Recently, in the United States, increased attention has been given by regulating agencies to the training and assessment of physicians in communication skills. Beginning in 1998, international medical graduates were required to have their communication skills assessed before beginning postgraduate training. The medical school class of 2005 has been the first to be required by the United States Medical Licensing Examination (USMLE) to take a clinical assessment with a standardized patient as part of Step 2 of the medical licensing exam. In 1999, the Accreditation Council for Graduate Medical Education (ACGME) introduced a set of six general competencies, three of which have communication skills as a critical component: interpersonal and communication skills, patient care, and professionalism.1 Postgraduate accredited training programs are required to demonstrate that they are teaching and assessing these skills in their trainees. Participation in communication skills training (CST) programs is not limited to trainees, because a growing body of licensed physicians around the world are contributing as participants in, and developers of, such programs.2,3
This focus on CST is founded on three basic premises. First, effective communication skills in consultations are linked to important patient and physician outcomes.4 Second, communication skills are not always optimal; thus, these patient and physician outcomes can be improved.5 Third, communication skills can be taught. Pretest/posttest methodologies are commonly employed to evaluate the success of training.
In 2002, Cegala and Broz6 published a systematic review of 26 intervention studies of CST for practicing physicians and trainees in graduate medical education commencing in 1990. The authors conducted a Medline search limiting their review to completed international research studies exploring CST in provider populations. They conclude there is good evidence that CST is effective in improving the communication skills of physicians. However, Cegala and Broz raise some concerns about this literature. First, they point out that very little information is usually provided in these articles about what skills are being taught. Without such detail, it is impossible to judge whether correct assessments are being used. Second, in the few articles where the skills are provided, there are several occasions of misalignment between the intervention’s objectives (e.g., promoting patient-centered interviewing) and the assessment tool. Third, they assert that “little effort has been made to provide an overarching framework for organizing communication skills.”6(p1005)
Since the 2002 review, 18 CST interventions studies have been published that fit the criteria of Cegala and Broz.3,7–22 The same criteria were used to search for these updated studies as were used in the Cegala and Broz review. In our review of these articles, we have found that for the most part Cegala and Broz’s critiques hold true for the most recently published literature; there is little detail about the skills that are taught (for an exception, see Back et al8), and none provide a framework for organizing communication skills. However, unlike the previous review, we did find several good examples of alignment between the stated objectives and the assessment.
In addition to Cegala and Broz’s critiques, we offer an additional limitation of the published literature in general: The term communication skill is used inconsistently across studies and is often ambiguous within studies. Various studies of CST use different terminology to explain a communication skill. These include terms such as: task,23 element,24 approach and technique,25 strategy,21 step, and component.26 In some cases these terms are used interchangeably within a publication without explanation.21,24 We have found only one textbook definition of communication skills: “the numerous acts that health workers express in caring for their patients.”27 Others, while offering no explicit definition of a communication skill, list skills of varying abstractness such as effective care, question style, and making eye contact.27 Additionally, differing degrees of complexity are present in communication skills, ranging from greet and obtain patient name to set consultation agenda to determine and acknowledge patient’s ideas.28
Because the peer-reviewed literature does not give explicit detail about curricula, we turned to copies of unpublished curricular material from CST programs throughout the world. The authors contacted recognized experts in the CST field (known to the authors) and asked to review the material. In the CST materials that we reviewed, the “skills” on offer are often unclear and need to be extracted from exemplars.
For instance, a breaking bad news workshop that we reviewed contained a step called encourage patients to express feelings, followed by an exemplar dialogue for this particular step.29,30 We have broken this example down to highlight the three skills necessary to convey the example (Table 1). The left column contains the published “step,” and the right column identifies the communication skills necessary. The right-hand column is our addition after we extracted and identified the skills in question. The approach of providing examples without description is not optimal, particularly in the context of teaching specific communication skills. Clearly, identifying skills makes teaching and assessment more precise.
The purpose of this article is thus to present a new model of CST, the Comskil Model, that the authors developed at Memorial Sloan-Kettering Cancer Center (MSKCC) between 2005 and the present. This model addresses the weaknesses we have identified in the previous literature, in that it provides an overarching framework for organizing communication skills, clearly defines a communication skill, and gives explicit descriptions of communication skills that are common across contexts. In doing so, this model provides the basis for curricula in which teaching and assessing specific skills are aligned. Before implementation by the Comskil laboratory to train MSKCC attendings and fellows, the model was reviewed favorably by three prominent international leaders in CST.
Theoretical Foundations of the Comskil Model
Physician–patient communication is interpersonal communication in a particular context. Thus, as interpersonal communication scholars have developed a body of theory to aid in the understanding of this process, we have drawn on this work to inform our conceptual model. We have drawn from two theories that explain the ways in which people formulate their communication: (1) Goals, Plans, and Action (GPA) theories, and (2) sociolinguistic theory.
Communication theorists provide a clear ordering of the components of interpersonal communication in GPA theories.31 These theories provide a useful framework for understanding interpersonal communication and also provide a distinction between communication elements that vary in abstractness. This theoretical framework, which originated in fields of communication and psychology,32,33 is based on the premise that when people communicate they rely on goals and plans35 to guide their communication. Goals have been defined as “future states of affairs that individuals desire to attain or maintain.”35(p68) Plans are more concrete than goals—they are mental representations of actions needed to achieve a goal.36 Plans vary in complexity and specificity. Actions are even more concrete as they are the enacting of the behavior that is planned. Although we use different labels that are more in line with the CST literature (e.g., we use strategy instead of plan and communication skills and process tasks as our actions), the principles of distinction are the same.
As a second theoretical foundation for the Comskil Model, sociolinguistic theory offers clarification about communication styles. According to this theory, there are two basic communication orientations: the position-centered approach and the person-centered approach. These are differentiated by the degree to which a person can adapt to a variety of communication contexts. The position-centered communicator relies on a restricted code of communication, following the rules and norms of a communication situation. The person-centered communicator adapts his or her communication in response to the perspectives, feelings, and intentions of others.31 Using a person-centered approach is one characteristic of what Epstein calls being a “mindful practitioner.”37 Our goal is that if curricula are based on the Comskil Model, they will aid in participants’ acquisition of, and practice with, the skills they need to enable them to take a person-centered approach. In other words, we recognize, as do GPA theories, that there is more than one way to meet a particular communication goal. The Comskil Model offers potential strategies and skills that individuals can use while adapting them to a variety of challenging situations (e.g., breaking bad news, discussing prognosis or treatment options) and allowing them to be congruent with their own interpersonal communication styles. In using this theory as a guide for our curriculum, we concur with Kurtz and colleagues,28(p45) who note that “communication training should increase rather than reduce flexibility by providing an expanded repertoire of skills that physicians can adeptly and intentionally choose to use as they require.”
To address the difficulties inherent in other explanations of communications skills, we have adapted the GPA and sociolinguistic theoretical frameworks as the basis of an innovative approach within which each component is defined, explicit, and unambiguous. This approach also enables more accurate and specific assessment to be made about how well trainees learn these skills, thus addressing an important limitation in the current CST literature.
Defining the Core Components of the Comskil Model
To make teaching communication skills more explicit, and also to aid in the evaluation of skills uptake, we conceive of consultation communication as having five components: goals, strategies, skills, process tasks, and cognitive appraisals. In this section, we define these terms and describe how the components are integrated.
A communication goal is the desired outcome of the consultation or portion of the consultation. For example, the communication goal of our breaking bad news module38 is “to convey threatening information in a way which promotes understanding, recall, and a sense of ongoing support.” As GPA theories explain, this definition of a goal focuses on the desired state that the individual is attempting to attain. The communication goal is achieved through the use of communication strategies, communication skills, process tasks, and cognitive appraisals.
Communication strategies are a priori plans that direct communication behavior toward the successful realization of a communication goal. The cumulative use of several strategies facilitates goal achievement. For example, respond empathically to emotion and provide information in a way that it will be understood are both strategies that may help to achieve the communication goal for breaking bad news. As with the notion of plans found in GPA theory, strategies are more concrete than goals. Further, a strategy can be accomplished in more than one way. In our curriculum, we recommend strategies that are useful to achieving a particular goal.
A communication skill is a discrete mode (unit of speech) by which a physician can further the clinical dialogue, and thus achieve a strategy. Unlike the definitions both implicit and explicit in the literature of communication skills, this definition describes the communication skill as concrete, teachable, and observable. Skills are parallel to the notion of actions in GPA theory; they are the least abstract elements of the hierarchy. In addition, a variety of communication skills may be used in the attainment of a particular strategy. For example, the strategy of respond empathically to emotion may be accomplished through acknowledgment, validation, or praising patient’s efforts. The strategy of provide information in a way that it will be understood may be accomplished through previewing information, summarizing information, and/or checking patient understanding.
Process tasks are sets of dialogues or nonverbal behaviors that create an environment for effective communication. These are similar to skills in that they are concrete, whereas goals and strategies are abstract, and that they help an individual enact a strategy as a means to meet a goal. Process tasks require consideration and can range on a continuum from basic to more complex. Examples of basic process tasks include introducing self to patient, providing a private space in which to break bad news, and ensuring that the doctor is at the patient’s eye level. Examples of more complex process tasks include avoiding premature reassurance, paying attention to information framing (words or numbers), and using a randomization story to help explain a randomized clinical trial.
During consultations, doctors observe and then internally process patients’ nonverbal and verbal behavior. This process of cognitive appraisal allows the doctor to formulate a hypothesis about the unstated or inexplicit needs and agendas the patient may have. This appraisal drives the communication strategy selection. These cognitive appraisals are critical to the effective communication process as some patient issues are not clearly articulated through conventional consultation discourse. Patients may have needs or agendas that, if not uncovered, may impede the trajectory of the consultation. Bringing these to light is a complex communication challenge which is achieved through making cognitive appraisals that lead to selection of communication strategies, and thus the utilization of communication skills. Although doctors are constantly making cognitive appraisals throughout an interaction, our model focuses on two specific types of cognitive appraisals: patient cues and barriers. We have chosen these appraisals to include in CST because if they are not addressed the physician–patient relationship may be impaired.
Patient cues are indirect statements that patients use to prompt doctors for informational or emotional support. For example, a patient may have a desire for particular information, yet lack confidence in asking direct questions. Consequently, to have the information need met, the patient may use an information cue such as “I really don’t know much about the different treatments.”39 Because this is not a direct request for information, the doctor would have to make a cognitive appraisal of the patient’s need for information. This is an iterative process leading to an appropriate response to the patient cue through strategy and skill use. Similarly, patients may cue their doctor for emotional support. An example of an operationalized emotion cue in the context of a treatment discussion would be, “I get so upset sometimes I can’t stop crying.”39
Patient barriers are undisclosed patient perceptions that may impede effective consultation communication. One example of a patient barrier is particular fears about the prospect of chemotherapy based on a patient’s previous knowledge and misconceptions of the side effects. This undisclosed patient perception will impede an effective decision making process and may be expressed by the patient’s hesitancy to discuss treatment, use of blocking behaviors, or expression of anxiety in the discussion. This is also an iterative process, and the strategies and communication skills will assist the doctor to uncover and resolve the hidden barrier.2
Integrating the Core Communication Components
Clearly, these definitions of communication goals, communication strategies, communication skills, process tasks, and cognitive appraisals are related to one another, as articulated in Figure 1.
The communication strategy is a higher-order category and is accomplished through the use of communication skills and/or process tasks. Communication skills differ from strategies and process tasks in that they provide a building block for complex communication tasks. As noted by Kurtz et al,28 (p38) core skills are fundamental: “Once core skills are mastered, specific communication issues are much more readily tackled.” Communication skills exist and are expressed in certain contexts. As we have explored both the communication skills literature and various teaching modules,2,30,40,41 we have compiled a list of 26 discrete communication skills (see Appendix 1 for more detail). We have organized these skills into six higher-order categories to assist in teaching and assessment and to aid learners’ understanding and recall. These are
▪ establishing the consultation framework;
▪ information organization skills;
▪ checking skills;
▪ questioning skills;
▪ empathic communication skills; and
▪ shared decision-making skills.
Teaching Core Communication Components
Teaching the MSKCC Comskil curriculum begins with the introduction of core communication components that then will be reinforced multiple times through the modules. The curriculum consists of eight modules and is taught by the authors and other laboratory faculty to MSKCC fellows. Modules are taught individually or in groups of three during the course of a one-day workshop. Each module takes two to three hours to complete, with the majority of the available time given to role play.
▪ In the modules, communication strategies and communication skills are introduced and described as part of didactic lectures, and labeled examples are incorporated throughout the exemplary videos.
▪ Cognitive appraisals are the focus of didactic teaching and exemplary videos showing examples of effective appraisal processes.
▪ Process tasks are emphasized throughout the modules. The importance of basic process tasks in establishing an effective communication environment is emphasized during the presentation of literature and by exemplary videos. Complex process tasks may receive more attention in the didactic and role-play sessions.
To make this clear, we have developed comprehensive modular blueprints for each module that provide the essential communication components of that module. These blueprints will guide the development of the didactic material, written material, videos, role-play, and the evaluation. We have included the modular blueprint for the breaking bad news module taught through the MSKCC Comskil Laboratory (see Table 2).
Assessment and Feedback
The Comskil Model provides training for a clear set of communication skills that can be measured to achieve useful feedback and a valid and reliable assessment process. To achieve this in the MSKCC CST program, we video-record participants in the outpatient consultation setting before and after their training. The coding system we have devised based on the 26 skills includes the use of a coding manual we developed to standardize recognition of skills between coders. Five laboratory staff are trained to code, and two consultations per trainee are coded by two of these lab members. This coding system is applied to each trainee’s recordings to assess baseline skills and posttraining uptake.
Participants receive feedback letters prepared by one of the two coders on the basis of this coding. These letters outline the presence or absence of skills and provide summaries that emphasize the learner’s current clinical communication strengths as well as areas for improvement. Average skill use is calculated for each group of participants before and after training; thus, in addition to individual feedback, participants are provided with information about their performance in comparison with their fellow trainees. Participants’ post training feedback letters describe their strengths, skills uptake, and areas for continued improvement.
In addition to formal feedback, participants receive informal feedback from their facilitators and peers during small-group role-play sessions. The Comskil Model allows for a common language to be used in giving this feedback. Participants are asked to name skills they are commenting on, and facilitators are trained to reinforce skills by name.
The coding system we have developed and apply to consultation video-recordings enables us to quantify the learners’ skill use before and after training. Our assessment method involves entering these data into a statistical program and then performing an analysis of grouped data to make pre- and posttraining comparisons based on frequency counts of the presence of particular skills. The particular strength of this method is that we are able to ensure that the skills taught are directly matched to those measured as part of the evaluation process.
There is a mounting body of research evidence describing the utility of workshop-based training to improve doctors’ communication skills. The Comskil Model adds to this literature by providing a framework supported by interpersonal communication theory. In doing so we have attempted to address some of the methodological limitations identified by ourselves and others that make it difficult to fully evaluate the success of published training programs. The specific aims that guided the development of the Comskil Model include to make communication skills organized and unambiguous, to enable the explicit presentation of communication skills, and to ensure accurate assessment through clear matching of training goals and outcome measurement.
The model achieves these goals by providing clear definitions of core communication components and explaining how these components are integrated to achieve communication goals. Through the use of such explicit definitions, we avoid ambiguity in teaching. This aim is achieved by developing modular blueprints that clearly outline the various components and how they operate within a specific communication context. Finally, through the use of rigorous coding techniques, our assessment methods directly match our teaching content with our outcomes. We achieve our learner-centered theoretical approach through the use of both individual and comparative feedback.
Another strength of this model is its ability to be adapted to suit various training needs. We have used the model with both graduate medical education and practicing physicians in oncology, yet the model is specific to neither education level nor context. Because of its focus on core communication skills that underlie good communication processes, this model could be easily adapted to CST courses in undergraduate medical education. Further, the skills are not content specific, making the model applicable to general medicine, specialty medicine, nursing, genetic counseling, and other settings.
To date, the curriculum based on this model has been used for more than a year with more than 100 attending physicians and fellows. At present, we are gathering prospective data on the efficacy of the Comskil Model to improve participants’ communication skills. In future research, we plan to evaluate the impact of different durations of communication skills training on skills uptake, to assess the model in multiple medical contexts, and to explore new communication challenges that can be addressed by the Comskil Model.
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