Review article: Biomedical intelligence
Vol. 145 No. 0304 (2015)
Teaching communication skills: beyond wishful thinking
- Noelle Junod Perron
- Johanna Sommer
- Martine Louis-Simonet
- Mathieu Nendaz
Summary
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.
References
- Dwamena F, Holmes-Rovner M, Gaulden CM, Jorgenson S, Sadigh G, Sikorskii A, et al. Interventions for providers to promote a patient-centred approach in clinical consultations. Cochrane Database Syst Rev 2012, 12:CD003267.
- Joosten EA, DeFuentes-Merillas L, de Weert GH, Sensky T, van der Staak CP, de Jong CA. Systematic review of the effects of shared decision-making on patient satisfaction, treatment adherence and health status. Psychother Psychosom 2008;77(4):219–26.
- Zolnierek KB, Dimatteo MR. Physician communication and patient adherence to treatment: a meta-analysis. Med Care. 2009;47(8):826–34.
- Aspegren K, Lonberg-Madsen P. Which basic communication skills in medicine are learnt spontaneously and which need to be taught and trained? Med Teach. 2005;27(6):539–43.
- Heaven C, Clegg J, Maguire P. Transfer of communication skills training from workshop to workplace: the impact of clinical supervision. Patient Educ Couns. 2006;60(3):313–25.
- Langewitz WA, Eich P, Kiss A, Wossmer B: Improving communication skills – a randomized controlled behaviorally oriented intervention study for residents in internal medicine. Psychosom Med. 1998;60(3):268–76.
- Yedidia MJ, Gillespie CC, Kachur E, Schwartz MD, Ockene J, Chepaitis AE, Snyder CW, Lazare A, Lipkin M, Jr.: Effect of communications training on medical student performance. JAMA. 2003;290(9):1157–65.
- Rao JK, Anderson LA, Inui TS, Frankel RM. Communication interventions make a difference in conversations between physicians and patients: a systematic review of the evidence. Med Care. 2007;45(4):340–9.
- Silverman J, Kurtz S, Draper J. Skills for communicating with patients. 2nd edition. Oxon: Radcliff Publishing Ltd; 2005.
- Kurtz S, Silverman J, Draper J. Teaching and learning communication skills in medicine. 2nd edition. Oxford: Radcliff Publishing Ltd; 2005.
- Spencer J. Learning and teaching in the clinical environment. BMJ. 2003;326(7389):591–4.
- Yardley S, Teunissen PW, Dornan T. Experiential learning: AMEE Guide No. 63. Med Teach. 2012;34(2):e102–15.
- Makoul G, Schofield T. Communication teaching and assessment in medical education: an international consensus statement. Netherlands Institute of Primary Health Care. Patient Educ Couns. 1999;37(2):191–5.
- Salmon P, Young B. The validity of education and guidance for clinical communication in cancer care: evidence-based practice will depend on practice-based evidence. Patient Educ Couns. 90(2):193–9.
- Epstein RM. Mindful practice. JAMA. 1999;282(9):833–9.
- Zoppi K, Epstein RM. Is communication a skill? Communication behaviors and being in relation. Fam Med. 2002;34(5):319–24.
- Essers G, van Dulmen S, van Es J, van Weel C, van der Vleuten C, Kramer A. Context factors in consultations of general practitioner trainees and their impact on communication assessment in the authentic setting. Patient Educ Couns. 2013;93(3):567–72.
- Aspegren K. BEME Guide No.2: Teaching and learning communication skills in medicine – a review with quality grading of articles. Medical Teacher. 1999;21:563–70.
- van Dalen J, Kerkhofs E, van Knippenberg-Van Den Berg BW, van Den Hout HA, Scherpbier AJ, van der Vleuten CP. Longitudinal and concentrated communication skills programmes: two dutch medical schools compared. Adv Health Sci Educ Theory Pract. 2002;7(1):29–40.
- van Weel-Baumgarten E, Bolhuis S, Rosenbaum M, Silverman J. Bridging the gap: How is integrating communication skills with medical content throughout the curriculum valued by students? Patient Educ Couns. 2013;90(2):177–83.
- Hulsman RL, Ros WJ, Winnubst JA, Bensing JM. Teaching clinically experienced physicians communication skills. A review of evaluation studies. Med Educ. 1999;33(9):655–68.
- Moore PM, Rivera Mercado S, Grez Artigues M, Lawrie TA. Communication skills training for healthcare professionals working with people who have cancer. Cochrane Database Syst Rev 2013, 3:CD003751.
- Berkhof M, van Rijssen HJ, Schellart AJ, Anema JR, van der Beek AJ. Effective training strategies for teaching communication skills to physicians: an overview of systematic reviews. Patient Educ Couns. 2011;84(2):152–62.
- Rotthoff T, Baehring T, David DM, Bartnick C, Linde F, Willers R, Schafer RD, Scherbaum WA. The value of training in communication skills for continuing medical education. Patient Educ Couns. 2011;84(2):170–5.
- Levinson W, Roter D. The effects of two continuing medical education programs on communication skills of practicing primary care physicians. J Gen Intern Med. 1993;8(6):318–24.
- Stein T, Frankel RM, Krupat E. Enhancing clinician communication skills in a large healthcare organization: a longitudinal case study. Patient Educ Couns. 2005;58(1):4–12.
- Kurtz SM, Laidlaw T, Makoul G, Schnabl G. Medical education initiatives in communication skills. Cancer Prev Control. 1999;3(1):37–45.
- Holmboe ES, Hawkins RE, Huot SJ. Effects of training in direct observation of medical residents’ clinical competence: a randomized trial. Ann Intern Med. 2004;140(11):874–81.
- Kalet A, Earp JA, Kowlowitz V. How well do faculty evaluate the interviewing skills of medical students? J Gen Intern Med. 1992;7(5):499–505.
- Howley LD, Wilson WG. Direct observation of students during clerkship rotations: a multiyear descriptive study. Acad Med. 2004;79(3):276–80.
- Hutul OA, Carpenter RO, Tarpley JL, Lomis KD. Missed opportunities: a descriptive assessment of teaching and attitudes regarding communication skills in a surgical residency. Curr Surg. 2006;63(6):401–9.
- Nogueira-Martins MC, Nogueira-Martins LA, Turato ER. Medical students’ perceptions of their learning about the doctor-patient relationship: a qualitative study. Med Educ. 2006;40(4):322–8.
- Rees CE, Sheard CE, McPherson AC. A qualitative study to explore undergraduate medical students’ attitudes towards communication skills learning. Med Teach. 2002;24(3):289–93.
- Rees C, Sheard C. The relationship between medical students' attitudes towards communication skills learning and their demographic and education-related characteristics. Med Educ. 2002;36(11):1017–27.
- Junod Perron N, Sommer J, Hudelson P, Demaurex F, Luthy C, Louis-Simonet M, et al. Clinical supervisors’ perceived needs for teaching communication skills in clinical practice. Medical Teacher. 2009(31):e316–22.
- Essers G, Van Weel-Baumgarten E, Bolhuis S. Mixed messages in learning communication skills? Students comparing role model behaviour in clerkships with formal training. Med Teach. 2012;34(10):e659–65.
- Van Nuland M, Thijs G, Van Royen P, Van den Noortgate W, Goedhuys J. Vocational trainees' views and experiences regarding the learning and teaching of communication skills in general practice. Patient Educ Couns. 2009;78(1):65–71.
- Williams KN, Ramani S, Fraser B, Orlander JD. Improving bedside teaching: findings from a focus group study of learners. Acad Med. 2008, 83(3):257–64.
- Tariq M, Motiwala A, Ali SU, Riaz M, Awan S, Akhter J. The learners’ perspective on internal medicine ward rounds: a cross-sectional study. BMC Med Educ. 2010;10:53.
- Malhotra A, Gregory I, Darvill E, Goble E, Pryce-Roberts A, Lundberg K, et al. Mind the gap: Learners’ perspectives on what they learn in communication compared to how they and others behave in the real world. Patient Educ Couns. 2009;76(3):385–90.
- Rosenbaum ME, Axelson R. Curricular disconnects in learning communication skills: what and how students learn about communication during clinical clerkships. Patient Educ Couns. 2012;91(1):85–90.
- Cote L, Leclere H. How clinical teachers perceive the doctor-patient relationship and themselves as role models. Acad Med. 2000;75(11):1117–24.
- Egnew TR, Wilson HJ. Role modeling the doctor-patient relationship in the clinical curriculum. Fam Med. 2011;43(2):99–105.
- Weissmann PF, Branch WT, Gracey CF, Haidet P, Frankel RM. Role modeling humanistic behavior: learning bedside manner from the experts. Acad Med. 2006;81(7):661–7.
- Novack DH, Volk G, Drossman DA, Lipkin M, Jr. Medical interviewing and interpersonal skills teaching in US medical schools. Progress, problems, and promise. JAMA. 1993;269(16):2101–5.
- Lane JL, Gottlieb RP. Structured clinical observations: a method to teach clinical skills with limited time and financial resources. Pediatrics. 2000;105(4 Pt 2):973–7.
- Chisholm CD, Whenmouth LF, Daly EA, Cordell WH, Giles BK, Brizendine EJ. An evaluation of emergency medicine resident interaction time with faculty in different teaching venues. Acad Emerg Med. 2004;11(2):149–55.
- Kassebaum DG, Eaglen RH. Shortcomings in the evaluation of students’ clinical skills and behaviors in medical school. Acad Med. 1999;74(7):842–9.
- Fromme HB, Karani R, Downing SM. Direct observation in medical education: a review of the literature and evidence for validity. Mt Sinai J Med. 2009;76(4):365–71.
- Rees C, Sheard C. Evaluating first-year medical students’ attitudes to learning communication skills before and after a communication skills course. Med Teach. 2003;25(3):302–7.
- Willis SC, Jones A, O’Neill PA. Can undergraduate education have an effect on the ways in which pre-registration house officers conceptualise communication? Med Educ. 2003;37(7):603–8.
- Kurtz S, Silverman J, Draper J. Teaching and learning communication skills in medicine. 2nd edition edition. Oxford: Radcliff Publishing Ltd; 2005.
- Silverman J. Teaching clinical communication: a mainstream activity or just a minority sport? Patient Educ Couns. 2009;76(3):361–7.
- Salmon P, Young B. Creativity in clinical communication: from communication skills to skilled communication. Med Educ. 2011;45(3):217–26.
- van den Eertwegh V, van Dalen J, van Dulmen S, van der Vleuten C, Scherpbier A. Residents’ perceived barriers to communication skills learning: Comparing two medical working contexts in postgraduate training. Patient Educ Couns. 2014;95(1):91–7.
- Yedidia MJ, Schwartz MD, Hirschkorn C, Lipkin M, Jr. Learners as teachers: the conflicting roles of medical residents. J Gen Intern Med. 1995;10(11):615–23.
- Seabrook MA. Medical teachers’ concerns about the clinical teaching context. Med Educ. 2003;37(3):213–22.
- Morrison EH, Shapiro JF, Harthill M. Resident doctors’ understanding of their roles as clinical teachers. Med Educ. 2005;39(2):137–44.
- Busari JO, Prince KJ, Scherpbier AJ, Van Der Vleuten CP, Essed GG. How residents perceive their teaching role in the clinical setting: a qualitative study. Med Teach. 2002;24(1):57–61.
- Laidlaw TS, MacLeod H, Kaufman DM, Langille DB, Sargeant J. Implementing a communication skills programme in medical school: needs assessment and programme change. Med Educ. 2002;36(2):115–24.
- Hafferty FW. Beyond curriculum reform: confronting medicine's hidden curriculum. Acad Med 1998;73(4):403–7.
- Goldstein IL, Ford JK. Training in organisations. Belmont, CA: Wadsworth; 2002.
- Blume BD, Ford JK, Baldwin TT, Huang JL. Transfer of training: a meta-analytic review. Journal of Management. 2010;36(4):1065–105.
- Lienard A, Merckaert I, Libert Y, Bragard I, Delvaux N, Etienne AM, et al. Transfer of communication skills to the workplace during clinical rounds: impact of a program for residents. PLoS One 2010;5(8):e12426.
- van den Eertwegh V, van Dulmen S, van Dalen J, Scherpbier AJ, van der Vleuten CP. Learning in context: Identifying gaps in research on the transfer of medical communication skills to the clinical workplace. Patient Educ Couns. 2013;90(2):184–92.
- Levinson W, D’Aunno T, Gorawara-Bhat R, Stein T, Reifsteck S, Egener B, et al. Patient-physician communication as organizational innovation in the managed care setting. Am J Manag Care. 2002;8(7):622–30.
- Salas E, Cannon-Bowers JA. The science of training: a decade of progress. Annual reviews psychology. 2001;52:471–99.
- Visser A, Wysmans M. Improving patient education by an in-service communication training for health care providers at a cancer ward: communication climate, patient satisfaction and the need of lasting implementation. Patient Educ Couns. 2010;78(3):402–8.
- Cruess SR, Cruess RL, Steinert Y. Role modeling – making the most of a powerful teaching strategy. BMJ. 2008;336(7646):718–21.
- Hirsh DA, Ogur B, Thibault GE, Cox M. “Continuity” as an organizing principle for clinical education reform. N Engl J Med. 2007;356(8):858–66.
- Kalet A, Pugnaire MP, Cole-Kelly K, Janicik R, Ferrara E, Schwartz MD, et al. Teaching communication in clinical clerkships: models from the macy initiative in health communications. Acad Med. 2004;79(6):511–20.
- Clever SL, Jin L, Levinson W, Meltzer DO. Does doctor-patient communication affect patient satisfaction with hospital care? Results of an analysis with a novel instrumental variable. Health Serv Res. 2008;43(5 Pt 1):1505–19.
- Coulter A, Cleary PD. Patients’ experiences with hospital care in five countries. Health Aff. (Millwood) 2001;20(3):244–52.
- Service qualité des soins -HUdG: Enquête de satisfaction des patients hospitalisés http://qualite.hug-ge.ch/enquetes_satisfaction/patient1.html.
- Norgaard B, Kofoed PE, Ohm Kyvik K, Ammentorp J. Communication skills training for health care professionals improves the adult orthopaedic patient's experience of quality of care. Scand J Caring Sci. 2012;26(4):698–704.
- Kurtz S, Silverman J, Benson J, Draper J. Marrying content and process in clinical method teaching: enhancing the Calgary-Cambridge guides. Acad Med. 2003;78(8):802–9.
- Kneebone R, Nestel D, Taylor P. Can “performing” a procedure help students explain it to their patients? Med Educ. 2003;37(5):481–2.
- Lang F, Everett K, McGowen R, Bennard B. Faculty development in communication skills instruction: insights from a longitudinal program with “real-time feedback”. Acad Med. 2000;75(12):1222–8.
- Egnew TR, Wilson HJ. Faculty and medical students’ perceptions of teaching and learning about the doctor-patient relationship. Patient Educ Couns. 2009;79(2):199–206.
- Jochemsen-van der Leeuw HG, van Dijk N, van Etten-Jamaludin FS, Wieringa-de Waard M. The attributes of the clinical trainer as a role model: a systematic review. Acad Med. 2013;88(1):26–34.
- Paice E, Heard S, Moss F. How important are role models in making good doctors? BMJ 2002;325(7366):707–10.
- Veloski J, Boex JR, Grasberger MJ, Evans A, Wolfson DB. Systematic review of the literature on assessment, feedback and physicians’ clinical performance: BEME Guide No. 7. Med Teach. 2006;28(2):117–28.
- Buyck D, Lang F. Teaching medical communication skills: a call for greater uniformity. Fam Med. 2002;34(5):337–43.
- Bylund CL, Brown RF, di Ciccone BL, Levin TT, Gueguen JA, Hill C, et al. Training faculty to facilitate communication skills training: development and evaluation of a workshop. Patient Educ Couns. 2008;70(3):430–6.
- Draper J, Silverman J, Hibble A, Berrington RM, Kurtz SM. The East Anglia Deanery Communication Skills Teaching Project-six years on. Med Teach. 2002;24(3):294–8.
- Junod Perron N, Nendaz M, Louis-Simonet M, Sommer J, Gut A, Baroffio A, et al. Effectiveness of a training program in supervisors’ ability to provide feedback on residents' communication skills. Adv Health Sci Educ Theory Pract. 2013;18(5):901–15.
- Bombeke K, Symons L, Debaene L, De Winter B, Schol S, Van Royen P. Help, I’m losing patient-centredness! Experiences of medical students and their teachers. Med Educ. 2010;44(7):662–73.
- Brown J. Transferring clinical communication skills from the classroom to the clinical environment: perceptions of a group of medical students in the United kingdom. Acad Med. 2010;85(6):1052–9.
- Adler R, Werner ER, Korsch B. Systematic study of four years of internship. Pediatrics. 1980;66(6):1000–8.
- Fann JR, Hunt DD, Schaad D. A sociological calendar of transitional stages during psychiatry residency training. Acad Psychiatry. 2003;27(1):31–8.
- Razack S, Meterissian S, Morin L, Snell L, Steinert Y, Tabatabai D, et al. Coming of age as communicators: differences in the implementation of common communications skills training in four residency programmes. Med Educ. 2007;41(5):441–9.
- Junod Perron N, Sommer J, Hudelson P, Demaurex F, Luthy C, Louis-Simonet M, et al. Residents’ perceived needs in communication skills across in- and outpatient clinical settings. Education for Health. 2009;22(1):280.
- Essers G, van Dulmen S, van Weel C, van der Vleuten C, Kramer A. Identifying context factors explaining physician's low performance in communication assessment: an explorative study in general practice. BMC Fam Pract. 2011;12:138.
- Rider EA, Volkan K, Hafler JP. Pediatric residents’ perceptions of communication competencies: Implications for teaching. Med Teach. 2008;30(7):e208–17.
- Sanson-Fisher R, Cockburn J. Effective teaching of communication skills for medical practice: selecting an appropriate clinical context. Med Educ. 1997;31(1):52–7.
- Wass V, Van der Vleuten C, Shatzer J, Jones R. Assessment of clinical competence. Lancet. 2001;357(9260):945–9.
- Epstein RM, Hundert EM. Defining and assessing professional competence. JAMA. 2002;287(2):226–35.
- Outcome Project [http://www.acgme.org/outcome/comp/GeneralCompetenciesStandards21307.pdf]
- Competence framework [http://www.rcgp-curriculum.org.uk/nmrgcp/wpba/competence_framework.aspx]
- Norcini JJ, Blank LL, Duffy FD, Fortna GS: The mini-CEX: a method for assessing clinical skills. Ann Intern Med. 2003;138(6):476–81.
- Steinert Y, Macdonald ME, Boillat M, Elizov M, Meterissian S, Razack S, et al. Faculty development: if you build it, they will come. Med Educ. 2010;44(9):900–7.
- Steinert Y. Perspectives on faculty development: aiming for 6/6 by 2020. Perspect Med Educ. 2012;1(1):31–42.
- O’Sullivan PS, Irby DM. Reframing research on faculty development. Acad Med. 2011;86(4):421–8.
- Barab SA, Barnett M, Squire K. Developping an empirical account of a community of practice: Characterizing the essential tensions. J Learn Sci. 2002;11(4):489–542.
- Junod Perron N, Cullati S, Hudelson P, Nendaz M, Dolmans D, van der Vleuten C. Impact of a faculty development programme for teaching communication skills on participants’ practice. Postgrad Med J. 2014;90(1063):245–50.