Teaching and Learning Communication Skills in Medicine

Suzanne Kurtz, Juliet Draper, Jonathan Silverman

• Publisher: CRC Press
• Year: 2017
• Print ISBN: 9781857756586
• eBook ISBN: 9781315358611
• Topic: Medicine
• Subtopic: Public Health, Administration & Care

This book and its companion, Skills for Communicating with Patients, Second Edition, provide a comprehensive approach to improving communication in medicine. Fully updated and revised, and greatly expanded, this new edition examines how to construct a skills curricular at all levels of medical education and across specialties, documents the individuals skills that form the core content of communication skills teaching programmes, and explores in depth the specific teaching, learning and assessment methods that are currently used within medical education. Since their publication, the first edition of this book and its companionSkills for Communicating with Patients, have become standards texts in teaching communication skills throughout the world, 'the first entirely evidence-based textbooks on medical interviewing. It is essential reading for course organizers, those who teach or model communication skills, and program administrators.

Part I

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An overview of communication skills teaching and learning

Chapter 1

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The ‘why’: a rationale for communication skills teaching and learning

Introduction

Let’s start at the beginning - why embark on trying to teach communication skills at all? Why do we feel that it is so important? What justification is there for expending the effort in an already overcrowded timetable for learning? Why should curriculum organisers at all three levels of medical education - undergraduate, residency and continuing medical education - adopt this subject with enthusiasm and organise communication skills teaching within their own programmes?

And if they do, will it work? Will it produce effective and long-lasting change in learners’ communication skills or will it simply look impressive on paper? Is it just a sop to the authorities to allow your institution to say ‘We’re doing something -see’? Or is it sufficiently grounded in theory and research to enable you to say ‘All this effort is worth it - our learners and their patients will truly benefit, both now and in the future’?

In this chapter we provide a rationale for communication skills teaching that is based squarely on theory and research. To do that, we need to answer the following questions.

1 Why teach communication skills?

• is it important to study the medical interview?
• are there problems in communication between doctors and patients?
• is there evidence that communication skills can overcome these problems and make a difference to patients, doctors and outcomes of care?

2 Can you teach and learn communication skills?

• is there evidence that communication skills can be taught and learned?
• is there evidence that learning is retained?

3 Is the prize on offer to doctors and their patients worth the effort?

• will expending the effort on communication skills teaching produce worthwhile rewards for both doctors and patients?

If the answer to any of these questions is ‘no’, then we can all relax and get back to our programmes without worrying about yet another change. However, if the answer to these questions is ‘yes’, then our work is cut out for the future and we ignore communication skills teaching at our peril.

Why teach communication skills?

Is it important to study the medical interview?

• The medical interview is central to clinical practice. It has been estimated that doctors perform 200 000 consultations in a professional lifetime so it is worth struggling to get it right.
• The interview is the unit of medical time, a critical few minutes for the doctor to help the patient with their problems. While the doctor may see each consultation as one of many routine encounters, for the patient it may be the most important or stressful aspect of their week.
• To achieve an effective interview, doctors need to be able to integrate four aspects of their work which together determine their overall clinical competence:
  - knowledge
  - communication skills
  - problem solving
  - physical examination.
• These four essential components of clinical competence are inextricably linked
  - outstanding expertise in any one alone is not sufficient. For example, it is not good enough to be factually excellent if communication difficulties stand between you and the patient and prevent you from discovering the reason for the patient’s attendance or from discussing a plan that the patient can understand and wishes to put into action. Communication is a core clinical skill rather than an optional extra.
• How we communicate is just as important as what we say. Communication bridges the gap between evidence-based medicine and working with individual patients.

Are there problems in communication between doctors and patients?

In our companion book, we describe in detail the research evidence which demonstrates that there are substantial problems in communication between doctors and patients. Here we simply provide examples of this research to spur your interest to delve deeper into our companion volume.

Discovering the reasons for the patient’s attendance

• 54% of patients’ complaints and 45% of their concerns are not elicited (Stewart et al. 1979).
• In 50% of visits, the patient and the doctor do not agree on the nature of the main presenting problem (Starfield et al. 1981).
• Only a minority of health professionals identify more than 60% of their patients’ main concerns (Maguire et al. 1996).
• Consultations with problem outcomes are frequently characterised by unvoiced patient agenda items (Barry et al. 2000).
• Doctors frequently interrupt patients so soon after they begin their opening statement that patients fail to disclose significant concerns (Beckman and Frankel 1984; Marvel et al. 1999).
• Doctors often interrupt patients after the initial concern has been voiced, apparently assuming that the first complaint is the chief one, yet the order in which patients present their problems is not related to their clinical importance (Beckman and Frankel 1984).

Gathering information

• Doctors often pursue a ‘doctor-centred’, closed approach to information gathering that discourages patients from telling their story or voicing their concerns (Byrne and Long 1976).
• Both a ‘high control style’ and premature focus on medical problems can lead to an over-narrow approach to hypothesis generation and to inaccurate consultations (Platt and McMath 1979).
• Oncologists preferentially listen for and respond to certain disease cues over others. While pain that is amenable to specialist cancer treatment is recognised, other pains are not acknowledged or are dismissed (Rogers and Todd 2000).
• Doctors rarely ask their patients to volunteer their ideas and in fact doctors often evade their patients’ ideas and inhibit their expression. Yet if discordance between doctors’ and patients’ ideas and beliefs about the illness remains unrecognised, poor understanding, adherence, satisfaction and outcome are likely to ensue (Tuckett et al. 1985).
• Doctors only respond positively to patient cues in 38% of cases in surgery and 21% of cases in primary care. In both settings this omission results in longer interviews (Levinson et al. 2000).

Explanation and planning

• In general, physicians give sparse information to their patients, with most patients wanting their doctors to provide more information than they do (Waitzkin 1984; Beisecker and Beisecker 1990; Pinder 1990; Jenkins et al. 2001; Richard and Lussier 2003).
• Patients responding to a Canadian survey were very satisfied with their family physician’s medical care but somewhat less satisfied with their doctor’s communication skills, particularly with regard to explanation and planning. Items that were rated lowest included soliciting information about the patient’s life, providing enough information about the presenting complaint(s) and actively involving the patient in treatment plans (Laidlaw et al. 2001).
• Doctors overestimate the time they devote to explanation and planning in the consultation by up to 900% (Waitzkin 1984; Makoul et al. 1995).
• Patients and doctors disagree over the relative importance of imparting different types of medical information. Patients place the highest value on information about prognosis, diagnosis and causation of their condition while doctors overestimate their patients’ desire for information about treatment and drug therapy (Kindelan and Kent 1987).
• Doctors consistently use jargon that patients do not understand (Svarstad 1974.
• There are significant problems with patients’ recall and understanding of the information that doctors impart (Tuckett et al. 1985; Dunn et al. 1993).
• Only a minority of patients achieve their preferred level of control in decision making with regard to cancer treatment (Degner et al. 1997).

Patient adherence

• Patients do not comply with or adhere to the plans that doctors make. On average 50% do not take their medicine at all or take it incorrectly (Meichen-baum and Turk 1987; Butler et al. 1996).
• Non-compliance is enormously expensive. The cost of funds wasted on prescription medications that are used inappropriately or not used in Canada amounts to CAN$5 billion a year, based on an annual expenditure of CAN$10.3 billion and data indicating that 50% of prescription medications are not used as prescribed. Estimates of the further costs of non-adherence (including extra visits to physicians, laboratory tests, additional medications, hospital and nursing home admissions, lost productivity and premature death) were CAN$7-9 billion in Canada (Coambs et al. 1995) and at least US$100 billion in the USA (Berg et al. 1993).

Medico-legal issues

• Breakdown in communication between patients and physicians is a critical factor leading to malpractice litigation (Levinson 1994). Lawyers identified physicians’ communication and attitudes as the primary reason for patients pursuing a malpractice suit in 70% of cases (Avery 1986). Beckman et al. (1994) showed that the following four communication problems were present in over 70% of malpractice depositions: deserting the patient, devaluing the patient’s views, delivering information poorly and failing to understand the patient’s perspective. Patients of obstetricians with a high frequency of malpractice claims are more likely to complain of feeling rushed and ignored and receiving inadequate explanation, even if they do not sue (Hickson et al. 1994).
• In several states of the USA, malpractice insurance companies award premium discounts of 3-10% annually to their insured physicians who have attended a communication skills workshop (Carroll 1996).

Lack of empathy and understanding

• Numerous reports of patient dissatisfaction with the doctor-patient relationship appear in the media. Many articles comment on doctors’ lack of understanding of the patient as a person with individual concerns and wishes.
• There are significant problems in medical education in the development of relationship-building skills. It is not correct to assume that doctors either have the ability to communicate empathically with their patients or that they will acquire this ability during their medical training (Sanson-Fisher and Poole 1978).

Is there evidence that communication skills can overcome these problems and make a difference to patients, doctors and outcomes of care?

So there are plenty of problems, but are there solutions? In our companion volume we document in detail the evidence that the use of specific communication skills can overcome the very problems that we have listed above.

Although here again we provide only a few examples to whet your appetite, many studies over the last 25 years have demonstrated that communication skills can make a difference in all of the following objective measurements of medical care.

Process of the interview

• The longer the doctor waits before interrupting at the beginning of the interview, the more likely they are to discover the full spread of issues that the patient wants to discuss and the less likely it will be that new complaints arise at the end of the interview (Beckman and Frankel 1984; Joos et al. 1996; Marvel et al. 1999).
• Even patients with complex problems tend to be remarkably succinct. When internists in a tertiary care centre were trained to actively listen without interrupting until patients had completed their initial descriptions of their problems, patients’ mean talking time was only 92 seconds (Langewitz et al. 2002).
• The use of open rather than closed questions and the use of attentive listening lead to greater disclosure of patients’ significant concerns (Cox 1989; Wissow et al. 1994; Maguire et al. 1996).
• Asking ‘What worries you about this problem7 is not as effective a question as ‘What concerns you about this problem7 in discovering unrecognised concerns (Bass and Cohen 1982).
• The more questions that patients are allowed to ask of the doctor, the more information they obtain (Tuckett et al. 1985).
• Picking up and responding to patient cues shortens rather than lengthens visits (Levinson et al. 2000).

Patient satisfaction

• Greater ‘patient-centredness’ in the interview leads to greater patient satisfaction (Stewart 1984; Arborelius and Bromberg 1992; Kinnersley et al. 1999; Little et al. 2001).
• Discovering and acknowledging patients’ expectations improves patient satisfaction (Korsch et al. 1968; Eisenthal and Lazare 1976; Eisenthal et al. 1990; Bell et al. 2002).
• Asking patients if they have any questions and trying to ensure that they do not leave with unanswered questions increases patient satisfaction (Shilling et al. 2003).
• Physician non-verbal communication (eye contact, posture, nods, distance, communication of emotion through face and voice) is positively related to patient satisfaction (Larsen and Smith 1981; Weinberger et al. 1981; DiMatteo et al. 1986; Griffith et al. 2003).
• Patient satisfaction is directly related to the amount of information that patients perceive they have been given by their doctors (Hall et al. 1988).
• Information giving, expression of affect, relationship building, empathy and greater patient-centredness lead to increased patient satisfaction (Williams et al. 1998).
• In cancer patients, satisfaction with the consultation and satisfaction with the amount of information and emotional support received are significantly greater in those who reported a shared role in decision making (Gattellari et al. 2001).
• Patients who have undergone joint replacement surgery perceive the quality o...

Table of contents

• Cover Page
• Title Page
• Copyright
• Contents
• Forewords
• Preface
• About this book
• About the authors
• Acknowledgements
• Introduction
• Part I An overview of communication skills teaching and learning
• Part 2 Communication skills teaching and learning in practice
• Part 3 Constructing a communication skills curriculum
• Appendix 1 Example of a communication curriculum
• Appendix 2 The two-guide format of the Calgary-Cambridge Process Guide
• Appendix 3 A protocol for writing simulated patient cases
• Appendix 4 Sample OSCE marking sheets
• Appendix 5 Medical skills evaluation: communication process skills
• Appendix 6 Notes on using the Calgary-Cambridge Guides
• References
• Index
• Author Index