Analyzing Expert Criteria for Authentic Resident Communication Skills.

Phenomenon: Training and assessing communication skills requires flexible and holistic approaches, including feedback practices. Historically, assessing communication skills has predominantly relied on itemized scoring, which is less useful for providing meaningful feedback to learners. Even more troublesome, theoretical scoring criteria tend to become a refractive lens allowing observation of only the conduct that aligns with the theory. Few skills assessment efforts have embraced a holistic understanding of how physician-patient communication skills are enacted in real patient care. Therefore, this study focused on what experts refer to when they speak about physicians' communication skills and what they treat as important when evaluating these skills enacted during real patient encounters.Approach: This qualitative study was based on observations and grounded theory. Residents' encounters with real patients were recorded as part of a formative communication skills assessment program from July 2015 to June 2016. Evaluation panels with diverse backgrounds (e.g., medicine, education, communication, conversation analysis, and layperson) listened to these recordings and jointly developed feedback comments for the resident from January 2016 to July 2017. For this study, we recorded forty-one panel discussions to observe their consensus evaluation. We conducted open and axial coding using a constant comparison approach to generate themes from the data.Findings: Elements of communication skills were connected and interdependent around the concepts of thoroughness and natural flow, which were not addressed by formative assessment criteria. Themes included (1) thoroughness within a boundary via agenda-setting; (2) natural yet, controlled flow: authentic conversation by active listening and questioning; (3) making agenda setting explicit to all parties in the beginning; (4) designing questions using both open-ended and closed questions; (5) pre-/post-conditions for patient education: patient contextual factors and teach-back; (6) preconditions for shared decision-making: patient education and patient contextual factors; and (7) multifaceted empathy demonstrated in multiple ways.Insights: The main message of the study findings is that communication skills criteria should be treated as organically interrelated and connected in assessing physicians' communication skills. Current communication skills assessment practice should be revisited as it itemizes physicians' communication skills as distinct and separate constructs rather than mutually affecting dynamics. Rather than imposing a theoretical rubric, assessment criteria should evolve through naturalistic observations of physician-patient communication.

A Tale of Two Inquiries (or, Doing Being Competent in a Clinical Skills Exam).

Phenomenon: In high-stakes evaluations of communicative competency, data-gathering skills are commonly assessed through the use of standardized patient encounters. This article seeks to document inquiry practices in 2 such encounters in a setting designed to emulate a consequential, clinical skills examination. Approach: Drawing on the methods and findings of Conversation Analysis, we examine selected fragments seeking to understand how, in the ways in which they are organized, they produce quite different outcomes. Findings: In the first encounter, the topic of the patient's history of depression arises naturally in the course of the interview. It happens to be a checklist item for the case and the examinee receives credit for having elicited it. In the second encounter, though the examinee was the more clinically experienced, the topic does not come up and the examinee fails to receive credit. Insights: When we examine how the two inquiry sequences develop on a turn-by-turn basis, it becomes clear that the differences between inquiry practices that carefully constrain patient responses and those that leave space for patient elaboration are subtle but evident. Both types of practice, however, are presumably a part of competent clinical performance. We argue that looking carefully at how specific interactional practices operate within clinical interviews can enable us to become more articulate as to what might count as communicative competence in the clinic.

The Most Common Feedback Themes in Communication Skills Training in an Internal Medicine Residency Program: Lessons from the Resident Audio-Recording Project.

Individualized structured feedback is an integral part of a resident's learning in communication skills. However, it is not clear what feedback residents receive for their communication skills development in real patient care. We will identify the most common feedback topics given to residents regarding communication skills during Internal Medicine residency training. We analyzed Resident Audio-recording Project feedback data from 2008 to 2013 by using a content analysis approach. Using open coding and an iterative categorization process, we identified 15 emerging themes for both positive and negative feedback. The most recurrent feedback topics were Patient education, Thoroughness, Organization, Questioning strategy, and Management. The residents were guided to improve their communication skills regarding Patient education, Thoroughness, Management, and Holistic exploration of patient's problem. Thoroughness and Communication intelligibility were newly identified themes that were rarely discussed in existing frameworks. Assessment rubrics serve as a lens through which we assess the adequacy of the residents' communication skills. Rather than sticking to a specific rubric, we chose to let the rubric evolve through our experience.

Teaching, Learning, and Performance in the Surgical Workplace: Insights From the Examination of Intraoperative Interactions.

This Conversations Starter article presents a selected research abstract from the 2017 Association of American Medical Colleges Central Region Group on Educational Affairs annual spring meeting. The abstract is paired with the integrative commentary of three experts who shared their thoughts stimulated by the study. These thoughts explore the value of examining intraoperative interactions among attending surgeons and residents for enhancing instructional scaffolding; entrustment decision making; and distinguishing teaching, learning, and performance in the workplace.

Why would the discovery of gestures produced by signers jeopardize the experimental finding of gesture-speech mismatch?

Mismatch occurs when there is a discrepancy between produced gestures and co-occurring speech. In this commentary, I explore why research on mismatch might be called into question by changing views of what constitutes a gesture. I argue that the experimental procedure for producing mismatch, through its coding methods, is blind to the tight temporal coordination of gesture and affiliated talk.

A stitch in time: Instructing temporality in the operating room.

This paper examines how time is made explicitly relevant in the way the attending surgeon monitors and corrects the performance of a resident during a kidney transplant surgery. In so doing, we observe how the attending constitutes time as a significant and constituent feature of the surgical actions performed by the resident. In order to instruct temporal competence in the performance of surgical procedures, the attending surgeon identifies and makes instructably observable the temporally significant features of the surgical work just as that work is performed, by (a) producing countdowns, pace prompts, and temporal accounts when and as avoidable errors occur, and (b) planning and coordinating current and upcoming actions in relation to other actions. Instructing a trainee in the temporal features of his/her performance occurs when the attending (a) coordinates the production of specific verbal tokens, remarks, and accounts with specific actions performed by the resident as the resident performs them, or (b) anticipates the performance of subsequent actions in relation to current surgical actions underway. This case demonstrates how temporality becomes an observably instructable matter in interaction.