Domain of Competence: Interpersonal and Communication

SkillsBradley J. Benson, MD

From the Departments of Internal Medicine and Pediatrics, University of Minnesota Medical School, Minneapolis, MinnThe views expressed in this report are those of the authors and do not necessarily represent those of the Accreditation Council for GraduateMedical Education, the American Board of Pediatrics, the Association of Pediatric Program Directors, or the Academic Pediatric Association.The author declares that he has no conflict of interest.Publication of this article was supported by the American Board of Pediatrics Foundation and the Association of Pediatric Program Directors.Address correspondence to Bradley J. Benson, MD, Department of Internal Medicine and Pediatrics, University of Minnesota Medical School,MMC 741, D-653 Mayo Memorial Building, 420 Delaware St SE, Minneapolis, MN 55455 (e-mail: benso040@umn.edu).KEYWORDS: pediatrics; residency; graduate medical education;undergraduate medical education; competency based education;medical knowledge; interpersonal skills; communication skills

ACADEMIC PEDIATRICS 2014;14:S55S65INTERPERSONAL AND COMMUNICATION skills areseparate and distinct parts of this integrated competency.Communication skills are defined by the performance ofspecific tasks, which can be directly observed and assessed,such as obtaining and presenting a patients history ordocumenting an encounter in the medical record. Interper-sonal skills, however, are inherently relationship based andprocess oriented; they are defined by the effect the commu-nication has on another person.1 For example, a skilledpediatrician may inform a family of a diagnosis in amannerthat establishes a sense of trust that in turn promotes a strongphysicianfamily partnership in the childs care. Thus, thelikelihood of adherence to the recommended treatmentregimen and the patient and family satisfaction increases.

Together, interpersonal and communication skills arefoundational for successful physician practice in the 21stcentury. Ample evidence links best practices in physicianpatient communication with a lower risk of litigation, butthe more important truth is that better communication leadsto better health outcomes for patients.2,3 The stakes arealso high for medical educators and learners because aninterdependence exists between interpersonal and com-ACADEMIC PEDIATRICSCopyright 2014 by American Board of Pediatrics andAccreditation Council for Graduate Medical Association

S55munication skills and assessment of the other competencydomains. For example, a learner with novice oralpresentation skills and an uncomfortable manner may notaccurately represent his medical knowledge or patient careskills in a case presentation on rounds. In putting togetherthis supplement, the Pediatrics Milestone Working Grouptook the opportunity to model the critical need foraccuracy and understanding in all forms of communicationby rethinking each behavioral narrative described in themilestones and editing as needed to enhance clarity.REFERENCES1. Duffy FD, Gordon GH, Whelan G, et al. Participants in the American

Academy on Physician and Patients Conference on Education and

Evaluation of Competence in Communication and Interpersonal Skills.

Assessing competence in communication and interpersonal skills: the

Kalamazoo II report. Acad Med. 2004;79:495507.

2. Stewart M. Effective physicianpatient communication and health

outcomes: a review. Can Med Assoc J. 1995;152:14231433.

3. Levinson W, Roter DL, Mullooly JP, et al. Physicianpatient commu-

nication. The relationship with malpractice claims among primary care

physicians and surgeons. JAMA. 1997;277:553559.Competency 1. Communicate effectively with patients, families, and the public, as appropriate,across a broad range of socioeconomic and cultural backgrounds

Bradley Benson, MD

BACKGROUND: The ability to communicate effectively with has been the cornerstone of teaching this domain in medi-

patients, families, and the public is a critical skill for themed-ical professional and has been directly related to the out-comes of clinical care.1 The importance of this is reflectedin the medical education literature in consensus statementson essential elements of communication,2,3 in guidelinesfor medical school curriculum development,4,5 and throughincreased emphasis placed on communication skills byprofessional practiceorganizations and accrediting bodies.6,7

The task approach is useful in conceptualizing the skillsneeded for effective physicianpatient communication andcal education. The Kalamazoo Consensus Statement3

clearly summarizes these essential communication tasks.The simplified list is as follows: 1) build the doctorpatientrelationship, 2) open the discussion, 3) gather information,4) understand the patients perspective, 5) share informa-tion, 6) reach agreement on problems and plans, and 7)provide closure. Multiple other models of effectivecommunication have been proposed; however, the essentialelements are similar to those above, and multiple validatedtools are available to assess learners competence in theseVolume 14, Number 2SMarchApril 2014

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S56 INTERPERSONAL AND COMMUNICATION SKILLS ACADEMIC PEDIATRICStasks.8 While the literature on how medical learnersdevelop this competence is limited, there is a large bodyof literature in other fields (particularly education) that in-forms the developmental progression proposed below.911

EARLY PHYSICIANPATIENT COMMUNICATION COMPE-TENCE: Early communication by the novice learner is pred-icated on the use of externally provided scripts or templates.During the interactions, the learner is focused as much onremembering the next question as on the responses of theinterviewee. The ability to tailor the scripts to patients ofdifferent socioeconomic and cultural backgrounds is limited.INTERMEDIATE PHYSICIANPATIENT COMMUNICATIONCOMPETENCE: As the templates become habit, the learneris freed in communication both to be more attentive as alistener and to reflect on barriers (physical, cultural, psy-chological, and social) to the communication. During thisstage of development, however, the learner has little expe-rience to draw from to mitigate these barriers. As experi-ence accrues and is reflected upon, the learner can bothidentify and mitigate barriers to communication undermost normal circumstances. When communication doesnot go well or a new circumstance is encountered, thecompetent communicator reflects on the experience andapplies lessons learned to future communication.ADVANCED PHYSICIANPATIENT COMMUNICATION COMPE-TENCE: Progression through the proficient and expertstages of communication involves appropriate responsive-ness to an ever-expanding set of circumstances that elicitsdeviations from traditional scripts in order to optimize theencounter and establish/maintain rapport. The mastercommunicator demonstrates continuous assessment ofthe interaction and intuitively extrapolates from previousexperience to meet the needs of the patient, family, or pub-lic in the communication. This individual can adjust to anycircumstance, even when engaged in crucial or difficultconversations and even when a similar experience hasnot been encountered in the past.DEVELOPMENTAL MILESTONES:

Uses standard medical interview template to prompt all questionswithout varying the approach based on a patients unique physical,cultural, socioeconomic, or situational needs. May be tentative oravoid asking personal questions of patients.

Uses the medical interview to establish rapport and focus oninformation exchange relevant to a patients or familys primaryconcerns. Identifies physical, cultural, psychological, and socialbarriers to communication, but often has difficulty managing them.Begins to use nonjudgmental questioning scripts in response tosensitive situations. Uses the interview to effectively establish rapport. Able to mitigatephysical, cultural, psychological, and social barriers in mostsituations. Verbal and nonverbal communication skills promotetrust, respect, and understanding. Develops scripts to approachmost difficult communication scenarios.

Uses communication to establish and maintain a therapeuticalliance. Sees beyond stereotypes and works to tailorcommunication to the individual. Has developed scripts for thegamut of difficult communication scenarios. Able to adjust scriptsad hoc for specific encounters.

Interacts with patients and families in an authentic manner thatfosters a trusting and loyal relationship. Effectively educatespatients, families, and the public as part of all communication.Models how to manage the gamut of difficult communicationscenarios with grace and humility.

REFERENCES1. Stewart M. Effective physicianpatient communication and health

outcomes: a review. Can Med Assoc J. 1995;152159.

2. Simpson M, Buckman R, Stewart M, et al. Doctorpatient commu-

nication: the Toronto consensus statement. BMJ. 1991;303:

13851387.

3. Participants in the Bayer-Fetzer Conference on PhysicianPatient

Communication in Med Educ. Essential elements of communication

in medical encounters: the Kalamazoo consensus statement. Acad

Med. 2001;76:390393.

4. Association of American Medical Colleges. Medical School Objec-

tives Project, Report III. Contemporary Issues in Medicine: Commu-

nication in Medicine. Washington, DC: Association of American

Medical Colleges; 1999.

5. GeneralMedical Council. TomorrowsDoctors: Recommendations on

Undergraduate Med Educ. London, UK: General Medical Council;

1993.

6. Communications Self-Evaluation Process (COM-SEP) Committee.

Minutes. Philadelphia, Pa: American Board of Internal Medicine;

1999.

7. Tate P, Foulkes J, Neighbour R, et al. Assessing physicians interper-

sonal skills via videotaped encounters: a new approach for the Royal

College of General Practitioners membership examination. J Health

Commun. 1999;4:143152.

8. Schirmer JM, Mauksch L, Lang F, et al. Assessing communication

competence: a review of current tools. Fam Med. 2005;37:184192.

9. Blunck PM.ACommunication Competency Assessment Framework: A

Literature Review of Communication Competency and Assessment.

Portland, Ore: Northwest Regional Educational Lab; Washington,

DC:Office ofEducational Research and Improvement; 1997.Available

at: http://www.worldcat.org/title/communication-competency-assessment-

framework-a-literature-review-of-communication-competency-and-

assessment/oclc/39305340. Accessed September 13, 2013.

10. Dreyfus HL, Dreyfus SE.Mind Over Machine: The Power of Human

Intuition and Expertise in the Age of the Computer. Oxford, UK: Basil

Blackwell; 1986.

11. Bereiter C, ScardemaliaM. SurpassingOurselves: An Inquiry Into the

Nature and Implications of Expertise. Chicago, Ill: Open Court Pub-

lishing Company; 1993.Competency 2. Demonstrate the insight and understanding into emotion and human responseto emotion that allow one to appropriately develop and manage human interactions

Bradley Benson, MD

1BACKGROUND: The concept of emotional intelligence isa useful construct in elucidating the development ofinsight and understanding into emotion and humanresponse to emotion that allows one to appropriatelydevelop and manage human interactions. Emotional in-telligence is a set of 4 separate but related abilities:perceiving emotions, using emotions, understandingemotions, and managing emotions.2 Table 1 provides a

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Table 1. Description and Examples of the Abilities of Emotional Intelligence

Ability Narrative Description Example

Perceiving emotions Accurate identification of emotions inoneself and others.

A senior resident reads fear and anxiety in a mothers face and bodylanguage during a discussion of routine vaccinations.

Using emotions Knowledge of and experience withemotions informs and changesbehavior.

The above resident acts upon the discovery of the mothers emotionalnonverbal cues and queries for further information about herexperiences and fears related to vaccination.

Understanding emotions Ability to analyze emotions in oneself andothers and describe the connectionsbetween those feelings and theresultant behavior.

The above resident learns that the mothers nephew has beendiagnosed with autism and makes the connection between themothers anxiety and her fear of the MMR vaccine causing autism inher child.

Managing emotions Ability to consciously regulate emotionsin oneself and others.

The above resident is able to manage her own strong feelings about thevalue of vaccinations and counsel the parent in a caring andempathetic manner, allaying her fear.

ACADEMIC PEDIATRICS INTERPERSONAL AND COMMUNICATION SKILLS S57description of each with an example from graduate med-ical education.

This model assumes that these 4 abilities encompassskills that are distinct from personality traits and environ-mental factors andmay be developed and improved throughpractice.3 This is supported by observational reports acrossmultiple learner levels and training programs.4,5

In addition to emotional intelligence, the Dreyfus andDreyfus model, describing the developmental skill pro-gression from novice to master as it applies to medical ed-ucation, greatly informed the ontogeny of the milestones.6

DEVELOPMENTAL MILESTONES:

Does not demonstrate anticipation or reading of others emotions inverbal and nonverbal communication. Does not demonstrateawareness of ones own emotional and behavioral cues and maytransmit emotions in communication (eg, anxiety, exuberance, andanger) that can precipitate unintended emotional responses inothers. Does not manage strong emotions in oneself or others.

Begins to demonstrate use of past experiences to anticipate andread (in real time) the emotional responses in herself and othersacross a limited range of medical communication scenarios, butdoes not yet demonstrate the ability or insight to moderate behaviorto effectively manage the emotions. Strong emotions in oneself andothers may interfere with performance.

Demonstrates anticipation of, reads, and reacts to emotions in realtime with professional behavior in nearly all typical medicalcommunication scenarios, including those evoking very strongemotions. Demonstrates use of these abilities to gain and maintaintherapeutic alliances with others. Demonstrates perception, understanding, use, and management ofemotions in a broad range of medical communication scenariosand is able to verbalize lessons learned from new or unexpectedemotional experiences. Demonstrates effective management of herown emotions in all situations. Demonstrates effective andconsistent use of emotions to gain and maintain therapeuticalliances with others.

Demonstrates perception, understanding, use, andmanagement of emotions to improve the health and well-being of others and to foster therapeutic relationships in anyand all situations.REFERENCES1. Grewal D, Davidson H. Emotional intelligence and graduate medical

education. JAMA. 2008;300:12001203.

2. Mayer J, Salovey P. What is emotional intelligence?. In: Salovey P,

Sluyter D, eds. Emotional Development and Emotional Intelligence:

Implications for Educators. New York, NY: Basic Books; 2007:

331.

3. Murphy KR, ed. A Critique of Emotional Intelligence. Mahwah, NJ:

Lawrence Erlbaum Associates; 2006.

4. Evans BJ, Stanley RO, Mestrovic R, Rose L. Effects of communication

skills training on students diagnostic efficiency. Med Educ. 1991;25:

517526.

5. Brent DA. The residency as a developmental process. J Med Educ.

1981;56:417422.

6. Carraccio C, Benson B, Nixon J, Derstine P. From the educational

bench to the clinical bedside: translating the Dreyfus Development

Model to the learning of clinical skills. Acad Med. 2008;83:761767.Competency 3. Communicate effectively with physicians, other health professionals, andhealth-related agencies

Bradley Benson, MDBACKGROUND: Competence in interprofessional commu-nication is a critical skill that underlies effectiveness acrossthe scope of medical practice and is integrally linked withthe issues of patient safety and medical error.1 Researchinto how competency in this domain develops, however,is scarce and is limited by the complexity of medicalcommunication across different specialties, settings, andcontexts.COMMUNICATIVE COMPETENCE: A useful construct in un-derstanding the developmental progression of skills ininterprofessional communication is that of communicativecompetence.2 This model was originally described by DellHymes3 and has been built upon by a legion of subsequentscholars studying how learners acquire a second language.Canale and Swain4 described the 3 components of commu-nicative competence listed in Table 2, each of which may

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Table 2. Description and Examples of the Components of Communicative Competence

Communicative Competence

Component Narrative Description

Example in Medical Interprofessional

Communication

Grammatical competence Concerned with mastery of the language codeitself (ie, the words and the rules).

Medical terminology and jargon, order of presentation(ie, chief complaint before the history of presentillness and the physical examination before thelabs).

Sociolinguistic competence Concerned with appropriateness of the chosengrammar and syntax for the particular situationor context.

Use of jargon may be inappropriate for discussionwith nonphysician care team members.

Strategy competence Concerned with adoption of the appropriatecommunication strategy for the situation orcontext.

Appropriate choice of communication type (eg, alphatext page versus e-mail versus telephone versusface-to-face) or the strategy within a given type (eg,30-second synopsis versus 5-minute fullpresentation).

S58 INTERPERSONAL AND COMMUNICATION SKILLS ACADEMIC PEDIATRICSbe applied to communication in medicine, as noted in thethird column.MEDICINE AS A SECOND LANGUAGE: The literature sup-ports the comparison of learning medicalese and oral pre-sentation skills to the acquisition of a new language.5,6 Infact, the observational study by Haber and Lingard5 usingrhetorical analysis to study oral presentation skill develop-ment provides great insight into the early milestones.

Competent medical communication requires fluency inthe complex language of health care and in the ability toadapt the communication of a message to the context inwhich it is delivered. This context consists of the audience(eg, supervising resident, consulting attending, pharmacist,nurse), the purpose (ie, to tell a story or make a case), andthe occasion (eg, bedside rounds, phone consult request,transfer of care).EARLY DEVELOPMENT IN INTERPROFESSIONAL COMMUNI-CATION: Using the observations of Haber and Lingard,5

in the early stages learners describe and conduct presen-tations as a rigid, rules based, data storage activity gov-erned by order and structure. Data are presented in thesame order in which the questions were asked and oftendirectly from a written note. The presentation does notchange based on context, and the same summary is givento the resident, the attending, and the consultant. Thepresenter is often not aware of the social purpose ofthe presentation (eg, to obtain permission from the in-fectious diseases specialist for use of a restricted antibi-otic), but is more focused on clearly stating all of thefacts.INTERMEDIATE DEVELOPMENT IN INTERPROFESSIONALCOMMUNICATION: As learners progress, they begin to under-stand the different audiences and occasions and can tailortheir language and corresponding message accordingly.They also begin to see the purpose of the presentation andare able to either tell the story ormake the case appropriately.While in some situations they may still err on the side of in-clusion of excess details out of fear of causing harm, theybegin to shorten presentations to include just the pertinent in-formation. The intermediate developmental stage here alsoincludes the emerging focus on and understanding ofcommunication strategies to adapt to the context of thecommunication (eg, the use of an e-mail for a quick informa-tional exchange, with face-to-face time reserved for crucialconversations or critical feedback).ADVANCED DEVELOPMENT IN INTERPROFESSIONAL COMMU-NICATION: As interprofessional communication skillsbecome advanced, the learner naturally tailors the messageand communication strategy to the context to maximizeeffectiveness and efficiency. The concept of improvisationis helpful in understanding the nature and development ofthese skills. In the words of Haidet,7 Improvisation guidesa physicians process of making moment-to-momentcommunicative decisions (eg, what to say next, how tostructure particular questions, which threads to follow,when to interrupt and when to let the patient keep going).With regular exposure to new communication scenariosand ongoing reflection, improvisation skills continue toevolve and are a hallmark of the expert communicator.

DEVELOPMENTAL MILESTONES:

Recites facts according to a given set of rules or scripts, oftendirectly from a template or prompt. Does not adjust communicationon the basis of context, audience, or situation. Appears unaware ofthe social purpose of the communication.

Adjusts communication to better fit the context, audience, andsituation and can present without templates or prompts, but maystill err on the side of inclusion of excess detail.

Successfully tailors communication strategy and message to theaudience, purpose, and context in most situations. Demonstratesawareness of the purpose of the communication; can efficiently tella story and effectively make an argument. Beginning to improvise inunfamiliar situations.

Uses the communication strategy that aligns with the situation.Distills complex cases into succinct summaries tailored toaudience, purpose, and context. Can improvise and has expandedstrategies for dealing with difficult communication scenarios (eg, aninterprofessional conflict).

Improvises in new or difficult communication scenarios. Recognizedas a highly effective public speaker and a role model for themanagement of difficult conversations.

REFERENCES1. Varpio L, Hall P, Lingard L, Schryer CF. Interprofessional communica-

tion and medical error: a reframing of research questions and ap-

proaches. Acad Med. 2009;83(suppl):10.

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ACADEMIC PEDIATRICS INTERPERSONAL AND COMMUNICATION SKILLS S592. Gillotti C, Thompson T, McNeilis K. Communicative competence in

the delivery of bad news. Social Sci Med. 2002;54:10111023.

3. Hymes DH. On communicative competence. In: Pride JB, Holmes J,

eds. Sociolinguistics. Baltimore, Md: Penguin Education, Penguin

Books Ltd; 1972:269293.

4. CanaleM, SwainM. Theoretical bases of communicative approaches to

second language teaching and testing. Appl Linguistics. 1980;1:147.5. Haber R, Lingard L. Learning oral presentation skills: a rhetorical anal-

ysis with pedagogical and professional implications. J Gen Intern Med.

2001;16:308314.

6. Sobel RK.MSLmedicine as a second language.N Engl J Med. 2005;

35:19451946.

7. Haidet P. Jazz and the art of medicine: improvisation in the medical

encounter. Ann Fam Med. 2007;5:164169.Competency 4. Work effectively as a member or leader of a health care team or otherprofessional group

Bradley Benson, MDBACKGROUND: The importance of teamwork in medicineis clear from a growing body of literature linking theseskills to patient safety, satisfaction, and improved clinicaloutcomes.13 The relationship between teamwork andpatient safety and outcomes was highlighted in thelandmark Institute of Medicine publications To Err IsHuman4 and Crossing the Quality Chasm,5 with specificrecommendations for teaching and assessing these knowl-edge, skills, and attitudes across the continuum of medicaleducation and continuing professional development, withthe goal of ingraining this into the culture of our medicalinstitutions. In these publications, however, it is clear thata comprehensive theoretical model of team performancein medical settings has not yet been fully developed andvalidated, adding to the challenges in assessment, aseloquently stated by Baker et al6:

For teamwork skills to be assessed and have credibility,team performance measures must be grounded in teamtheory, account for individual and team-level perfor-mance, capture team process and outcomes, adhere tostandards for reliability and validity, and address realor perceived barriers to measurement.

The focus here will be on the individual competenciesthat a provider brings to a team in order to contribute toeffective team function. However, it is important toconsider that the development of these competencies isinfluenced by the individual competencies of other teammembers, competencies of the team as a unit, and compe-tencies of the organization as a whole.7

Before detailing the proposed milestones for the com-petency of interprofessional teamwork, we must beginwith an accepted definition of a team and a descriptionof the specific knowledge, skills, and attitudes thatcomprise teamwork. For the purposes of this work, ateam will be considered to be a group of 2 or more peo-ple with the following characteristics: specific roles,interdependent tasks, adaptability, and a shared commongoal.TEAMWORK-RELATED KNOWLEDGE: Cannon-Bowers andSalas7 describe multiple knowledge areas related to effec-tive team performance. Simply stated, to function effec-tively in a team, a team member must know what teamskills are required, what team behaviors are appropriate,and how to perform these skills and behaviors in a teamsetting. Team members must also know the teamsmission and goals as well as each others roles and re-sponsibilities in achieving them. This knowledge is thenused to determine the best strategies for interaction andcoordination among teammates to best achieve themission.TEAMWORK-RELATED SKILLS: The literature in this area isextensive and context specific, leading to amyriad of skill la-bels and definitions. A review of the teamwork literature in1995 identified over 130 terms to describe the various team-work skills.8 Much work has been done to distill these intogeneric skill sets required for effective performance on anyteam, independent of the context.9 The 4 key skills identifiedby Alonso and colleagues10 are leadership, mutual support,situation monitoring, and communication.11 These formthe basis of the Agency for Healthcare Research and Qualitysupported team training program, TeamSTEPPSTM, whichwas released to the public domain in 2006 and has been im-plemented at health care institutions across the nation andabroad.9 The outcomes of this program strengthen the argu-ment that these core skills are teachable and that improvedindividual performance positively impacts team outcomes.They are clearly interrelated, and improvements in onearea may lead to observable improvements in the others.The ontogeny of these 4 team skills is based on develop-mental models used throughout the milestones work and in-cludes the work of Dreyfus and Dreyfus,11 Monrouxe,12 andPangaro.13 The developmental progression of these skills isan area ripe for research.

TEAM COMMUNICATION

For the purposes of this competency, team communica-tion is defined as the initiation of a message by the sender,verification of receipt and acknowledgment of the messageby the receiver, and verification of the initial message bythe sender. The developmental progression for this skillgoes from unidirectional communication (ie, with a focuson sending or receiving a message only) to bidirectional in-formation exchange with verification of understanding byboth team members and commitment to the greater purposeof the communication. This skill is integral to effective pa-tient handoffs and is discussed in detail in related mile-stones. Using this example, the early learner would focuson the specific task of providing or receiving the sign-outdocument. The advanced learner would augment the written

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S60 INTERPERSONAL AND COMMUNICATION SKILLS ACADEMIC PEDIATRICSsign-out document with a succinct verbal summary, verifythat the covering provider understands the key clinical issuesand the tasks that need to be followed up, and ensure thatthey commit to providing the needed care.

MUTUAL SUPPORT

A working definition of mutual support focuses onproviding coaching and support to improve performanceor, when a lapse is detected, assisting teammates in per-forming a task or completing a task for the team memberwhen an overload is detected. The proposed develop-mental progression for this skill moves from a self-centered view of ones work to one that includes the otherindividual team members and their work to a team-focused view of our work. Early learners perform theirown work but may not seek help when beyond their capa-bilities or overloaded. With progression, intermediatelearners will ask for help with their work as needed andwill provide support when other team members ask forit, or passively offer support if it is clear that team mem-bers are overwhelmed or unable to complete their work.Finally, advanced learners make certain they get anyneeded help when overloaded and automatically steps inor arranges for assistance when our work is uneven ornot adequately completed for any reason. This later stageincludes initiation of active assistance as opposed to thepassive offering of assistance.

SITUATION MONITORING

Situation monitoring is defined here as tracking fellowteam members performance to ensure that the work isrunning as expected and that proper procedures are fol-lowed. In the early stages, the proposed developmental pro-gression for this skill begins with the self-awareness ofones needs, abilities, and contributions, and progressesto include awareness of the needs, abilities, and contribu-tions of the other team members. The more advancedstages are characterized by a global view of team perfor-mance as it relates to achieving team goals.TEAM LEADERSHIP

For our purposes, team leadership is defined as the abil-ity to direct/coordinate team members, assess team perfor-mance, allocate tasks, motivate subordinates, plan/organize, and maintain a positive team environment.When translated into behaviors, these may be observedand assessed in any member of a health care team, notjust the designated leader. The proposed developmentalprogression for this skill involves moving from behavingas a passive bystander on the team, to taking an activeownership role, to ensuring that the overall team goalsare met.TEAMWORK-RELATED ATTITUDES: Teamwork-related atti-tudes are internal states that affect a team members choicesand behavior. Examples include shared vision, mutual trust,collective orientation, and a belief in the importance ofteamwork as the best approach to achieve a goal. Studiesdemonstrating better performance of individuals who viewsuccess as more a function of cooperation than competitionas compared to those with the opposite view suggest theimportance of attitudes in team outcomes.14

It is upon this foundation of team theory that develop-mental milestones in this competency are proposed. Aswith other milestones, there is significant overlap, particu-larly with systems-based practice and professionalism. Thedevelopment of a team-based systems approach to healthcare provision is well described in the systems-based prac-tice milestones, and similar overlap is noted in the discus-sion of leadership related to personal and professionaldevelopment.While the teamwork-related knowledge, skills, and atti-

tudes could be further parsed by the various elements thatcomprise this competency, we will not attempt that here.We propose rather to unify them into developmental stagesinformed by the work of Dreyfus and Dreyfus,15 Zabar-enko and Zabarenko,16 and Brent.17

DEVELOPMENTAL MILESTONES:

Demonstrates limited initiative to interact with team members withminimal participation in team discussion. Passively follows the leadof others on the team. Focuses more on her own than the teamsperformance. Demonstrates limited awareness of her own needsand abilities with minimal recognition and acknowledgment of thecontributions of others.

Demonstrates an understanding of the roles of various teammembers by interacting with appropriate team members toaccomplish assignments. Actively works to integrate herself intoteam function and meet or exceed the expectations of her givenrole. Works toward achieving team goals, but may put personalgoals related to professional identity development (eg, recognition)above pursuit of team goals.

Identifies herself and is seen by others as an integral part of the team.Seeks to learn the individual capabilities of each fellow teammember and will offer coaching and performance improvement asneeded. Adapts and shifts roles and responsibilities as needed toachieve team goals. Communication is bidirectional, withverification of understanding of the message sent and the messagereceived in all cases.

Initiates problem solving, frequently provides feedback to other teammembers, and appears to take personal responsibility for theoutcomes of the teams work. Actively seeks feedback and initiatesadaptations to help the team function more effectively in changingenvironments. Engages in closed loop communication in all cases,ensuring that all understand the correct message. Seeks out andtakes on leadership roles in areas of expertise and makes sure thejob gets done.

Assumes the role of leader or follower, seamlessly, as needed. Goalsof the team appear to supersede any personal goals. Creates ahigh-functioning team de novo or joins a poorly functioning teamand facilitates improvement, such that team goals are met.

REFERENCES1. MeterkoM,Mohr DC, YoungGJ. Teamwork culture and patient satis-

faction in hospitals. Med Care. 2004;425:492498.

2. Morey JC, Simon R, Jay GD, et al. Error reduction and performance

improvement in the emergency department through formal teamwork

training: evaluation results of theMedTeams project.Health Serv Res.

2002;37:15531581.

3. Baker DP, Gustafson S, Beaubien JM, et al. Medical Teamwork and

Patient Safety: The Evidence-Based Relation. Rockville, Md: Agency

for Healthcare Research and Quality; 2005. Publication No. 050053.

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ACADEMIC PEDIATRICS INTERPERSONAL AND COMMUNICATION SKILLS S614. Kohn LT, Corrigan J, Donaldson MS. To Err Is Human: Building a

Safer Health System. Washington, DC: National Academies Press;

2000.

5. Corrigan J.Crossing the Quality Chasm: A NewHealth System for the

21st Century. Washington, DC: National Academies Press; 2001.

6. Baker DP, Salas E, King H, et al. The role of teamwork in the

professional education of physicians: current status and assess-

ment recommendations. Jt Comm J Qual Patient Saf. 2005;31:

185202.

7. Cannon-Bowers JA, Salas E. A framework for developing team per-

formance measures in training. In: Brannick MT, Salas E, Prince C,

eds. Team Performance Assessment and Measurement. Mahwah,

NJ: Lawrence Erlbaum Associates; 1997:4562.

8. Cannon-Bowers JA, Tannenbaum SI, Salas E, Volpe CE. Defining

competencies and establishing team training requirements. In:

Guzzo RA, Salas E, eds. Improving Teamwork in Organizations.

San Francisco, Calif: Jossey-Bass; 1995:333380.

9. King HB, Battles J, Baker DP, et al. TeamSTEPPSTM: Team Strate-

gies and Tools to Enhance Performance and Patient Safety. Agency

for Healthcare Research and Quality. Available at: http://www.ahrq.gov/downloads/pub/advances2/vol3/Advances-King_1.pdf Accessed

September 7, 2013.

10. Alonso A, Baker D, Holtzman A, et al. Reducing medical error in the

military health system: is team training the right prescription? Hum

Res Manage Rev. 2006;16:396415.

11. Dreyfus HL, Dreyfus SE.Mind Over Machine: The Power of Human

Intuition and Expertise in the Age of the Computer. Oxford, UK: Basil

Blackwell; 1986.

12. Monrouxe L. Identity, identification and medical education: why

should we care? Med Educ. 2010;44:4049.

13. Pangaro L. A new vocabulary and other innovations for improving

descriptive in-training evaluations. Acad Med. 1999;74:12031207.

14. Driskell JE, Salas E. Collective behavior and team performance.

Humn Factors. 1992;34:277288.

15. Dreyfus HL, Dreyfus SE. Mind Over Machine. New York, NY: Free

Press; 1988.

16. Zabarenko RN, Zabarenko LM. The Doctor Tree. Pittsburgh, Pa: Uni-

versity of Pittsburgh Press; 1978.

17. Brent DA. The residency as a developmental process. J Med Educ.

1981;56:417422.Competency 5. Act in a consultative role to other physicians and health professionals

Bradley Benson, MD

BACKGROUND: The medical consultation is not a straight- al,4 Ten Commandments for Effective Consultations,

forward procedure, and the effectiveness of such consulta-tions is not easily studied in a randomized controlled trial.1

It is, however, a common intervention in patient care, andnearly all medical professionals request or provide consul-tative services as part of their clinical work. As with manyother competencies and subcompetencies, there is signifi-cant overlap in the skill sets that are required. For consul-tation skills in particular, specific expertise is required inthe domains of medical knowledge and patient care.Certain specific aspects of professionalism are also criticaland have been the subject of much ethical and medicolegaldebate as they relate to consultation.2 The American Med-ical Association3 noted 9 ethical principles directly per-taining to physician consultation, 3 of which apply to thereferring physician; the remaining 6 focus on the consul-tant. These serve to clarify the responsibilities and role ofthe consultant and are summarized briefly as follows: 1)one physician should direct the patients care and treat-ment, and the consultant should not take on primary man-agement without the consent of that primary provider; 2)the consultation should be done in a timely manner, the re-sults should be communicated directly to the referring pro-vider, and the results should be shared with the patient onlyby prior consent of that provider; and 3) differences ofopinion need to be resolved with a second consultation orwithdrawal of the consultation, although the consultanthas the right to discuss her opinion with the patient in thepresence of the referring physician.

At the heart of effective consultation is the communica-tion with the referring provider. There is a body of literatureon factors that improve compliance with consultant recom-mendations, and these findings support the importance ofadvanced communication skills for an effective consultant.This literature has formed the basis of most subsequentwriting on the knowledge, skills, and attitudes required foreffective consultation. The cardinal article by Goldman etpragmatically summarizes this work. This work has beenupdated to reflect current practice, but the key principlesremain the same.5 Review of Goldmans 10 key skills is pro-vided in Table 3; however, the developmental process ofbecoming an expert consultant is much more complex andinvolves not only the acquisition of specific knowledgeand skills but also attitudes and behaviors related to profes-sional identity, which are addressed in other milestones.The skills noted in Table 3 are relatively straightforward

and amenable to assessment by chart audits and multisourceassessments. More difficult to conceptualize and assess isthe development of the professional identity of a consultant.6

Much has been written about the development of profes-sional expertise. Refer to Bereiter and Scardemalia,7 Eraut,8

and Dreyfus and Dreyfus9 for a deeper understanding of thefoundation on which this framework is developed.

DEVELOPMENTAL MILESTONES:

Participates as a member of the consultation team; gathers andpresents the patients histories and physical findings, and scribesrecommendations in the medical record. Demonstrates limiteddiscipline-specific knowledge, which impacts ability to focus thedata gathering and presentation to those details relevant to thequestion asked.

Identifies self as amember of the consultation team.Demonstrates theability to accurately gather and present the patients history andphysical findingswitha focuson thosedetailspertinent to thequestionasked. Demonstrates increased discipline-specific knowledge andability to filter andprioritize information; presents a focuseddifferential,realistic working diagnosis and more specific recommendations withmore succinct documentation. Takes ownership of the patientsoutcomes during follow-up of initial recommendations.

Identifies self as an integral member of the consultation teamand demonstrates advanced knowledge and skills in thespecific area. Independently assesses and confirms data.Consistently provides recommendations that align withbest practice. Develops relationships with referring providers,but may not encourage the bidirectional feedback that makes therelationship truly collaborative.

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Table 3. Key Skills for Effective Communication*

Skill Narrative

Anchor

Novice Expert

Clarify the question Communicate with the referringprovider to determine whether aspecific question is to beanswered, a procedurerequested, or if co-managementis the goal.

Does not attempt to clarify clinicalquestions where needed.

Negotiates (and, if needed,renegotiates) most appropriaterole and question on the basis ofthe needs of provider and patient.

Determine the urgency Understanding the question andthe patients situation allowsdetermination of how quickly anopinion needs to be given toprovide optimal patient care.

Not able to determine urgency; owntime constraints trump patient/provider needs.

Determines urgency and conveysthis to the requestor of theconsultation, mobilizing the teamas needed in acute situations.

Independently assessthe patient

Independent assessment of thepatient is necessary.

Relies primarily on othersassessments in the medicalrecord.

Approaches each patientindependently and verifies allimportant data while seeking outmissing information to obtain acomplete and accurate clinicalpicture.

Be as brief as appropriate Succinct medical documentationand communication improvecompliance.

Lengthy documentation oftenincludes unnecessary detail andirrelevant information.

Brief documentation synthesizesclinical picture with just the rightamount of detail.

Be specific Treatment recommendationsshould be as specific as possible(eg, medication doses, routes ofadministration, duration oftherapy).

Makes vague generalrecommendations.

Makes specific recommendationsthat could be transcribed asorders.

Provide contingency plans Communication of the anticipatedclinical course with clearrecommendations to helpmanage potential complicationsthat may arise is ideal.

Does not anticipate clinical courseor provide contingency plans.

Clearly communicates predictablecomplications and clinical courseand plans for monitoring,prevention, and treatment, asappropriate.

Stay within your expected/negotiated role

Writing orders on patients may beinappropriate; in other cases,comanagement is what thereferring provider wants. Thismust be tactfully negotiated upfront.

Does not determine what role isexpected/desired by therequesting physician.

Tactfully negotiates the mostappropriate role up front with therequesting physician.

Carry out teaching role Discipline-specific teaching is animportant role of the consultantand must be tailored to theindividual needs/expectations ofthe requesting physician. Apejorative style must be avoided.

Does not teach or iscondescending incommunicatingrecommendations.

Effectively tailors education to meetthe needs and expectations ofthe requesting physician in arespectful manner.

Make direct contact withreferring provider

Direct communication allowsquestioning, specific teaching,and feedback regardingsatisfaction with the consultation.

Does not directly communicate withthe referring provider; may simplyuse the medical record.

Determines and practices thepreferred mode ofcommunication with eachrequesting physician and makessure that two-waycommunication is clear andeffective.

Provide adequatefollow-up

Appropriate interval and level offollow-up required to assessoutcomes and patient andreferring provider needs and toadjust recommendationsaccordingly.

Timing and level of follow-up notappropriate to the clinical picture.

Timing and level of follow-upoptimally tailored to the patientsand the requesting physiciansneeds and expectations; makesconscientious use of resources.

*Based on the work of Goldman et al.4

S62 INTERPERSONAL AND COMMUNICATION SKILLS ACADEMIC PEDIATRICS

ACADEMIC PEDIATRICS INTERPERSONAL AND COMMUNICATION SKILLS S63 Identifies self as an expert in her discipline and demonstratesadvanced knowledge and vast experience. Clinical reasoningis succinctly communicated to answer the specific questionsasked. Communication includes the strength of the evidenceon which recommendations are based. Consistently developsand maintains collaborative relationships with the referringproviders that maximizes adherence to recommendations andsupports continuous bidirectional feedback.

Is identified by self and others as a master clinician whoeffectively and efficiently lends a practical wisdom toconsultation. Answers to all but the most difficult diagnosticdilemmas are intuitive, leaving most mental energy availablefor reinvestment in ongoing clinical, educational, and/orresearch contributions to the field.

REFERENCES1. Lee T. Proving and improving the value of consultations. Am J Med.

2002;113:527528.2. Cohn S. The role of the medical consultant.Med Clin North Am. 2003;

87:16.

3. Opinions and reports of the Judicial Council. In: Gross R, Caputo G,

eds.Kammerer and Gross Medical Consultation: The Internist on Sur-

gical, Obstetric, and Psychiatric Services. Philadelphia, Pa: Lippin-

cott, Williams & Wilkins; 1998.

4. Goldman L, Lee T, Rudd P. Ten commandments for effective consulta-

tions. Arch Intern Med. 1983;143:17531755.

5. Salerno S, Hurst F, Halvorson S, Mercado D. Principles of effective

consultation: an update for the 21st century. Arch Intern Med. 2007;

167:271275.

6. Monrouxe L. Identity, identification and medical education: why

should we care? Med Educ. 2010;44:4049.

7. Bereiter C, Scardemalia M. Surpassing Ourselves: An Inquiry Into the

Nature and Implications of Expertise. Chicago, Ill: Open Court Pub-

lishing Company; 1993.

8. Eraut M. Developing Professional Knowledge and Competence. Phil-

adelphia, Pa: Falmer Press, Taylor & Francis Inc; 1994.

9. Dreyfus HL, Dreyfus SE. Mind Over Machine: The Power of Human

Intuition and Expertise in the Age of the Computer. Oxford, UK: Basil

Blackwell; 1986.Competency 6. Maintain comprehensive, timely, and legible medical records, if applicable

Bradley Benson, MDBACKGROUND: Medical documentation serves many pur-poses in our health care system,1 including the following: Communication and clinical care planning among care-

givers. Providing a basis for assessing quality of care.2 Legal recording for protection of patients, providers, and

facilities. Providing a clinical database for research and educa-

tion.3,4

Documentation for billing of the services provided.The quality and accuracy of medical documentation are

closely linked with competence in all of the other do-mains, with special emphasis on medical knowledgeand patient care. For this discussion of the developmentof competence in the specific area of medical documenta-tion, however, we will focus on those aspects that are rela-tively independent of the specific medical content of thedocumentation. For example, an expert history and phys-ical for a patient with developmental delay might includea thorough developmental assessment and discussion ofhow the findings suggest a unifying genetic diagnosiswith a detailed plan for testing and follow-up. This, how-ever, requires advanced medical knowledge and patientcare skills that are evidenced in the content of the docu-mentation, which reflects clinical assessment and deci-sion-making abilities. This competency, whileinextricably linked to the other competencies that targetcontent, will focus primarily on the structure and timingof the medical documentation, as these aspects are alsoindependently linked to the quality of patient care. Thewidespread adoption of electronic health records hasdramatically changed documentation practices and haseliminated some problems (legibility), but it has createdothers.5,6 For example, the practice of cutting andpasting, or copying forward, parts of a medical recordfrom one encounter to another may contributesignificantly to medical error.7

To adequately address this competency, we mustdefine the key terms, specifically comprehensive, timely,and legible. In the assessment of comprehensiveness, weask 2 key questions: first, is the record complete (ie, doesit contain all of the appropriate information)? Second, isthe record accurate (ie, does it reflect what was actuallysaid and done)? The concepts of complete and accuratedocumentation also refer not only to the records for anindividual patient encounter (ie, an admission historyand physical examination) but to a patients medicalrecord as a whole. For the individual physicianpatientencounter, the documentation standards are settingand context specific. For example, a complete intervalnote for a continuity panel patient seen for follow-upof eczema would differ considerably from that of anew patient seen in consultation for developmentaldelay. Chart audit and video review of encounters aremost often used to assess the completeness and accuracyof documentation and interventions; use of thesemethods has been demonstrated to improve physiciancompliance with set standards.8,9 There are alsogenerally accepted standards for comprehensive medicalrecords as a whole.10,11 The specific requirements varywith the patient setting (eg, inpatient versusambulatory) and the specific disease state (eg, diabetesversus cystic fibrosis), but there are similarities toall. As an example, the Joint Commission forAccreditation of Healthcare Organizations requiresaccredited hospitals to perform chart audits for 19 dataitems (eg, identification data, medical history, physicalexaminations, progress notes, consultation reports,reports of diagnostic and therapeutic procedures) and todocument their presence, timeliness, legibility, and

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S64 INTERPERSONAL AND COMMUNICATION SKILLS ACADEMIC PEDIATRICSauthentication to ensure that the medical records arecomprehensive.

The definition of timely is more straightforward. Inthis context, timely documentation refers to the availabil-ity of the written communication regarding a medicalencounter within an accepted time frame that allowsothers involved in the care of the patient to use it in un-derstanding the course of medical events that haveoccurred during a hospitalization, a clinical encounter(eg, an outpatient visit), or an interval between visits.The most common example would be the availabilityof a discharge summary for the primary pediatrician toreview prior to the scheduled follow-up visit with thechild.

Last, the definition of legible is similarly straightfor-ward. Handwritten documentation or an order is eithereasily readable or not. This aspect of medical commu-nication is critical, and a learner who persists in illeg-ible documentation would not ever be judgedcompetent. As we shift to universal use of electronichealth records, however, we must move beyond theconcept of legibility and focus on the comprehensibilityof medical documentation. This construct addressesgrammar and syntax, culturally competent communica-tion, use of jargon, and other critical issues, such asflow and cohesiveness. In other words, does it tell thepatients story in a way that the reader can easily followand understand?

Little literature exists on the development of thisspecific competency, but the following progression is pro-posed on the basis of work focusing on the development ofexpertise.1215

EARLY DEVELOPMENT IN MEDICAL DOCUMENTATION:Early learners focus on the individual encounter and,with progression of competence, gain the larger view ofthe importance of the comprehensive medical record. Intheir documentation of the individual encounter, earlylearners lack the ability to filter and prioritize and there-fore commit both errors of omission (leaving out impor-tant information) and commission (includingunimportant information). With progression, the errorsof omission decrease and errors of commission increase,as evidenced by more lengthy documentation with moreextraneous information.INTERMEDIATE DEVELOPMENT IN MEDICAL DOCUMENTA-TION: As the learner progresses to competence andbeyond, the documentation becomes succinct, contain-ing just the right amount of information. At this level,care must be taken to balance the brevity with theneed for thoroughness and to accurately documentthe key aspects of what was said and done during aspecific encounter.ADVANCED DEVELOPMENT IN MEDICAL DOCUMENTATION:As further development occurs, more focus is placed onmanagement of the medical record as a whole. Maintaininga problem list, medication list, immunization status(including those administered elsewhere), growth curves,and communicating with specialists are examples of itemsthe advanced learner focuses on.DEVELOPMENTAL MILESTONES:

Commits both errors of omission and errors of commission indocumentation. In the former case, documentation is oftenincomplete; critical data sections (eg, medical history) and criticaldata (eg, specific diagnoses in the medical history) may be missingand may not document what was actually said and done. In thelatter case, documentation is subject to errors of inclusion ofunnecessary information or detail. Documentation is often notavailable for other providers to review in time for their use in thepatients care. Handwritten documentation may be illegible,abbreviations are often used, and date/time/signature may beomitted.

Includes all appropriate data sections in documentation, thoughsome information may be missing from some sections or presentedin a sequence that confuses the reader (eg, evolution of symptomsis not documented chronologically). Documentation may be overlylengthy and detailed. It may contain erroneous information carriedforward from review of the medical record. However, thepractitioner at this stage begins to go beyond documentation ofspecific encounters andmay update the patient-specific databases(eg, problem list and diabetes care flow sheet) where applicable.Documentation is often in the medical record in a timely manner butmay need subsequent amendment to be considered complete.Handwritten documentation is usually legible, timed, dated, andsigned.

Accurately documents the patients story and the service provided,yet is not overly long and detailed. Begins to tailor thedocumentation to the specific situation. All important data areverified or the source is stated. Identified errors in the medicalrecord are reported and appropriate measures initiated to correctthem. Key patient-specific databases are maintained and updatedwhere applicable. Documentation is completed and available forothers to review within an appropriate time frame for it to aid in theircare of the patient. Handwritten documentation is always legible,prohibited abbreviations are avoided, and all documentation has atime, date, and signature.

Tailors documentation to the specific care situation without loss ofcomprehensiveness. Synthesizes key information in a succinctmanner. Begins to develop standard templates or tools for ensuringthat documentation includes all appropriate quality markers,supports accurate billing and coding, meets legal and communitycare standards, enables identification of patients for diseaseregistries, and supports chart audits. Regularly participates in chartaudits for quality of documentations and acts on the results for self-improvement.

Demonstrates behaviors in milestone immediately above. Inaddition, uses her expertise to improve documentation systems todrive better patient care outcomes and works to disseminate bestpractices.

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Domain of Competence: Interpersonal and CommunicationSkillsReferences

Competency 1. Communicate effectively with patients, families, and the public, as appropriate, across a broad range of soci ...Developmental MilestonesReferences

Competency 2. Demonstrate the insight and understanding into emotion and human response to emotion that allow one to approp ...Developmental MilestonesReferences

Competency 3. Communicate effectively with physicians, other health professionals, and health-related agenciesDevelopmental MilestonesReferences

Competency 4. Work effectively as a member or leader of a health care team or other professional groupTeam CommunicationMutual SupportSituation MonitoringTeam LeadershipDevelopmental MilestonesReferences

Competency 5. Act in a consultative role to other physicians and health professionalsDevelopmental MilestonesReferences

Competency 6. Maintain comprehensive, timely, and legible medical records, if applicableDevelopmental MilestonesReferences