Losh, David P. MD; Mauksch, Larry B. MEd; Arnold, Richard W. MD; Maresca, Theresa M. MD; Storck, Michael G. MD; Maestas, Raye R. MD; Goldstein, Erika MD, MPH
At the University of Washington, a group of educators were charged with defining and teaching a set of communication skills, or “benchmarks,” appropriate for second-year medical students conducting their first inpatient histories and physical examinations. In this article, we describe the communication benchmarks that were developed and an innovative tool for teaching those benchmarks to both students and their teachers. We then present the results of feedback from teachers and students about the content of the benchmarks and the design of the training.
Importance of Communication Skills
Effective communication between health care providers and their patients enhances health outcomes, increases satisfaction for patients and providers and decreases risk for medical malpractice litigation. New requirements and recommendations from national regulatory bodies, educational organizations, and policy centers reflect the importance of effective communication. In 2004, the National Board of Medical Examiners (NBME) began requiring clinical skills examinations to assess competence in communication.1 Communication is one of the six required competencies identified by the Accreditation Council on Graduate Medical Education (ACGME).2 The Institute of Medicine report Crossing the Quality Chasm3 emphasizes the importance of good communication in patient-centered care and the development of trust in minority communities. A 2004 Institute of Medicine report has identified basic and complex communication skills as two of the highest priorities for inclusion in medical school curricula.4
The majority of medical schools report that they are now teaching communication skills within their curricula.5 Overall communication competence can be significantly improved using skill-based teaching methods that employ established educational models.6 However, communication training requires specific content and teaching techniques that sometimes differ from those used to teach traditional medical subjects.7
Several challenges confront educators who are responsible for teaching communication skills. Many of today's medical teachers were not exposed to an organized, skill-based communication curriculum during their own training. They may be unfamiliar with the language used to describe communication techniques and may not be familiar with a model or structure for teaching specific communication skills. Overly general suggestions to listen carefully, ask open-ended questions, and have a “good bedside manner” offer little guidance to students who struggle to find ways of organizing their time and data-gathering during interviews.
Essential elements of effective medical communication were identified in 2001 in the first Kalamazoo Consensus Statement.8 It divides communication elements into seven areas: (1) building the relationship, (2) opening the discussion, (3) gathering information, (4) understanding the patient's perspective, (5) sharing information, (6) reaching agreement on problems and plans, and (7) providing closure. However, the communication skills that are required of students in specific clinical settings and at particular levels of training and development have not yet been described.
The communication training described in this article was developed as a part of the University of Washington School of Medicine's new “College” system. Under the College system, 30 clinically experienced teachers from various specialties oversee a four-year integrated curriculum of clinical skills and professionalism, which includes teaching history and physical diagnosis skills, to approximately 180 second-year students in the second-year Introduction to Clinical Medicine (ICM II) course. Each faculty member mentors six students from each class and is responsible for bedside teaching of history, physical examination, and communication skills. While students are introduced to communication principles and interview patients in their first year, their contact with actual patients and bedside communication is much greater in the second year. Since communication skills are so critical to each patient encounter, and second-year students are scheduled to do a large number of patient interviews, in 2003, we formed a committee of six College teachers—including the course director (EG) and a behavioral science consultant (LBM)—and decided to define the communication expectations for second-year students and start our ICM II course with a training session on communication skills.
The training session on communication skills was the first of several classroom sessions scheduled throughout the year to teach specific physical diagnosis or interviewing skills. In the weeks following the communication teaching session, and during most weeks throughout the year, students have been able to immediately apply what they learned by doing actual history and physical examinations on hospitalized patients as their College teacher observed and gave feedback.
Development of Communication Benchmarks
A benchmark is a point of reference by which performance is measured.9 At the University of Washington, this term has been used to identify learning objectives in a variety of subjects such as professionalism, physical diagnosis skills, and medical communications. In the simplest of terms, the benchmarks are a list of effective communication skills that students should demonstrate by the end of their second year in medical school. The final benchmarks were reviewed and approved by the entire 30-member College faculty in August of 2003.
As the communication benchmarks were developed, we (the present authors) incorporated the applicable principles from the Kalamazoo Consensus Statement and added others. The key communication concepts that were used in our benchmarks were
▪ establishing rapport with the patient
▪ respecting the patient's time and privacy and giving attention to the patient's comfort
▪ establishing the patient's agenda
▪ understanding the patient's perspective
▪ using active listening
▪ using open- and closed-ended questions effectively
▪ responding to verbal and visual cues
▪ reaching agreement with the patient on plans
▪ using summaries to confirm information
▪ demonstrating contextual and cultural sensitivity
▪ providing effective closure
The benchmarks describe five phases of the inpatient interview and physical examination: the introduction, the history of the present illness, general data collection, the physical examination, and the summary and closure. A summary of the benchmarks is provided in List 1, and the full set of benchmarks appears in the Appendix. As shown in the Appendix, the full set of benchmarks that is used with students provides examples in each section to illustrate how the communication could be worded to flow in a natural and seamless manner. Even if learners are aware of a set of communication concepts, it can be challenging to translate those concepts into language during a clinical encounter. The examples at the end of each section also show how quickly a number of principles may be addressed and linked in conversation.
An Innovative Teaching Tool
Teaching communication skills is challenging and can be intimidating if one is not familiar with the specific subject matter, methods, and language used in the communication field. Teachers not only need to understand the subject matter but also need to be able to identify teaching opportunities, give students focused feedback, and demonstrate effective communication.
We, the members of the communication committee and present authors, were challenged to train College faculty and provide them with a tool to transform a set of rather dry principles into living examples of good communication. We needed a tool that would help teachers who had various levels of formal experience teaching communication to organize their methods of teaching and standardize the content. Finally, we needed a tool that would draw the students into active observation and assessment of the communication techniques we were trying to teach.
To meet those goals, we (the authors) developed a set of five short videotaped scenarios representing each of the five phases of the benchmarks. Each scenario consisted of two parts and lasted from 30 seconds to about two minutes each. The first part demonstrated “OK” communication but did not include many of the benchmarked skills outlined in List 1. The second “better” part was a reenactment of the same interaction that demonstrated the appropriate benchmarked skills. The technique of “OK” versus “better” video scenarios was developed by one of us (LBM) and has been used successfully in teaching patient-centered communication during a third-year clerkship10 and in the teaching of agenda-setting and time management in a family medicine residency.11 However, to our knowledge, it has not been used in the inpatient setting or with students doing their first history and physical examinations. The technique has several positive points.
* Since the first version is “OK” but not horrible, the scenario is fairly realistic and is less likely to be cast off by students as so inept that they would never commit such blatant communication errors themselves.
* The “better” version includes the targeted skills for learning but is not necessarily perfect. It illustrates realistic techniques that the learner can achieve.
* These contrasting videotape scenarios prompt students to differentiate effective communication from less effective communication without placing themselves in awkward or embarrassing situations.
* The videotapes also allow illustration of nonverbal communication. For example, in the “OK” version the student enters the room without knocking. In the “better” version, the student knocks first and asks permission to enter the patient's space.
* Finally, the videotapes provide a tool that can be used to provide consistent teaching from year to year and are not highly dependent on the variations between teachers.
The following brief segment from one of the scenarios illustrates some obvious differences between an “OK” version and the “better” version related to benchmarks on open-ended questioning and attention to patient cues.
Student: Mr. G, I saw from looking at your chart that you're here to have your gallbladder removed, and you are scheduled for surgery tomorrow. Is that correct?
Patient: You're right. Dr. Smith is going to take it out tomorrow morning.
Student: Did you have pain?
Patient: You bet I did—a terrible pain in my side. I thought I was going to die, and I'm still not so sure I won't.
Student: Did you feel nauseated?
Patient: I was really sick to my stomach after meals.
Student: Mr. G, can you tell me in you own words when you first became ill and what brought you to the hospital?
Patient: Sure: It all started about two weeks ago. I began throwing up everything I ate and developed this terrible pain in my side. I thought I was going to die, and I'm still not too certain I won't. It got so bad that I went to see my doctor. I never felt so bad before in my life. My doctor sent me to the ER and they did some blood tests and an ultrasound, and evidently I've got gallstones. I'm not sure how, but they seem to be causing the pain.
Student: I see. Before we go on, you mentioned some concern that you still might die. Can you help me understand that feeling?
Patient: I don't know. It's just that my mother was having her gallbladder removed a couple of years ago and she just never woke up. I just keep thinking about that.
Our technique for producing the videotape scenarios was relatively low-budget. It involved having several of the faculty script and review the scenarios prior to taping them with a digital video camera. Two of the College teachers (TMM, RWA) served as actors, one (LBM) served as the camera person and editor, and one (DPL) served as an observer and consultant during the videotaping. The scripts illustrated many of the communication benchmarks described in this article and were used as guides by the actors. The videotaping was done in a vacant hospital room over two afternoon sessions. Video editing for the five scenarios took approximately 12 hours and was done using a G4 Macintosh computer using the video editing software Final Cut Express™. Other less complicated video editing programs such as iMovie™ are available.
Faculty and Student Training
Prior to using the videotaped scenarios with students, two training sessions were held with the thirty faculty members who were responsible for teaching the material. The first hour-long session, delivered by one of us (LBM), introduced faculty members to the language of communication training through the critiquing of a videotaped interview that was missing many essential communication elements identified in the Kalamazoo Consensus Statement. To facilitate discussion, the faculty members were divided into three groups of ten and the session was repeated for each group. The second session, several weeks later, allowed the entire faculty of 30 College teachers to do a final review of the benchmarks and preview the ”OK“ and ”better“ versions of each videotaped scenario created for teaching students. Each faculty member was given a written description of the teaching points and benchmarks that were illustrated in the scenarios.
One week after the completion of the faculty training, pairs of College teachers presented the videotaped scenarios and the benchmarks to groups of 12–14 students during two-hour teaching sessions. The sessions were completed for all 180 students within a one-week period. The goals of the teaching sessions were to (1) introduce students to the communication benchmarks, (2) engage students in identifying and contrasting good higher-quality communications (the ”better“ version) versus common but less than adequate (′OK”) communications, and (3) stimulate group discussion about communication issues that could be expected in the course of students’ history and physical examinations.
Written copies of the benchmarks were provided to all the students in their syllabus materials and at the start of each training session. Each group had students first view the “OK” version of a videotaped scenario. The videotape was then stopped and students were asked to share their observations of which communications had gone well, what was missing, or what could have been done better. Then the “better” version of the same scenario was viewed by the group. Students were then asked to share their observations with the group and contrast the better version with the “OK” version. The better version allowed students to observe most of the communication techniques identified in the benchmarks as they might actually occur in the course of typical students’ patient history and physical examinations. A similar sequence of observation followed by comments and discussion was done for each of the five scenarios, moving from the introduction to the closing of a typical student inpatient history and physical examination.
Results of Feedback
The response of students
At the end of each teaching session, students were asked to anonymously rate the value of the session and the videotaped teaching technique on an evaluation questionnaire. Questions used a Likert scale with the midpoint indicating the intervention had no effect, the two points on one side indicating it was a little worse or a lot worse, and the two points on the other side signifying a little better or a lot better. A total of 120 of 180 students responded to the survey for a 66% response rate, a rate that is typical of the student body in evaluating courses or completing other surveys. When asked if the session on communication helped them to feel any more comfortable about talking with hospitalized patients, 64% (77 of 120) responded that the session helped them to feel a little more comfortable and 18% (21 of 120) felt much more comfortable. Another 18% felt that the session did not affect their comfort level one way or the other. The majority, 76%, of students felt that the videotapes aided them either a little or a lot in understanding the written communication benchmarks, and 21% felt that their understanding of the benchmarks was neither helped nor hurt by the videotapes. All but two students felt that the videotapes helped stimulate group discussion about communication issues. The vast majority of students—107, or 92%, of only 116, since four of the 120 responders answered two conflicting answers, so their responses were discarded–felt that the videotapes helped to point out some subtle communication issues that might otherwise be missed, and only 13 students thought the differences in the scenarios were so obvious that they were not very helpful. None of the responding students felt that the communications on the tapes were too subtle or theoretical to be of use at this point in their training.
The response of teachers
After the teachers completed the teaching sessions with students, they were each sent a survey via e-mail asking them for feedback on the sessions and the use of the videotapes. Nineteen of 30 teachers responded to the survey, for a response rate of 63%. Teachers were asked to respond on a five-point Likert scale to most questions. They were also asked open-ended questions about what worked well and what they would change if they were going to do the session over again. Eighty-four percent (16 of 19) teachers felt that the material in the videotapes was appropriate for the student's current level of knowledge and communication skills. Sixteen percent (3 of 19) felt that the material was somewhat below the student's level of skill and training. Seventy-nine percent (15 of 19) felt that the “OK” versus “better” design of the videotapes was extremely useful for teaching, and 100% (19 of 19) felt that the design was either extremely useful or somewhat useful. Eighty-four percent (16 of 19) also found that the tapes either helped a lot or helped somewhat to develop a discussion about the communication benchmarks. Sixteen percent (3 of 19) felt that the tapes neither helped nor hindered the discussion. Fifty-three percent of the teachers (10 of 19) indicated that the benchmarks and the tapes helped somewhat in their own understanding of these concepts, and 42% (8 of 19) indicated that the benchmarks and tapes helped their own understanding a lot. In their open-ended responses, a number of faculty teachers suggested developing future scenarios that would illustrate an example of a difficult communication issue such as would exist with an angry or noncommunicative patient. It was suggested that such a scenario would challenge the students with a more advanced communication problem in addition to focusing on basic communication skills.
Comments on the Curriculum
To summarize: We developed a communication curriculum with a set of benchmarks tailored to the developmental level of second-year medicals students. An innovative set of videotaped scenarios used in teaching the curriculum was well received by students and faculty. Feedback from faculty and students indicated that the educational method stimulated discussion about communication issues, and helped students and faculty enhance and refine their understanding of communication skills.
We expect that the benchmarks developed in this project will be used throughout the second year of medical school as a reference point for students and teachers. We also anticipate that the benchmarks will be helpful references in the future as curriculum objectives are defined for first-, third-, and fourth-year students.
Evaluation of student performance over time will help us assess the effectiveness of the teaching program. The benchmarks have been helpful in developing student evaluation and feedback forms that are currently being used in the second-year ICM II course. The student's College teacher observes each student's patient interviews throughout the year and completes an evaluation of the student's progress each quarter. Among other attributes, the feedback forms rate the student's interviewing and communication skills from “beginning” through “mastering” in ten areas. These include clarification of patient data, the use of notes during the interview, elicitation of the patient's perspective, the use of open-ended and closed-ended questions, the use of active listening techniques, the use of effective transitions, direction and control of the interview, demonstration of empathy and nonjudgmental attitudes, attention to patient comfort, the avoidance of jargon, and appropriate closure. In addition to observation of student communication at the bedside, student performance in interviewing and communication is also being evaluated in a series of objective structured clinical examinations given during the last quarter of the second year. Evaluation of student performance in these areas will require further study and is planned in the future.
Since 95% of the faculty respondents felt that the training in the use of the benchmarks and the videotapes was helpful in their own understanding of communication concepts, our data support the importance of offering communication skills training to physician educators. The teacher needs a language to define, differentiate, and demonstrate communication skills. Our findings are consistent with previous work at the University of Washington that found that faculty who received training in communication skills reported that their communication with patients improved and that they were able to teach more effectively.10
A skill-based curriculum tailored to the developmental level and practice setting of the student is useful for several reasons. Evidence suggests that most practicing physicians do not use many of the essential elements of medical communication cited in the Kalamazoo Consensus Statement.12,13 This is not surprising, since most of today's physicians were not exposed to these concepts and skills in an organized manner in medical school. Students are just beginning to develop their clinical personalities and are usually open to learning new skills and methods. The listing of communication skills in a logical sequence helps students apply a structure to the medical encounter. Feedback from our students and residents who are exposed to this skill-based model is that they feel less anxious and freer to focus on the patient and the patient's problem.10 Practicing physicians express concerns about losing control of time as an impediment to communication. However, evidence suggests that the application of certain communication skills such as agenda-setting and picking up on patients’ cues actually helps organize and control time and enhance the quality of care.14,15
The principles used in teaching communication skills to second-year students are transferable to other institutions and trainees at various levels. The benchmarks we have presented are specifically tailored to the learner's level of development and training at our institution. However, other institutions may elect to devise different benchmarks tailored to differing expectations. At our institution a second-year student is not expected to devise a therapeutic plan and discuss it with the patient, but the student is expected to gather accurate information in a timely and sensitive manner. These benchmarks reflect those expectations.
The development of contrasting videotape scenarios is a tool that can be used to teach a variety of skills in addition to communication skills. Experienced students or faculty who have been taught the language and skills only need general guidelines to enact teaching scripts that illustrate selected skills. Digital video camera and editing equipment is relatively inexpensive and easy to use. For our initial attempt at developing videotaped scenarios, two of the College teachers served as the actors. In order to make the scenarios more realistic and provide a more powerful role model for students, there may be some advantages to using a well-trained student as one of the actors.10
We feel that the benchmarks and the “OK” versus “better” videotapes have helped us expose students to good communication and interviewing principles early in their interviewing careers. The benchmarks have helped us provide a standard for teachers and students by which performance is being measured. Finally, the benchmarks, training sessions, and videotapes have helped our faculty mentors increase their own understanding of communication concepts so they may identify and demonstrate specific communication skills as they work with students.
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Appendix The Benchma...Image Tools
Appendix (Continued)...Image Tools