a Division of Primary Care, Department of community care, primary care and emergency, Geneva University Hospitals, Switzerland
bUnit of Development and Research in Medical Education, University of Geneva Faculty of Medicine, Switzerland
c Unit of primary care medicine, University of Geneva Faculty of Medicine, Switzerland
d Service of general internal medicine, Department of internal medicine, rehabilitation and geriatric medicine, Geneva University Hospitals, Switzerland
Communication skills tend to decline with time unless they are regularly recalled and practiced. However, most medical schools still deliver clinical communication training only during pre-clinical years although the clinical environment is considered to be ideal for acquiring and teaching clinical communication. The aim of this article is to review the barriers that prevent communication skills teaching and training from occurring in clinical practice and describe strategies that may help enhance such activities. Barriers occur at several levels: students, junior doctors and clinical supervisors sometimes have negative attitudes towards communication training; structured training in communication skills is often insufficient; clinical supervisors behave as poor role models and lack effective communication and teaching skills; finally, there are organisational constraints such as lack of time, competing priorities, weak hierarchy support and lack of positive incentives for using, training or teaching good communication skills in clinical practice. Given the difficulty of assessing transfer of communication skills in practice, only few studies describe successful educational interventions. In order to optimise communication skills learning in practice, there is need to: (1.) modify the climate and structure of the working environment so that that use, training and teaching of good communication skills in clinical practice becomes valued, supported and rewarded; (2.) extend communication skills training to any field of medicine; (3.) provide regular structured trainings and tailor them to trainees’ needs. Practical implications of such findings are discussed at the end of this review.
Key words: communication skills; training; teaching; clinical practice; barriers; strategies
The words “trainees” or “students/junior doctors” will be used interchangeably in the text. Similarly, “clinical supervisors” or “trainers” will be used to name senior doctors who teach in clinical practice. Finally, “training programmes” for clinical supervisors will also sometimes be named as Faculty development programmes.
“Clerkships” refer to students’ clinical training and rotations during pre-graduate training and "graduate training" to training occurring after completion of pre-graduate training.
Research conducted over the last decades has shown that good clinical communication has a positive influence on many outcomes ranging from patient satisfaction, consultation process, health behaviours, to human and economic costs of care [1–3].
Although some elements of clinical communication can be learned through practice such as being civil, maintaining eye contact and avoiding medical jargon, skills such as setting the agenda, regular use of summarising and perception skills (building rapport, exploration of patients’ perspectives) are less easily acquired even after many years of practice . There is now strong evidence that clinical communication can be effectively taught to and learned by medical students, junior doctors and nurses [5–7]. A recent systematic review showed that nearly all educational interventions resulted in improved communication behaviours among physicians .
The way communication should be taught is highly debated. Most experts share the conviction that good communication skills are not innate and can be learned through intentional, systematic and experiential training [9, 10]. Experiential learning includes role playing, interaction with simulated patient, practice under supervision and observation of self and others’ practice. From theoretical perspectives, experiential learning differs from learning by doing in that it is considered as a structured cyclic process: its aim is to increase learning through the use of activated knowledge, practice, reflection and feedback that can take place either on an individual or collective level, in structured or daily practice [11, 12]. Focusing on tasks and skills encourages physicians to acquire a repertoire of strategies helping them meet their patients’ needs [10, 13]. Others argue that divising communication into skills defined, taught and then assessed by experts is too reductionist: communication is inherently subjective and there may be different ways to communicate that cannot be labelled as right or wrong since different patients may experience the same communication style differently . Alternatives to skill-based communication training include approaches such as as mindfulness and self-awareness: they allow doctors to explore and analyse their thoughts, feelings and emotions towards patients and use their emotional reactions to patients for patients’ benefits . As in different arts, both approaches are thought to be complementary : applying communication skills is not a matter of “one size fits all” but requires creativity and flexibility .
Most medical schools have now structured communication skills programme in undergraduate medical education. However, communication skills tend to decline with time unless they are regularly recalled and practiced [18, 19]. Most communication courses are given exclusively during pre-clinical years and delivered separately from other clinical skills such as history taking, physical and clinical reasoning . Apart from a few exceptions , medical schools and hospitals still find it difficult to implement clinically-based, longitudinal communication skills training programmes during clerkships and graduate training. Still, there are few reports about graduate training except in fields such as general practice, psychiatry and oncology [21, 22], and even less in continuing medical education [23, 24]. Finally, longitudinal programmes are rare [25–27].
Although the clinical environment, as opposed to classrooms, is still considered to be the best place to acquire clinical skills (including patient communication), the teaching and evaluation of communication skills in a clinical context remain insufficient [28, 29]: many students and junior doctors have never been observed while taking history and very seldom get feedback on communication skills [30, 31].
The aim of this article is to first review the barriers to communication skills learning and teaching in clinical practice and second to provide a few strategies based on a review of literature and education principles in order to help enhance such training during clinical practice.
Barriers to communication skills learning and teaching in clinical practice
Barriers to communication skills learning and teaching in clinical practice are multiple and can be analysed at four levels: trainees, trainers, training and work environment/organisation (table 1).
Several authors have described students and junior doctors’ negative attitudes towards communication skills and their reluctance to learn them. The belief still exists that communication is innate and is a subjective social and non academic science that cannot be taught [32, 33]. Personal factors also influence students’ perceptions of communication skills: in UK studies, students with more positive attitudes towards communication skills learning tended to be female, to have parents who were not doctors, and to think their communication skills needed improving .
Trainees’ attitudes may also vary according to their level of experience. Junior and inexperienced doctors are described as more stressed and less open to communication issues than more experienced ones because they are still struggling to reach a quick diagnosis and prompt treatment . Coping with difficulties such as gaps in knowledge and clinical reasoning and use of technical procedures (electronic medical records) tend to hamper good communication [36, 37].
Despite these elements, several papers show that junior doctors value communication skills and expect them to be taught during bed-side teaching and ward rounds [31, 38, 39]. They also expect their clinical supervisors to take an active role in observing them and giving feedback, and to teach exemplary communication [40, 41].
Teaching communication skills in clinical practice requires trainers to believe in, demonstrate and teach them . Shortcomings in communication skills teaching may be perpetuated by the supervisor’s beliefthat it is not essential to their expertise and cannot be taught .
In addition, clinical supervisors tend to teach communication and relationship skills by role modeling, in a very variable and rarely explicit way . When clinical supervisors address communication issues with junior doctors, they tend to intervene more often as rescuers, clinicians or coaches than teachers . By simply watching and listening, they expect that junior doctors will recognise, accept and reproduce desirable behaviours and skills . Supervisors are often described as poor role models . They report little training in communication and do not feel confident enough to teach and evaluate skills that they themselves have not mastered . Finally, lack of faculty training in teaching skills is another important barrier to teaching communication skills .
The training of learners
Although students and junior doctors expect to be taught through direct observation of their performance followed by feedback , they often report that observation rarely occurs [30, 47, 48], or “informally, without structure or dedicated time and without distinct goals” .
Structured training itself can impact negatively on students’ perception, depending on the type of teaching methods used . It has been observed that the less experiential training they have received in communication skills, the less they consider communication as a skill that can be learned and used to improve patients’ outcomes . Use of experiential training methods (role playing, interaction with simulated patients, practice followed by feedback, etc…) for both trainees and trainers is highly recommended . However, trainees can negatively perceive such experiential sessions if they are not conducted in a safe, non-judgemental and trustful climate .
Communication is also often taught by separate groups of teachers. Specialist physicians or surgeons tend to teach history taking and physical examination while general practitioners, psychiatrists and health scientists are those who address mostly communication and relationship issues . Such a division of teaching fields conveys a tacit message to students that specialists are those who know about core medicine while the others are specialists of psychosocial and less scientific issues. It may also carry the message that communication skills are a goal in itself and not a tool that allows for providing a higher quality of care to patients.
Finally, the way clinical communication is assessed can generate a counterproductive effect towards communication. For example, use of checklists is sometimes not well accepted by trainees since it gives the message that a conversation can be reduced to mere behavioural components and does not take into account the uniqueness of each consultation [54, 55].
The working environment
Lack of time is regularly described as a major barrier to teaching in clinical practice. The supervisors’ first mandate is to address the medical needs of patients whatever their level of training or professional position . When time is limited, other mandates such as teaching and research often become secondary. This suggests that teaching in general and more specifically communication skills teaching are not priorities in working settings [57–59] and that the institution itself gives little value to communication skills and its training [33, 51, 60]. Scarce resources to communication skills training may indicate to students and junior doctors that these competencies are less valued by their faculty or within each setting. This often called the “hidden curriculum” which refers to cultural values that are transmitted but not explicitly acknowledged through formal and informal educational activities .
|Table 1: Barriers to communication skills learning and teaching in clinical practice.|
|Trainees||Personal beliefs and socio-cultural factors
Level of experience
Poor role models
Lack of communication skills
Lack of teaching skills
|Training||Use of non experiential teaching methods
Separation of communication and clinical skills training
Assessment with checklists not perceived as clinically relevant
|Organisation||Lack of time
Lack of communication skills consideration
|Table 2: Strategies to improve communication skills training in clinical practice.|
|(1.) To adjust the work environment:
– to ensure the adequacy between the formal, the informal and the hidden curriculum
– toformalise communication and interpersonal skills as learning objectives
– to integrate clinical communication in mainstream clinical training activities
(2.) To teach communication skills in any medical field
(3.) To integrate communication skills training inside other training activities
(4.) To train clinical supervisors in communication and teaching skills in order to allow:
– positive role modeling
– students' observation (to recognise poor or good skill performance) followed by a well-intentioned, detailed and descriptive feedback
– consideration of communication issues during case presentation
(5.) To tailor communication skills training to trainees' individual needs
(6.) To integrate communication skills evaluation in assessment of clinical practice
(7.) Tobuild communities of practice of communication skills teachers
Strategies/tips to improve communication skills training in clinical practice
In order to develop and implement strategies aimed at improving communication skills training in practice, there is first a need to understand the notion of transfer and its effectiveness. Training transfer is effective when the knowledge, skills and abilities acquired in the training context produce the desired behavioural change in the workplace context . It is influenced by the trainees’ personal and professional characteristics, the design and content of the training programme, and the workplace environment . Because communication and teaching are considered to be skills for which there is much freedom about what and when to transfer, the degree of transfer may depend as much on personal and working situation factors than on the training itself . Although there are very few communication studies which assessed the transfer effectiveness of a training in communication skills and identified key elements of successful transfer [5, 64, 65], a review of the educational literature in this field and educational theory-based principles suggests that the implementation of seven strategies may facilitate communication skills learning and teaching in clinical practice (table 2). They will be addressed from a general to a more specific perspective.
Adjusting the working environment
The organisation of the working environment is an important element for successful and sustainable transfer in the field of communication skills [26, 66]. If trainees and trainers perceive that there will be no support for the transfer of training, they will not be very motivated to invest the effort required to master the content of the training . Successful and durable implementation of communication skills training in practice requires a change in strategy at the level of an institution or working structure such as a service in order to align the training to the institutional goals and strategies . Moreover, it requires an adequacy between the different types of curriculum prevailing inside an institution or working structure: (1.) the formal curriculum: the stated, intended and formally offered learning goals which are outlined in mission statements and course objectives; (2.) the informal curriculum: the unscripted and highly interpersonal form of teaching and learning occurring between students/junior doctors and more experienced clinicians such as role modeling and supervision; and (3.) the hidden curriculum which refers to the structural factors and the culture and values of the institution as described above [61, 69].
In order to harmoniously integrate communication into an institution mission, the first step is to ensure that communication and interpersonal skills are all recognised and formalised as learning objectives inside an institution. Communication, together with professionalism, teamwork and evidence-based decision making must be considered core themes for clinical practice .
The second step is to link communication learning objectives to relevant clinical training activities so that it is not considered as something optional .
The third step is to ensure that the learned skills are applied and improved in practice.
This implies faculty development activities to train faculty members in teaching and assessing communication skills. Sufficient time should, therefore, be allowed to effectively supervise students and junior doctors and help them improve their communication skills.
Changes at an institutional level depend mainly on the perceived need of the institution leaders although this perception may be favoured by interventions of national or regional educational boards that usually take place through accreditation processes.
Teaching communication skills in any medical field
Extending communication skills training to all fields of medicine is another way to promote the importance of communication skills training. It transmits the message that good clinical communication is important and desirable for patient care in any medical discipline. Although such development requires considerable patience, flexibility and negotiation, two studies have shown that implementation of communication skills training in clerkships of different medical disciplines is not only feasible and well-appreciated by students  but also effective with significant improvement in students’ communication skills performance . Ingredients of success encompass strong support from the hierarchy (that can be obtained by matching institutional interests with course interests through accreditation) and active involvement of all clerkships’ medical coordinators in several steps: (1.) defining the communication skills to be taught during each clerkship and ensuring that they are in line with the departments’ interests (explaining a surgical procedure in surgery, breaking bad news such multiple sclerosis in neurology,…); (2.) developing regular structured teaching experiential sessions; (3.) providing clinical supervisors teaching skills to help them facilitate such training sessions, (4.) providing effective feedback during clinical practice and positive role models .
At an undergraduate level, the educational committee for clinical years in medical schools may play an important role in encouraging all clerkship coordinators to think of one communication issue that could be addressed during their clerkship and providing help to ensure its development and implementation.
At a graduate level, hospital satisfaction surveys and reports of patients show that patients regularly complain about the quality of communication [72–74]. Regular discussions initiated by quality officers about such issues inside each working structure may be another way for their heads to become aware of the problem. They could trigger efforts to improve the quality of communication teaching and training at the postgraduate level in their settings. Ultimately, it may improve the quality of communication between physicians and patients .
Integrating communication skills training into clinical training activities
Several changes or adjustments have been suggested to help clinical communication training being part of the mainstream activities during medical education . The key concept revolves around integration. There is a definite need to integrate clinical communication with other skills such as history taking, physical examination and clinical reasoning and not teach it as a separate skill in order to show that content and process of history taking or counselling forms a whole in pre-graduate but also graduate clinical training [53, 76]. For example, addressing communication issues inside training management of depression, diabetes or coronary heart disease may be a convincing way to show that appropriate management of the patients suffering from these diseases requires mastery of both content and process in order to provide high quality of care. Providing opportunities for trainees to train simultaneously technical and communication skills for procedures such as venous puncture, urinary catheter placement in skill labs is also another nice and rather innovative way to integrate communication with other skills [53, 77].
Training clinical supervisors to teach communication skills in practice
Experts agree on the importance of faculty development to enhance communication skills teaching in practice since clinical supervisors’ attitudes, communication patterns and teaching skills heavily influence communication performance of students and junior doctors [43, 78, 79].
Communication skills teaching in clinical practice can take place in several ways: role modeling, observation of performance followed by feedback and feedback on case presentation.
In clinical practice where learning occurs mostly informally, role modeling is considered by both clinical supervisors and junior doctors to be a powerful way to enhance learning and convey professional values, attitudes and behaviours and learn about the doctor-patient relationship . The most important qualities of good role models are: medical competence with up-to-date knowledge, commitment to excellence, being compassionate, caring, patient-centred, a humanistic attitude towards patients with good communication skills, a humanistic style of teaching, compassion for patients and interest in teaching . Since trainees tend to emulate positive role models , it is important to improve trainers’ role modeling with regard to communication skills. Ingredients of effective role modeling include being aware of being a role model, being reflective, participating in staff development and having time to teach . With regard to communication, it implies being aware of one’s own communication patterns, mastering good communication skills, maintaining them through reflection and continuing training and having time to teach.
Being able to observe students and junior doctors perform in a clinical setting and deliver a well-intentioned, detailed and descriptive feedback is considered to be one of the most powerful ways to teach communication skills in clinical practice [10, 23]. Feedback can positively change medical students’, junior doctors’, or trained physicians’ performance, whatever their level of training and whatever the setting . Effective communication skills teaching requires clinical supervisors to know what is important to teach and to be able to recognise good or poor skill performance . Therefore, faculty development programmes on communication skills training often offer preliminary communication skills training to help the trainers recognise and expand their repertoire of communication skills in various clinical situations [84, 85]. A study showed that training supervisors in both teaching strategies and communication skills was effective in that it objectively improved supervisors’ feedback skills after the training .
The necessity to regularly and appropriately evaluate junior doctors’ performance at work has led to the development of faculty development programmes in order to equip supervisors with effective teaching skills. Integration of vignettes that systematically include communication challenges together with clinical reasoning or procedural issues during training sessions may be a way to train and stimulate supervisors to address them in clinical practice.
A third strategy to teach communication skills in practice takes place when students and junior doctors make patient presentations to their supervisors . Although trainers’ feedback after such case presentation often focuses on biomedical content and missing information, taking the opportunity to address the necessary skills to hold an interview, obtain information, elicit patients’ perspectives may help trainees perceive and understand what constitutes effective interviewing and its impact on the accuracy and efficiency on which correct diagnoses are made [41, 76]. To facilitate transfer of learned communication skills, it appears important to address content (medical information and reasoning) and process (communication skills) of history taking together and not separately .
From such a perspective, development or reinforcement of structured communication skills training at the graduate level may be an effective transfer strategy for communication skills teaching: it allows a higher number of clinical supervisors to practice and master such skills and may also reinforce collaboration and continuity across the pre-clinical, clinical and graduate education  since the same supervisors tend to teach both the students and junior doctors. It may also help decrease the discordance perceived by students and young doctors between the formal training in communication skills they have received and their observation of how these are used in the workplace [87, 88].
Tailoring communication skills training to trainees’ individual needs
It may be hazardous to teach communication skills in a uniform way because learning needs tend to differ according to personal, training and contextual factors .
Professional development itself also shapes learners’ perspectives and needs. As young physicians progress in their training, self-representations change and their perceptions and attitudes towards psychosocial issues and patient-physician relationships evolve. Over time, they also feel more confident in their ability to deal with psychosocial issues  and give more importance to patient-centred models of care .
The importance of contextual factors has been highlighted in a study that showed that junior doctors from different specialties emphasised different communication norms, values and skills: in paediatrics and internal medicine they emphasised reflective practice while in surgery, obstetrics and gynaecology they focused more on specific skills and behaviour acquisition . Needs for communication skills also differ between in- and outpatient care contexts: in the inpatient setting where clinical work focuses on making diagnoses and managing biomedical dimensions of care, junior doctors expressed needs to learn transmitting information and handling their own emotions. In the outpatient context, where patients are seen as more autonomous and empowered, more attention was paid to using communication tools that help manage time in the clinical encounter and increase patients’ compliance with recommended care . In addition, inside a working setting, the communication is modulated by the context and cannot be applied according fixed rules .
More generally, junior doctors express training needs for communication issues that are complex, challenging and relevant in their working context [37, 94].
Therefore, it seems reasonable to move beyond uniform communication skills training usually delivered during pre-clinical years and to target educational interventions in later clinical practices tailored to learners’ needs. In order for communication skills to be effectively maintained in post-training medical practice, the issues must be those frequently encountered in clinical practice and associated with a high burden . Asking regularly junior doctors about their problems encountered while communicating with patients or families may orient on the communication issues to address both formally and informally – they may change according to their present and past clinical and training experiences.
Integrated assessment of communication skills
Assessing communication skills is another powerful way to demonstrate their value and legitimacy as a focus of training. Although the statement “assessment drives learning” is often debated , there is a consensus that assessment must be educational, formative so as to promote learning and that it should provide guidance and support to address learning needs . In order to be relevant and meaningful, the focus of assessment must closely match the learning objectives and content of the taught curriculum. Methods used to assess trainees’ communication skills usually include direct observations of their performance in simulated or real clinical encounters. To involve clinical supervisors in the development of examination material and assessment itself is an additional way to value and facilitate integration of communication skills inside an institution . The fact that the interpersonal and communication skills are defined now as one of the core medical competencies and that their assessment in graduate training programmes becomes mandatory in many countries [98, 99] may change such culture and increase institutional support for such training. Implementation of work-based performance assessment such as mini-CEX may be a powerful way to emphasise such assessment . However, one must ensure that assessment is performed in a fair and adaptable way since clinical communication changes according to the context in which the consultation takes place .
The way these different strategies can interact in order to improve physician-patient communication is illustrated in figure 1.
To build communities of practice of communication skills teachers
Finally, recent articles have shown the importance of building communities of practice to lead and sustain faculty development in the workplace [101, 102] since social networking, mentorship and peer support are essential for supporting and strengthening workplace teaching . Communities of practice are defined as “persistent, sustaining, social networks of individuals who share an overlapping knowledge base, set of beliefs, values, history and experiences focused on a common practice and/or a mutual enterprise” . Becoming a member of a communication skills teaching community may contribute to maintain one’s own motivation to practice and stimulate continuous improvement thanks to an exchange of ideas and a sharing of encountered difficulties with peers . Indeed, a study showed that being involved in structured communication skills teaching activities appears to facilitate communication skills teaching in clinical practice . For example, teaching regularly how to break bad news will encourage a trainer to address this issue while supervising a junior doctor.
Given the fact that patients regularly complain about the quality of communication in health care settings, there is real need to improve communication skills training during pre- and graduate training from both trainees and trainers’ perspectives. Structured communication skills training is still needed in graduate training and should be tailored to junior doctors’ needs and work context in order to be successful and well perceived. Training clinical supervisors from all specialties to teach communication skills is a powerful way to ensure continuity between pre-graduate and graduate education and to reinforce the message that communication is essential to patient care in any medical field. However, in order to ensure regular and systematic communication skills teaching in clinical practice, more emphasis should be given to post-training incentives to sustain such efforts. These include academic recognition of teaching activities, peer and supervisory coaching, increased opportunities to practice and creation of a community of teachers; other incentives should also include development of institutional rewards for teaching communication skills and use of patient satisfaction regarding communication issues as a feedback loop in a quality improvement cycle.
This article is a shortened version of the post graduate professorship thesis of Noelle Junod Perron defended on 3 February 2014 at the Faculty of Medicine, Geneva University, Geneva, Switzerland and was inspired by her PhD thesis in medical education defended on 24 October 2013 at Maastricht University, Maastricht, the Netherlands.
Funding / potential competing interests: No financial support and no other potential conflict of interest relevant to this article was reported.
Correspondence: Noëlle Junod Perron, Division of Primary Care, Department of community care, primary care and emergency, Geneva University Hospitals, CH-1211 Geneva, noelle.junod[at]hcuge.ch
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