A randomized controlled trial assessing behavioral, cognitive, emotional and physiological changes resulting from a communication skills training in physicians caring for cancer patients.

OBJECTIVE: This randomized study assesses behavioral, cognitive, emotional and physiological changes resulting from a communication skills training (CST) for physicians caring for cancer patients. METHODS: Medical specialists (N = 90) were randomly assigned in groups to complete a manualized 30-h CST or to a waiting list. Assessments included behavioral (communication skills), cognitive (self-efficacy, sense of mastery), emotional (perceived stress) and physiological (heart rate) measures. Assessments were made at baseline (both groups), after CST program (training group), and four months after (waiting list group). All assessments were conducted before, during, and after a complex communication task with an advanced-stage cancer simulated patient (SP). RESULTS: Trained physicians had higher levels of communication skills (from RR=1.32; p = .003 to RR=41.33; p < .001), self-efficacy (F=9.3; p = .003), sense of mastery (F=167.9; p < .001) and heart rate during the SP encounter (from F=7.4; p = .008 to F=4; p = .050) and same levels of perceived stress (F=3.1; p = .080). CONCLUSION: A learner-centered, skills-focused and practice-oriented manualized 30-h CST induced multilevel changes indicating physician engagement in a learning process. PRACTICE IMPLICATIONS: Trainers should consider the CST multilevel benefits (behavioral, cognitive, emotional and physiological) before, during and after a complex communication simulated task as an innovative way to assess the efficacy of a communication skills learning process.

Insight on variables leading to burnout in cancer physicians.

Although communication skills training programs have been recommended to reduce physicians' burnout, few studies have investigated their efficacy. This study assessed the impact of two training programs on cancer physicians' burnout. Especially, it identified some variables leading to burnout in order to develop effective interventions. Burnout was assessed with the Maslach Burnout Inventory. No statistically significant impact of training programs on burnout was observed. The amount of clinical workload and the overuse of some facilitative communication skills were associated with cancer physicians' burnout. The content of such programs must be redefined to reduce burnout.

Predictors and correlates of burnout in residents working with cancer patients.

There are few studies which have investigated variables associated with the development of burnout among residents working with cancer patients. The aim of this study is to identify variables leading to residents' burnout in order to develop effective interventions. Burnout was assessed with Maslach Burnout Inventory. Person- (i.e., emotional-focused coping) and work-related (i.e., changes in lack of organizational support index) variables explain 28% of the variance in changes in emotional exhaustion. Training programs may be improved by adding specific modules for residents, about problem-focused coping in interviewing patients, and for supervisors, about effective team management.

Factors influencing physicians' detection of cancer patients' and relatives' distress: can a communication skills training program improve physicians' detection?

PURPOSE: This study aimed to assess the impact on physicians' detection of patients' and relatives' distress of six 3-h consolidation workshops (CW) following a 2.5-day communication skills basic training (BT) program and to investigate factors associated with detection of distress. METHODS: Physicians, after BT, were randomized to CW or to a waiting list. Physicians' detection of patients' and relatives' distress was measured through differences between physicians' ratings of patients' and relatives' distress (VAS) and patients' and relatives' self-reported distress (HADS). Communication skills were analysed according to the CRCWEM. RESULTS: Mixed-effects modelling of physicians' detection of patients' distress showed a positive group by time effect in favour of physicians in the CW group. Detection of patients' distress was associated negatively with patients' distress, positively with physicians' concurrent use of psychological assessment and supportive skills, and negatively with general assessment skills. Mixed-effects modelling of physicians' detection of relatives' distress showed no significant group by time effect. Detection of relatives' distress was associated negatively with relatives' distress and with general assessment skills. CONCLUSION: CW following a 2.5-day BT are needed to improve physicians' detection of patients' distress in three-person interviews. Results indicate the need to further improve physicians' detection of relatives' distress.

Factors that influence cancer patients' and relatives' anxiety following a three-person medical consultation: impact of a communication skills training program for physicians.

BACKGROUND: No study has yet assessed the impact of physicians' skills acquisition after a communication skills training program on changes in patients' and relatives' anxiety following a three-person medical consultation. This study aimed at comparing, in a randomized study, the impact, on patients' and relatives' anxiety, of a basic communication skills training program and the same program consolidated by consolidation workshops and at investigating physicians' communication variables associated with patients' and relatives' anxiety. METHODS: Consultations with a cancer patient and a relative were recorded and analyzed by the Cancer Research Campaign Workshop Evaluation Manual. Patients' and relatives' anxiety were assessed with the State-Trait Anxiety Inventory-State. RESULTS: No statistically significant change over time and between groups was observed. Mixed-effects modeling of changes in patients' and relatives' anxiety showed that decreases in both patients' and relatives' anxiety were linked with patients' and relatives' self-reported distress (p = 0.031 and 0.005), and that increases in both patients' and relatives' anxiety were linked with physicians' breaking bad news (p = 0.028 and 0.005). CONCLUSION: No impact of the training program was observed. Results indicate the need to further study communication skills which may help reduce patients' and relatives' anxiety especially when breaking bad news.

Development of the LaComm 1.0, A French medical communication analysis software: A study assessing its sensitivity to change.

OBJECTIVE: To test and compare the sensitivity to change of a communication analysis software, the LaComm 1.0, to the CRCWEM's using data from a randomized study assessing the efficacy of a communication skills training program designed for nurses. METHODS: The program assessment included the recording of two-person simulated interviews at baseline and after training or 3 months later. Interview transcripts were analyzed using the CRCWEM and the LaComm 1.0 tools. RESULTS: One hundred and nine oncology nurses (mainly graduated or certified) were included in the study. The CRCWEM detected 5 changes out of 13 expected changes (38%) (e.g., more open directive questions after training) and the LaComm 1.0, 4 changes out of 7 expected changes (57%) (e.g., more empathic statements after training). For open directive question, the effect sizes of the group-by-time changes were slightly different between tools (CRCWEM: Cohen's d=0.97; LaComm 1.0: Cohen's d=0.67). CONCLUSIONS: This study shows that the LaComm 1.0 is sensitive to change. PRACTICE IMPLICATIONS: The LaComm 1.0 is a valid method to assess training effectiveness in French. The use of the Lacomm 1.0 in future French communication skills training programs will allow comparisons of studies.

Is it possible to improve communication around radiotherapy delivery: A randomized study to assess the efficacy of team training?

BACKGROUND AND PURPOSE: The aim of this study was to assess the efficacy of a 38-h communication skills training program designed for multidisciplinary radiotherapy teams. MATERIALS AND METHODS: Four radiotherapy teams were randomly assigned to a training program or to a waiting list. Assessments were scheduled at baseline (T1) and then after the training was completed or four months later (T2), respectively. Communication around radiotherapy delivery was assessed based on audio recordings of the first and last radiotherapy sessions in order to assess team members' communication skills and the expression of concerns by breast cancer patients (analyzed with content analysis software LaComm). RESULTS: 198 radiotherapy sessions were recorded. During the first radiotherapy sessions, members of the trained teams exhibited more assessment skills (p=0.048), provided more setting information (p<0.001), and used more social words (p=0.019) compared to the members of the untrained teams. During the last radiotherapy session, members of the trained teams used more assessment skills (p=0.004) and patients interacting with members of the trained teams expressed more sadness words (p=0.023). CONCLUSION: Training of multidisciplinary teams has the potential to transfer skills that affect the short exchanges that take place around radiotherapy delivery.

How to optimize physicians' communication skills in cancer care: results of a randomized study assessing the usefulness of posttraining consolidation workshops.

PURPOSE: Although there is wide recognition of the usefulness of improving physicians' communication skills, no studies have yet assessed the efficacy of post-training consolidation workshops. This study aims to assess the efficacy of six 3-hour consolidation workshops conducted after a 2.5-day basic training program. METHODS: Physicians, after attending the basic training program, were randomly assigned to consolidation workshops or to a waiting list. Training efficacy was assessed through simulated and actual patient interviews that were audiotaped at baseline and after consolidation workshops for the consolidation-workshop group, and approximately 5 months after the end of basic training for the waiting-list group. Communication skills were assessed according to the Cancer Research Campaign Workshop Evaluation Manual. Patients' perceptions of communication skills improvement were assessed using a 14-item questionnaire. RESULTS: Sixty-three physicians completed the training program. Communication skills improved significantly more in the consolidation-workshop group compared with the waiting-list group. In simulated interviews, group-by-time repeated measures analysis of variance showed a significant increase in open and open directive questions (P =.014) and utterances alerting patients to reality (P =.049), as well as a significant decrease in premature reassurance (P =.042). In actual patient interviews, results revealed a significant increase in acknowledgements (P =.022) and empathic statements (P =.009), in educated guesses (P =.041), and in negotiations (P =.008). Patients interacting with physicians who benefited from consolidation workshops reported higher scores concerning their physicians' understanding of their disease (P =.004). CONCLUSION: Consolidation workshops further improve a communication skills training program's efficacy and facilitate the transfer of acquired skills to clinical practice.

Transfer of communication skills to the workplace: impact of a 38-hour communication skills training program designed for radiotherapy teams.

PURPOSE: This study assessed the efficacy of a 38-hour communication skills training program designed to train a multidisciplinary radiotherapy team. METHODS: Four radiotherapy teams were randomly assigned to a training program or a waiting list. Assessments were scheduled at baseline and after training for the training group and at baseline and 4 months later for the waiting list group. Assessments included an audio recording of a radiotherapy planning session to assess team members' communication skills and expression of concerns of patients with breast cancer (analyzed with content analysis software) and an adapted European Organisation for Research and Treatment of Cancer satisfaction with care questionnaire completed by patients at the end of radiotherapy. RESULTS: Two hundred thirty-seven radiotherapy planning sessions were recorded. Compared with members of the untrained teams, members of the trained teams acquired, over time, more assessment skills (P = .003) and more supportive skills (P = .050) and provided more setting information (P = .010). Over time, patients interacting with members of the trained teams asked more open questions (P = .022), expressed more emotional words (P = .025), and exhibited a higher satisfaction level regarding nurses' interventions (P = .028). CONCLUSION: The 38-hour training program facilitated transfer of team member learned communication skills to the clinical practice and improved patients' satisfaction with care.

The effect of communication skills training on residents' physiological arousal in a breaking bad news simulated task.

OBJECTIVE: Breaking bad news (BBN) is a complex task which involves dealing cognitively with different relevant dimensions and a challenging task which involves dealing with intense emotional contents. No study however has yet assessed in a randomized controlled trial design the effect of a communication skills training on residents' physiological arousal during a BBN task. METHODS: Residents' physiological arousal was measured, in a randomized controlled trial design, by heart rate and salivary cortisol before, during and after a BBN simulated task. RESULTS: Ninety-eight residents were included. MANOVA showed significant group-by-time effects. Trained residents' mean heart rate levels remained elevated after training and cortisol areas under the curve increased after training compared to untrained residents. CONCLUSION: Communication skills training has an effect on residents' physiological arousal. Residents' self-efficacy and communication skills improvements in a BBN simulated task are associated with an elevated physiological arousal, which becomes proportional to the complexity of the task and reflects a better engagement and performance. PRACTICE IMPLICATIONS: Residents should be informed that, to perform a task, they need to engage in the task with a physiological arousal proportional to the complexity of this task. Communication skills training should be adapted.

Is it possible to improve radiotherapy team members' communication skills? A randomized study assessing the efficacy of a 38-h communication skills training program.

BACKGROUND AND PURPOSE: Optimizing communication between radiotherapy team members and patients and between colleagues requires training. This study applies a randomized controlled design to assess the efficacy of a 38-h communication skills training program. MATERIAL AND METHODS: Four radiotherapy teams were randomly assigned either to a training program or to a waiting list. Team members' communication skills and their self-efficacy to communicate in the context of an encounter with a simulated patient were the primary endpoints. These encounters were scheduled at the baseline and after training for the training group, and at the baseline and four months later for the waiting list group. Encounters were audiotaped and transcribed. Transcripts were analyzed with content analysis software (LaComm) and by an independent rater. RESULTS: Eighty team members were included in the study. Compared to untrained team members, trained team members used more turns of speech with content oriented toward available resources in the team (relative rate [RR]=1.38; p=0.023), more assessment utterances (RR=1.69; p<0.001), more empathy (RR=4.05; p=0.037), more negotiation (RR=2.34; p=0.021) and more emotional words (RR=1.32; p=0.030), and their self-efficacy to communicate increased (p=0.024 and p=0.008, respectively). CONCLUSIONS: The training program was effective in improving team members' communication skills and their self-efficacy to communicate in the context of an encounter with a simulated patient. Future study should assess the effect of this training program on communication with actual patients and their satisfaction. Moreover a cost-benefit analysis is needed, before implementing such an intensive training program on a broader scale.

How much is residents' distress detection performance during a clinical round related to their characteristics?

OBJECTIVE: The aim of this study was to investigate residents' characteristics associated with their performance in detecting patients' distress (detection performance). METHODS: Residents' detection performance was assessed in a clinical round. A mean detection performance score was calculated for each resident by comparing residents' rating of patients' distress (VAS) with patients' reported distress (HADS). Residents' characteristics include general (socio-demographic, professional and psychological), detection (self-efficacy, attitudes and outcome expectancies) and performance characteristics (communication skills (LaComm), psychological arousal (STAI) and physiological arousal (heart rate and blood pressure) in a highly emotional and complex simulated interview task). RESULTS: Ninety-four residents and 442 inpatients were included. 30% of the variance in residents' detection performance was related to residents' performance characteristics: anxiety level (p=.040) and mean arterial blood pressure (p=.019) before the task; empathy (p=.027) and mean heart rate (p=.043) during the task; mean arterial blood pressure changes (p=.012) during the assessment procedure. CONCLUSION: Residents' detection performance is partly related to their performance characteristics. Psychological and physiological arousals are key characteristics--beside empathic skills--that need to be considered in models designed to determine detection performance. PRACTICE IMPLICATIONS: Future interventions designed to improve residents' detection performance should focus notably on their performance characteristics.

Transfer of communication skills to the workplace during clinical rounds: impact of a program for residents.

BACKGROUND AND PURPOSE: Communication with patients is a core clinical skill in medicine that can be acquired through communication skills training. Meanwhile, the importance of transfer of communication skills to the workplace has not been sufficiently studied. This study aims to assess the efficacy of a 40-hour training program designed to improve patients' satisfaction and residents' communication skills during their daily clinical rounds. METHODS: Residents were randomly assigned to the training program or to a waiting list. Patients' satisfaction was assessed with a visual analog scale after each visit. Transfer of residents' communication skills was assessed in audiotaped actual inpatient visits during a half-day clinical round. Transcripted audiotapes were analyzed using content analysis software (LaComm). Training effects were tested with Mann-Whitney tests and generalized linear Poisson regression models. RESULTS: Eighty-eight residents were included. First, patients interacting with trained residents reported a higher satisfaction with residents' communication (Median=92) compared to patients interacting with untrained residents (Median=88) (p=.046). Second, trained residents used more assessment utterances (Relative Risk (RR)=1.17; 95% Confidence intervals (95%CI)=1.02-1.34; p=.023). Third, transfer was also observed when residents' training attendance was considered: residents' use of assessment utterances (RR=1.01; 95%CI=1.01-1.02; p=.018) and supportive utterances (RR=0.99; 95%CI=0.98-1.00; p=.042) (respectively 1.15 (RR), 1.08-1.23 (95%CI), p<.001 for empathy and 0.95 (RR), 0.92-0.99 (95%CI), p=.012 for reassurance) was proportional to the number of hours of training attendance. CONCLUSION: The training program improved patients' satisfaction and allowed the transfer of residents' communication skills learning to the workplace. Transfer was directly related to training attendance but remained limited. Future studies should therefore focus on the improvement of the efficacy of communication skills training in order to ensure a more important training effect size on transfer.

Physicians are different when they learn communication skills: influence of the locus of control.

PURPOSE: Although it is widely recognised that educational interventions may be more effective for people with an 'internal' Locus of Control (who believe that life outcomes are controlled by their own characteristics or actions) compared to people with an 'external' Locus of Control (who believe that life outcomes are controlled by external forces such as luck, fate or others), no study has yet assessed the influence of physicians' Locus of Control (LOC) on communication skills learning. This study aims to test the hypothesis that, in a communication skills training program, physicians with an 'internal' LOC would demonstrate communication skills acquisition to a greater degree than those with an 'external' LOC. METHODS: A non-randomised longitudinal intervention study was conducted between January 1999 and April 2001. Sixty-seven volunteer physicians from private and institutional practice in Belgium participated in a learner-centred, skills-focused, practice-oriented communication skills training program. Communication skills changes were assessed in 2 standardised simulated interviews before and after training (one two-person and one three-person interview). Communication skills were assessed using the Cancer Research Campaign Workshop Evaluation Manual. Physicians' LOC was assessed using the Rotter I-E scale. Communication skills changes of the upper and lower third of physicians in respect of their scores on this scale were compared using group by time repeated measures of variance. RESULTS: In the two-person and three-person interviews, changes in the use of open directive questions were more important among physicians with an "internal" LOC compared with changes observed among physicians with an 'external' LOC (P=0.066 and P=0.004, respectively). In the three-person interview, changes in the use of directive questions, assessing functions and moderate feelings stated explicitly were more important among physicians with an 'internal' LOC compared with changes observed among physicians with an 'external' LOC (P= 0.001; P=0.002 and P=0.011 respectively). CONCLUSION: This study shows that physicians' LOC is a psychological characteristic that could influence the efficacy of a communication skills training program. This evidence supports the idea that a psychological characteristic such as 'internal' LOC may facilitate communication skills acquisition through physicians' belief that communication with patients may be controlled by physicians themselves.

Does psychological characteristic influence physicians' communication styles? Impact of physicians' locus of control on interviews with a cancer patient and a relative.

CONTEXT: Physicians' psychological characteristics may influence their communication styles and may thus interfere with patient-centred communication. OBJECTIVE: Our aim was to test the hypothesis that, in interviews with a cancer patient and a relative, physicians with an "external" locus of control (LOC; who believe that life outcomes are controlled by external forces such as luck, fate or others) have a communication style different from that of physicians with an "internal" LOC (who believe that life outcomes are controlled by their own characteristics or actions). DESIGN, SETTING, PARTICIPANTS AND INTERVENTION: Eighty-one voluntary physicians practising in the field of oncology were recorded while performing an actual and a simulated interview with a cancer patient and a relative. MAIN OUTCOME MEASURES: Physicians' communication skills were assessed using the Cancer Research Campaign Workshop Evaluation Manual. Physicians' LOC was assessed using the Rotter I-E scale. The communication skills of the upper and lower quartiles of physicians in respect of their scores on this scale were compared using Student's t test. RESULTS: In actual interviews, physicians with an "external" LOC talked more to the relative (P=0.017) and used more utterances with an assessment function (P=0.010) than physicians with an "internal" LOC. In simulated interviews, physicians with an "external" LOC used less utterances that give premature information (P=0.031) and used more utterances with a supportive function, such as empathy and reassurance (P=0.029), than physicians with an "internal" LOC. CONCLUSION: These results provide evidence that physicians' LOC can influence their communication styles. Physicians' awareness of this influence constitutes a step towards a tailoring of their communication skills to every patient's and relative's concerns and needs and thus towards a patient-centred communication.

Teaching communication and stress management skills to junior physicians dealing with cancer patients: a Belgian Interuniversity Curriculum.

BACKGROUND: Ineffective physicians' communication skills have detrimental consequences for patients and their relatives, such as insufficient detection of psychological disturbances, dissatisfaction with care, poor compliance, and increased risks of litigation for malpractice. These ineffective communication skills also contribute to everyday stress, lack of job satisfaction, and burnout among physicians. Literature shows that communication skills training programs may significantly improve physicians' key communication skills, contributing to improvements in patients' satisfaction with care and physicians' professional satisfaction. This paper describes a Belgian Interuniversity Curriculum (BIC) theoretical roots, principles, and techniques developed for junior physicians specializing in various disciplines dealing with cancer patients. CURRICULUM DESCRIPTION: The 40-h training focuses on two domains: stress management skills and communication skills with cancer patients and their relatives. The teaching method is learner-centered and includes a cognitive, behavioral, and affective approach. The cognitive approach aims to improve physicians' knowledge and skills on the two domains cited. The behavioral approach offers learners the opportunity to practice these appropriate skills through practical exercises and role plays. The affective approach allows participants to express attitudes and feelings that communicating about difficult issues evoke. Such an intensive course seems to be necessary to facilitate the transfer of learned skills in clinical practice. CONCLUSIONS: The BIC is the first attempt to bring together a stress management training course and a communication training course that could lead not only to communication skills improvements but also to burnout prevention.

Factors that influence physicians' detection of distress in patients with cancer: can a communication skills training program improve physicians' detection?

BACKGROUND: No study to date has assessed the impact of skills acquisition after a communication skills training program on physicians' ability to detect distress in patients with cancer. METHODS: First, the authors used a randomized design to assess the impact, on physicians' ability to detect patients' distress, of a 1-hour theoretical information course followed by 2 communication skills training programs: a 2.5-day basic training program and the same training program consolidated by 6 3-hour consolidation workshops. Then, contextual, patient, and communication variables or factors associated with physicians' detection of patients' distress were investigated. After they attended the basic communication skills training program, physicians were assigned randomly to consolidation workshops or to a waiting list. Interviews with a cancer patient were recorded before training, after consolidation workshops for the group that attended consolidation workshops, and approximately 5 months after basic training for the group that attended basic training without the consolidation workshops. Patient distress was recorded with the Hospital Anxiety and Depression Scale before the interviews. Physicians rated their patients' distress on a visual analog scale after the interviews. Physicians' ability to detect patients' distress was measured through computing differences between physicians' ratings of patients' distress and patients' self-reported distress. Communication skills were analyzed according to the Cancer Research Campaign Workshop Evaluation Manual. RESULTS: Fifty-eight physicians were evaluable. Repeated-measures analysis of variance showed no statistically significant changes over time and between groups in physicians' ability to assess patient distress. Mixed-effects modeling showed that physicians' detection of patients' distress was associated negatively with patients' educational level (P = 0.042) and with patients' self-reported distress (P < 0.000). Mixed-effects modeling also showed that physicians' detection of patient distress was associated positively with physicians breaking bad news (P = 0.022) and using assessment skills (P = 0.015) and supportive skills (P = 0.045). CONCLUSIONS: Contrary to what was expected, no change was observed in physicians' ability to detect distress in patients with cancer after a communication skills training programs, regardless of whether physicians attended the basic training program or the basic training program followed by the consolidation workshops. The results indicated a need for further improvements in physicians' detection skills through specific training modules, including theoretical information about factors that interfere with physicians' detection and through role-playing exercises that focus on assessment and supportive skills that facilitate detection.

Physicians' communication with a cancer patient and a relative: a randomized study assessing the efficacy of consolidation workshops.

BACKGROUND: Although patients with cancer are often accompanied by a relative during medical interviews, to the authors' knowledge little is known regarding the efficacy of communication skills training programs on physicians' communication skills in this context. The objective of the current study was to assess the efficacy of 6 consolidation workshops, 3 hours in length, that were conducted after a 2.5-day basic training program. METHODS: After attending the basic training program, physicians were assigned randomly to consolidation workshops or to a waiting list. Training efficacy was assessed through simulated and actual interviews that were recorded on an audio tape at baseline, after consolidation workshops for the consolidation-workshops group, and 5 months after the end of basic training for the waiting-list group. Communication skills were assessed according to the Cancer Research Campaign Workshop Evaluation Manual. Patients' and relatives' perceptions of and satisfaction with physicians' communication performance were assessed using a 15-item questionnaire. RESULTS: Sixty-two physicians completed the training program. Compared with physicians who participated to the basic training program, when addressing the patient, physicians who were randomized to the consolidation workshops used more open, open directive, and screening questions (P = 0.011 in simulated patient interviews and P = 0.005 in actual patient interviews) and elicited and clarified psychologic concerns more often (P = 0.006 in simulated patient interviews and P < 0.001 in actual patient interviews). When they addressed the relative, physicians who were randomized to the consolidation workshops gave less premature information (P = 0.032 in simulated patient interviews and P < 0.001 in actual patient interviews). When they addressed the patient and the relative simultaneously, physicians who were randomized to the consolidation workshops used more empathy, educated guesses, alerting to reality, confronting, negotiating, and summarizing (P = 0.003 in simulated patient interviews and P = 0.024 in actual patient interviews). Patients, but not relatives, who interacted with physicians in the consolidation-workshops group were more satisfied globally with the interviews (P = 0.022). CONCLUSIONS: Six 3-hour consolidation workshops resulted in improved communication skills addressed to patients and to relatives. The current results showed that the transfer of skills addressing relatives' concerns remained limited and that consolidation workshops should focus even more systematically on the practice of three-person interviews.