Elizabeth A. Rider

A model for communication skills assessment across the undergraduate curriculum.

Physicians’ interpersonal and communication skills have a significant impact on patient care and correlate with improved healthcare outcomes. Some studies suggest, however, that communication skills decline during the four years of medical school. Regulatory and other medical organizations, recognizing the importance of interpersonal and communication skills in the practice of medicine, now require competence in communication skills. Two challenges exist: to select a framework of interpersonal and communication skills to teach across undergraduate medical education, and to develop and implement a uniform model for the assessment of these skills. The authors describe a process and model for developing and institutionalizing the assessment of communication skills across the undergraduate curriculum. Consensus was built regarding communication skill competencies by working with course leaders and examination directors, a uniform framework of competencies was selected to both teach and assess communication skills, and the framework was implemented across the Harvard Medical School undergraduate curriculum. The authors adapted an assessment framework based on the Bayer–Fetzer Kalamazoo Consensus Statement adapted a patient and added and satisfaction tool to bring patients’ perspectives into the assessment of the learners. The core communication competencies and evaluation instruments were implemented in school-wide courses and assessment exercises including the first-year Patient–Doctor I Clinical Assessment, second-year Objective Structured Clinical Exam (OSCE), third-year Patient–Doctor III Clinical Assessment, fourth-year Comprehensive Clinical Practice Examination and the Core Medicine Clerkships. Faculty were offered workshops and interactive web-based teaching to become familiar with the framework, and students used the framework with repeated opportunities for faculty feedback on these skills. A model is offered for educational leaders and others who are involved in designing assessment in communication skills. By presenting an approach for implementation, the authors hope to provide guidance for the successful integration of communication skills assessment in undergraduate medical education.

Pediatric residents' perceptions of communication competencies: Implications for teaching.

Background: Medical regulatory organizations worldwide require competency in communication skills. Pediatric communication competencies are unique, and little is known about pediatric residents’ perceptions regarding these skills. Aim: The purpose of this study was to examine pediatric residents’ attitudes about communication skills, their perceptions of the importance of learning 15 specific communication skills relevant to pediatrics, confidence in these skills, and relevant program supports. Methods: We developed a 47-item cross-sectional questionnaire to study pediatric residents’ attitudes and perceptions regarding communication competencies. 104 pediatric housestaff in a university-affiliated program in the US were asked to complete the questionnaire. Scale variables were created and evaluated for reliability. Data were analysed using descriptive and univariate statistics. Results: Response rate was 86% (89/104). Cronbachs alpha reliabilities of the Importance Scale (r = 0.92) and Confidence Scale (r = 0.90) were excellent. Ninety nine percent of the participants agreed that learning to communicate effectively with patients was a priority. All agreed it is important to demonstrate empathy and caring, and to teach medical students to communicate effectively with patients. Pediatric residents agreed that the 15 communication competencies studied were important to learn. Most reported confidence in core communication competencies (interviewing, listening, building rapport, demonstrating caring and empathy), but only half or fewer were confident in 7 more advanced communication skills (ability to discuss end-of-life issues, speaking with children about serious illness, giving bad news, dealing with the ‘difficult’ patient/parent, cultural awareness/sensitivity, understanding psychosocial aspects, and understanding patients’ perspectives). Few reported the availability of relevant program supports for learning these skills. Conclusions: Pediatric residents perceive communication competencies as important and a priority for learning, yet report a lack of confidence in advanced communication skills and insufficient program supports. Our measurement scales can add to the evaluation of residency programs, and may provide suggestions for pediatric curricular content in core and advanced communication skills.

Assessment of Communication Skills and Self-Appraisal in the Simulated Environment: Feasibility of Multirater Feedback with Gap Analysis

Introduction: Multirater assessment is a powerful means of measuring communication skills. The use of gap analysis to assess self-appraisal is a strength of this technique. On the basis of Kalamazoo Consensus Statement framework and 360-degree assessment models, we developed a multirater instrument with gap analysis, with the goals of examining both communication skills and situational self-appraisal, and assessing the feasibility of the combined approach. Methods: The multirater communication skills instrument was used to assess Pediatric and Neonatal Intensive Care fellows after participation in seven simulated family meetings. Instrument reliability was determined using Cronbach’s Alpha and Factorial Analysis. Correlations between rater groups were examined with Spearman’s Rank Coefficient. Gap analyses and rater perceptions of the instruments were analyzed using descriptive statistics. Results: Seven pediatric intensive care unit and neonatal intensive care fellows were each assessed by 11 to 18 raters (108 total assessments). Correlations were identified between disciplinary groups within each encounter. Among the 7 fellows, 30 communication strengths or areas needing improvement and 24 significant gaps were identified, indicating self under-appraisals, 9 (38%) of which overlapped. The instrument was logistically feasible and well received. Conclusions: Our multirater communication skills instrument with gap analysis proved useful in identifying areas of strength and areas needing improvement, and in highlighting areas of self over- and under-appraisal that require focused feedback. The use of multirater assessment with gap analysis, in a simulated and “safe” environment, may assist in the delivery of feedback to trainees.

Assumptions and blind spots in patient-centredness: action research between American and Italian health care professionals

Objective  To examine how patient‐centredness is understood and enacted in an American (US) and an Italian group of health care professionals.

Evaluating ego defense mechanisms using clinical interviews: an empirical study of adolescent diabetic and psychiatric patients *

Ego defense mechanisms were studied in three groups of early adolescents: diabetic patients, non-psychotic psychiatric patients, and healthy high school students. Defenses were assessed from ratings of open-ended, in-depth interviews. High levels of denial and low levels of asceticism were found in all three groups. Comparisons between groups indicated that psychiatric patients had a distinctive profile of defense usage, in comparison to adolescents from the other two groups. An independent measure of ego development was positively correlated with the defenses of altruism, intellectualization, and suppression, while it was negatively correlated with acting out, avoidance, denial, displacement, projection, and repression. The findings of substantial differences in defense usage between the psychiatric and non-psychiatric samples, and the size and directions of the correlations with ego development level, lend support to the validity of the defense codes.

Cross-cultural adaptation of an innovative approach to learning about difficult conversations in healthcare.

Background: The Program to Enhance Relational and Communication Skills (PERCS) was developed at a large hospital in the United States to enhance clinicians’ preparedness to engage in difficult conversations. Aim: To describe the implementation of PERCS in an Italian hospital and assess the programs efficacy. Methods: The Italian PERCS program featured 4-h experiential workshops enrolling 10–15 interdisciplinary participants. The workshops were organized around the enactment and debriefing of realistic case scenarios portrayed by actors and volunteer clinicians. Before and after the workshop, participants rated their perceived preparation, communication and relational skills, confidence, and anxiety on 5-point Likert scales. Open-ended questions explored their reflections on the learning. T-tests and content analysis were used to analyze the quantitative and qualitative data, respectively. Results: 146 clinicians attended 13 workshops. Participants reported better preparation, confidence, and communication skills (p < 0.001) after the workshops. The program had a different impact depending on the discipline. Participants valued the emphasis on group feedback, experiential and interdisciplinary learning, and the patients perspective, and acquired: new communication skills, self-reflective attitude, reframed perspective, and interdisciplinary teamwork. Conclusion: PERCS proved culturally adaptable to the Italian context and effective in improving participants’ sense of preparation, communication skills, and confidence.

Microethics: the ethics of everyday clinical practice.

Over the past several decades, medical ethics has gained a solid foothold in medical education and is now a required course in most medical schools. Although the field of medical ethics is by nature eclectic, moral philosophy has played a dominant role in defining both the content of what is taught and the methodology for reasoning about ethical dilemmas. Most educators largely rely on the case-based method for teaching ethics, grounding the ethical reasoning in an amalgam of theories drawn from moral philosophy, including consequentialism, deontology, and principlism. In this article we hope to make a case for augmenting the focus of education in medical ethics. We propose complementing the traditional approach to medical ethics with a more embedded approach, one that has been described by others as “microethics,” the ethics of everyday clinical practice.

The reliability of a modified Kalamazoo Consensus Statement Checklist for assessing the communication skills of multidisciplinary clinicians in the simulated environment.

OBJECTIVE With increased recognition of the importance of sound communication skills and communication skills education, reliable assessment tools are essential. This study reports on the psychometric properties of an assessment tool based on the Kalamazoo Consensus Statement Essential Elements Communication Checklist. METHODS The Gap-Kalamazoo Communication Skills Assessment Form (GKCSAF), a modified version of an existing communication skills assessment tool, the Kalamazoo Essential Elements Communication Checklist-Adapted, was used to assess learners in a multidisciplinary, simulation-based communication skills educational program using multiple raters. 118 simulated conversations were available for analysis. Internal consistency and inter-rater reliability were determined by calculating a Cronbachs alpha score and intra-class correlation coefficients (ICC), respectively. RESULTS The GKCSAF demonstrated high internal consistency with a Cronbachs alpha score of 0.844 (faculty raters) and 0.880 (peer observer raters), and high inter-rater reliability with an ICC of 0.830 (faculty raters) and 0.89 (peer observer raters). CONCLUSION The Gap-Kalamazoo Communication Skills Assessment Form is a reliable method of assessing the communication skills of multidisciplinary learners using multi-rater methods within the learning environment. PRACTICE IMPLICATIONS The Gap-Kalamazoo Communication Skills Assessment Form can be used by educational programs that wish to implement a reliable assessment and feedback system for a variety of learners.

The International Charter for Human Values in Healthcare: An interprofessional global collaboration to enhance values and communication in healthcare

OBJECTIVES The human dimensions of healthcare--core values and skilled communication necessary for every healthcare interaction--are fundamental to compassionate, ethical, and safe relationship-centered care. The objectives of this paper are to: describe the development of the International Charter for Human Values in Healthcare which delineates core values, articulate the role of skilled communication in enacting these values, and provide examples showing translation of the Charters values into action. METHODS We describe development of the Charter using combined qualitative research methods and the international, interprofessional collaboration of institutions and individuals worldwide. RESULTS We identified five fundamental categories of human values for every healthcare interaction--Compassion, Respect for Persons, Commitment to Integrity and Ethical Practice, Commitment to Excellence, and Justice in Healthcare--and delineated subvalues within each category. We have disseminated the Charter internationally and incorporated it into education/training. Diverse healthcare partners have joined in this work. CONCLUSION We chronicle the development and dissemination of the International Charter for Human Values in Healthcare, the role of skilled communication in demonstrating values, and provide examples of educational and clinical programs integrating these values. PRACTICE IMPLICATIONS The Charter identifies and promotes core values clinicians and educators can demonstrate through skilled communication and use to advance humanistic educational programs and practice.

Multi-rater feedback with gap analysis: an innovative means to assess communication skill and self-insight.

OBJECTIVE Multi-rater assessment with gap analysis is a powerful method for assessing communication skills and self-insight, and enhancing self-reflection. We demonstrate the use of this methodology. METHODS The Program for the Approach to Complex Encounters (PACE) is an interdisciplinary simulation-based communication skills program. Encounters are assessed using an expanded Kalamazoo Consensus Statement Essential Elements Checklist adapted for multi-rater feedback and gap analysis. Data from a representative conversation were analyzed. RESULTS Likert and forced-choice data with gap analysis are used to assess performance. Participants were strong in Demonstrating Empathy and Providing Closure, and needed to improve Relationship Building, Gathering Information, and understanding the Patients/Familys Perspective. Participants under-appraised their abilities in Relationship Building, Providing Closure, and Demonstrating Empathy, as well as their overall performance. The conversion of these results into verbal feedback is discussed. CONCLUSIONS We describe an evaluation methodology using multi-rater assessment with gap analysis to assess communication skills and self-insight. This methodology enables faculty to identify undervalued skills and perceptual blind spots, provide comprehensive, data driven, feedback, and encourage reflection. PRACTICE IMPLICATIONS Implementation of graphical feedback forms coupled with one-on-one discussion using the above methodology has the potential to enhance trainee self-awareness and reflection, improving the impact of educational programs.