In this study, we evaluated the impact of a 5.5-hour, pediatric-focused communication course on provider satisfaction, self-efficacy of learned communication skills, and provider burnout within a large, multi-disciplinary, pediatric health care organization.
In alignment with other communication studies describing high provider satisfaction and likelihood to recommend,20 , 22–24 participants of Texas Children’s Breakthrough Communication reported a high level of satisfaction with the course. The majority of participants felt that the course was a valuable use of their time and the communication skills learned in the course would be relevant to their practice. Anecdotal evidence of provider satisfaction was, also, received via free-texted verbatims and e-mails, and primarily consisted of frequent and successful utilization of learned communication skills within their own specialties and enhanced patient experiences. Feedback from 1 seasoned physician (in practice for over 20 years) stated that after completing the course, he received multiple letters from patients’ family members thanking him for his care of their children. Caregivers were specifically impressed with how his explanations enhanced their understanding of their child’s disease and treatment. By emphasizing the benefits of relationship-centered communication, demonstrating and facilitating evidence-based communication skills practice, and tying its applicability within multi-specialty, clinical environments, participants felt the course was of educational value and a prioritized and necessary component of their continuing medical education. Provider satisfaction nurtured continued growth and development of the course via word-of-mouth marketing and collegial recommendations and referrals.
The high postcourse satisfaction may also be a reflection of our health care providers’ desire for more standardized communication training. Despite the essential need for empathic and interpersonal communication in health care, there is still little programmatic or curricular emphasis on building interpersonal skills in medical school or training.25 Although the Accreditation Council for Graduate Medical Education and American Board of Medical Specialties jointly endorse interpersonal and communication skills as one of the 6 general core competencies for physicians, most health care providers informally learned their medical communication skills via nonstandardized observations and modeling.26 , 27 Most providers demonstrate improvement in their communication performance during medical school and clinical training,28–30 yet generally do not attain professional expertise in communication.31–36 Building and sustaining strong health care provider-patient relationships, while also navigating difficult encounters and conversations, requires a set of modifiable behaviors that are not innate, but learned and reinforced through deliberate practice.37–40 Perceived inadequacies and gaps in communication education and training may also be contributing to participants’ satisfaction of a more formalized, communication course.
Upon completion of the course, improved self-efficacy and comfort in utilizing the relationship-centered communication skills (7 out of 12 domains) were achieved and sustained for at least 3 months. Our findings corroborate prior research showing gains in self-assessment as a result of educational interventions for health care professionals.20 , 41 , 42 Although the direct impact of our course on provider behaviors and implementation within practice was not analyzed, studies correlating self-efficacy as an evaluation measure of competence have been previously documented.41 , 43–45 In delineating the relationship between self-efficacy and performance, Bandura’s social-cognitive theory contends that behavior changes occur as a result of enhanced self-confidence in one’s ability to successfully enact tasks or skills.46 Because it plays a predictive and mediating role in relation to motivation, learning, and performance, many postulate that self-efficacy is necessary in the adoption and retention of new behaviors and skills.44 Whereas individuals avoid tasks perceived as exceeding their capabilities, they undertake and successfully perform tasks they are capable of handling.47
Educational programs, which incorporate role play or simulated skills practice, have proven to be particularly successful when evaluating for self-efficacy.48 , 49 Although there are varying degrees of discrepancy between self-assessment and observers’ ratings of corresponding skills,50 previous studies have shown positive correlations between self-efficacy and performance with communication skills training.51 , 52 Brown et al.41 demonstrated a statistical improvement in trainee’s self-assessment of competence in overall and specific communication skills after conducting a randomized trial of a simulation-based multi-session workshop to improve palliative care communication skills. Longer term increases on self-efficacy, along with a significantly positive correlation between performance after training and self-efficacy 3 years later, was demonstrated after providers participated in a 20-hour communication skills training based on the Four Habits approach.53 From their study, Gulbrandsen et al.45 concluded that communication skills training may not only cause lasting improvements in physicians’ self-confidence in their communication skills ability, but that the increased confidence is accurately associated with improvements in performance.
Many health care providers derive energy, strength, and professional satisfaction from the physician-patient relationship. Because the clinical encounter is a dynamic process, underlying patient, caregiver, and health care provider characteristics and behaviors can have a direct effect on verbal and nonverbal communication styles and can promote or alleviate interpersonal difficulty. Clinicians who repeatedly experience difficult encounters with patients and/or families tend to feel less job satisfaction and more professional burnout.54 The impact of professional burnout is not inconsequential, with up to 60% of practicing physicians reporting symptoms of emotional exhaustion, depersonalization, and a low sense of personal accomplishment.55 In 2012, Shanafelt et al.56 , 57 conducted a national study of burnout in a large sample of U.S. physicians and delineated burnout rates by specialty, with emergency medicine, general internal medicine, neurology, and family medicine exhibiting the highest rates of burnout, and general pediatrics, dermatology, pathology, and preventative medicine with the lowest rates.
Our study’s MBI scores for emotional exhaustion and depersonalization positively improved for 25% of our participants. As the majority of our course participants were primary pediatricians, primary care advanced practice providers and pediatric subspecialists, baseline MBI median scores of 13 (emotional exhaustion), 8 (depersonalization), and 42 (personal accomplishment) were unsurprisingly low. In a study published by Boissy et al.,20 they reported moderate, baseline burnout scores for each MBI domain, and for 16% of National Provider Identifier-matched participants, improvement in all measures was noted at 3 months postcourse. Perhaps, our communication course’s impact on burnout did not produce similarly significant change, given the low baseline burnout levels of our group.54 Although statistical significance was not achieved, even small decreases in burnout may translate to more meaningful change, re: wellness, resiliency, and turnover.
Difficult to correlate with long-term outcomes, the consequences of burnout among practicing clinicians include both professional (poorer quality of care, increased medical errors and malpractice claims, and decreased clinician workforce) and personal (decreased ability to express empathy, problematic alcohol and drug use, stress-related health problems, broken relationships, and suicidal ideation) consequences.58 , 59 Identifying, improving upon, and practicing empathic and other effective communication skills through frequent and deliberate practice may not only strengthen the health care provider-patient relationship, improve medical outcomes, increase patient satisfaction, and prevent future difficult encounters, but also enhance job satisfaction, decrease stress and burnout, and reduce medical malpractice and litigation.60
Our study has some important limitations. Given the design of the study, we could not exclude other causes for the improvement in scores among those who participated in the course. By mandating enrollment for a select number of specialties (pediatric emergency medicine, pediatric hospital medicine, and primary care pediatrics) and offering CME credits to all course participants, we were able to control for volunteer and other unmeasurable biases that often weaken nonexperimental studies.
Aside from the MBI, we used a nonvalidated instrument for measurement of course satisfaction and self-efficacy of communication skills. Non-MBI survey questions were based on previously established course assessment surveys and piloted before study initiation. Additionally, the decline in survey completion for both post- and 3-month postintervention may have caused results not to be representative of all participants.
Performance utilization and improvement and patient satisfaction scores were not collected or analyzed for our study. Although positive correlations between self-efficacy and performance have been discussed, further research is needed to determine whether providers finding the course valuable and relevant is associated with behavior changes in application of the skill sets and patient satisfaction.
Finally, our communication course was offered to only one, largely employed, health care organization. However, we administered the training program to a diverse array of clinicians, including primary care pediatricians, pediatric subspecialists, pediatric surgical subspecialists, obstetrician-gynecologists, physician assistants, and nurse practitioners. Even though the single-site setting of our study might seem to limit generalizability, other large organizations, such as Kaiser Permanente, Cleveland Clinic, and Mayo Clinic, have demonstrated improved self-efficacy, empathy, burnout, and/or patient satisfaction scores.17 , 18 , 20
A pediatric-focused communication course was well-received by multi-specialty, practicing clinicians within a large, academic health care organization. This 5.5-hour relationship-centered communication course not only enhanced clinician self-efficacy and comfort with newly learned skills, but also improved burnout (domains of emotional exhaustion and depersonalization) and well-being. Further research is necessary to investigate the effects on communication skill utilization and performance, patients’ experience of care, and clinical outcomes. Additionally, a future study measuring the impact of communication training on patient care, satisfaction, and follow-up would be of value.
Texas Children’s Hospital Breakthrough Communication can be successfully implemented in a large, pediatric, multi-specialty organization. Course satisfaction, self-efficacy and comfort with relationship-centered communication skills, and provider burnout may improve after participation in a pediatric-focused, experiential communication course. Whether this course positively impacts quality and clinical outcomes, such as patient safety, enhanced teamwork, patient satisfaction, and adherence with treatment requires further investigation.
The authors thank Dr. Larry Hollier and Dr. Joan Shook for their unwavering vision, leadership, and support; our dedicated and energetic course facilitators, Ruth Abelt CPNP, Aba Coleman MD, Erin Gottlieb MD, Cheryl Hardin MD, Laura Monson MD, Kamini Muzumdar MD, Ruben Rodriguez MD, Mary Shapiro MD, Moushumi Sur MD, Veronica Victorian PA-C; our unwavering and dependable course administrators, Andrea Romay and Tara Enders; and, our incomparable and hard-working research support manager, Betty Tung.
1. Institute of Medicine. Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. 2001.Washington, DC: National Academy Press;
2. Chaitoff A, Sun B, Windover A, et al. Associations between physician empathy, physician characteristics, and standardized measures of patient experience. Acad Med. 2017;92:1464–1471.
3. Smith RC. Patient-centered Interviewing: An Evidence-based Method. 2002.Philadelphia PA: Lippincott Williams & Wilkins;
4. Beach MC, Inui T; Relationship-Centered Care Research Network. Relationship-centered care. A constructive reframing. J Gen Intern Med. 2006;21:S3–S8.
5. Levinson W, Lesser CS, Epstein RM. Developing physician communication skills for patient-centered care. Health Aff (Millwood). 2010;29:1310–1318.
6. Safran DG, Taira DA, Rogers WH, et al. Linking primary care performance to outcomes of care. J Fam Pract. 1998;47:213–220.
7. Levinson W, Roter DL, Mullooly JP, et al. Physician-patient communication. The relationship with malpractice claims among primary care physicians and surgeons. JAMA. 1997;277:553–559.
8. Stewart MA. Effective physician-patient communication and health outcomes: a review. CMAJ. 1995;152:1423–1433.
9. Saha S, Beach MC. The impact of patient-centered communication on patients’ decision making and evaluations of physicians: a randomized study using video vignettes. Patient Educ Couns. 2011;84:386–392.
10. King A, Hoppe RB. “Best practice” for patient-centered communication: a narrative review. J Grad Med Educ. 2013;5:385–393.
11. Weiner SJ, Schwartz A, Sharma G, et al. Patient-centered decision making and health care outcomes: an observational study. Ann Intern Med. 2013;158:573–579.
12. Kelley JM, Kraft-Todd G, Schapira L, et al. The influence of the patient-clinician relationship on healthcare outcomes: a systematic review and meta-analysis of randomized controlled trials. PLoS One. 2014;9:e94207.
13. American Academy of Pediatrics, Future of Pediatric Education II Task Force. The future of pediatric education II: organizing pediatric education to meet the needs of infants, children, adolescents, and young adults of the 21st century. Pediatrics. 2000;105:162–212.
14. Morgan ER, Winter RJ. Teaching communication skills. An essential part of residency training. Arch Pediatr Adolesc Med. 1996;150:638–642.
15. Baile WF, Kudelka AP, Beale EA, et al. Communication skills training in oncology. Description and preliminary outcomes of workshops on breaking bad news and managing patient reactions to illness. Cancer. 1999;86:887–897.
16. Wouda JC, van de Wiel HB. Education in patient-physician communication: how to improve effectiveness? Patient Educ Couns. 2013;90:46–53.
17. Stein T, Frankel RM, Krupat E. Enhancing clinician communication skills in a large healthcare organization: a longitudinal case study. Patient Educ Couns. 2005;58:4–12.
18. Roter DL, Hall JA, Kern DE, et al. Improving physicians’ interviewing skills and reducing patients’ emotional distress. A randomized clinical trial. Arch Intern Med. 1995;155:1877–1884.
19. Brown JB, Boles M, Mullooly JP, et al. Effect of clinician communication skills training on patient satisfaction. A randomized, controlled trial. Ann Intern Med. 1999;131:822–829.
20. Boissy A, Windover AK, Bokar D, et al. Communication skills training for physicians improves patient satisfaction. J Gen Intern Med. 2016;31:755–761.
21. Maslach C, Jackson SE, Leiter MP. Maslach Burnout Inventory Manual. 3rd edition. Palo Alto, Calif.: Consulting Psychologists Press, Inc 1996.
22. Salib S, Glowacki EM, Chilek LA, et al. Developing a communication curriculum and workshop for an internal medicine residency program. South Med J. 2015;108:320–324.
23. Liu X, Rohrer W, Luo A, et al. Doctor-patient communication skills training in mainland China: a systematic review of the literature. Patient Educ Couns. 2015;98:3–14.
24. Rao JK, Anderson LA, Inui TS, et al. Communication interventions make a difference in conversations between physicians and patients: a systematic review of the evidence. Med Care. 2007;45:340–349.
25. Levetown M. American Academy of Pediatrics Committee on bioethics. Pediatrics. 2008;121:e1441–1460.
26. Baumal R, Benbassat J. Current trends in the educational approach for teaching interviewing skills to medical students. Isr Med Assoc J. 2008;10:552–555.
27. Silverman J. Teaching clinical communication: a mainstream activity or just a minority sport? Patient Educ Couns. 2009;76:361–367.
28. Hodges B, Turnbull J, Cohen R, et al. Evaluating communication skills in the OSCE format: reliability and generalizability. Med Educ. 1996;30:38–43.
29. Yedidia MJ, Gillespie CC, Kachur E, et al. Effect of communications training on medical student performance. JAMA. 2003;290:1157–1165.
30. Wouda JC, van de Wiel HB. The communication competency of medical students, residents and consultants. Patient Educ Couns. 2012;86:57–62.
31. Barth J, Lannen P. Efficacy of communication skills training courses in oncology: a systematic review and meta-analysis. Ann Oncol. 2011;22:1030–1040.
32. Mukerji G, Weinerman A, Schwartz S, et al. Communicating wisely: teaching residents to communicate effectively with patients and caregivers about unnecessary tests. BMC Med Educ. 2017;17:248.
33. Fellowes D, Wilkinson S, Moore P. Communication skills training for health care professionals working with cancer patients, their families and/or careers. Cochrane Database Syst Rev. 2004;2:CD003751 [review].
34. Hulsman RL, Ros WJ, Winnubst JA, et al. Teaching clinically experienced physicians communication skills. A review of evaluation studies. Med Educ. 1999;33:655–668.
35. Kramer AW, Düsman H, Tan LH, et al. Acquisition of communication skills in postgraduate training for general practice. Med Educ. 2004;38:158–167.
36. Sullivan AM, Lakoma MD, Block SD. The status of medical education in end-of-life care: a national report. J Gen Intern Med. 2003;18:685–695.
37. Ericsson KA. Deliberate practice and acquisition of expert performance: a general overview. Acad Emerg Med. 2008;15:988–994.
38. Ericsson KA. An expert-performance perspective of research on medical expertise: the study of clinical performance. Med Educ. 2007;41:1124–1130.
39. Hodges BD, Kuper A. Theory and practice in the design and conduct of graduate medical education. Acad Med. 2012;87:25–33.
40. Epstein RM. Assessment in medical education. N Engl J Med. 2007;356:387–396.
41. Brown CE, Back AL, Ford DW, et al. Self-assessment scores improve after simulation-based palliative care communication skill workshops. Am J Hosp Palliat Care. 2018;35:45–51.
42. Nørgaard B, Ammentorp J, Ohm Kyvik K, et al. Communication skills training increases self-efficacy of health care professionals. J Contin Educ Health Prof. 2012;32:90–97.
43. Parle M, Maguire P, Heaven C. The development of a training model to improve health professionals’ skills, self-efficacy, and outcome expectancies when communicating with cancer patients. Soc Sci Med. 1991;66:762–769.
44. Heaven CM, Maguire P. Training hospice nurses to elicit patient concerns. J Adv Nurs. 1996;23:280–286.
45. Gulbrandsen P, Jensen BF, Finset A. [Self-efficacy among doctors in hospitals after a course in clinical communication]. Tidsskr Nor Laegeforen. 2009;129:2343–2346.
46. Bandura A. Social Learning Theory. 1977.New Jersey: Englewood Cliffs: Prentice Hall;
47. Bandura A. Reflections on self-efficacy. Adv Beh Res Ther. 1978;1:234–269.
48. Jenkins V, Fallowfield L. Can communication skills training alter physicians’ beliefs and behavior in clinics? J Clin Oncol. 2002;20:765–769.
49. Gude T, Vaglum P, Anvik T, et al. Do physicians improve their communication skills between finishing medical school and completing internship? A nationwide prospective observational cohort study. Patient Educ Couns. 2009;76:207–212.
50. Ward M, Gruppen L, Regehr G. Measuring self-assessment: current state of the art. Adv Health Sci Educ Theory Pract. 2002;7:63–80.
51. Gruppen LD, Garcia J, Grum CM, et al. Medical students’ self-assessment accuracy in communication skills. Acad Med. 1997;72:S57–S59.
52. Gordon MJ. A review of the validity and accuracy of self-assessments in health professions training. Acad Med. 1991;66:762–769.
53. Gulbrandsen P, Jensen BF, Finset A, et al. Long-term effect of communication training on the relationship between physicians’ self-efficacy and performance. Patient Educ Couns. 2013;91:180–185.
54. Bragard I, Libert Y, Etienne AM, et al. Insight on variables leading to burnout in cancer physicians. J Cancer Educ. 2010;25:109–115.
55. Shanafelt TD, Balch CM, Bechamps GJ, et al. Burnout and career satisfaction among American surgeons. Ann Surg. 2009;250:463–471.
56. Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med. 2012;172:1377–1385.
57. Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clin Proc. 2015;90:1600–1613.
58. Wallace JE, Lemaire JB, Ghali WA. Physician wellness: a missing quality indicator. Lancet. 2009;374:1714–1721.
59. Williams ES, Konrad TR, Scheckler WE, et al. Understanding physicians’ intentions to withdraw from practice: the role of job satisfaction, job stress, mental and physical health. Health Care Manage Rev. 2001;26:7–19.
60. Boudreaux ED, O’Hea EL. Patient satisfaction in the emergency department: a review of the literature and implications for practice. J Emerg Med. 2004;26:13–26.
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