Communication Skills in Postgraduate to Established Practice
Communication Skills in Postgraduate to Established Practice
Introduction Communication breakdown is a factor in the majority of all instances of medical error. Despite the importance, a relative paucity of time is invested in communication skills in postgraduate curricula. Our objective is to systematically review the literature to identify the current tools used to assess communication skills in postgraduate trainees in the latter 2 years of training and in established practice.
Methods Two reviewers independently reviewed the literature identifying communication skill assessment tools, for postgraduate trainees in the latter 2 years of training and in established practice following Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework, and inclusion/exclusion criteria from January 1990 to 15 August 2014. Databases: PubMed/CINAHL/ERIC/EMBASE/PsycInfo/Psyc Articles/Cochrane.
Results 222 articles were identified; after review, 34 articles fulfilled criteria for complete evaluation; the majority (26) had a high level of evidence scoring 3 or greater on the Best Evidence Medical Education guide. 22 articles used objective structured clinical examination/standardised patient (SP)-based formats in an assessment or training capacity. Evaluation tools included author-developed questionnaires and validated tools. Nineteen articles demonstrated an educational initiative.
Conclusions The reviewed literature is heterogeneous for objectives and measurement techniques for communication. Observed interactions, with patients or SPs, is the current favoured method of evaluation using author-developed questionnaires. The role of self-evaluation of skill level is questioned. The need for a validated assessment tool for communication skills is highlighted.
Communication breakdown is a factor in >50% of all postoperative complications, 70% of all medication errors and 80% of delays in treatment that resulted in death or permanent loss of function for patients. Poor communication can exist at any level of patient and healthcare worker interaction, and most errors occur in verbal communication. Awareness surrounding adverse events in healthcare is increasing, thought to be attributed to behavioural failures rather than failures in technical expertise. Litigation for medical error is increasing. Physicians who provide information, spend more time defining patient expectations and solicit patient opinion tend to have fewer malpractice claims and higher patient satisfaction. Communication skills and behavioural interactions have been recognised as important in other high-risk industries such as aviation, and protocols for training communication skills specifically with management teams during stressful events have been developed to address these behaviours.
In medicine, communication skills are thought to be acquired primarily by observation and by modelling, generally without formal feedback or formal assessment. Integrating communication skills into programmes has been attempted in many forms. The use of single lectures, series lectures, workshops and simulations has been demonstrated. Communication is multidimensional, and assessment needs to include the indistinct aspects such as establishing the physician–patient relationship, empathy and non-verbal interaction.
The Kalamazoo conference identified three methods for evaluating communication skills, namely checklists of observed behaviours, patient experience surveys and oral or written examinations. Checklists, objective structured clinical examination (OSCE) examinations with standardised patients (SPs) and observed interactions with real patients (whether recorded or observed in real time) are all methods that can be used to develop and test these skills within undergraduate and postgraduate training programmes.
It is recognised that medical education must function on a continuum from medical school onwards throughout a career. At different points, individuals progress through transitions (eg, from postgraduate training to subspecialty training) that require additional support and a rebalance in educational needs and responsibilities. Learning habits shift abruptly when exiting training programmes from an enforced curriculum to a self-directed one, for which trainees may be unprepared.
With communication skills, these are emphasised in the undergraduate curriculum; however, attitudes towards communication skills development tend to diminish as medical students graduate to postgraduate training programmes. New postgraduate trainees are fresh from medical school with recent experience of a formalised curriculum, which includes communication skills training. As time progresses through postgraduate training, other necessary skills take priority over communication skills in the learning programme. A decline or erosion in communication skills has been noted over time in undergraduate students.
In a review of risk communication in postgraduate programmes in the USA, only a median of 12 h was allotted to communication skills development. Similarly, a survey of accredited postgraduate oncology fellowship programs in the USA showed only 30% had some form of formal communication skills training. Though recognised as a core competency in medical training, barriers exist such as lack of faculty time and expertise. Imposing a mandatory core competency assessment is equally hampered by the lack of an accepted, validated method of assessment. With new graduates entering into the workforce and physicians from many countries migrating to new healthcare systems, it is necessary to ensure that communication skills are, at minimum, adequate to meet standards for the safe treatment of patients.
The objective of this study was to identify the methods used to evaluate communication skills in postgraduate training and in established practice. The focus is to examine the tools used in the latter 2 years of a primary postgraduate training programme, the point where graduates are potentially transitioning to practice and evaluation methods used for those in established practices. The methodological rigour of these studies will be assessed.
Abstract and Introduction
Abstract
Introduction Communication breakdown is a factor in the majority of all instances of medical error. Despite the importance, a relative paucity of time is invested in communication skills in postgraduate curricula. Our objective is to systematically review the literature to identify the current tools used to assess communication skills in postgraduate trainees in the latter 2 years of training and in established practice.
Methods Two reviewers independently reviewed the literature identifying communication skill assessment tools, for postgraduate trainees in the latter 2 years of training and in established practice following Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework, and inclusion/exclusion criteria from January 1990 to 15 August 2014. Databases: PubMed/CINAHL/ERIC/EMBASE/PsycInfo/Psyc Articles/Cochrane.
Results 222 articles were identified; after review, 34 articles fulfilled criteria for complete evaluation; the majority (26) had a high level of evidence scoring 3 or greater on the Best Evidence Medical Education guide. 22 articles used objective structured clinical examination/standardised patient (SP)-based formats in an assessment or training capacity. Evaluation tools included author-developed questionnaires and validated tools. Nineteen articles demonstrated an educational initiative.
Conclusions The reviewed literature is heterogeneous for objectives and measurement techniques for communication. Observed interactions, with patients or SPs, is the current favoured method of evaluation using author-developed questionnaires. The role of self-evaluation of skill level is questioned. The need for a validated assessment tool for communication skills is highlighted.
Introduction
Communication breakdown is a factor in >50% of all postoperative complications, 70% of all medication errors and 80% of delays in treatment that resulted in death or permanent loss of function for patients. Poor communication can exist at any level of patient and healthcare worker interaction, and most errors occur in verbal communication. Awareness surrounding adverse events in healthcare is increasing, thought to be attributed to behavioural failures rather than failures in technical expertise. Litigation for medical error is increasing. Physicians who provide information, spend more time defining patient expectations and solicit patient opinion tend to have fewer malpractice claims and higher patient satisfaction. Communication skills and behavioural interactions have been recognised as important in other high-risk industries such as aviation, and protocols for training communication skills specifically with management teams during stressful events have been developed to address these behaviours.
In medicine, communication skills are thought to be acquired primarily by observation and by modelling, generally without formal feedback or formal assessment. Integrating communication skills into programmes has been attempted in many forms. The use of single lectures, series lectures, workshops and simulations has been demonstrated. Communication is multidimensional, and assessment needs to include the indistinct aspects such as establishing the physician–patient relationship, empathy and non-verbal interaction.
The Kalamazoo conference identified three methods for evaluating communication skills, namely checklists of observed behaviours, patient experience surveys and oral or written examinations. Checklists, objective structured clinical examination (OSCE) examinations with standardised patients (SPs) and observed interactions with real patients (whether recorded or observed in real time) are all methods that can be used to develop and test these skills within undergraduate and postgraduate training programmes.
It is recognised that medical education must function on a continuum from medical school onwards throughout a career. At different points, individuals progress through transitions (eg, from postgraduate training to subspecialty training) that require additional support and a rebalance in educational needs and responsibilities. Learning habits shift abruptly when exiting training programmes from an enforced curriculum to a self-directed one, for which trainees may be unprepared.
With communication skills, these are emphasised in the undergraduate curriculum; however, attitudes towards communication skills development tend to diminish as medical students graduate to postgraduate training programmes. New postgraduate trainees are fresh from medical school with recent experience of a formalised curriculum, which includes communication skills training. As time progresses through postgraduate training, other necessary skills take priority over communication skills in the learning programme. A decline or erosion in communication skills has been noted over time in undergraduate students.
In a review of risk communication in postgraduate programmes in the USA, only a median of 12 h was allotted to communication skills development. Similarly, a survey of accredited postgraduate oncology fellowship programs in the USA showed only 30% had some form of formal communication skills training. Though recognised as a core competency in medical training, barriers exist such as lack of faculty time and expertise. Imposing a mandatory core competency assessment is equally hampered by the lack of an accepted, validated method of assessment. With new graduates entering into the workforce and physicians from many countries migrating to new healthcare systems, it is necessary to ensure that communication skills are, at minimum, adequate to meet standards for the safe treatment of patients.
The objective of this study was to identify the methods used to evaluate communication skills in postgraduate training and in established practice. The focus is to examine the tools used in the latter 2 years of a primary postgraduate training programme, the point where graduates are potentially transitioning to practice and evaluation methods used for those in established practices. The methodological rigour of these studies will be assessed.
