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Essential Elements of Communication in Medical Encounters

The Kalamazoo Consensus Statement

Makoul, Gregory, PhD

EDUCATING PHYSICIANS: ESSAYS
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In May 1999, 21 leaders and representatives from major medical education and professional organizations attended an invitational conference jointly sponsored by the Bayer Institute for Health Care Communication and the Fetzer Institute. The participants focused on delineating a coherent set of essential elements in physician—patient communication to: (1) facilitate the development, implementation, and evaluation of communication-oriented curricula in medical education and (2) inform the development of specific standards in this domain. Since the group included architects and representatives of five currently used models of doctor—patient communication, participants agreed that the goals might best be achieved through review and synthesis of the models. Presentations about the five models encompassed their research base, overarching views of the medical encounter, and current applications. All attendees participated in discussion of the models and common elements. Written proceedings generated during the conference were posted on an electronic listserv for review and comment by the entire group. A three-person writing committee synthesized suggestions, resolved questions, and posted a succession of drafts on a listserv. The current document was circulated to the entire group for final approval before it was submitted for publication. The group identified seven essential sets of communication tasks: (1) build the doctor—patient relationship; (2) open the discussion; (3) gather information; (4) understand the patient's perspective; (5) share information; (6) reach agreement on problems and plans; and (7) provide closure. These broadly supported elements provide a useful framework for communication-oriented curricula and standards.

Gregory Makoul, PhD, director of the Program in Communication and Medicine at Northwestern University Medical School, provided leadership in the writing process.

Correspondence and requests for reprints should be addressed to the Bayer Institute for Health Care Communication, 400 Morgan Lane, West Haven, CT 06516; e-mail: 〈bayer.institute@bayer.com〉.

The Bayer—Fetzer Conference on Physician—Patient Communication in Medical Education was held May 11–14, 1999. The Bayer Institute for Health Care Communication is a non-commercial, nonprofit, organization whose mission is to improve health through education, research, and advocacy in the area of clinican—patient communication. The Fetzer Institute is a nonprofit, private operating foundation that supports research, education, and service programs exploring the integral relationships among body, mind, and spirit. The conference site was Seasons, A Center for Renewal, owned and operated by the Fetzer Institute, in Kalamazoo, Michigan.

This consensus statement reflects the views of the conference participants; it does not necessarily imply endorsement by their institutions or associations.

Participants in the Bayer—Fetzer Conference on Physician—Patient Communication in Medical Education

The conference participants are listed in a box at the end of the text.

A growing emphasis on physician—patient communication in medicine and medical education is reflected in international consensus statements,1,2 guidelines for medical schools,3–6 and standards for professional practice and education.7–12 In May 1999, with work in these areas and related research13–17 as a backdrop, 21 people from medical schools, residency programs, continuing medical education providers, and prominent medical educational organizations in North America convened for three days in Kalamazoo, Michigan, for the Bayer—Fetzer Conference on Physician—Patient Communication in Medical Education. The aim of this invitational conference was to identify and specifically articulate ways to facilitate communication teaching, assessment, and evaluation.

The group used an open-ended, iterative process to identify and prioritize topics for discussion. A major topic of interest to the entire group was delineating a set of essential elements in physician—patient communication. Participants expressed three goals for the discussion:

  1. Reaching consensus on a “short list” of elements that would characterize effective communication in several clinical contexts.
  2. Providing tangible examples of skill competencies that would be useful for licensing bodies, organizations that accredit medical schools and residency programs, and directors of medical education programs at all levels.
  3. Ensuring that the product generated by the group would be evidence based and appropriate for teaching, assessment, and evaluation.

Since the group included architects and representatives of five currently used models of doctor—patient communication, participants agreed that the goals might best be achieved through review and synthesis of the models' essential elements. Toward that end, brief presentations were delivered about each of the five models:

  • Bayer Institute for Health Care Communication E4 Model18
  • Three Function Model/Brown Interview Checklist19
  • The Calgary—Cambridge Observation Guide20
  • Patient-centered clinical method21
  • SEGUE Framework for teaching and assessing communication skills22

Each presentation included an explicit description of the model, encompassing its research base, overarching views of the medical encounter, and current applications. After discussion of the models, attendees from the Accreditation Council for Graduate Medical Education (ACGME), the CanMEDS 2000 Project, the Educational Commission for Foreign Medical Graduates (ECFMG), and the Macy Health Communication Initiative provided information about their efforts to develop criteria for teaching and evaluating physician—patient communication. The group then began looking for commonalities among the models as well as points of departure. This process was enriched by the number and diversity of organizations represented by conference participants.

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THE ESSENTIAL ELEMENTS

Consensus on the essential elements of physician—patient communication was reached by using the three goals outlined above to guide and ground discussion. The group's perspective on essential elements is consistent with the task approach, a concept that has been well supported in communication skills teaching since the early 1980s.3,18–25 As noted by Makoul and Schofield,2 “focusing on tasks provides a sense of purpose for learning communication skills. The task approach also preserves the individuality of [learners] by encouraging them to develop a repertoire of strategies and skills, and respond to patients in a flexible way.”

By identifying specific communication tasks, the group worked to highlight behaviors that are embedded in existing consensus statements, guidelines, and standards. While the list is by no means exhaustive, the intent was to make it easier for people working in this area to identify not only the key tasks, but the relevant knowledge, skills, and attitudes as well. References for the supporting research are listed and discussed in a number of texts.20,21,23–28

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Build a Relationship: The Fundamental Communication Task

A strong, therapeutic, and effective relationship is the sine qua non of physician—patient communication.29,30 The group endorses a patient-centered, or relationship-centered, approach to care, which emphasizes both the patient's disease and his or her illness experience.31,32 This requires eliciting the patient's story of illness while guiding the interview through a process of diagnostic reasoning. It also requires an awareness that the ideas, feelings, and values of both the patient and the physician influence the relationship.2,15,33 Further, this approach regards the physician—patient relationship as a partnership, and respects patients' active participation in decision making.34–36 The task of building a relationship is also relevant for work with patients' families and support networks. In essence, building a relationship is an ongoing task within and across encounters: it undergirds the more sequentially ordered sets of tasks identified below.

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Open the Discussion

  • Allow the patient to complete his or her opening statement
  • Elicit the patient's full set of concerns
  • Establish/maintain a personal connection
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Gather Information

  • Use open-ended and closed-ended questions appropriately
  • Structure, clarify, and summarize information
  • Actively listen using nonverbal (e.g., eye contact) and verbal (e.g., words of encouragement) techniques
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Understand the Patient's Perspective

  • Explore contextual factors (e.g., family, culture, gender, age, socioeconomic status, spirituality)
  • Explore beliefs, concerns, and expectations about health and illness
  • Acknowledge and respond to the patient's ideas, feelings, and values
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Share Information

  • Use language the patient can understand
  • Check for understanding
  • Encourage questions
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Reach Agreement on Problems and Plans

  • Encourage the patient to participate in decisions to the extent he or she desires
  • Check the patient's willingness and ability to follow the plan
  • Identify and enlist resources and supports
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Provide Closure

  • Ask whether the patient has other issues or concerns
  • Summarize and affirm agreement with the plan of action
  • Discuss follow-up (e.g., next visit, plan for unexpected outcomes)
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CONCLUSION

This outline of essential elements in effective physician—patient communication provides a coherent framework for teaching and assessing communication skills, determining relevant knowledge and attitudes, and evaluating educational programs. In addition, the outline can inform the development of specific standards in this domain. Most of the elements included in this document are present in each of the five models examined during the process of consensus building. A major strength of the outline is that it represents the collaboration and consensus of individuals with a variety of backgrounds and interests in medical education. Further, the basic outline can be tailored to meet the needs of different specialties, settings, and health problems. Conscientious efforts to address these essential elements across practice settings will help increase the efficiency and effectiveness of physician—patient communication,37 enhance patient and physician satisfaction,38,39 and improve health outcomes.40

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REFERENCES

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7. Liaison Committee on Medical Education. Functions and Structure of a Medical School. Washington, DC: Liaison Committee on Medical Education, 1998.
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9. Whelan GP. Educational Commission for Foreign Medical Graduates: clinical skills assessment prototype. Med Teach. 1999;21:156–60.
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18. Keller V, Carroll JG. A new model for physician—patient communication. Patient Educ Couns. 1994;23:131–40.
19. Novack DH, Dube C, Goldstein MG. Teaching medical interviewing: a basic course on interviewing and the physician—patient relationship. Arch Intern Med. 1992;152:1814–20.
20. Kurtz S, Silverman J, Draper J. Teaching and Learning Communication Skills in Medicine. Abingdon, Oxon, U.K.: Radcliffe Medical Press, 1998.
21. Stewart M, Belle Brown J, Weston WW, McWhinney IR, McWilliam CL, Freeman TR. Patient-Centered Medicine: Transforming the Clinical Method. Thousand Oaks, CA: Sage, 1995.
22. Makoul G. Communication research in medical education. In: Jackson L, Duffy BK (eds). Health Communication Research: A Guide to Developments and Directions. Westport, CT: Greenwood Press, 1998:17–35.
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26. Lipkin M Jr, Putnam SM, Lazare A (eds). The Medical Interview: Clinical Care, Education, and Research. New York: Springer-Verlag, 1995.
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29. Novack DH. Therapeutic aspects of the clinical encounter. J Gen Intern Med. 1987;2:346–55.
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32. Kleinman A. The Illness Narratives: Suffering, Healing and the Human Condition. New York: Basic Books, 1988.
33. Novack DH, Suchman AL, Clark W, Epstein RM, Najberg E, Kaplan C. Calibrating the physician: personal awareness and effective patient care. JAMA. 1997;278:502–9.
34. Williams GC, Freedman ZR, Deci EL. Supporting autonomy to motivate patients with diabetes for glucose control. Diabetes Care. 1998;21:1644–51.
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36. Gudagnoli E, Ward P. Patient participation in decision making. Soc Sci Med. 1998;47:329–39.
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38. Williams S, Weinman J, Dale J. Doctor—patient communication and patient satisfaction: a review. Fam Pract. 1995;15:480–92.
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Participants in the Bayer–Fetzer Conference on Patient—Physician Communication in Medical Education, May 1999

Patrick H. Brunett, MD

Assistant Professor of Emergency Medicine, Oregon Health Sciences University; member of Society for Academic Emergency Medicine

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Thomas L. Campbell, MD

Professor of Family Medicine and Psychiatry, University of Rochester School of Medicine; member of Society of Teachers of Family Medicine; Advisory Council, Bayer Institute for Health Care Communication

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Kathleen Cole-Kelly, MS, MSW

Associate Professor of Family Medicine, Case Western Reserve University School of Medicine; Director of Curriculum and Faculty Development at Case Western for the Macy Health Communication Initiative

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Deborah Danoff, MD

Assistant Vice President, Division of Medical Education, Association of American Medical Colleges

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Robert Frymier, MD

National Director, Educational and Partnerships Division, Veterans Affairs Learning University; Associate Professor of Family Medicine, Case Western Reserve University School of Medicine

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Michael G. Goldstein, MD

Associate Director, Clinical Education and Research, Bayer Institute for Health Care Communication; Adjunct Professor of Psychiatry, Brown University School of Medicine

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Geoffrey H. Gordon, MD

Associate Director, Clinical Education and Research, Bayer Institute for Health Care Communication; Assistant Clinical Professor of Medicine and Psychiatry, Yale University School of Medicine

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Daniel J. Klass, MD

Director, Standardized Patient Project, National Board Medical Examiners

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Suzanne Kurtz, PhD

Professor of Communication, Faculties of Medicine and Education, University of Calgary

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Jack Laidlaw, MD

Head, Division of Education, Cancer Care Ontario; Advisory Council, Bayer Institute for Health Care Communication

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Forrest Lang, MD

Vice Chair, Department of Family Medicine, East Tennessee State University; member of Society of Teachers of Family Medicine

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Anne-Marie MacLellan, MD

Faculty of Medicine, McGill University; member of Association of Canadian Medical Colleges

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Gregory Makoul, PhD

Associate Professor and Director, Program in Communication and Medicine, Northwestern University Medical School

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Steven Miller, MD

Director, Pediatric Medical Student Education, Columbia University School of Medicine; Council on Medical Student Education in Pediatrics

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Dennis Novack, MD

Professor of Medicine and Associate Dean for Education, Medical College of Pennsylvania Hahnemann School of Medicine; member of American Academy on Physician and Patient

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Elizabeth A. Rider, MSW, MD

Clinical Instructor in Pediatrics and Instructor in Medical Education, Harvard Medical School; Office of Educational Development, Harvard Medical School

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Frank A. Simon, MD

Director, Division of Graduate Medical Education, American Medical Association

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David Sluyter, EdD

Vice President for Education, Fetzer Institute

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Susan Swing, PhD

Director of Research, Accreditation Council for Graduate Medical Education

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Wayne Weston, MD

Professor of Family Medicine, University of Western Ontario; member of College of Family Physicians of Canada

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Gerald P. Whelan, MD

Vice President for Clinical Skills Assessment, Educational Commission for Foreign Medical Graduates

40. Greenfield S, Kaplan S, Ware JE. Expanding patient involvement in care: effects on patient outcomes. Ann Intern Med. 1985;102:520–8.
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