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Patient Education and Counseling 58 (2005) 1–3

Editorial

Commentary on enhancing clinician communication

skills in a large healthcare organisation

Barry Lewis *

Department of Postgraduate Medicine and Dentistry, GP Division, Floor 4, Barlow House Minshull St., Manchester M1 3DZ, UK

Received 5 April 2005; received in revised form 3 May 2005; accepted 8 May 2005

Fig. 1. Reproduced from Ref. [2] with permission.

1. Introduction

The paper by Stein et al. [1] contains important lessons for

other healthcare organisations on the development and im-

plementation of a teaching programme to improve clinician–

patient communication. The development is based on sound

educational principles although these are not overtly ex-

pressed in the paper. Implementation uses a ‘top down’

cascade and faculty development that could form the basis of

an integrated approach to teaching a skill set required across

medical specialities.

The paper, therefore, is significant:

- f

*

07

do

or the demonstration that the systematic delivery of

communication skills teaching is possible in a post-

graduate medical education setting;

- f

or the demonstration of an organisation’s ability to

develop a theoretical model on current evidence, apply the

model using teaching faculty from within the organisation

and evaluate the outcome.

This latter cycle matches two essential models of

educational delivery often quoted in curriculum design:

Miller’s pyramid [2; see Fig. 1] of personal development

and Davis’s model [3] for sustaining changed behaviour.

Miller lays out the steps from pure, theoretical, knowl-

edge through skill acquisition and rehearsal to integration

into practice. It is the basis for course design by teaching

faculty that moves delivery from a lecture base to a method

involving skill demonstration, practice and feedback. Davis

describes the steps in delivery of education that lead to

Tel.: +44 161 234 6171.

E-mail address: barrylewis@doctors.org.uk.

38-3991/$ – see front matter # 2005 Published by Elsevier Ireland Ltd.

i:10.1016/j.pec.2005.05.001

sustained changes in behaviour. These steps move through

‘academic detail’—the delivery of theoretical information,

‘modelling’—the opportunity to witness and rehearse new

skills, ‘action’—considering then putting into place the new

skills and finally, ‘review’—where the effects of the

application of new skills can be considered and the

education cycle repeated.

In this commentary, I will expand on some aspects of the

Stein paper content and process that I feel have important

lessons for those tasked with delivering postgraduate

education (particularly within the UK) and for organisations

committed to ‘patient centeredness’ as a central plank of

delivery of care.

2. Academic detail—the evidence base and outcome

measures

The authors link their 4 Habits model to the physician

behaviours outlined in the Toronto and Kalamazoo

B. Lewis / Patient Education and Counseling 58 (2005) 1–32

Consensus statements [4]. The most recent, Kalamazoo,

outlines the essential elements of patient-centred consulting:

- b

uilding the doctor–patient relationship;

- o

pening the discussion;

- in

formation gathering;

- u

nderstanding the patient’s perspective;

- s

haring information;

- r

eaching agreement on the problems and plans;

- p

roviding ‘closure’ of the consultation.

These principles are incorporated into teaching and

analysis models internationally. The Undergraduate Medical

Education for the 21st Century (UME-21) [5] medical

schools project has the Kalamazoo consensus as the

‘essential skills’ spine of its teaching curriculum. In the

United Kingdom, the Calgary–Cambridge model [6] has

been adopted at undergraduate and postgraduate level as it

has a patient-centred consulting philosophy and teaching

format. The consulting skills end point examinations

(MRCGP/Summative Assessment) for UK GPs (Primary

Care Physicians) have developed their performance criteria

from the same core principles.

The ‘challenge’ to the evidence of effectiveness of the

patient-centered approach has been raised by Mead and

Bower [7] who have dissected the evidence base for ‘patient-

centred’ consulting in terms of patient outcomes. They have

found a ‘suggestive relationship’ of benefit to patients but

state clearly that the case needs to be made definitively. The

Permanente Medical Group method, using patient satisfac-

tion, is an important outcome measure. The paper does not

share with us the format or content of the patient satisfaction

questionnaire. Those of us in the UK using the GPAS [8]

(satisfaction survey) in Primary Care know how ‘tolerant’

our patients are. What patient satisfaction outcome measures

fail to consider are the outcome measures from a learner or

teacher perspective, in particular, both specific skill

acquisition and application and ‘transferability’ of skills.

There are also other influences on patient satisfaction

beyond the skills and behaviours of the physician. Context,

defined as the medical, structural and societal setting for the

consultation, is of increasing importance in all healthcare

consultations. Patient expectations of health related inter-

actions have changed over the last 10–20 years and continue

to evolve. We are all aware of the increased vocalisation of

concerns and expectations along with, for a subsection of our

populations, increased ‘prior knowledge’ gained from

internet and media sources. This effect is seen across age

groups and has been researched in detail by Tates et al. [9]

who has observed this effect in children and adolescents.

The question raised, therefore, is—how much of the

improved patient satisfaction relates to skill acquisition

and application and how much to these factors combined

with changes in healthcare setting and increased active

involvement by the patient out-with physician encourage-

ment? A difficult question to answer but potentially

important to educationalists charged with changing beha-

viours and managers required to improve patient satisfac-

tion.

3. Faculty development—delivering the educational

intervention

An effective teaching faculty needs to be well versed in

the model being used, able to identify teaching areas and

opportunities, deliver teaching in a learner-centred facil-

itative format and encourage participants to audit skill

development for further improvement. Buyk and Lang [10]

have identified variation in the recognition of teaching

possibilities and variation in the prioritisation of the issues to

teach on in undergraduates. This is in the setting of a faculty

developed to teach communication skills in a longitudinal

programme with active student feedback [11]. Faculty

development and the development of improved, practical,

teaching tools were amongst the recommendations of Haq

and Steele [12] in their review of UME-21 project. Much of

the work around faculty development relates to the

undergraduate curriculum where there is, usually, unifor-

mity of purpose and committed recipients. Applying similar

models in the postgraduate setting is subject to the

confounding factors of service delivery, patient expectations

of outcomes and the relative autonomy of the ‘older,

clinically experienced, learner’.

In the UK, ‘faculty’ is most highly developed in the GP

training system. Here a cohort of one-to-one trainers

provides both employment (the trainee is employed by the

training practice) and educational supervision for the

trainees in their final year of training for independent

General Practice. Most of these teachers have had structured

teaching in consultation analysis, feedback and skill

development. Within UK Secondary Care, there is little

experience of this type of educational delivery, limited

mainly to the fields of Psychiatry and Palliative Care.

Despite this, the specialist examinations for Physicians and

Surgeons now have OSCE stations designed to examine the

candidate’s communication skills. Clearly, the inclusion of

this type of examination will drive, along with the new

curriculum for Foundation training, an increase in commu-

nication skills teaching at postgraduate level. The Perma-

nente Medical Group has shown the benefits of cross

speciality communication skills teaching, current changes in

the organisation and delivery of healthcare in the UK may

lead to development of similar models in the near future.

Delivery of teaching, by the TPMG faculty, mainly uses

small group techniques well established in medical

education. Other methods of delivery are being developed.

Roter and Larrson [13] describe a process of skill

recognition based on video, personalised feedback and re-

analysis added to academic detailing in small groups.

Lewis and Bailey [14] describe the application of a

specific topic teaching pack containing academic detail,

B. Lewis / Patient Education and Counseling 58 (2005) 1–3 3

modelling and analysis tools cascaded through ‘generic’ GP

teachers. Both of these methods demonstrate their ability to

encourage and achieve behaviour change, little evidence is

available on sustained change of behaviour as the teaching

intervention recedes.

Whatever method of dissemination is to be employed,

there is no doubt that larger numbers of teachers need to be

developed to deliver communication skills training than

currently exist within broader teaching faculties. These

teachers will need teaching materials that are consistent in

content, valid in terms of the models proposed and analysis

techniques to be used and, above all else, suitable for use in a

postgraduate setting. The use of generic teaching packs has

not, previously, been successful. The reasons for this are

various [15], above all else, they are perceived as challenging

the primacy of the local tutor in developing and delivering

teaching by ‘imposing’ uniformity. If we are to achieve some

uniformity of postgraduate teaching in this topic area

agreement of the content at national level then training of

faculty in the use of the materials is a vital first step.

Teaching packs can form both a basis for the introduction

of communication skills teaching and, beyond this, more

specialised interventions on a one to one basis using video,

audiotape or computer based feedback that would require a

learner’s engagement with clinicians experienced in teach-

ing communication skills. The latter require different,

possibly ‘higher’ skills, and require more in depth faculty

development programmes. Stein and colleagues have

demonstrated their ability to achieve both facets—a

structured introduction to the topic and detailed individual

work where requested or required, which leads to the final

area for comment.

4. Organisational implementation

The commitment to introducing communication skills

teaching by TPMG was based on assessing patient

satisfaction and the expressed dissatisfaction of the

clinicians in specific types of encounter. The integrated

nature of the organisation allowed cross speciality teaching

on a common theme. The appointment of a single Director of

clinician–patient communication for a region allowed

leadership, advocacy, faculty development, program design

and research. It also gave a high profile and ‘respect’ to the

process. Integration of health services is currently an

important topic for debate within the NHS [16], this paper

allows us to see how, within an NHS Health Economy (the

‘virtual’ organisation combining health and social care to a

defined population), an educational initiative with positive

patient outcomes could be used as a template for cross

speciality/cross organisation collaborative working whilst

building on the baseline communication skills developed at

undergraduate level. The Curriculum for the Foundation

Years of Postgraduate medical training [17] has commu-

nication skills as a ‘core skills’ section, perhaps this is the

window of opportunity within UK postgraduate medical

education to apply some of the lessons from TPMG

experience (Fig. 1).

Reference

[1] Stein T, Frankel R, Krupat P. Enhancing Clinician Communication

Skills in a large Healthcare Organisation. Patient Educ Counsel

2005;58:4.

[2] Miller G. A model for developing competence. Acad Med 1990;65.

[3] Davis. et al. CME review, changing physician behaviour. JAMA 1995.

[4] Kalamazoo Consensus. Essential Elements of Communication in

medical encounters. Acad. Med. 2001; 76.

[5] Haq C, Steele J, et al. Integrating the art and science of medical

practice, innovations in teaching medical communication skills. Fam

Med 2004;36.

[6] Kurtz S, Silverman J, Draper J. Teaching and learning communication

skills in medicine. Radcliffe Medical Press; 2004.

[7] Mead N, Bower P. Patient centred consultations in primary care, a

review of the literature. Patient Educ Counsel 2002;48:51–61.

[8] Ramsey J, Campbell J, Schroter S, Green J, Roland M. The General

Practice Assessment Survey (GPAS): tests of data quality and mea-

surement. Fam Pract 2000;17:372–9.

[9] Tates K, Meeuwesen L, Elbers E, Bensing J. I’ve come for his throat;

roles and identities in doctor–parent–child communication. Child Care

Health Dev 2002;28:109–16.

[10] Buyk D, Lang F. Teaching medical communication skills: a call for

greater uniformity. Fam Med 2002;34.

[11] Lang F, Everett K, et al. Faculty development in communication skills

instruction. Acad Med 2000;75.

[12] Haq C, Steele J, et al. Integrating the Art and Science of Medical

Practice, Innovations in teaching medical communication skills. Fam

Med 2004;36.

[13] Roter D, Larrson S, et al. Use of an innovative video feedback

technique to enhance communication skills teaching. Med Educ

2004;38.

[14] Lewis B, Bailey JS. Can generic teachers use a standardised teaching

CD-Rom to analyse and teach communication skills in triadic con-

sultations? (In peer review stage).

[15] Singleton A, Smith F, Lewis B. The use of education packs and barriers

to implementation by course organisers in UK GP training—report of

the RCGP Mental Health Fellowship, 1996.

[16] Feachem RC, Sekhri NK. US and UK healthcare; a special relation-

ship? moving towards true integration. BMJ 2005;330:787–8.

[17] Curriculum for the foundation years in postgraduate education and

training. Academy of Royal Colleges with Modernising Medical

Careers in the Department of Health UK; March 2005.