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Competency-Based Curriculum Resource for Preclerkship Education (using ACGME Structure):

Interpersonal and Communication Skills

Lead Authors: Steve Miller, MD, Mary Ann Kuzma, MD, and Christine Matson, MD

Competency

Students must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their families, and professional colleagues.

Goals

Create and sustain a therapeutic and ethically sound relationship with patients and families.

• Understand the importance of the patient-physician relationship as the cornerstone of medical care.
• Greet the patient appropriately.
• Establish rapport with patients and families.
• Demonstrate caring and respectful behaviors when interacting with patients and their families.
• Maintain a respectful tone.
• Describe strategies for establishing positive patient-doctor relationships.
• Understand that physicians and patients bring attitudes, emotions, beliefs, and culture to encounters that may have significant impact upon patient-doctor interactions and outcomes.
• Describe patient, physician, and system barriers to effective communication.
• Appreciate and begin to develop cultural awareness and cross-cultural communication skills to improve patient-physician relationships.
• Demonstrate a patient centered interview that includes:
• Eliciting the patient's entire agenda.
• Eliciting the patient's story without bias from the interviewer, including the symptoms, the setting, and the patient's emotional response and perspective on the illness.
• Identifying and responding to emotional cues.
• Summarizing and checking for accuracy of content and interpretation.
• Negotiating a common understanding of the patient's issues.
• Agreeing on a plan that includes patient and physician/student involvement.
• Demonstrate sensitivity to gender, racial and cultural diversity.
• Describe patient, physician, and system barriers to successfully negotiated treatment plans, and patient adherence.
• Describe strategies that may be used to overcome these barriers.
• Maintain confidentiality.
• Close patient encounter appropriately.

Demonstrate effective listening skills.

• Maintain eye contact at comfortable intervals throughout interview.
• Maintain open body posture.
• Encourage the patient to continue speaking, using appropriate facilitation skills.
• Use silence and nonverbal facilitation to encourage the patient's expression of thought and feelings.

Elicit and provide validation and information using effective nonverbal, facilitative, questioning, reflective, and explanatory skills.

• Elicit patient requests, concerns, and expectation from a range of patients diverse in age, gender, and sociocultural background.
• Elicit the patient's view of health problem(s).
• Discuss how the health problem(s) affect the patient's life.
• Respond in elementary fashion to patient concerns and expectations.
• Express willingness to be helpful to the patient in addressing his/her concerns.
• Respond to empathic opportunities by naming the emotions or feelings expressed.
• Demonstrate validation of the patient's feelings.
• Avoid use of medical jargon.
• Support the patient's self-efficacy, such as acknowledging and complimenting the patient on a positive behavior.
• Reach a common understanding with the patient on an elementary description of diagnosis, prognosis, and treatment plan.

Work effectively with others as a member of a health care team or other professional group.

Present in chronological and organized fashion both verbally and in writing the basic elements of the history and physical examination accurately and objectively.

• Present a prioritized problem list that demonstrates a biopsychosocial understanding of disease, health care systems and barriers to health care.
• Report the basic elements of an assessment and plan that addresses the patient's issues as well as biomedical considerations.
• Demonstrate the ability to make clear and concise presentations about assigned research topics.
• Outline the roles of health care team members.
• Demonstrate the belief that each member of the health care team is valuable, regardless of degree or occupation.
• Demonstrate the ability to work in team settings by identifying and accepting the responsibilities of a team member.
• Outline strategies for conflict management and resolution.

Educational Methods

The competency domain of interpersonal and communication skills requires a well-designed and multifaceted approach in order to convey the knowledge, skills, and attitudes required for effective, efficient, professional, and compassionate communication in the health care setting. The traditional apprenticeship model is insufficient to completely accomplish this goal. Modeling may be useful in changing attitudes but students often cannot identify the specific communication skills that make an exemplary physician communicator exemplary. The essential components of communication skills learning are delineation of critical skills, observation, feedback, video or audio recording and review, rehearsal and practice of skills, and active small-group or one-on-one learning 1 . The content of communication curricula, in particular the specific skills to be learned, must be clearly defined and made explicit to both learners and teachers (e.g. the Calgary-Cambridge Observational Guide 2 , the SEGUE Framework 3 , the 5 Kalamazoo Consensus statement 4 ). Knowledge content may be transmitted in conventional didactic ways such as lectures and readings; however, transmission of knowledge alone is not sufficient to result in behavior change.5 The most effective means of teaching communication skills requires experiential, interactive, and one-on-one teaching methods. Multiple methods have been used in this regard including directed, active small-group discussions, structured skills seminars (e.g., the program developed by the Bayer Institute for Health Care Communication 6 ), role-play activities, video or audio taped sessions, direct observation by faculty members, and modeling of exemplary clinicians. Students must be given ample opportunity to hone their communication skills, first in low-stakes training sessions, with simulated patients, and ultimately in real patient encounters. These encounters should be directly observed or taped. Specific, formative feedback is critical for these experiences to result in behavior change. Appropriate communication skills should be taught in multiple clinical environments including inpatient and outpatient settings, and with patients of varied sociocultural backgrounds and interactive styles. Problem-oriented skills such as "difficult" physician-patient interactions, dealing with sensitive topics, end-of-life issues, and breaking bad news should also be incorporated. Students must be formally instructed regarding the oral case presentation and how the general presentation must be modified to fit different clinical situations.

Teaching communication skills depends on methods that include direct observation and feedback. Methods must also incorporate an accepted framework that defines the explicit behaviors of effective communication. General skills of setting a therapeutic environment, gathering information and providing information and closure must be included. (See Kurtz S. et al.) Specific methods should include: 1) Modeling an explicit framework. 2) Providing opportunities for observed practice. 3) Providing feedback to learners from explicitly trained faculty. 4) Providing opportunities for further observed practice - which incorporates the feedback. Methods used to improve interpersonal communication may include

• videotape analysis and small-group observation.
• observed practice done using standardized patients, role plays, and real patients -- with bedside observation.
• faculty leaders trained to provide explicit feedback with the proposed framework, providing a consistent and common language for working on communication skills.

Parallel methods for communication and evaluation with patient's family members, colleagues, staff, and faculty must also be in place.

Resources

• Kurtz S, Silverman J, Draper J. Teaching and Learning Communication Skills in Medicine. Radcliffe Medical Press Ltd, Oxford, 1998.
  This text provides a complete framework for developing a curriculum in communication skills. It uses the Calgary-Cambridge Model for effective communication, a well-respected and validated model.
• Kurtz SM, Silverman JD. The Calgary-Cambridge Referenced Guides; an aid to defining the curriculum and organizing the teaching in communication training programmes. Medical Education. 1996; 30:83-9.
• Makoul G. The SEGUE Framework for teaching and assessing communication skills. Patient Education and Counseling. 2001; 45:23-34.
  This article describes another well-respected framework for teaching and practicing effective communication.
• Makoul G. Essential element of communication in medical encounters: the Kalamazoo consensus statement. Acad Med. 2001; 76:390-3.
  This article describes a model that was agreed upon at a consensus conference on communication. It incorporates SEGUE, Calgary-Cambridge, Patient Centered, Bayer, and Brown models of effective communication and distills them into one framework with wide acceptance.
• Makoul G. Communication skills education in medical school and beyond. JAMA. 2003; 289:93.
• Clinician-Patient Communication To Enhance Health Outcomes. The Bayer Institute for Health Care communication, Inc., West Haven, Connecticut, 1998.
  This includes the attached annotated bibliography on the link between outcomes and effective patient communication and an annotated bibliography of difficult patient physician encounters. The Web site http://www.bayerinstitute.org , also includes materials for faculty development.
• Platt FW and Gordon GH. Field Guide to the Difficult Patient Interview.
  Inside this superb guide, you'll discover the communication techniques and practical strategies you need to handle even the most difficult physician-patient encounters. From delivering bad news to dealing with the angry patient to somatization -each chapter defines a commonly encountered problem and examines the cardinal principles and procedures to follow in the interaction.
• Rollnick S, Mason P, and Butler C. Health Behavior Change: A Guide For Practitioners. Stephen Rollnick, Pip Mason and Chris Butler take the concepts developed by Miller and Rollnick, Motivational Interviewing, and apply it to the work of the medical practitioner working with health behaviors: overeating, physical inactivity, smoking, and adherence to therapeutic regimens. Recognizing that clinicians must work quickly to influence health behavior, the authors address the issues of resistance to change and lack of motivation. The book is filled with examples and dilemmas that will ring true for all clinicians.
• Stewart M, Brown JB, Weston WW, McWhinney IR, McWilliam CL, and Freeman TR. Patient-Centered Medicine: Transforming The Clinical Method. The authors present a six-component model to assist health practitioners in expanding and strengthening their relationships with patients. Thoughtful discussions and case studies present topics as diverse as conceptualizations of ill health, consideration of the patient as an individual, the establishment of goals and cooperative strategy between physician and patient, and the realistic allocation of time, energy, and other resources of the health care provider. Emphasizing a holistic philosophy, the work encourages physicians to surpass treatment based strictly on a one-dimensional, biomedical assessment of their patients -- and achieve greater results.
• Silverman J, Kurtz S, and Draper J. Skills For Communicating With Patients. This book and its companion, Teaching and Learning Communication Skills in Medicine, present a comprehensive approach to improving communication in medicine. They are an invaluable resource for practitioners, course organizers, facilitators, and learners at all levels from undergraduate to continuing medical education, and apply equally to specialist and primary care physician. The core communication skills are addressed as well as ways to develop the skills. The two volumes are based upon a careful reading and understanding of the literature on physician-patient communication.
• Kurtz S, Silverman J, and Draper J. Teaching and Learning Communication Skills in Medicine. This book and its companion, Skills for Communicating With Patients, present a comprehensive approach to improving communication in medicine. They are an invaluable resource for practitioners, course organizers, facilitators, and learners at all levels from undergraduate to continuing medical education, and apply equally to specialist and primary care physician. The core communication skills are addressed as well as ways to develop the skills. The two volumes are based upon a careful reading and understanding of the literature on physician-patient communication
• AAMC MSOP Special Report on Communication Skills, October 1999 Communication in Medicine: http://www.aamc.org
  Effective communication is the lynchpin in the relationship between physician and patient, and is critical in exchanging information with families, colleagues, and related professionals administering care. In order to communicate effectively with patients, physicians will also need to understand how patients' spirituality and culture affect how they perceive health and illness, and particularly their desires regarding end-of-life care. Contemporary Issues in Medicine: Communication in Medicine (PDF - 176KB, 32 pages), October 1999.
• http:// www.sunyit.edu/library/html/culturedmed/bib/medical/
  This site has a bibliography for interpreter use in medicine.

Assessment Strategies

Assessment of communication skills learning must be both formative and summative. The knowledge, skills, and attitudes to be assessed must be made explicit to both learners and teachers alike. Potential evaluators include local experts, course faculty, simulated and real patients, peers, and the learners themselves. Formative assessment should occur throughout the communication skills curriculum and is intended to shape and improve future behaviors. This requires direct observation (in person or videotaped) of the skills during role-play activities, with standardized patients, and with real patients. The feedback provided should be balanced and nonjudgmental. Self-assessment during the learning process should be encouraged. Summative assessment is necessary to demonstrate competency in the domain of interpersonal and communication skills. The summative assessment must be more than low-stakes in order to validate to students the essential nature of this competency domain. Although written examinations may be used successfully to test knowledge, they do not test skills. Therefore, written examinations cannot be the only means of summative assessment. The tools and standards for summative assessment should parallel those used for formative assessment and the teaching methods employed. Again, learners and teachers must be fully aware of these tools and standards. The objective structured clinical examination is common method used to assess multiple clinical skills. Communication skills can be evaluated by this method as well. When possible the student-standardized patient interaction should be videotaped. Careful review by evaluators and learners will then be possible and provides factual record of what happened during the encounter. It is also possible either to directly observe or videotape real patient encounters as part of the summative assessment. The standards for assessment should include items such as detailed checklists, numerical or visual analogue rating scales that may also include guiding descriptors, and descriptive commentary.

Assessment of communication skills must include direct observation of performance. Evaluation of setting a therapeutic environment, gathering data and providing information, and closure must be included. Evaluation of advanced skills, including use of interpreters, providing bad news and promoting behavior change should be done as well. Criteria should match the novice level of the end-of-second-year student, who should be able to identify the critical issues for effective communication and perform the skills under straightforward circumstances.

Specific tools can be chosen from among the following:

1) Standardized patients 2) OSCEs 3) Observed performance with patients and others 4) Written reflections describing how a learner would approach a certain situation 5) MCQs.

At least one method that assesses actual performance of the skills should be included.

Faculty Development

The principles of faculty development for this core skill include the following:

• A faculty leader should be identified who has the time and resources to develop, organize, and oversee this aspect of the curriculum. This leader should have administrative support to coordinate a large and diverse program, which will by necessity involve more than 20 faculty and as many locations (for a school of approximately 100 students). Support for this faculty member should include resources to network with national leaders and organizations.
• A core group of faculty champions should be identified, representing a diverse group of departments. They should be supported in some fashion and recognized for their contribution to the school. These faculty members should be the core faculty developers for the general faculty and house staff.
• All preceptors should have yearly training in making the skills explicit, providing opportunities for observed practice and for giving effective and explicit feedback, and for evaluating the explicit behaviors and the global effectiveness of the learners.
• Faculty development should include partnership with national experts from other institutions to validate the approaches that are being taken.
• Each school should consider ways to influence the messages that the approach to learning communication skills is a critical skill of excellent doctoring and is a core concept of professionalism and humanism, and not a luxury or "touchy feely" add-on. This means that it should have a high-stakes quality in the curriculum, and opportunities to link effective communication to specific health outcomes should be reinforced.

For questions or comments, please contact Webmaster or Ardis Davis

This page last updated November 6, 2004