High-quality medical communication enhances health outcomes, is more satisfying for patients, and decreases malpractice liability for physicians without adding to the length of the medical consultation.1 Yet the majority of medical encounters are missing the core elements that define high-quality communication. Patients often do not have the opportunity to state all their concerns and expectations, and physicians routinely miss cues about emotional and social issues. Patients rarely are invited to share in medical decisions, and decision-making processes usually fail to adhere to the basic principles of informed consent.2 Consequently, calls to improve the quality of communication training at all levels of medical education are being heralded by expert panels and prominent medical education organizations.3,4
One phase of medical education where communication-training efforts can be bolstered is during the clinical years of medical school. Preclinical communication training occurs in an environment where the importance of and context for learning patient-centered skills may not be apparent to students. Third-year students shift from this in vitro educational model to the demanding in vivo experience of patient care. The endless flow of patients represents new opportunities for learning interviewing skills.5 But curricula during the third year that might guide students to articulate, refine, and integrate communication skills are often missing or underdeveloped.
Important barriers to providing communication training in the third year include limited time for teaching, lack of training for clinical faculty, and few models for curriculum integration. In this article, we describe the content and implementation of a curriculum to teach communication skills during a family medicine clerkship, and report students’ and preceptors’ responses to it.
The patient-centered communication (PCC) curriculum is part of a required six-week, third-year family medicine rotation at the University of Washington School of Medicine, first implemented in July 2001. The clerkship accommodates over 160 students per year and is offered in 24 sites—private practices, community clinics, and family practice residencies—scattered throughout Washington, Wyoming, Alaska, Montana, and Idaho. (The implementation of PCC training was partially funded by a HRSA Title VII Training in Predoctoral Education grant.)
The curriculum highlights three of the seven core elements described in the Kalamazoo consensus statement6 on medical communication that we have termed Establishing Focus, Understanding the Patient's Perspective of the Illness, and Reaching Common Ground. We chose these elements to promote organization, efficiency, shared decision making, and an understanding of the patient's beliefs and feelings.
Establishing Focus (EF) involves collaboratively facilitating an understanding between patient and physician of what is to be accomplished within the time constraints of the consultation.7 Assuring that the concerns to be addressed include those that are most important to patients fosters investment in their health care. Determining all concerns, prioritizing as necessary, increases both patient and provider satisfaction. It also promotes organization and efficiency by decreasing the probability that new agenda items will surface late in the interview.8
Understanding the Patient's Perspective of the Illness (PPI) is an essential aspect of treating the whole person. Patients often do not verbalize their emotions but instead offer clues that are frequently unexplored by clinicians.9 Exploring the PPI often uncovers psychosocial issues that complicate management and confound treatment plans. Understanding the PPI also augments physician empathy and allows the physician to learn the values and goals patients hold towards their health care. Such knowledge assists the clinician to meet their patients’ needs in an efficient, sensitive fashion.
Reaching Common Ground (RCG) occurs when patient and physician agree on the diagnosis, the goals of treatment, and their respective roles in treatment.10 Physicians commonly perceive symptoms as less serious or disabling than do patients. They frequently fail to solicit patient preferences for treatment and do not order anticipated tests or referrals, which erodes patient satisfaction.11 RCG can improve efficiency, decrease costs by reducing diagnostic tests and referrals, and enhance health outcomes by promoting treatment adherence. Additionally, the process of RCG helps assure that patients are fully informed regarding treatment options.
Our PCC curriculum is summarized in List 1. It consists of five modules administered over the six weeks of the clerkship. Didactic information is provided through readings and slide shows that students access on the department Web site. Students are thus responsible for didactic instruction while preceptors concentrate on observing students and providing feedback.
During the first week, students orient themselves to the curriculum, receive information for accessing course materials, and review a videotape using fourth-year medical students as models in communication scenarios. The tape uses an “OK” and “Better” design to highlight the skills to be acquired. This design teaches by contrasting video clips of the same scenario, first showing an interview that does not have the targeted skills (“OK”), followed by a replay of the same scenario with the desired skills (“Better”). Students are also introduced to an interview tracking form we adapted from the first Kalamazoo consensus statement (see List 2). This form has no validity or reliability and is used solely to guide preceptor observations for providing formative feedback. Students also observe their preceptors, using the form to provide feedback and strengthen their ability to identify skills. During the second through fourth weeks, students repeat the pattern of focused readings followed by preceptor observations of specific PCC skills with feedback to the student. The final week emphasizes integration of skill learning.
Since preceptors vary in their abilities to teach and evaluate interviewing skills,12 faculty development preceded curriculum implementation. The clerkship is administered through quarterly meetings of representatives from each clinical site and faculty from the university. Beginning in October 2000, we presented a total of eight hours of faculty development during four consecutive quarterly meetings before the curriculum was implemented in July 2001.
The initial faculty development session provided an overview of the skills to be taught, and each succeeding session addressed a specific curriculum skill. Instructional methods included lectures, video demonstration, role-plays, and group discussions. The goals of this training were to enlist faculty support, define the skills to be taught, explore barriers to implementation, augment preceptor observation and feedback skills, and bolster preceptor confidence in teaching interviewing skills.
A second strategy for faculty development involved on-site consultations. Only one individual per site attended quarterly meetings and received training. The other preceptors at that site received no faculty development, so we designed on-site consultation to familiarize all preceptors with the curriculum. We recruited behavioral scientists from the Family Practice Residency Network of the University of Washington Department of Family Medicine to provide consultations, both within their residencies and at nearby community clerkship sites. Two of us (TE and LM) provided the behavioral scientists three hours of training to acquaint them with the curriculum and prepare them for their roles as consultants. Consultations occurred during routine annual site visits by university faculty or special behavioral scientist visits funded by the federal training grant.
A typical site visit included a lecture with video demonstration, followed by group discussion and consultation. Consultants observed preceptors, using the interview tracking form to detail their interview behaviors and provide feedback, thus paralleling the teaching process desired with students. At some sites not visited by a behavioral scientist, university faculty provided consultation and gave feedback both to students in front of preceptors and to preceptors after seeing their own patients.
Feedback from Students
A course evaluation is required upon completion of the clerkship. Students provide an anonymous Web-based evaluation to the Department of Medical Education; the collated results are reported biannually to the Department of Family Medicine. Students were asked, “How did learning about PCC contribute to your education?” We analyzed the comments of students in the clerkship during the 2001–02 academic year.
One of us (LM) initially coded the comments, dividing them into 15 subthemes. Next, we independently coded the comments using these subthemes as guides. We then met, compared codes, and through an iterative, dialectic process reached consensus on coding. The 15 subthemes were then condensed into 6 themes and a category we called “Other,” as summarized in Table 1.
There were 111 (65%) responses from the 165 students matriculating the course in the 2001–02 academic year. Of these, 97 (87%) were deemed positive and 14 (13%) were considered neutral or negative. Of the neutral/negative comments, ten described the curriculum as redundant to prior training, two declared that PCC skills are intuitive, and two were clearly negative. One student noted, “I feel I've been using this method during the entire third year, nothing very new in family medicine. The ICM curriculum covers this well.” Another student had stronger sentiments: “Info overload! Teach the essentials in a short to-the-point lesson, and it would be much more useful. All these PowerPoint slides, presentations, articles, etc.—sheer overkill!”
The 97 positive comments often included multiple elements. There were 177 elements associated with the positive comments. With the 14 additional elements associated with the negative comments, there were a total of 191 elements, an average of 1.7 elements per comment. Table 1 lists the themes, the number of elements that apply to each theme, the percentage of all the elements each of those numbers is, and the subthemes associated with each theme.
Thirty percent of the positive elements asserted that PCC skills facilitate good patient–physician relationships. Of these, two thirds focused on increased patient satisfaction, enhanced ability to meet patients’ needs, and improved communication. The remaining third of these elements addressed the promotion of shared decision making and patient–physician partnership. The curriculum, a student noted, “taught me the value of working with and not at the patient, establishing a team-approach with patient, a basis for trust and understanding.”
Enhanced educational experience.
Comments that the curriculum enhanced educational experience were also common. Of these elements, “Deepened and enhanced learning” was mentioned in 45%, while 22% declared PCC a most important part of medical education. “The principles [of PCC],” summarized a student, “need to be considered for each and every patient whether or not each is used in every encounter. I am glad that they are presented and are integral to the curriculum of the family medicine clerkship.” Exposure to the curriculum also enhanced learning family medicine during the clerkship. The curriculum was “helpful in promoting my learning about clinical problems,” a student reported, “as they [skills] allow me to focus more on learning about the pathology and the patient experience during the interview rather than spending the time worrying about how long the interview was taking or how disorganized it was.” This theme also included 16 (29%) generically positive, nonspecific elements.
Curricular modules reinforced.
The curricular modules were reinforced throughout the training experience, according to 20% of the positive elements. EF (46%), PPI (37%), and RCG (17%) were specifically mentioned. A student summarized these observations: “It was one of the first times that making clinical decisions was viewed in the context of what the patient and the doctor want to achieve in the care of the patient—something very effective and not addressed anywhere else.”
Approximately 13% of the positive elements noted that PCC skills promote efficiency. These elements were either focused on time management (61%) or organizational skills (39%). “It [PCC] was an efficient way to identify all of the patient's complaints,” a student wrote, “prioritize them, then agree on which we could tackle on that particular day.” Another student reported: “It helped me to better utilize the limited amount of time that is available for the interview.”
Enhanced adherence was a benefit of PCC noted by a few students. There were also sporadic comments that fit no theme and were coded as “Other.”
Overall, students were enthused about the curriculum and reported that it enhanced their medical education. This view is captured in the following student comment: “Patient-centered communication contributed by giving me a perspective that is not always medical. It was educational to see what real people were thinking causes their illness and fears. Approaching patients this way also created immediate trust—it was interesting to participate and observe—definitely a great way to practice.” In summary, students reported the PCC curriculum enhanced their learning of medicine by teaching them to efficiently structure their interviews while strengthening their relationships with patients.
Feedback from Preceptors
Preceptor feedback was gathered via written surveys during meetings in January 2002 and March 2003. The surveys were not identical and, given preceptor turnover, were not completed by the same cohort of preceptors. The first survey sampled 23 preceptors from 22 (92%) of the 24 training sites. The second survey sampled 21 preceptors and sites, but one preceptor was new and unfamiliar with the curriculum. Data were therefore derived from 20 (83%) sites. Both surveys explored curriculum implementation, on-site consultations, and the impact of teaching PCC on preceptor practices.
Six months after curriculum implementation, dissemination of the curriculum to all site preceptors and time for direct observation and feedback were the principal barriers to implementation. Only eight (36%) of the 22 sites sampled had received consultation at this time and twelve sites (55%) had implemented the curriculum with modifications to meet time constraints. “I thought it would be easy to do,” wrote a preceptor, “but find myself discussing extensively with students after we see the patients.” Eleven preceptors (48%) believed teaching PCC had positively affected the way they practiced medicine, while seven (30%) were unsure about this. “It's very nice to have this refresher on PCC for myself,” observed a preceptor, “I find myself interacting better with patients given my awareness.”
Twenty-one months after implementation, all 20 of the sites sampled in the second survey reported teaching portions of the curriculum. A total of 15 sites (75%) had received consultations, and site coordinators had received further faculty development training in quarterly meetings. Understanding the curriculum was less of an implementation barrier the second time, and preceptors voiced greater confidence in their abilities to teach PCC concepts. “I now try to make PCC concepts more explicit to students and residents,” a preceptor reported, “rather than just doing it and hoping they ‘get it.’ ” Another preceptor noted, “I now have a framework and language for teaching interviewing.”
Continued exposure to teaching PCC increased the percentage of preceptors who felt teaching had affected their style of practice to 67% upon the second survey; only one preceptor (5%) was uncertain about the impact of training. Preceptors who reported that teaching PCC affected their practice style had received on-site consultation and attended at least three EOQ faculty development sessions. A preceptor summarized the positive impact of teaching PCC on his style of practice: “It has helped me become more efficient and I think better serve my patients’ needs as well as teach students effective communication.”
The second survey indicated tension between productivity and training in busy preceptor private practices, as was summarized in a preceptor's observation of implementation barriers: “Time, time, and time. I really struggle with the demands for productivity and the time to teach.” To facilitate time management, some faculty reported selecting the last patient–student interaction of a clinic session for observation and feedback. Some preceptors with videotaping capabilities reported filming a patient–student interaction and providing review with feedback after clinic.
We have learned much from our efforts to implement the PCC curriculum. The curriculum reinforces interview behaviors associated with better satisfaction and health outcomes and builds upon earlier communication training that students receive in their preclinical years. Students are generally positive about the experience and perceive the skills acquired as valuable and applicable to their future practice of medicine. Preceptors are enthused about teaching PCC skills, and many report that review of the skills has positively influenced their patient care efforts.
Several lessons may be of value to others attempting to integrate communication training for medical students and residents in community sites. Considerable time and effort are required to develop and implement the curriculum described. Securing faculty support for teaching and providing effective and ongoing faculty development is crucial. Preceptors are motivated to implement curricula they believe in and feel prepared to teach. A longitudinal faculty development process helped us assess the readiness of faculty to teach PCC and provide essential training to most preceptors. Our 21-month start-up process allowed our training sites time to tailor the curriculum to be feasibly implemented in busy clinical practices.
On-site consultation, using a process that parallels the process preceptors are expected to use with students, is an effective faculty development strategy. However, providing on-site consultation for large numbers of training sites requires budgeting for training time and expenses. Still, the power of a visiting consultant is evident, as a preceptor observed: “It's hard for the local person to drum up support for something, especially if it's time-consuming. More help from the university would be great for big changes.”
Our experience has taught us that faculty development needs to be both didactic and experiential to optimally foster preceptor readiness to use and teach PCC. Preceptors are empowered by both developing a language for discussing specific interviewing skills and experiencing the consultation/feedback process. We have learned that the combination of continued exposure to faculty development and on-site consultation increases the likelihood of influencing the personal interview styles of preceptors and sharpens their awareness of their use of PCC skills. Our experience supports observations that carefully training preceptors to teach clinical interviewing is an important aspect of developing effective interviewing curricula.13
Achieving full curriculum integration across all sites remains a challenge. Verbal feedback from preceptors suggests that time spent in direct observation and feedback varies considerably from site to site and between preceptors. We do not have specific data on preceptor time spent per week, but a variety of factors may explain the variability in curriculum implementation. Uneven exposure of preceptors to faculty development, differences in patient volumes and practice pressures at individual sites, and variability of preceptor receptivity all affect curriculum implementation. To provide additional support, we are training preceptors who have fully integrated the curriculum to provide peer consultation, during regularly scheduled site visits, to other preceptors struggling with implementation. Faculty development remains a priority at quarterly meetings.
Our PCC curriculum closely approximates evidence-based guidelines for teaching patient-centered interviewing described by Smith et al.14 The experiential focus on skills acquisition, use of a syllabus, and grounding in a patient-centered conceptual framework are proven curricular strategies. However, our curriculum focuses on fewer interviewing skills than that described by Smith et al. and is integrated into a clinical rotation for medical students rather than being a block rotation for first-year residents.
Evaluation of the curriculum needs to be more rigorous than our present efforts.15 Our curriculum is designed to build didactically and experientially. While 20% of positive student comments identified the reinforcement of curricular modules as a benefit, we do not know how students integrate PCC skills into their interviewing repertoires. A more comprehensive evaluation would use validated and reliable methods to determine the impact of the curriculum on interview behaviors and on the patient's experience. Observation of students to determine whether interviewing behaviors are generalized to other clinical rotations following exposure to the PCC curriculum would be enlightening. Future evaluation could also assess whether the personal feedback in our PCC curriculum enhances students’ self-awareness, as reported elsewhere.16
We surmise that focusing on PCC skills during a third-year ambulatory clinical rotation may indeed enhance student acquisition of communication skills. Students develop their clinical personalities when assuming patient care, and the ambulatory setting is a rich environment for teaching communication skills.17 The opportunity to repeatedly practice in real-life situations, in concert with the vulnerability of being novices to clinical medicine, may render third-year students particularly receptive to feedback. We believe the clinical years of medical school represent an underutilized window of opportunity for learners to optimally assimilate communication-skills training. The enthusiasm with which our students and preceptors have embraced our PCC curriculum appears to affirm this observation.