Carla L. Spagnoletti

Addressing health literacy through clear health communication: A training program for internal medicine residents

OBJECTIVE To develop, pilot, and test the effectiveness of a clear health communication curriculum to improve resident knowledge, attitudes, and skills regarding health literacy. METHODS Thirty-one internal medicine residents participated in a small group curriculum that included didactic teaching, practice with a standardized patient, and individualized feedback on videotaped encounters with real patients. Outcomes were assessed using a pre-post survey and a communication skills checklist. RESULTS Mean knowledge scores increased significantly from 60.3% to 77.6% (p<0.001). Residents also reported increased familiarity with the concept of health literacy (mean response 3.2 vs. 4.5 on a 5 point scale), importance placed on health literacy (4.2 vs. 4.9), frequency of considering health literacy in patient care (3.3 vs. 4.0), and confidence in communicating with low literacy patients (3.3 vs. 4.1) (all p<0.001). Use of plain language increased significantly from 33% to 86% (p=0.023). There were nonsignificant increases in the use of teach-back (0-36%, p=0.116) and encouraging questions (0-14%, p=0.502). CONCLUSION Training in clear health communication improves resident knowledge, attitudes, and skills regarding health literacy. PRACTICE IMPLICATIONS The increased use of clear health communication techniques can significantly improve the care and outcomes of vulnerable patients with limited health literacy.

Teaching the Teachers: Faculty Preparedness and Evaluation of a Retreat in Screening, Brief Intervention, and Referral to Treatment

ABSTRACT Effective clinical faculty are essential for disseminating substance abuse screening, brief intervention, and referral to treatment (SBIRT). The authors developed an 8-hour SBIRT training for internal medicine faculty preceptors. Trainers conducted SBIRT lectures and small-group communication practice sessions. The authors assessed participants’ (n = 27) knowledge, skills, and attitudes using an enhanced Alcohol and Alcohol Problems Perceptions Questionnaire (AAPPQ). Participants self-assessed their changes in SBIRT competence and comfort. Faculty trainees did not feel competent in SBIRT, particularly in intervention and referral to treatment. AAPPQ subscale scores were highest in Role Legitimacy and Motivation and lowest in Role Adequacy and Satisfaction. After training, faculty members reported greater likelihood of performing and teaching SBIRT. In some topic areas, faculty attending an SBIRT training reported limited knowledge and competence for treating drinkers; however, their interest and motivation for doing so was high. Ongoing faculty and organizational development efforts may help close these gaps.

R-E-S-P-E-C-T: Even More Difficult to Teach than to Define

“Respect” is a word like “empathy”, “love”, and “compassion”, that everyone agrees connotes a positive attribute; however, there are innumerable ideas about what respect means. Perhaps the reason it is so difficult to define is because it can mean different things to different people, depending on whether it is being used as a verb or as a noun, on the person’s cultural background, and the context in which it is being discussed. For instance, when a parent tells a teenager “to show some respect” the meaning is somewhat different than when philosophers talk about “respect for persons”. Aretha1 put it very simply: “R-E-S-P-E-C-T, find out what it means to ME!” Still, it is useful to examine why and how a physician can show respect to patients. After all, the American Board of Internal Medicine’s Medical Professionalism in the New Millennium: A Physician Charter mentions “respect for patient autonomy” as a core principle and the Project Professionalism states that “Respect for others (patients and their families, other physicians, and professional colleagues such as nurses, medical students, residents, and subspecialty fellows) is the essence of humanism, and humanism is both central to professionalism and fundamental to enhancing collegiality among physicians.”2,3 In this issue of JGIM, Beach et al attempt to define the object of physicians’ respect and what respect requires4. They believe autonomy is too limited as the object of our respect because it seems to make respect conditional on whether we admire a patient’s values, and because it limits our obligation to those patients who lack autonomy. They propose that it is a physician’s moral duty to respect all patients equally as persons, as a professional extension of one’s universal duty to respect all people because of their “unconditional intrinsic value as human beings.” They go on to describe this respect as bidimensional; that is, the concept of respect is both an attitude and a set of behaviors that one ought to have as a physician. Both dimensions, they argue, are morally required of physicians. This article is likely to be widely read and discussed. Whereas philosophers may argue about whether their concept of autonomy is biased, we agree that respect should not be contingent on a patient’s lifestyle or health decisions. For medical educators who are charged with training respectful physicians for the future, the article raises questions about the barriers to respect, how to teach respect, whether a focus on behavior is sufficient, and what behaviors constitute respect. We will focus our attention on these issues.

Teaching error disclosure: Advanced communication skills training for residents

Abstract Disclosing errors to patients is an advanced communication skill necessary in clinical practice but traditionally not taught during residency training. We developed an educational seminar for senior residents utilizing didactic, small group discussion, and role play that incorporates principles of error disclosure. Our objectives were to improve residents knowledge of the key components of disclosing medical errors to patients and to provide opportunity to practice communicating medical error in a safe environment. We assessed whether residents are participating in error disclosure and compared self-rated preparedness to disclose an error before and after the teaching session. Nearly all residents (94%) reported that learning about disclosure of medical errors is a very important part of residency training and 58% of residents had already participated in a disclosure discussion. Residents reported they were significantly more prepared to disclose medical errors to patients after participating in the curriculum compared with before, both in terms of the components of medical error disclosure and the emotional aspects of disclosure. This curriculum was associated with improvement in comfort level with error disclosure. Error disclosure represents an ideal educational opportunity for residencies to address multiple core competencies including patient care, communication skills, and professionalism.

Recognizing Patients' Emotions: Teaching Health Care Providers to Interpret Facial Expressions.

Purpose Facial expressions are an important clue to a patient’s emotions. The authors developed a 90-minute workshop in May 2011 to teach physicians and physicians-in-training to interpret facial expressions and to use that skill in the context of patient care. Method The workshop included a didactic presentation in which facial expression features were taught using progressively more difficult examples, followed by three interactive exercises. The authors presented the workshop at six separate venues in the United States in 2011 and 2012. To test the effectiveness of this workshop, the authors designed a comprehensive pre- and postworkshop evaluation which assessed participants’ skill, knowledge, attitude (toward importance), and confidence. Results A total of 156 health care providers participated in the workshop and completed pre- and postworkshop evaluations. Participants showed substantial improvement in skill and knowledge (fact- and case-based) scores, as well as modest improvement in importance and confidence ratings. Faculty and medical students demonstrated similar baseline measures of skill, knowledge, and importance, though faculty reported a slightly higher confidence in their skills. No correlation was found between baseline ratings of confidence in abilities and any baseline measure of performance. Conclusions Given the similar baseline performance of faculty and medical students, the ability to interpret facial expressions does not appear to be learned through routine clinical practice, highlighting the need for dedicated facial expression training. The authors were able to demonstrate that physicians and physicians-in-training could effectively learn to recognize emotion by interpreting facial expressions through a short workshop.