Special Theme Articles
Teaching Communication in Clinical Clerkships: Models from the Macy Initiative in Health Communications
Kalet, Adina MD, MPH; Pugnaire, Michele P. MD; Cole-Kelly, Kathy MS, MSW; Janicik, Regina MD; Ferrara, Emily MA; Schwartz, Mark D. MD; Lipkin, Mack Jr. MD; Lazare, Aaron MD
Dr. Kalet is associate professor of medicine and master, Walter Reed Society for Health Policy and Public Health; Dr. Janicik is instructor of clinical medicine; Dr. Schwartz is associate professor of medicine, director, General Internal Fellowship Program, and master, Walter Reed Society for Health Policy and Public Health; and Dr. Lipkin is professor of medicine. All are in the Division of Primary Care, Department of Medicine, New York University School of Medicine, New York, New York. Dr. Pugnaire is associate professor and vice dean for undergraduate medical education and Ms. Ferrara is director, Division of Grants and Special Projects and assistant professor of family medicine and community health, both in the Office of Medical Education, University of Massachusetts Medical School, Worcester, Massachusetts. Ms. Cole-Kelly is professor of family medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio. Dr. Lazare is chancellor and dean, University of Massachusetts Medical School. Versions of this paper were presented at the Program in Medical Communications Annual Meeting, Barcelona, Spain, September 2000; the meeting of the Group on Education Affairs of the AAMC, Chicago, Illinois, October 2000; and the Society of General Internal Medicine, Annual Meeting, Boston, Massachusetts, May 2001.
Correspondence and requests for reprints should be addressed to Dr. Kalet, New York University School of Medicine, 550 First Avenue, Old Bellevue, D401B, New York, NY 10016: telephone: (212) 263-1137; fax: (212) 263-8234; e-mail: 〈firstname.lastname@example.org〉. For information about the authors, see the end of the article.
For articles on related topics, see pp. 495–507 and 508–510.
Medical educators have a responsibility to teach students to communicate effectively, yet ways to accomplish this are not well-defined. Sixty-five percent of medical schools teach communication skills, usually in the preclinical years; however, communication skills learned in the preclinical years may decline by graduation. To address these problems the New York University School of Medicine, Case Western Reserve University School of Medicine, and the University of Massachusetts Medical School collaborated to develop, establish, and evaluate a comprehensive communication skills curriculum. This work was funded by the Josiah P. Macy, Jr. Foundation and is therefore referred to as the Macy Initiative in Health Communication. The three schools use a variety of methods to teach third-year students in each school a set of effective clinical communication skills. In a controlled trial this cross-institutional curriculum project proved effective in improving communication skills of third-year students as measured by a comprehensive, multistation, objective structured clinical examination.
In this paper the authors describe the development of this unique, collaborative initiative. Grounded in a three-school consensus on the core skills and critical components of a communication skills curriculum, this article illustrates how each school tailored the curriculum to its own needs. In addition, the authors discuss the lessons learned from conducting this collaborative project, which may provide guidance to others seeking to establish effective cross-disciplinary skills curricula.
Numerous studies have confirmed the importance of communication between physician and patient.1,2 The medical interview determines the quantity, quality, and accuracy of data the physician elicits, which affects both the physician's approach to the problem and the care of the patient.3–6 The interaction directly influences the accuracy of the diagnosis; approximately 80% of diagnostic information comes from the medical history.7 By communicating clearly, patients and physicians forge a therapeutic alliance, which will determine the patient's adherence to treatment plans and to medication regimens as well as recommended changes in lifestyle.8–12 Particular qualities of the doctor–patient interaction have been shown to be major determinants of the biological, psychological, social, and legal outcomes of care; efficiency and cost-effectiveness of care; iatrogenic harm created in the course of care; and patient and physician satisfaction with the relationship.13–25
U.S. medical schools generally teach communication skills during the first or second year. In 1978, 35% of schools had a formal preclinical year curriculum in communication skills, and by 1993 the proportion had increased to 65% of schools.26 This preclinical curricular approach provides limited reinforcement and training during the clinical years, a long-standing concern supported by the early findings of a decline in communication skills during that crucial training phase.27 Recently, professional groups have begun to create a demand for change. The Association of American Medical Colleges (AAMC) and the Accreditation Council for Graduate Medical Education (ACGME) reflect the thinking of other academic leaders that the training in these skills must be improved.28–30 In an effort to participate in their own care, patients have also demanded that physicians communicate better.31–34 In addition, educators now understand the most effective instructional methods to teach communications skills.35–37 Finally, market forces underscore the value of teaching communication skills; managed care organizations recognize that the quality of the doctor-patient relationship is an important factor, just below competitive premiums and waiting times, in their ability to recruit and retain patients.38–40
In January 1999, funded by the Josiah Macy, Jr. Foundation, the New York University School of Medicine (NYU), Case Western Reserve University School of Medicine (CWRU), and University of Massachusetts Medical School (UMass) began a three-year collaborative project—the Macy Initiative in Health Communication—to improve physicians’ communication skills through the development of innovative, competency-based curricula for third-year medical students.
The project had five components: (1) define a comprehensive set of communication competencies for medical students to master by graduation; (2) develop and establish an integrated and comprehensive communication skills curriculum focusing on the clinical clerkship years; (3) design faculty development to support this curriculum; (4) evaluate the impact of the project; and (5) disseminate the findings. Each school developed and established its own curriculum and designed faculty development measures individually but worked collaboratively on competencies, evaluation, and dissemination.
The effectiveness of the project was demonstrated in a controlled study using a ten-station, performance-based, objective structured clinical examination (OSCE) with standardized patients (SPs) conducted before and after the third year of each medical school's curriculum intervention. This study showed that in all three schools, the educational intervention produced a significant improvement in communication skills performance compared with the baseline curriculum.41 These differences were found at each school although they varied in magnitude. To enhance the validity and generalizability of the evaluation, the curriculum teams that developed the intervention were blinded to the specific content of the ten-station OSCE.
In this article we describe how this effective intervention was developed collaboratively but implemented individually, and provide details about the new curricula.
Defining a Comprehensive Set of Communication Skills
Grounded in a model of doctor-patient communication, we began by creating a comprehensive set of communication competencies.42 With this framework of a communication skills model and a defined set of competencies, each school conducted a detailed curriculum inventory, which provided data that would guide the development of new curricula to improve the communication skills of our students.
The Macy Initiative Competency Document
To define the core skills in communication that would guide curriculum development and evaluation, a project team was established with representatives from each of the three schools. This curriculum committee surveyed faculty and students at each school, carried out a comprehensive review of the medical and psychological literature, and reviewed documents from accreditation groups (e.g., Liaison Committee on Medical Education, ACGME),29,30 professional organizations (e.g., American Academy on Physician and Patient, Society of Teachers of Family Medicine, Clerkship Directors in Internal Medicine, Program in Communication and Medicine),43–46 and foundations (e.g., Pew-Fetzer Task Force, Bayer Institute for Health Care Communication).47,48 The final list of competencies was organized into three domains of communication: Communicating with Patients, Communicating about Patients, and Communicating about Medicine and Science. Each domain was then subdivided into three functions of the medical interview—gathering data, building relationships, and educating—as described by Lipkin and Lazare.1 The final comprehensive document is outlined in List 1. (See also the Macy Initiative Web site 〈http://macyinitiative.med.nyu.edu/〉 for the full document.)
The Macy Model of Doctor–Patient Communication
We developed a communication skills model that summarizes the objectives of the first domain of the Macy Initiative Competency Document and builds on other conceptual work.48–51 The Macy Model illustrates fundamental processes applicable to every meeting between physician and patient, and represents a complete set of core skills (see Figure 1). Depending on the context of the medical interview (e.g., acute visit, follow-up visit) or the content (e.g., obtaining informed consent, discussing bad news), the model provides an overall framework for systematically teaching vital communication elements.
Developing and Establishing an Integrated and Comprehensive Curriculum
Establishing the Baseline
Before developing the curriculum, each school took a complete inventory of its baseline communication skills curriculum, as well as an assessment of institutional characteristics and barriers and promoters for curriculum change.
Using the Competency Document as a framework, each school systematically assessed its formal and informal teaching of communication skills. At baseline, most of the structured effective teaching took place in the preclinical years at all three schools. Although some clerkships provided relevant written goals and objectives, few of them offered formal learning opportunities and teaching methods that effectively reinforced the complex new communication skills students had to master. Further, there was no overall strategy for the coordinated integration of communication skills teaching across all four years.
The start of the Macy Initiative coincided with curricular reform at two of the three schools, a factor that may have influenced the outcome of the project. CWRU was in the midst of changing its curriculum, which shortened clinical clerkships significantly. NYU planned a large-scale reorganization to coincide with the project, which provided the opportunity to integrate communication skills into the curriculum. The third school, UMass, which had undergone curricular reform several years before the project, introduced a new curriculum in the mid-1990s that provided enhancements to the preclinical in years one and two. Each school took its own approach to creating a sustainable, effective communication skills curriculum that targeted the clinical clerkship years and capitalized on organizational characteristics.
Diverse Curriculum Development Approaches
Each school developed its own approach to curriculum development that built on local expertise and existing programs, and reflected the differing baseline institutional characteristics and such variables as mission, funding, and location. Data from the 1998 AAMC Graduation Questionnaire provide an example of institutional variations in teaching communication skills at each of the three schools. For example, in assessing the adequacy of teaching communication skills, 16.5% of UMass graduates considered the amount of time spent on instruction to be excessive, and 0% stated the amount to be inadequate; at NYU and CWRU, 3.6% and 4.7%, respectively, indicated the amount of time spent on instruction as excessive, and 15.7% at NYU and 7.0% at CWRU rated it inadequate.
University of Massachusetts: simulating a multi-modal approach
UMass offered mini-grants as incentives for clerkship faculty to develop innovative teaching methods. A request for proposals presented a set of funding priorities that reflected the Macy Initiative competencies and curricular needs as identified in the inventory and by the leadership of the clinical clerkships, interclerkship program, and the institution's Educational Policy Committee. They took three forms: the intraclerkship model (within a single clerkship); the interclerkship model (required day-long educational programs focused on specific topics not otherwise adequately covered in the curriculum); and the integrated model (across two or more clerkships and/or interclerkships). Eight proposals were funded, involving all six required clerkships and three interclerkships. The projects used diverse teaching methods, such as OSCEs, interactive workshops, interviews of SPs, role modeling, role-play, videotape review, and skills practice. As a result of these efforts, after completing the six required clerkships, a UMass student had more than 30 hours of new and enhanced communication-skills activities. See Figure 2 for the structure of the clerkship year and specific communication curriculum content.
New York University: the intraclerkship model of embedded curriculum
The NYU Macy Initiative team negoti-ated and worked individually with the directors of the seven required clerkships to develop communication skills educational activities that would fit the unique resources and reinforce the relevant clinical content. These activities were also designed to meet other institutional needs, including increasing the amount of direct observation of and feedback to students. The Macy Initiative curriculum development team managed the process, developed and continuously improved curricular materials, conducted faculty development and evaluation activities, and provided technical support to clerkship directors who implemented the curriculum as a seamlessly integrated part of the clerkships. As a result of these efforts, after completion of the seven required clerkships, an NYU student had 37 new hours of substantive and varied communication skills activities, including bedside rounds, seminars, eight to ten opportunities to role-play with SPs and receive feedback, one lecture, and a multistation group activity. See Figure 3 for the structure of the clerkship year and specific clinical communication curriculum content.
Case Western Reserve University: cross-clerkship model
At CWRU, participants in a retreat about the third-year curriculum cited communication skills as needing improvement in the newly proposed clerkship structure. This created the impetus for the development of a Macy Initiative Communication Workshop for each clerkship. Two models were developed to take into account available clerkship time and space. A two- to three-hour workshop included a brief discussion of clinical and communication considerations; demonstration of the skills by the clerkship director; students’ observation of the skills, using a checklist; and students’ rehearsal of the skills with a SP and a student partner. The second workshop included all the elements of the first except for rehearsal with a SP. Both workshops continue as part of the core curriculum in each of the clerkships. See Figure 4 for the specific content and structure of the curriculum. These workshops added 11 hours of communication skills teaching for each student in the third year.
Curriculum Activities for Teaching Communication Skills
The following examples from each school illustrate the rich variety of approaches to the teaching of communication skills within clerkship curricula through the Macy Initiative.
Talking about Sex and Sexuality
In the obstetrics-gynecology (ob-gyn) clerkship, NYU reinforces in two sessions the skills necessary to talk with patients about sex and sexuality: a 90-minute faculty-facilitated, small-group seminar, and a SP interview with feedback a week later. The seminar begins with a brief exploration of the students’ questions and self-perceived challenges about the topic. Students then view and discuss three brief videotapes: a woman, age 55, reluctant to discuss her dyspareunia; a recent widow, age 65, considering sexual relations with a new partner, who has questions about the risk of HIV; and a woman, age 35, seen for routine care whose sexual partner is female. After each video the faculty seminar leader discusses the relevant communication skills. In the final half hour students discuss sexual issues they find particularly challenging (e.g., uncovering domestic violence or unusual sexual practices in a woman close to their age) and generate a role-play to practice relevant skills in pairs. In the final minutes the impact of attitudes on ability to conduct a comprehensive sexual history are discussed. Relevant reading is provided.52
The following week each student spends 15 minutes interviewing a SP who is portraying a young sexually active woman poorly informed about contraception. Following the interview the SP assesses the interview using a checklist of communication behaviors and then provides feedback to the student. An end-of-clerkship written survey of self-perceived changes in knowledge and skills, and satisfaction with the educational experience is used to judge the educational value of the sessions.
Dealing with the Angry Patient
At CWRU, “Dealing with the Angry Patient,” a workshop included in the ambulatory family medicine and internal medicine clerkship, presents students with six scenarios common to primary care practice. Ambulatory psychiatry is also integrated in this clerkship. The scenarios include a patient who wants to be hospitalized for the routine removal of colon polyps; a grandmother who cares for her grandchild who has attention deficit hyperactivity disorder and wants his recently adjusted dose of Ritalin increased; a patient whose physician forgot to call to say the throat culture was positive; a patient denied antibiotics for a cold who has a friend who received them for similar symptoms; a patient with chronic mild low back pain who requests a handicapped-parking sticker; and a resident upset at a third-year student who failed to get a requested blood culture.
Students attend a brief presentation about understanding and responding to anger. The students then watch the clerkship director play the role of the physician who sees the patient with colon polyps. Then, in groups of four to six, students meet with each of the SPs so that all students practice one of the scenarios and observe the others. Student observers and the SPs provide feedback at the end of the interview. Students attend a final session to review what they learned.
Interclerkship on Multiculturalism
UMass developed a required, one-day Interclerkship in Multiculturalism to teach all third-year students how to conduct a culturally sensitive interview. The interclerkship also increases students’ awareness of the impact of the migration experience on refugees and immigrants, and of racial and cultural variations in health beliefs and practices, and health outcomes. Teaching methods feature large group plenary sessions, hour-long workshops, and small-group role-play exercises with faculty feedback. Students are allowed to select two of the four workshop options, which included nutrition and culture; cancer screening across cultures; ethnic, racial, and sociocultural barriers to emergency room care; and racism and health outcome disparities. In groups of five, students participate in the role play exercises; each conducts an interview with one of five SPs representing Puerto Rican, Somalian, Vietnamese, African-American, or gay cultures, and observe their peers interviewing the other four SPs. The course is taught by an interdisciplinary, culturally diverse group of more than 20 faculty, who are provided with faculty development training, designed and implemented by the interclerkship's co-directors. A pre-post written survey of knowledge, skills, and attitudes is used to appraise the educational outcomes of the interclerkship.
Designing Faculty Support Measures for the Curriculum
In order to support and maximize the effectiveness of the curriculum each school had an explicit, systematic, and comprehensive approach to faculty development with two main goals: to familiarize a large group of medical school faculty with the Macy Initiative communication competencies and the Macy Model of doctor-patient communications, and to provide them with basic teaching skills, including the ability to make accurate observations, give effective feedback, and facilitate small groups.
New York University School of Medicine
NYU used four strategies to enrich the ability of the medical school faculty to teach communication skills. These included conducting extensive clerkship-specific faculty development within each clinical discipline (e.g., workshops for over 25 surgery faculty); establishing Medical Education Colloquia, a cross-disciplinary medical education forum to discuss relevant medical education topics with national and international experts; developing online multimedia modules using videotaped student interviews to train faculty to make behaviorally specific observations and give effective feedback;53 and conducting Resident-as-Teacher workshops in most of the clinical disciplines (e.g., medicine, neurology, surgery, psychiatry).
Case Western Reserve University
CWRU employed a series of workshops for faculty presented by outside “leaders” in the field of doctor-patient communication. This effort was not as successful as expected, so the university is changing its approach and finding new methods to teach communication skills. At the time of initiating these workshops, many clerkship faculty were also in the midst of curriculum reform and had multiple demands on their time. Had these faculty development efforts been more closely associated with the ACGME Interpersonal and Communication Skills competency, there might have been a broader base of participation. The two groups that benefited most from faculty development activities were faculty involved in the curriculum of the first two years and faculty actively participating in the teaching of the Macy Initiative workshops. Faculty members involved in the first two years of Introduction to Clinical Medicine curriculum were exposed to the Macy Model throughout the year in multiple components of the curriculum (clinical learning group preceptors or interviewing program preceptors). Most significant development of faculty occurred with the involvement by the clerkship faculty who had a direct role in teaching the communication workshops. Their involvement produced a positive attitude toward the program and several faculty became active communication advocates in their own departments, promoting it through grand rounds and other presentations.
University of Massachusetts School of Medicine
In support of the Macy Initiative, the UMass Macy leadership team worked with the school's interdisciplinary Community Faculty Development Center (CFDC) to develop a comprehensive, systematic way to evaluate and improve faculty teaching skills in communication. The UMass team took on three major tasks: exploration of new models for faculty development in the form of the objective structured teaching exercise (OSTE) using “standardized students”;54 teacher-training programs that focused on specific areas of the UMass curricular interventions (e.g., nutrition, multiculturalism, sexuality, sexual orientation); and a program to develop core skills in cooperation with a group of faculty opinion leaders (e.g., clerkship directors, curriculum project directors). The CFDC also offered individual consultation to clerkship directors and project directors as part of the technical assistance provided through the mini-grants process.
In spite of the recognized difficulty of introducing new curricula into the clinical clerkship years,55 NYU, UMass, and CWRU each successfully developed, established, and demonstrated the effectiveness of a comprehensive program of communication skills. The evaluation of this comprehensive educational intervention was unusually rigorous and convincing.56 We were successful with both curriculum implementation and collaborative evaluation in the face of significant obstacles, which included competing curricular priorities, decreased faculty time available for teaching, and faculty's and students’ resistance to change in general and to the content in particular. Several critical organizational components enabled us to overcome these obstacles.
Support from Oversight Bodies and Accreditation Standards
The growing international recognition of the need to focus on communication skills as a central competency helped us to validate the importance of communication skills teaching and thereby garner support and gain acceptance from opinion leaders within our respective institutions and among various clinical disciplines and health professions. At each school we were able to align broad institutional interests (e.g., accreditation requirements, curricular standards) with departmental and course-specific interests to achieve a shared goal of expanding communication skills teaching across diverse components of the curriculum.
Establishing an Evidenced-Based Model
Drawing on data that linked communication skills to important clinical outcomes, participants in the three-school Macy Initiative worked collaboratively to build a strong theoretical and evidence-based model to support the need for curriculum enhancement in teaching these skills. This allowed the schools to reach agreement on the meaning and scope of communication skills and facilitated curriculum and faculty development by providing a common vocabulary and set of objectives as a framework for coordinating the project across the three schools.
Institutional Flexibility and Choice in Curriculum Content and Methodology
Although the three schools worked from a unified conceptual model of communication skills competencies, each school also found it essential to have the autonomy to develop and establish its own curriculum intervention. Doing so unleashed creativity and enthusiasm needed for effective implementation and dissemination of this ambitious project. At the Macy Initiative partner schools, clerkship directors and key faculty were empowered to serve as “communication skills educators” for their peers across the country, disseminating their innovative approaches to teaching communication skills in the context of their particular disciplines, such as neuroscience, ob-gyn, surgery, or primary care.57
Curriculum Change through Coordinated Integration
During the implementation phase of the project, each school was undergoing competing curricular changes and demands. None of the schools was afforded the opportunity to add more hours to the curriculum, and for CWRU, clinical year's clerkship curricular time was actually reduced from 14 months to 12 months. The schools also encountered resistance to the content of the curriculum as well as resource limitations that broadly affected medical education in general, such as mergers and financial constraints. The explicit strategy of integrating communication skills into relevant clinical content areas identified as “programmatic gaps” garnered support for new curriculum in the face of competing needs and resource constraints. For example, when students learned to talk with patients about an abnormal Papanicolaou test result, they mastered not only the principles of patient education and delivering bad news but also evidence regarding this common clinical screening procedure.
Faculty Development as a Fundamental Cornerstone
From the outset, faculty development was an integral component of the effective implementation of our curricular programs. We used faculty-development activities both to ensure adequate preparation for teachers of the new curriculum and to gain support from faculty who were active clinicians and role models for students, housestaff, and other faculty. In this way we expanded communication skills teaching beyond the faculty and resources directly supported by the Macy Initiative and trained a new cohort of “experts.”
Strength through Collaboration
As a three-school collaboration, the Macy Initiative allowed each partner school to contribute its unique strengths to a common resource pool shared among the partner institutions. The engagement of other schools also served to showcase the project as one of broad scope and national visibility. This provided an effective springboard for launching the project, publicizing it, and stimulating support from key constituencies such as educational leadership and curriculum committees.
Finally, how do we propose to sustain the gains made as part of the Macy Initiative? During the funding period generous foundation support contributed to the success of the collaboration and of the program at each school. However, flexibility and sustainability beyond the funding period was a critical consideration in curriculum development from the start. Several curricular activities have evolved as faculty time and other resources changed, but most remain intact. Results of the performance-based controlled evaluation provide evidence about the importance of this teaching. Data from the continuing performance-based assessment (e.g., National Board of Medical Examiners Step 2 Clinical Skills Examination), along with the analysis of the AAMC Graduation Questionnaire data, will help us determine whether the effectiveness of the teaching is maintained in the long run. The analyses will also help us determine if other programs, stimulated by such policy making organizations as the ACGME Outcomes Project30 and the American Board of Internal Medicine's Project Professionalism,58 might provide us with longer-term measures of the effectiveness of our intervention.
We have shown that it is possible to teach communication skills during the clinical years in an effective and meaningful manner. In doing so, we have identified a number of lessons we learned from this experience: aligning such institutional efforts with a broader national agenda and trends in medical education; applying an evidence-based model for curriculum change; using flexible curricular models and diverse methods to best meet the individualized needs of courses and faculty; seamlessly integrating new curricula with relevant clinical material and course content; providing substantive faculty development in support of curriculum change; and reaping the benefits of cross-institutional partnership to stimulate and sustain curriculum change. These lessons can serve as general principles that can be applied to other cross-disciplinary topics in medical education such as pain management, end-of-life issues, bioterrorism, and professionalism. In the next phase of our project we will establish programs to disseminate our experience to other institutions interested in developing such curricula, expand programs to graduate medical education, and evaluate our work to ensure its effectiveness.
This paper was supported by a grant from Josiah Macy, Jr. Foundation. We acknowledge our collaborators on the Macy Initiative in Health Communication, especially the leadership of the Macy Steering Committees at University of Massachusetts Medical School (Marjorie Clay, Nancy Fontneau, Susan Gagliardi, Wendy Gammon, David Hatem, Kathleen Mazor, Judith Ockene, and Mark Quirk) Case Western Reserve University School of Medicine (Ted Parran, Clint Snyder, Teri Novak, and Susan Wentz), and New York University School of Medicine (Sondra Zabar, Lynn Buckvar-Keltz, Benard Dreyer, Arthur Fierman, Robert Laurence, Kathleen Hanley, David Stevens, and Linda Tewksbury). We also thank Marian Anderson for administrative support and Nissa Simon for editing this manuscript.
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