Successful implementation of a longitudinal skill-based teaching curriculum for residents.

BACKGROUND: Despite significant teaching responsibilities and national accreditation standards, most residents do not receive adequate instruction in teaching methods. Published reports of residents-as-teachers programs vary from brief one-time exposures to curricula delivered over several months. A majority of interventions described are one or two-day workshops with no clear follow-up or reinforcement of skills. A three-year longitudinal teaching skills curriculum was implemented with these goals: 1) deliver an experiential skill-based teaching curriculum allowing all residents to acquire, practice and implement specific skills; 2) provide spaced skills instruction promoting deliberate practice/reflection; and 3) help residents gain confidence in their teaching skills. METHODS: One hundred percent of internal medicine residents (82/82) participated in the curriculum. Every 10 weeks residents attended a topic-specific experiential skills-based workshop. Each workshop followed the same pedagogy starting with debriefing/reflection on residents' deliberate practice of the previously taught skill and introduction of a new skill followed by skill practice with feedback. Every year, participants completed: 1) assessment of overall confidence in each skill and 2) retrospective pre-post self-assessment. A post-curriculum survey was completed at the end of 3 years. RESULTS: Residents reported improved confidence and self-assessed competence in their teaching skills after the first year of the curriculum which was sustained through the three-year curriculum. The curriculum was well received and valued by residents. CONCLUSIONS: A formal longitudinal, experiential skills-based teaching skills curriculum is feasible and can be delivered to all residents. For meaningful skill acquisition to occur, recurrent continuous skill-based practice with feedback and reflection is important.

Improving Postoperative Conversations With Families: What We Can Learn From Experience.

BACKGROUND: Postoperative conversations with families are an integral part of the patient-physician relationship. Faculty and resident surgeons alike agree on their importance; however, there is little exposure and formal training during residency training. This study explored faculty surgeons' perspectives on common themes, impressions, and potential teaching points that could provide a basis for developing a comprehensive formal curriculum on postoperative conversations. METHODS: Interviews were conducted at a single teaching hospital with faculty surgeons with over 5 y of practice regarding important aspects and teaching points of postoperative conversations with families. Qualitative review was performed using thematic analysis to determine common themes regarding postoperative conversations with families. RESULTS: Based on interviews with 15 faculty surgeons, components of postoperative conversation with families were grouped into "what" (sharing data with the patient), "how" (creating an atmosphere, i.e., private, honest, with attention to empathy and reassurance), and "verify" (ensuring clear communication and comprehension). Faculty surgeons stated that challenges in postoperative conversations included discussing poor outcomes, reporting unexpected findings, and ensuring clear communication with families. When teaching residents, developing the appropriate atmosphere and rapport was most emphasized as well as need for additional practice. Yet, faculty frequently noted minimal exposure to these conversations during their residency and stated some logistical and trust barriers from preventing them as faculty to allow surgical trainees to participate in these postoperative conversations. CONCLUSIONS: This study identified the themes to guide and challenges involved in postoperative conversations with families. Using this data, a complete curriculum could be developed to teach trainees the essential portions of this critical portion of patient care.

Comparing resident-patient encounters and case presentations in a family medicine clinic.

OBJECTIVES: Oral case presentations following resident-patient interactions provide the primary mechanism by which faculty supervisors assess resident competence. However, the extent to which these presentations capture the content and quality of resident-patient communication during the encounter remains unknown. We aimed to determine whether: (i) the resident-patient encounter content matched information conveyed in the case presentation; (ii) the quality of resident-patient communication was accurately conveyed, and (iii) supervisors addressed effective and ineffective communication processes. METHODS: A total of 22 pairs of resident-patient encounters and family medicine resident case presentations were video- or audiorecorded, transcribed and compared for content. Resident-patient communication was assessed using adapted versions of the Calgary-Cambridge Guide to the Medical Interview and Explanation and Planning Scale. RESULTS: Interviews and presentations contained largely congruent content, but social history and the patient's perspective were consistently excluded from case presentations. Although six of 19 specific communication skills were used in over 80% of resident encounters, the effective use of communication skills was widely variable. In most presentations, the quality of resident-patient communication was not explicitly conveyed to the supervisor. Although resident presentations provided 'cues' about communication issues, supervisors rarely responded. CONCLUSIONS: This study lends support to direct observation in workplace-based learning of communication skills. When content areas such as the patient's perspective and education are excluded, supervisors cannot address them. In addition, presentations provided minimal insight about the quality of resident-patient encounters and limited the ability to address communication skills. These skills could be enhanced by attending to communication cues during case presentations, making increased use of direct observation and feedback, and promoting faculty development to address these missed teaching opportunities.

Learning to drive: resident physicians' perceptions of how attending physicians promote and undermine autonomy.

BACKGROUND: Providing appropriate levels of autonomy to resident physicians is an important facet of graduate medical education, allowing learners to progress toward the ultimate goal of independent practice. While studies have identified the importance of autonomy to the development of resident physicians, less is known about resident perspectives on their "lived experiences" with autonomy and ways in which clinical educators either promote or undermine it. The current study aims to provide an empirically based practical framework based on resident perspectives through which supervising physicians can attempt to more adequately foster resident physician autonomy. METHODS: Residents completed open ended surveys followed by facilitated group discussions of their perspectives on autonomy. Qualitative thematic analysis identified key themes in resident definitions of autonomy and how clinical educators either promote or undermine resident autonomy during supervision. Fifty-nine resident physicians representing six different specialties from two institutions participated. RESULTS: Learners felt that autonomy was critical to their development as independent physicians. Leading the approach to care, a sense of ownership for patients, and receiving appropriate levels of supervision were identified as key components of autonomy. Attending physicians who promoted this active involvement with patient care were felt to have a strong positive influence on resident autonomy. Autonomy was undermined when decisions were micromanaged and resident input in decision-making process was minimized. CONCLUSIONS: Fostering autonomy is a critical aspect of medical education. Allowing residents to take the lead in the delivery of patient care while supporting them as important members of the health care team can help to promote resident autonomy in the clinical setting.

Resident perceptions of the impact of duty hour restrictions on resident-attending interactions: an exploratory study.

BACKGROUND: The institution of duty hour reforms by the Accreditation Council for Graduate Medical Education in 2003 has created a learning environment where residents are consistently looking for input from attending physicians with regards to balancing duty hour regulations and providing quality patient care. There is a paucity of literature regarding resident perceptions of attending physician actions or attitudes towards work hour restrictions. The purpose of this study was to identify attending physician behaviors that residents perceived as supportive or unsupportive of their compliance with duty hour regulations. METHODS: Focus group interviews were conducted with residents exploring their perceptions of how duty hour regulations impact their interactions with attending physicians. Qualitative analysis identified key themes in residents' experiences interacting with faculty in regard to duty hour regulations. Forty residents from five departments in two hospital systems participated. RESULTS: Discussion of these interactions highlighted that attending physicians demonstrate behaviors that explicitly or implicitly either lend their support and understanding of residents' need to comply with these regulations or imply a lack of support and understanding. Three major themes that contributed to the ease or difficulty in addressing duty hour regulations included attending physicians' explicit communication of expectations, implicit non-verbal and verbal cues and the program's organizational culture. CONCLUSIONS: Resident physicians' perception of attending physicians' explicit and implicit communication and residency programs organization culture has an impact on residents' experience with duty hour restrictions. Residency faculty and programs could benefit from explicitly addressing and supporting the challenges that residents perceive in complying with duty hour restrictions.

'I wish someone watched me interview:' medical student insight into observation and feedback as a method for teaching communication skills during the clinical years.

BACKGROUND: Experts suggest observation and feedback is a useful tool for teaching and evaluating medical student communication skills during the clinical years. Failing to do this effectively risks contributing to deterioration of students' communication skills during the very educational period in which they are most important. While educators have been queried about their thoughts on this issue, little is known about what this process is like for learners and if they feel they get educational value from being observed. This study explored student perspectives regarding their experiences with clinical observation and feedback on communication skills. METHODS: A total of 125 senior medical students at a U.S. medical school were interviewed about their experiences with observation and feedback. Thematic analysis of interview data identified common themes among student responses. RESULTS: The majority of students reported rarely being observed interviewing, and they reported receiving feedback even less frequently. Students valued having communication skills observed and became more comfortable with observation the more it occurred. Student-identified challenges included supervisor time constraints and grading based on observation. Most feedback focused on information gathering and was commonly delayed until well after the observed encounter. CONCLUSIONS: Eliciting students' perspectives on the effect of observation and feedback on the development of their communication skills is a unique way to look at this topic, and brings to light many student-identified obstacles and opportunities to maximize the educational value of observation and feedback for teaching communication, including increasing the number of observations, disassociating observation from numerically scored evaluation, training faculty to give meaningful feedback, and timing the observation/feedback earlier in clerkships.

Resident involvement in postoperative conversations: an underused opportunity.

BACKGROUND: Because of established attending-patient and family relationships and time constraints, residents are often excluded from the immediate postoperative conversation with family. Interpersonal and communication skills are a core competency, and the postoperative conversation is an opportunity to develop these skills. Our objective is to assess attitudes, experience, and comfort regarding resident participation during postoperative conversations with families. MATERIALS AND METHODS: Residents and attending surgeons in an academic surgery center were surveyed regarding resident involvement in the postoperative conversation with families. Paper surveys were administered anonymously. Nonparametric statistics compared responses. RESULTS: There were 45 survey respondents (23 residents, 22 attendings). All residents rated postoperative conversations with families, as "important" or "very important". Residents reported being "comfortable" or "very comfortable" with postoperative conversations. However, on average, residents reported fewer than 10 postoperative conversation experiences per year. Feedback was received by <30% on postoperative communication skills, but 88% wanted feedback. Most attendings reported it is "important" or "very important" for residents to communicate well with families during postoperative conversations, but rated residents' performance as significantly lower than the residents' self-assessments (P < 0.001). Attendings on average were only "somewhat comfortable" or "moderately comfortable" with residents conducting postoperative conversations with families, and only 68% reported allowing residents to do so. When bad news was involved, only 27% allowed resident participation. Most attendings (86%) believed residents need more opportunities with postoperative conversations. CONCLUSIONS: Although most residents reported being comfortable with postoperative conversations, these survey results indicate that they have few opportunities. Developing a workshop on communication skills focused on the postoperative conversations with families may be beneficial.

A randomized controlled trial assessing the feasibility of examination room versus conference room teaching in a psychiatric setting.

BACKGROUND: Teaching in the presence of the patient is an acceptable model in medical settings. Questions have been raised about the appropriateness of this type of teaching (exam room teaching) with patients with mental health issues. PURPOSES: This prospective randomized controlled study examined outpatient exam room teaching in a psychiatric setting. METHODS: In 2011-2012, patients in the adult outpatient psychiatry clinic at the University of Iowa were randomized to have faculty-learner presentations either in the presence of the patient or in the conference room. Teaching encounters were timed and faculty, learners, and patients completed post encounter surveys. RESULTS: Participation included 126 patients, nine faculty, and 16 residents. Comparison of patient encounters randomized to exam room (n = 58) or conference room (n = 64) demonstrated that exam room teaching was roughly twice as time efficient as conference room teaching (p ≤ .0001). Patients expressed a preference for exam room teaching during future visits (p ≤ .003) for those patients who experienced exam room teaching during the study. Faculty were generally comfortable with exam room teaching and felt it had some advantages for patient decision making. Learners felt they had to choose their words more carefully in exam room teaching and expressed some concerns about depth of teaching. CONCLUSIONS: Once exposed to exam room teaching, this model is acceptable and feasible to faculty, learners, and patients in a psychiatry clinic setting.

Family Medicine Clinician Screening and Barriers to Communication on Food Insecurity: A CERA General Membership Survey.

PURPOSE: Food insecurity (FI) is a hidden epidemic associated with worsening health outcomes affecting 33.8 million people in the US in 2021. Although studies demonstrate the importance of health care clinician assessment of a patient's food insecurity, little is known about whether Family Medicine clinicians (FMC) discuss FI with patients and what barriers influence their ability to communicate about FI. This study evaluated FM clinicians' food insecurity screening practices to evaluate screening disparities and identify barriers that influence the decision to communicate about FI. METHODS: Data were gathered and analyzed as part of the 2022 Council of Academic Family Medicine's Educational Research Alliance survey of Family Medicine general membership. RESULTS: The majority of respondents reported (66.9%) that their practice has a screening system for food insecurity, and most practices used a verbal screen with staff other than the clinician (41%) at specific visits (63.8%). Clinicians reported "rarely or never asking about FI" 40% of the time and only asking "always or frequently" 6.7% of the time. Inadequate time during appointments (44.5%) and other medical issues taking priority (29.4%) were identified as the most common barriers. The lack of resources available in the community was a significant barrier for clinicians who worked in rural areas. CONCLUSIONS: This survey provides insight into food insecurity screening disparities and identifies obstacles to FMC screening, such as time constraints, lack of resources, and knowledge of available resources. Understanding current communication practices could create opportunities for interventions to identify food insecurity and impact "Food as Medicine."

A medical interviewing curriculum intervention for medical students' assessment of suicide risk.

OBJECTIVE: Effective communication strategies are required to assess suicide risk. The authors determined whether a 2-hour simulated-patient activity during a psychiatry clerkship improved self-assessment of medical interviewing skills relevant to suicide risk-assessment. METHODS: In the 2-hour simulated-patient intervention, at least one psychiatrist, a non-clinician communication expert, and a specifically-trained simulated patient worked with groups of 4-6 students to address student-identified challenges with patient encounters involving suicide risk-assessment. Six of twelve clerkships between July 2010 and October 2011 were assigned to this educational intervention in addition to a communications curriculum. RESULTS: On a retrospective pre-post self-assessment, the 61 of 118 students assigned to the intervention group reported greater improvements in relevant skills. The process of discovering/responding to patients' feelings and identifying/addressing verbal and nonverbal cues specifically improved. CONCLUSION: The psychiatry clerkship provides a unique opportunity to reinforce and develop communications skills with a formal, skills-based curriculum.

Feedback conversations: First things first?

OBJECTIVE: This study explores medical students' perceptions regarding the order in which feedback is given and its impact on how that feedback is received. METHODS: Medical students were interviewed regarding their feedback experiences during medical school and preferred order in which to receive feedback. Thematic analysis was applied to interview transcripts to identify salient themes in students' comments related to feedback order. RESULTS: Twenty-five students entering their second, third, and fourth years of medical school participated in the study. Students indicated that the order in which feedback was conveyed influenced their receptivity to its content, but varied in their specific order preferences. Most students indicated that they preferred feedback conversations that started with positive observations. Only the most senior students expressed a preference for feedback based on self-assessment. CONCLUSION: Feedback conversations are complicated interactions. Students' responses to feedback are influenced by a variety of factors, including the order in which feedback is delivered. PRACTICE IMPLICATIONS: Educators should recognize that students' feedback needs may be influenced by a variety of factors, and should aim to tailor feedback and the order of its delivery to the learner.

Self-Assessment in Feedback Conversations: A Complicated Balance.

PURPOSE: Learner-centered feedback models encourage educators to ask learners to self-assess at the start of feedback conversations. This study examines how learners perceive and respond to self-assessment prompts during feedback conversations and assesses medical students' perceptions of and approach to self-assessment used as the basis for these conversations. METHOD: All rising second-, third-, and fourth-year medical students at a midwestern U.S. medical school were invited to participate in this study. Students participated in 1-on-1 interviews between June and August 2019 during which they were asked open-ended questions about their experiences with self-assessment and feedback during medical school. The interviews were audio recorded and transcribed, and comments related to self-assessment in feedback conversations were extracted. Thematic analysis was used to identify recurrent ideas and patterns within the transcripts, and all excerpts were reviewed and coded to ensure that the identified themes adequately captured the range of student responses. RESULTS: A total of 25 students participated in the study. Although some students noted improvement in their self-assessment abilities with increasing experience, no consistent gender, race, or training-level differences were found in reported attitudes or preferences. Students identified many benefits of self-assessment and generally appreciated being asked to self-assess before receiving feedback. Students had varied responses to specific self-assessment prompts, with no clear preferences for any particular self-assessment questions. Students described weighing multiple factors, such as image concerns and worries about impact on subsequent evaluations, when deciding how to respond to self-assessment prompts. CONCLUSIONS: The process by which learners formulate and share self-assessments in feedback conversations is not straightforward. Although educators should continue to elicit self-assessments in feedback discussions, they should recognize the limitations of these self-assessments and strive to create a safe environment in which learners feel empowered to share their true impressions.

Through students' eyes: ethical and professional issues identified by third-year medical students during clerkships.

BACKGROUND: Education in ethics and professionalism should reflect the realities medical students encounter in the hospital and clinic. METHOD: We performed content analyses on Case Observation and Assessments (COAs) written by third-year medical students about ethical and professional issues encountered during their internal medicine and paediatrics clinical clerkships. RESULTS: A cohort of 141 third-year medical students wrote 272 COAs. Content analyses identified 35 subcategories of ethical and professional issues within 7 major domains: decisions regarding treatment (31.4%), communication (21.4%), professional duties (18.4%), justice (9.8%), student-specific issues (5.4%), quality of care (3.8%), and miscellaneous (9.8%). CONCLUSIONS: Students encountered a wide variety of ethical and professional issues that can be used to guide pre-clinical and clinical education. Comparison of our findings with results from similar studies suggests that the wording of an assignment (specifying "ethical" issues, "professional" issues, or both) may influence the kinds of issues students identify in their experience-based clinical narratives.

Health care professionals' perspectives on barriers to elder abuse detection and reporting in primary care settings.

The purpose of this study was to explore health care professionals' perspectives on elder abuse to achieve a better understanding of the problems of reporting and to generate ideas for improving the detection and reporting process. Through a mailed survey, nurses, physicians, and social workers were invited to participate in an interview. Nine nurses, 8 physicians, and 6 social workers were interviewed, and thematic analysis was used to identify the following core themes: preconceptions, assessment, interpretation, systems, and knowledge and education. Participants suggested a reorganization of the external reporting system. More frequent and pragmatic education is necessary to strengthen practical knowledge about elder abuse.

Developing communication curricula in healthcare education: An evidence-based guide.

OBJECTIVE: To present a guide for communication curriculum development in healthcare professions for educators and curriculum planners. METHODS: We collated a selection of theories, frameworks and approaches to communication curriculum development to provide a roadmap of the main factors to consider when developing or enhancing communication skills curricula. RESULTS: We present an evidence-based guide for developing and enhancing communication curriculum that can be applied to undergraduate and postgraduate healthcare education. Recommended steps to consider during the communication curricula development process include thoughtful examination of current communication education, needs assessment, focused learning goals and objectives, incorporation of experiential educational strategies allowing for skills practice and feedback and use of formative and summative assessment methods. A longitudinal, developmental and helical implementation approach contributes to reinforcement and sustainment of learners' knowledge and skills. CONCLUSION AND PRACTICE IMPLICATIONS: Drawing on best practices in developing communication curricula can be helpful in ensuring successful approaches to communication skills training for any level of learner or healthcare profession. This position paper provides a guide and identifies resources for new and established communication curriculum developers to reflect on strengths and opportunities in their own approaches to addressing the communication education needs of their learners.

Evaluation of Physician Assistants' Self-Reported Attitudes and Behaviors After Completion of a Hospital-Wide Multidisciplinary Communication Skills Training Workshop.

Physician's assistants (PA) are an integral part of hospital teams. To the best of our knowledge, this is the first study to examine the effects of a multidisciplinary hospital-wide communication skills training (CST) workshop on PAs. From November 2017 to November 2019, all participants in the CST workshop were sent a web-based retrospective pre-post survey to measure self-reported attitudes and behaviors related to communicating with patients, CST, and specific skills taught. PA responses were analyzed alone and were compared to non-PAs. Non-PAs were physicians and 1 nurse practitioner. In total, 258 PA and 333 non-PA participants were surveyed for an overall response rate of 25%. Among PAs, in 9 out of 10 domains measured, there was a significant change in self-reported attitudes and behaviors toward communicating with patients, CST, and skills taught (P < .05). Similar to other providers, PAs experienced positive changes in these self-reported attitudes and behaviors after CST, however, there were some significant differences found when comparing PAs and non-PAs in the covariate analysis.

Physician-Patient Communication in the Orthopedic Clinic: Surgeon-Identified Challenges.

Background: Effective communication between the physician and the patient is crucial to quality healthcare. The orthopedic surgery clinic setting provides an environment for cultivating the physician-patient relationship, eliciting diagnostic data, and developing treatment strategies. However, little is known about the orthopedic surgeon perspective on communicating with patients. The purpose of the study was to identify patient communication and care issues faced in the orthopedic surgery clinic setting that physicians categorize as challenging. Methods: All surgeons in the department of orthopedics in a large tertiary care center were invited to respond to an online survey on common communication challenges. Physicians were asked to rate 13 challenges identified by the literature and opinion leaders using a four-point Likert scale ranging from "Not at all challenging" to "Extremely challenging". In addition, the survey included open ended questions regarding common challenges in communicating with patients and types of encounters, and thematic analysis was applied. Mean scores were calculated. Results: Nineteen orthopedic surgeons completed the survey and were included in the analysis. Orthopedic surgeons identified misaligned expectations for surgical intervention for a nonsurgical diagnosis as the most challenging encounter in the clinic (16/19). Managing postoperative patient expectations (14/19) and communicating with patients who were dissatisfied with their surgical outcome (13/19) were also commonly rated as particularly challenging. Open ended responses echoed these ratings and additional difficulty facilitating patient understanding of complex information as common communication challenges. Conclusion: Common challenges in the orthopedic clinic often surround managing patient expectations and providing effective explanations, particularly where physicians perceive a surgical intervention as inappropriate for addressing the patient complaint. Identifying these issues can guide training efforts to help orthopedic physicians in managing these and improving communication. These findings can also provide basis for collecting information about communication challenges from orthopedic surgeons across institutions. Level of Evidence: IV.

Effect of Experiential Communication Skills Education on Graduate Medical Education Trainees' Communication Behaviors: A Systematic Review.

PURPOSE: A better understanding of how communication skills education impacts trainees' communication skills is important for continual improvement in graduate medical education (GME). Guided by the Kirkpatrick Model, this review focused on studies that measured communication skills in either simulated or clinical settings. The aim of this systematic review was to examine the effect of experiential communication skills education on GME trainees' communication behaviors. METHOD: Five databases were searched for studies published between 2001 and 2021 using terms representing the concepts of medical trainees, communication, training, and skills and/or behaviors. Included studies had an intervention design, focused only on GME trainees as learners, used experiential methods, and had an outcome measure of communication skills behavior that was assessed by a simulated or standardized patient (SP), patient, family member, or outside observer. Studies were examined for differences in outcomes based on study design; simulated versus clinical evaluation setting; outside observer versus SP, patient, or family member evaluator; and length of training. RESULTS: Seventy-seven studies were ultimately included. Overall, 54 (70%) studies reported some positive findings (i.e., change in behavior). There were 44 (57%) single-group pre-post studies, 13 (17%) nonrandomized control studies, and 20 (26%) randomized control studies. Positive findings were frequent in single-group designs (80%) and were likely in nonrandomized (62%) and randomized (55%) control trials. Positive findings were likely in studies evaluating communication behavior in simulated (67%) and clinical (78%) settings as well as in studies with outside observer (63%) and SP, patient, and family member (64%) evaluators. CONCLUSIONS: This review demonstrates strong support that experiential communication skills education can impact GME trainees' communication behaviors. Marked heterogeneity in communication trainings and evaluation measures, even among subgroups, did not allow for meta-analysis or comparative efficacy evaluation of different studies. Future studies would benefit from homogeneity in curricular and evaluation measures.

National train-the-trainer certificate programme for improving healthcare communication in Austria.

OBJECTIVES: In Austria a national train-the-trainer programme (TTT) has been developed, implemented and evaluated with the aim of training and certifying participants for developing, implementing and delivering communication skills training (CST) for health professionals. METHODS: The programme included 5 in-person courses, application homework with feedback, peer work, and regular trainer network meetings. Global satisfaction with training and changes in self-efficacy among TTT-participants and their learners in the CST delivered as practice projects were evaluated. RESULTS: 18 participants have graduated from the TTT-pilot. 98 people took part in the 9 CST delivered by TTT-participants. Participants' satisfaction has been rated very positively both for TTT and CST. At post-programme/post-training, statistically significant improvement was observed in self-efficacy for the TTT-participants and for the CST-participants. Additionally, valuable suggestions for programme/training improvement were identified. CONCLUSIONS: This programme is an important step to sustainably improving CST in Austria. To guarantee high quality and consistency, a set of standards for certification have been developed for TTT and CST. PRACTICE IMPLICATIONS: Implementation of best practices in training trainers and communication skills teaching can be guided by a structured approach. Those wanting to implement similar programmes can benefit from strengths and suggestions for improvement identified in this national project.