful. Positive correlations were found between the length of out-of-hours (OOH) but not in-hours training and the level of supervision or feedback received for telephone consultations.

CONCLUSION

This project sheds light on GP trainees' current experiences of telephone consultations and the need to enhance future training. The findings will inform a wider debate among stakeholders and postgraduate learners regarding training for telephone consultations, and potentially for other remote technologies.

The medical consultation through the lenses of language and social interaction theory

The well-structured medical communication models that are typically described in textbooks are relevant to practice, but the actual messy interactional realities of consultations are often a far cry away from them. As a result, medical trainees frequently encounter difficulties when applying communication skills acquired during training to medical practice. This paper reflects on how clinical communication research and courses can incorporate the growing need for context-bound communication skills training. This paper illustrates how concepts from the research field of language and social interaction can facilitate the description and analysis of communication in clinical encounters, drawing on a real-life example from an increasingly common clinical scenario: a consultation in the emergency department involving a patient who does not speak the same language as the clinician. The proposed way of looking at clinical communication can enrich clinical skills training as it provides a tool to study, analyze, visualize and discuss communication from a different perspective that simultaneously accounts for interactional and clinical reasoning aspects of medical consultations.

Barriers to teaching communication skills in Spanish medical schools: a qualitative study with academic leaders

BACKGROUND

In recent years, Spanish medical schools (MSs) have incorporated training in communication skills (CS), but how this training is being carried out has not yet been evaluated.

OBJECTIVE

To identify the barriers to the introduction and development of CS teaching in Spanish MSs.

METHODS

In a previous study, 34 MSs (83% of all MSs in Spain) were invited to participate in a study that explored the factual aspects of teaching CS in these schools. The person responsible for teaching CS at each school was contacted again for this study and asked to respond to a single open-ended question. Two researchers independently conducted a thematic analysis of the responses.

RESULTS

We received responses from 30 MSs (85.7% of those contacted and 73% of all MSs in Spain). Five main thematic areas were identified, each with different sub-areas: negative attitudes of teachers and academic leaders; organisation, structure and presence of CS training in the curriculum; negative attitudes of students; a lack of trained teachers; and problems linked to teaching methods and necessary educational logistics.

CONCLUSIONS

The identified barriers and problems indicate that there are areas for improvement in teaching CS in most Spanish MSs. There seems to be a vicious circle based on the dynamic relationship and interdependence of all these problems that should be faced with different strategies and that requires a significant cultural shift as well as decisive institutional support at the local and national levels. The incorporation of CS training into MS curricula represents a major challenge that must be addressed for students to learn CS more effectively and avoid negative attitudes towards learning CS.

[Consultation skills training as an element of general practice training in Germany - a qualitative survey]

INTRODUCTION

The consultation is at the heart of general practice. It is the central setting through which primary care is delivered. The competency requirements are laid down internationally by competency-based curricula for undergraduate and postgraduate education. So far, there is no competency-based vocational training to develop consultation skills in general practice in Germany. The study describes experiences with consultation skills training as an element of general practice training as reported by trainees and trainers in Germany.

METHODS

A qualitative and exploring approach was chosen because there is little experience with the German situation. We conducted structured focus group interviews with trainees and trainers, respectively. We recruited all participants by e-mail via the mail distributor "Junge Allgemeinmedizin Deutschland" (JADE, a trainee and junior GP organization) and the academic teachers of the Friedrich-Alexander University Erlangen-Nürnberg. Altogether, four focus group interviews with three to five participants were conducted, varying in length from 25 to 65minutes. All interviews were recorded digitally and transcribed verbatim. Then a qualitative content analysis was performed.

RESULTS

The statements of the ten trainees and five trainers mapped a system of four main categories: (a) association with the term consultation, (b) parts of a consultation, (c) competencies required for professional practice, (d) consultation skills training as an element of vocational training. Overall, all participants regarded the consultation as the most important element in general practice. Important content of consultations is to build a relationship with the patient, gather information, conduct physical examinations and achieve informed consent on further proceedings. All participants agreed that physicians need different sets of competencies: medical expertise, communication skills, examination skills and professionalism. Finally, there was a broad consensus that a competency-based general practice training to support the development of consultation skills is lacking in Germany. The majority acknowledged the need for change.

CONCLUSION

So far, the consultation skills development within the general practice training in Germany is regarded as deficient. Both trainees and trainers have stressed the importance of change in vocational training. With the new competency-based curriculum for general practice in Germany and the associated development of supporting tools important prerequisites have been provided.

Video training with peer feedback in real-time consultation: acceptability and feasibility in a general-practice setting

Objective

Since many years, teaching and training in communication skills are cornerstones in the medical education curriculum. Although video recording in a real-time consultation is expected to positively contribute to the learning process, research on this topic is scarce. This study will focus on the feasibility and acceptability of video recording during real-time patient encounters performed by general practitioner (GP) trainees.

Method

The primary research question addressed the experiences (defined as feasibility and acceptability) of GP trainees in video-recorded vocational training in a general practice. The second research question addressed the appraisal of this training. The procedure of video-recorded training is developed, refined and validated by the Academic Teaching Practice of Leuven since 1974 (Faculty of Medicine of the University of Leuven). The study is set up as a cross-sectional survey without follow-up. Outcome measures were defined as ‘feasibility and acceptability’ (experiences of trainees) of the video-recorded training and were approached by a structured questionnaire with the opportunity to add free text comments. The studied sample consisted of all first-phase trainees of the GP Master 2011–2012 at the University of Leuven.

Results

Almost 70% of the trainees were positive about recording consultations. Nevertheless, over 60% believed that patients felt uncomfortable during the video-recorded encounter. Almost 90% noticed an improvement of own communication skills through the observation and evaluation of. Most students (85%) experienced the logistical issues as major barrier to perform video consultations on a regular base.

Conclusions

This study lays the foundation stone for further exploration of the video training in real-time consultations. Both students and teachers on the field acknowledge that the power of imaging is underestimated in the training of communication and vocational skills. The development of supportive material and protocols will lower thresholds.

Practice implications

Time investment for teachers could be tempered by bringing up students to peer tutors and by an accurate scheduling of the video training. The development of supportive material and protocols will lower thresholds. Further research should finally focus on long-term efficacy and efficiency in terms of learning outcomes and on the facilitation of the technical process.

Strategies for effective goals of care discussions and decision-making: perspectives from a multi-centre survey of Canadian hospital-based healthcare providers

Background

Communication gaps impact the quality of patient care. Previous research has focused on communication barriers rather than seeking solutions. Our aim was to identify strategies for effective communication and decision-making about goals of care for medical interventions in serious illness, from the perspectives of hospital-based healthcare providers.

Methods

A cross-sectional survey composed of closed- and open-ended questions about goals of care communication and decision-making was administered to healthcare providers in 13 centres in six Canadian provinces. We analyzed a portion of the open-ended survey questions, specifically (1) suggestions for overcoming barriers encountered in discussing goals of care, and (2) currently effective practices. Thematic content analysis was used to analyze responses to the open-ended questions.

Results

Of the 1,256 respondents to the larger survey, 468 responded to the open-ended questions (37 %), including 272 of 512 nurses (53 %), 153 of 484 internal medicine trainees (32 %), and 43 of 260 attending physicians (17 %). Responses to each of the two questions were similar, generating a common set of themes and subthemes. Effective strategies and ideas for improving communication and decision-making about goals of care clustered under five themes: patient and family factors, communication between healthcare providers and patients, interprofessional collaboration, education, and resources. Subthemes highlighted core elements of shared decision-making.

Conclusions

Translating our findings into multifaceted interventions that consider patient and family factors, address knowledge gaps, optimize resource utilization, and facilitate communication and collaboration between patients, families and healthcare providers may improve communication and decision-making about goals of care.

Electronic supplementary material

The online version of this article (doi:10.1186/s12904-015-0035-x) contains supplementary material, which is available to authorized users.

Exploring residents' communication learning process in the workplace: a five-phase model

Context

Competency-based education is a resurgent paradigm in professional medical education. However, more specific knowledge is needed about the learning process of such competencies, since they consist of complex skills. We chose to focus on the competency of skilled communication and want to further explore its learning process, since it is regarded as a main competency in medical education.

Objective

This study aims to explore in more detail the learning process that residents in general practice go through during workplace-based learning in order to become skilled communicators.

Methods

A qualitative study was conducted in which twelve GP residents were observed during their regular consultations, and were interviewed in-depth afterwards.

Results

Analysis of the data resulted in the construction of five phases and two overall conditions to describe the development towards becoming a skilled communicator: Confrontation with (un)desired behaviour or clinical outcomes was the first phase. Becoming conscious of one’s own behaviour and changing the underlying frame of reference formed the second phase. The third phase consisted of the search for alternative behaviour. In the fourth phase, personalization of the alternative behaviour had to occur, this was perceived as difficult and required much time. Finally, the fifth phase concerned full internalization of the new behaviour, which by then had become an integrated part of the residents’ clinical repertoire. Safety and cognitive & emotional space were labelled as overall conditions influencing this learning process.

Conclusions

Knowledge and awareness of these five phases can be used to adjust medical working and learning environments in such a way that development of skilled medical communication can come to full fruition and its benefits are more fully reaped.

Context factors in general practitioner-patient encounters and their impact on assessing communication skills--an exploratory study

Background

Assessment of medical communication performance usually focuses on rating generically applicable, well-defined communication skills. However, in daily practice, communication is determined by (specific) context factors, such as acquaintance with the patient, or the presented problem. Merely valuing the presence of generic skills may not do justice to the doctor’s proficiency.

Our aim was to perform an exploratory study on how assessment of general practitioner (GP) communication performance changes if context factors are explicitly taken into account.

Methods

We used a mixed method design to explore how ratings would change. A random sample of 40 everyday GP consultations was used to see if previously identified context factors could be observed again. The sample was rated twice using a widely used assessment instrument (the MAAS-Global), first in the standard way and secondly after context factors were explicitly taken into account, by using a context-specific rating protocol to assess communication performance in the workplace. In between first and second rating, the presence of context factors was established. Item score differences were calculated using paired sample t-tests.

Results

In 38 out of 40 consultations, context factors prompted application of the context-specific rating protocol. Mean overall score on the 7-point MAAS-Global scale increased from 2.98 in standard to 3.66 in the context-specific rating (p < 0.00); the effect size for the total mean score was 0.84. In earlier research the minimum standard score for adequate communication was set at 3.17.

Conclusions

Applying the protocol, the mean overall score rose above the level set in an earlier study for the MAAS-Global scores to represent ‘adequate GP communication behaviour’. Our findings indicate that incorporating context factors in communication assessment thus makes a meaningful difference and shows that context factors should be considered as ‘signal’ instead of ‘noise’ in GP communication assessment. Explicating context factors leads to a more deliberate and transparent rating of GP communication performance.

Learning in context: identifying gaps in research on the transfer of medical communication skills to the clinical workplace

OBJECTIVE

In order to reduce the inconsistencies of findings and the apparent low transfer of communication skills from training to medical practice, this narrative review identifies some main gaps in research on medical communication skills training and presents insights from theories on learning and transfer to broaden the view for future research.

METHODS

Relevant literature was identified using Pubmed, GoogleScholar, Cochrane database, and Web of Science; and analyzed using an iterative procedure.

RESULTS

Research findings on the effectiveness of medical communication training still show inconsistencies and variability. Contemporary theories on learning based on a constructivist paradigm offer the following insights: acquisition of knowledge and skills should be viewed as an ongoing process of exchange between the learner and his environment, so called lifelong learning. This process can neither be atomized nor separated from the context in which it occurs. Four contemporary approaches are presented as examples.

CONCLUSION

The following shift in focus for future research is proposed: beyond isolated single factor effectiveness studies toward constructivist, non-reductionistic studies integrating the context.

PRACTICE IMPLICATIONS

Future research should investigate how constructivist approaches can be used in the medical context to increase effective learning and transition of communication skills.

Optimizing the utility of communication OSCEs: omit station-specific checklists and provide students with narrative feedback

OBJECTIVE

To evaluate how the utility (reliability, validity, acceptability, feasibility, cost and educational impact) of a communication-OSCE was influenced by whether or not station-specific (StSp) checklists were used together with a generic instrument and whether or not narrative feedback was provided to students.

METHODS

At ten stations, faculty members rated standardized patient-student interactions using the common ground (CG) instrument (at all stations) and StSp-checklists. Both raters and patients provided written feedback. The impact of changing the design on the various utility parameters was assessed: reliability by means of a generalizability study, cost using the Reznick model and the other utility parameters by means of a survey.

RESULTS

Use of the generic instrument (CG) proved more reliable (G coefficient=0.67) than using the StSp-checklists (G=0.47) or both (G=0.65) while there was a high correlation between both scale scores (Pearsons'r=0.86). The cost was 6.5% higher when StSp-checklists were used and 5% higher when narrative feedback was provided.

CONCLUSION

The utility of a communication OSCE can be enhanced by omitting StSp-checklists and by providing narrative feedback to students.

PRACTICE IMPLICATIONS

The same generic assessment scale can be used in all stations of a communication OSCE. Providing feedback to students is promising but it increases the costs.

Pre-registration dietetic students' attitudes to learning communication skills

BACKGROUND

  Communication is a core skill and a prerequisite for dietitians' clinical competence. It is generally acknowledged that communication skills can be taught and learned. There is a paucity of published work identifying dietetic students' attitudes towards learning communication skills, and understanding this is important.

METHODS

  The present cross-sectional study aimed to address this issue using an adapted version of the Communication Skills Attitude Scale (CSAS), which was designed to capture information concerning positive and negative attitudes to learning communication skills. An online questionnaire was sent to all undergraduate and post-graduate dietetic programmes in the UK.

RESULTS

  Of the students' solicited for enrolment in the study, 33.4% (n = 300) completed the questionnaire. A one-way analysis of variance showed attitudes to learning communication skills differed significantly between years of study on both subscales of the CSAS. Subsequent analyses indicated that first-year students' attitudes to learning communication skills were significantly more positive than those of fourth-year students (P = 0.042). Third-year students had significantly more positive attitudes to learning communication skills than fourth-year students (P = 0.028). Negative attitudes were also linked to the year of study with fourth-year students having significantly more negative attitudes than third-year students (P = 0.046). Sex, practice placement experience and parental occupation did not significantly influence attitudes to learning communication skills.

CONCLUSIONS

  These findings indicate that efforts are required to maintain positive attitudes to learning communication skills. Further longitudinal studies are recommended in this respect.

Identifying context factors explaining physician's low performance in communication assessment: an explorative study in general practice

Background

Communication is a key competence for health care professionals. Analysis of registrar and GP communication performance in daily practice, however, suggests a suboptimal application of communication skills. The influence of context factors could reveal why communication performance levels, on average, do not appear adequate. The context of daily practice may require different skills or specific ways of handling these skills, whereas communication skills are mostly treated as generic. So far no empirical analysis of the context has been made. Our aim was to identify context factors that could be related to GP communication.

Methods

A purposive sample of real-life videotaped GP consultations was analyzed (N = 17). As a frame of reference we chose the MAAS-Global, a widely used assessment instrument for medical communication. By inductive reasoning, we analyzed the GP behaviour in the consultation leading to poor item scores on the MAAS-Global. In these cases we looked for the presence of an intervening context factor, and how this might explain the actual GP communication behaviour.

Results

We reached saturation after having viewed 17 consultations. We identified 19 context factors that could potentially explain the deviation from generic recommendations on communication skills. These context factors can be categorized into doctor-related, patient-related, and consultation-related factors.

Conclusions

Several context factors seem to influence doctor-patient communication, requiring the GP to apply communication skills differently from recommendations on communication. From this study we conclude that there is a need to explicitly account for context factors in the assessment of GP (and GP registrar) communication performance. The next step is to validate our findings.