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From the Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry (C.J.W.), and Centre for Studies in Family Medicine (J.B.B.), University of Western Ontario, London, Ontario, Canada.
Address correspondence and reprint requests to Dr. Christopher J. Watling, Department of Clinical Neurological Sciences, London Health Sciences Centre–Victoria Hospital, Room C3-302, 800 Commissioners Road East, London, Ontario, Canada N6A 5W9 chris.watling{at}lhsc.on.ca
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Abstract. |
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 Top. Abstract. METHODSRESULTSDISCUSSIONAppendix 1REFERENCES |
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Methods: A group of 12 neurology residents participated in a series of six case-based communication skills workshops. Each workshop focused on a particular clinical scenario, including breaking bad news, discussing do-not-resuscitate orders, communicating with "difficult" patients, disclosing medical errors, obtaining informed consent for neurologic tests and procedures, and discussing life-and-death decisions with families of critically ill patients. Residents also kept reflective portfolios in which real examples of these interactions were recorded.
Results: The program was well accepted, and residents rated the workshops as effective and relevant to their practice. Analysis of residents’ portfolios revealed three themes relevant to patient–physician communication: 1) communication is more successful when adequate time is allowed, 2) the ability to empathize with patients and their families is essential to successful interactions, and 3) the development of specific approaches to challenging scenarios can facilitate effective interactions. The portfolios also demonstrated that residents would engage in reflective practice.
Conclusions: Targeting of communication skills training around specific clinical scenarios using neurologic cases was well accepted and was deemed relevant to practice. The use of portfolios may promote lifelong learning in this area.
Abbreviations: ALS = amyotrophic lateral sclerosis; DNR = do-not-resuscitate; ER = emergency room; ICU = intensive care unit; MS = multiple sclerosis; tPA = tissue plasminogen activator.
Time and experience alone often fail to produce improvements in physicians’ communication skills,6–8 but there is compelling evidence for a positive effect of communication skills training.9 Residency programs should therefore develop specific educational interventions that address communication skills.
The practicing neurologist must be able to rely on a repertoire of communication skills to facilitate effective, patient-centered care. To date, the area of communication skills training has been largely neglected in the neurologic literature.10 The objectives of this pilot project were to develop a communication skills training program specifically for neurology residents, directed at some of the most challenging clinical scenarios that they will face in practice, and to foster reflective practice as a tool for enhancement of communication skills.
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METHODS |
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Top.Abstract.METHODSRESULTSDISCUSSIONAppendix 1REFERENCES |
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Educational intervention. Residents participated in a series of six 2-hour workshops over the course of a single academic year. Each workshop focused on a specific clinical scenario of particular relevance to neurologic practice. Workshop topics were as follows: 1) breaking bad news, 2) discussing do-not-resuscitate orders, 3) communicating with "difficult" patients or family members, 4) obtaining informed consent for neurologic tests, procedures, or therapies, 5) communicating with families around life-and-death decision making for patients with critical illness, and 6) disclosing medical errors.
All workshops followed a four-part format. Part 1 was a video clip chosen to trigger discussion on the workshop topic. Part 2 was a facilitated discussion among the residents, providing them with an opportunity to discuss with peers their experiences in the topic area of the workshop. Part 3 was a didactic session that reviewed the literature and the relevant ethical and medicolegal principles guiding patient–physician communication in the scenario being covered, and provided strategies for effective communication. Part 4 involved role-play exercises with peers or standardized patients using neurology cases relevant to the workshop topic. These role-plays allowed residents to practice the communication techniques discussed in the workshop and receive immediate feedback from peers, workshop facilitators, and standardized patients.
Further detail regarding course content is contained in appendix 1.
Program evaluation. Before the first workshop, residents completed a survey that assessed their level of prior training in each of the six scenarios targeted by the workshops. The survey also asked how stressful these scenarios were for them and how effective they usually felt in their communications with patients or their families on these topics. After all six workshops, residents completed a postcourse survey where they again rated the stressfulness of the scenarios and their self-perceived effectiveness when faced with these scenarios in practice. The precourse and postcourse surveys were identical in format. Residents were presented with a series of statements such as "I find it stressful to give bad news to patients and their families" or "I am usually satisfied that I have been effective when breaking bad news" and were asked to respond as strongly agree, agree, disagree, or strongly disagree.
After each workshop, residents completed a short evaluation form on which they rated the effectiveness of the video trigger, the usefulness of the facilitated discussion, didactic, and role-play components of the workshop, their comfort with role-playing as a learning technique, and the relevance of the workshop to their practice. In addition, the postcourse survey asked residents to provide overall ratings of the enjoyability and relevance to practice of the course, as well as the effectiveness of the teaching methods used.
Two additional methods of evaluation were used in an attempt to determine the extent to which this educational program influenced real-life patient–resident communication. Each resident was provided with a portfolio in which they were asked to record examples of real clinical scenarios in each of the program’s six topic areas. Residents were asked to briefly describe the scenario without providing identifying data, to describe their own approach to communicating with the involved patient or family, and to reflect on how well the interaction went and how effective they were. Portfolios were collected by the investigators 1 month after the last workshop and were subjected to a content analysis to identify themes. The purpose of the portfolios was twofold. First, it was hoped the portfolios would provide a window on real-life patient–physician encounters and the extent to which residents were applying the techniques and skills from the workshops in their day-to-day practice. Second, the portfolios were intended as a tool to encourage reflection on the communication aspect of neurologic practice.
Residents were also provided with pocket-sized evaluation cards that they were encouraged to give to health professionals who had the opportunity to observe a discussion they had with a patient or family member relating to a topic covered by one of the workshops. Completed cards were then mailed directly to the principal investigator by the evaluator, whose name would not appear on the card. A copy of this evaluation card is provided in appendix 2.
Time and resources. Approximately 60 hours of the lead investigator’s time was required to create the six workshops. The workshops, totaling 12 hours, were slotted into the residents’ preexisting weekly academic half-day over the course of the year. Few additional resources were required for this program, apart from the purchase of notebooks for each resident to serve as portfolios and the copying of survey and evaluation forms.
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RESULTS |
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Top.Abstract.METHODSRESULTSDISCUSSIONAppendix 1REFERENCES |
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Residents’ evaluations of the program. Workshops were well attended, though not all residents attended all sessions because of scheduling conflicts. Residents participated actively in the discussion and role-play portions of each workshop. All residents who attended a session completed an evaluation form for that session, and results of these evaluations are summarized in table 2.
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Residents were also asked, in the postcourse survey, to provide feedback about the course as a whole. All 12 residents rated the course highly in terms of its enjoyability and effectiveness, and particularly in terms of its relevance to neurologic practice. Residents were split on the effectiveness of role-playing as a tool for practicing communication skills, with three-fourths of residents rating the technique effective and one-fourth rating it ineffective. Of the 10 residents responding to the question "Do you prefer role-playing with colleagues or with standardized patients?" 9 favored standardized patients. All 12 residents thought that the program should be offered again.
Observations of residents’ communication skills in practice. Twelve evaluation cards from observers were received. Evaluators included three nurses, five nurse practitioners, and three social workers. Only 5 of the 12 residents submitted evaluation cards. A numbering system was used to track how many different residents participated in providing evaluation cards to observers without revealing the identity of the residents to the investigators. Observed scenarios included two examples of do-not-resuscitate discussions, one example of obtaining informed consent, three examples of breaking bad news, five examples of discussions around life-and-death decision making for critically ill patients, and one example of an interaction with a difficult patient and family. In all instances, observers gave high scores to residents in all categories, but these evaluations likely reflect a highly selected sample.
Analysis of portfolios. All but one resident returned their portfolio to the investigators. Two of the 11 portfolios contained no entries. The 9 other residents described between 3 and 7 scenarios each, and a total of 36 different communication interactions were described in this format. Of these, 25 occurred after the relevant workshop, 6 occurred before the relevant workshop, and in 5 the timing was not specified. The key themes that emerged from analysis of the portfolios are summarized in table 3.
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DISCUSSION |
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Residents did not find, after completing this program, that their interactions with patients and their families around difficult issues were less stressful. On the contrary, residents came to view certain scenarios, namely breaking bad news and meeting with families of critically ill patients to make care decisions, as more stressful. It may be that the workshops forced residents to reflect on the complexity of these challenging scenarios, permitting new insight into just how difficult effective patient–physician communication can be. If this explanation is accurate, we view this effect of the program as a positive one. The aim is less to make difficult situations less stressful and more to help residents become competent and effective in navigating these stressful interactions.
Role-playing may be a useful tool in communication skills training because it promotes active rather than passive learning, allows participants to experience the perspective of both physician and patient, and permits participants to practice approaches and responses in a safe environment with immediate feedback.12 Although learner dislike of the technique has been cited as a challenge in the successful incorporation of role-playing into skill development programs,13,14 the majority of residents participating in this program embraced role-playing as a method of practicing communication skills. A minority of residents neither enjoyed the technique nor thought that it was an effective learning tool. Although resident discomfort with this method may not imply that it was unhelpful, it does highlight the difficulty in gaining unanimous learner acceptance of new teaching methods. Because it requires a significant investment of time and effort to create effective and challenging role-play scenarios and to engage learners in the process, it would be important for future work to determine whether this technique is sufficiently effective in improving communication skills to justify these efforts.
The use of portfolios is gaining acceptance as a method of assessing the achievement of core competencies by medical students and residents. Portfolios also promote reflective practice, which may be important in directing successful lifelong learning strategies.15 Here, the portfolios offered limited insight into the effect of the program, though we believe that the potential exists for portfolios to be quite powerful in this regard. For portfolios to become more helpful in measuring behavior change, greater efforts would be required to achieve consistent compliance with portfolio-keeping, with particular attention to the recording of entries both before and after communication skills training.
The portfolios did demonstrate, however, that most residents would engage in reflective practice. Many of the portfolio entries provided evidence of residents critically assessing their own approaches to challenging communication scenarios. A key aspect of residency training is the development of skills of lifelong learning and self-assessment, and for this purpose even a simple portfolio such as the one used in this project can be a valuable tool.
Encouraging compliance with portfolio-keeping is challenging, however, as evidenced by the fact that some residents did not record even a single interaction over the course of the year. The successful use of portfolios requires new skills and a "cultural transformation."15 Given the time investment required of both residents and educators to incorporate portfolios into residency education, future work will need to address whether the promotion of reflective practice regarding patient–physician interactions really leads to durable improvements in skill, and on whether the use of portfolios is superior to other, less labor-intensive methods of encouraging reflection. The facilitated discussion portion of each workshop in this program, for example, provided another opportunity for reflection, and by encouraging each resident to bring to the discussion a critical appraisal of one of their own recent interactions, one might achieve a similar level of self-reflection without the effort required to create compliance with portfolios.
There were several key lessons learned from this project. First, neurology residents embraced the devotion of valuable time and effort to the development of better communication skills, and most engaged in active reflection on their own communication interactions in practice. These observations are critical because the success of any such program depends on the willingness of the participants to learn and improve, and on their buying into the concept that communication is a learned skill and not simply a personality trait.16 Second, the targeting of communication skills training around specific scenarios using neurologically authentic cases was well accepted and was deemed highly relevant to clinical practice. Finally, the introduction of new educational tools, such as role-playing and portfolios, can be challenging and labor-intensive. With limited time and resources, it is critical that we choose our educational strategies wisely for maximum impact. Future research should therefore objectively examine which educational interventions are most effective in developing better communication skills for residents.
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Appendix 1 |
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Top.Abstract.METHODSRESULTSDISCUSSIONAppendix 1REFERENCES |
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Disclosure: The authors report no conflicts of interest.
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
