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Theory/Concepts/Rationale
- Bartlett EE, Grayson M, Barker R, Levine DM, Golden A, Libber S. The effects of physician communications skills on patient satisfaction; recall, and adherence. J Chronic Dis 1984; 37:755-764.
Abstract: An understanding of means to improve patient adherence to the therapeutic regimen is a subject of increasing concern in medical care. This study examined the effects of physician interpersonal skills and teaching on patient satisfaction, recall, and adherence to the regimen. We studied the ambulatory visits of 63 patients to five medical residents at a teaching hospital in Baltimore. It was found that quality of interpersonal skills influenced patient outcomes more than quantity of teaching and instruction. Secondary analyses found that all the effects of physician communication skills on patient adherence are mediated by patient satisfaction and recall. These findings indicate that the physician might pay particular attention to these two variables in trying to improve patient adherence, and that enhancing patient satisfaction may be pivotal to the care of patients with chronic illness.
- Carroll JG, Platt FW. Engagement: The grout of the clinical encounter. JCOM 1998;5:43-45.
Abstract: Engagement is the process by which doctor and patient initiate and maintain an effective working relationship. Every physician can learn to facilitate engagement with a patient and to repair the relationship when engagement goes awry.
To access the full text article listed above go to
www.jcomjournal.com and click on the Clinical Communication section listed on the left side of the page. Reprinted with permission from Turner White Communications, Inc.
- Keller VF, Carroll JG. A new model for physician-patient communication. Patient Educ Couns 1994;23:131-140.
Abstract: The E4 Model for physician-patient communication is presented with specific techniques for implementing the model. Derived from an extensive review of the literature on physicians-patient communication, the model has proved to be a useful tool in workshops for and coaching physicians regardless of specialty, experience or practice setting information on how to obtain descriptive materials about the workshop and an annotated bibliography included.
Reprinted from Patient Educ Couns, 23, Keller VF,Carroll JG, A new model for physicians-patient communication, 131-140, Copyright 1994, with permission from Elsevier Science. www.elsevier.com
- Keller VF, Kemp-White M. Choices and Changes: A New Model for Influencing Patient Health Behavior. JCOM 1997;4:33-36.
Abstract: Patient health behavior has an important impact on clinical outcomes, but helping patients change their behavior can be challenging for physicians. In this article, the authors present their model for influencing patient behavior and describe techniques for furthering the therapeutic relationship.
To access the full text article listed above go to
www.jcomjournal.com and click on the Clinical Communication section listed on the left side of the page. Reprinted with permission from Turner White Communications, Inc.
- Kemp-White M, Keller VF. Difficult clinician-patient relationship. JCOM 1998;5:32-36. Abstract: All clinicians encounter patients whom they regard as difficult. The authors identify three major reasons why difficulties occur and offer clinical approaches to use when a relationship is in trouble.
To access the full text article listed above go to
www.jcomjournal.com and click on the Clinical Communication section listed on the left side of the page. Reprinted with permission from Turner White Communications, Inc.
- Laine C, Davidoff F. Patient-centered medicine. A professional evolution. JAMA 1996; 275:152-6.
Abstract: American medicine is in the midst of a professional evolution driven by a refocusing of medicine's regard for the patient's viewpoint. Historically, medicine has been largely physician centered, but physicians have begun to incorporate patients' perspectives in ways that increasingly matter. Some call this shift "patient-centered" care. In support of the view that this refocusing reflects a broad professional shift, we describe the evolution to patient-centered care in many areas of medicine: patient care, health-related law, medical education, research, and quality assessment.
Reprinted with permission by JAMA, 1996, 275:152-6, Copyrighted 1996, American Medical Association.
- Lang F, Floyd MR, Beine KL. Clues to patients' explanations and concerns about their illnesses. A call for active listening. Arch Fam Med 2000; 9:222-7.
Abstract: Most patients who experience illness symptoms develop an explanatory model. More frequently than physicians realize, these attributions involve serious and potentially life-threatening medical conditions. Only a minority of patients spontaneously disclose or "offer" their ideas, concerns, and expectations. Often patients suggest or imply their ideas through "clues." Active listening is a skill for recognizing and exploring patients' clues. Without this communication skill, patients' real concerns often go unrecognized by health care professionals. Qualitative techniques including videotape analysis, postinterviewing debriefing, and interpersonal process recall were used to identify types of clues. We propose a taxonomy of clues that includes (1) expression of feelings (especially concern or worry), (2) attempts to understand or explain symptoms, (3) speech clues that underscore particular concerns of the patient, (4) personal stories that link the patient with medical conditions or risks, and (5) behaviors suggestive of unresolved concerns or unmet expectations. This clue taxonomy will help physicians recognize patients' clues more readily and thereby improve their active listening skills. A deeper understanding of the true reasons for the visit should result in increased patient satisfaction and improved outcomes.
Reprinted with permission by Archives of Family Medicine, 2000, 9:222-7, Copyrighted 2000, American Medical Association.
- Moore W. Medical education. Speak to me before it's too late. Health Serv J 1997; 107:20-2.
Abstract: Doctors' failure to communicate with patients is at the root of many complaints. But an increasing number of medical schools are now teaching their students how to talk to patients. Wendy Moore reports.
Reproduced by kind permission of the Editor of the Health Services Journal.
- Thom DH, Campbell B. Patient-physician trust: an exploratory study. J Fam Pract 1997; 44:169-76.
Abstract: BACKGROUND: Patients' trust in their physicians has recently become a focus of concern, largely owing to the rise of managed care, yet the subject remains largely unstudied. We undertook a qualitative research study of patients' self-reported experiences with trust in a physician to gain further understanding of the components of trust in the context of the patient-physician relationship. METHODS: Twenty-nine patients participants, aged 26 to 72, were recruited from three diverse practice sites. Four focus groups, each lasting 1.5 to 2 hours, were conducted to explore patients' experiences with trust. Focus groups were audio- recorded, transcribed, and coded by four readers, using principles of grounded theory. RESULTS: The resulting consensus codes were grouped into seven categories of physician behavior, two of which related primarily to technical competence (thoroughness in evaluation and providing appropriate and effective treatment) and five of which were interpersonal (understanding patient's individual experience, expressing caring, communicating clearly and completely, building partnership/sharing power and honesty/respect for patient). Two additional categories were predisposing factors and structural/staffing factors. Each major category had multiple subcategories. Specific examples from each major category are provided. CONCLUSIONS: These nine categories of physician behavior encompassed the trust experiences related by the 29 patients. These categories and the specific examples provided by patients provide insights into the process of trust formation and suggest ways in which physicians could be more effective in building and maintaining trust.
Reprinted with permission from Thom DH,Campbell B, Patient-physician trust:an exploratory study, 44(3), 169-176, ©1997 The Journal of Family Practice.
Teaching-Learning
- Boulton M, Griffiths J, Hall D, McIntyre M, Oliver B, Woodward J. Improving communication: a practical programme for teaching trainees about communication issues in the general practice consultation. Med Educ 1984; 18:269-74.
Abstract: This paper describes a teaching programme, for use in general practice vocational training, which provides a theoretical and practical framework for exploring key aspects of the consultation with trainees. A particular emphasis is on the educational or 'cognitive' outcomes of the consultation and skills for improving them. The five stages of the programme are described and an example of experience of each stage is given. The paper concludes with an evaluation of the programme by the trainers, trainees and social scientist involved.
Reprinted with permission by
Blackwell Science, Inc.
- Burack JH, Irby DM, Carline JD, Root RK, Larson EB. Teaching compassion and respect. Attending physicians' responses to problematic behaviors. J Gen Intern Med 1999;14:49-55.
Abstract: OBJECTIVE: To describe how and why attending physicians respond to learner behaviors that indicate negative attitudes toward patients. SETTING: Inpatient general internal medicine service of a university- affiliated public hospital. PARTICIPANTS: Four ward teams, each including an attending physician, a senior medicine resident, two interns, and up to three medical students. DESIGN: Teams were studied using participant observation of rounds (160 hours); in-depth semistructured interviews (n = 23); a structured task involving thinking aloud (n = 4, attending physicians); and patient chart review. Codes, themes, and hypotheses were identified from transcripts and field notes, and iteratively tested by blinded within-case and cross- case comparisons. MAIN RESULTS: Attending physicians identified three categories of potentially problematic behaviors: showing disrespect for patients, cutting corners, and outright hostility or rudeness. Attending physicians were rarely observed to respond to these problematic behaviors. When they did, they favored passive nonverbal gestures such as rigid posture, failing to smile, or remaining silent. Verbal responses included three techniques that avoided blaming learners: humor, referring to learners' self-interest, and medicalizing interpersonal issues. Attending physicians did not explicitly discuss attitudes, refer to moral or professional norms, "lay down the law," or call attention to their modeling, and rarely gave behavior-specific feedback. Reasons for not responding included lack of opportunity to observe interactions, sympathy for learner stress, and the unpleasantness, perceived ineffectiveness, and lack of professional reward for giving negative feedback. CONCLUSIONS: Because of uncertainty about appropriateness and effectiveness, attending physicians were reluctant to respond to perceived disrespect, uncaring, or hostility toward patients by members of their medical team. They tended to avoid, rationalize, or medicalize these behaviors, and to respond in ways that avoided moral language, did not address underlying attitudes, and left room for face-saving reinterpretations. Although these oblique techniques are sympathetically motivated, learners in stressful clinical environments may misinterpret, undervalue, or entirely fail to notice such subtle feedback.
Reprinted with permission by Blackwell Science, Inc.
- Garg A, Buckman R, Kason Y. Teaching medical students how to break bad news. CMAJ 1997; 156:1159-64.
Abstract: PROGRAM OBJECTIVE: To teach medical students to break bad news to patients and their families empathically and competently. SETTING: Seven teaching hospitals affiliated with the University of Toronto since 1987. PARTICIPANTS: All medical students in their third preclinical year. PROGRAM: The course presents a 6-point protocol to guide students in breaking bad news and comprises 2 half-day (3-hour) teaching sessions. Each session incorporates a video presentation, a discussion period and small-group teaching, consisting of exercises followed by 4 different role-playing scenarios conducted with the use of standardized patients. The course was evaluated through 2 questionnaires, 1 administered before and 1 after the course, which measured changes in the students' attitude and strategy. Questionnaires were administered during 5 of the years since the course was started. A total of 914 precourse and 503 postcourse questionnaires were completed, of which 359 matched pairs of precourse and postcourse questionnaires were analysed to study any changes due to the course. OUTCOMES: Precourse questionnaires showed that 68% of the students had thought about the task of breaking bad news often or very often. Of the 56% of students who had seen clinicians performing this task, 75% felt that they had seen good examples. The proportion of the students who had a plan for how to conduct such an interview rose from 49% before the course to 92% after it, and the proportion who felt they might be reasonably competent in breaking bad news rose from 23% before the course to 74% after it. CONCLUSIONS: The subject of breaking bad news is important to medical students, and it is practicable to design a course to teach the basic techniques involved. Most students perceive such a course as enjoyable and useful and find that it increases their sense of competence and their ability to formulate a strategy for such situations.
- Gask L, Goldberg D, Boardman J, Craig T, Goddard C, Jones O et al. Training general practitioners to teach psychiatric interviewing skills: an evaluation of group training. Med Educ 1991;25:444-51.
Abstract: Group teaching in problem-based interviewing based on video and/ audiotape feedback of the doctor's own consultations significantly improved the ability of experienced general practitioners to teach psychiatric skills to their trainees. When the GPs were randomly allocated to one of three further training experiences--video feedback of their tutorial sessions, discussion about how to teach and no further teaching, there were very few differences between the groups. The greatest impact on improving teaching skills was brought about by watching their own consultations in a group feedback setting.
Reprinted with permission by
Blackwell Science, Inc.
- Gordon GH, Duffy FD. Educating and Enlisting Patients. JCOM 1998;5:45-50.
Abstract: Most patients want more information from their physicians than they currently receive. Educating patients and enlisting them to become active participants in their care can lead to increased satisfaction compliance.
To access the full text article listed above go to
www.jcomjournal.com and click on the Clinical Communication section listed on the left side of the page. Reprinted with permission from Turner White Communications, Inc.
- Henwood PG, Altmaier EM. Evaluating the effectiveness of communication skills training: a review of research. Clin Perform Qual Health Care 1996; 4:154-8.
Abstract: This review considers the effectiveness of communication skills training programs within medical school settings. Several components of training are evaluated: microcounseling, standardized patients, role play, and videotape review. Overall, these interventions have been shown to be effective in improving targeted communication skills (ie, use of open-ended questions). However, outcome data that support the transfer of training to actual patient encounters and subsequent patient outcomes (i.e., satisfaction, adherence)are lacking.
Reprinted with permission from Henwood PG, Altmaier EM, Evaluating the effectiveness of communication skills training: a review of research. Clin Perform Qual Health Care, 1996, 4:154-8, ©1996, MCB University Press. www.emeraldinsight.com
- Kurtz S, Laidlaw T, Makoul G, Schnabl G. Medical education initiatives in communication skills. Cancer Prev Control 1999; 3:37-45.
Abstract: Medical educators at undergraduate,postgraduate, and continuing medical education level acknowledge that communication is a fundamental medical skill. Responding to patient, professional, governmental advocates, as well as advances in research on patient-physician communication and its teaching, some medical educators are in the process of starting new communication curricula, while others are working at expanding, integrating and further developing already well-established programs. For most people working in this area, the question is no longer whether to teach and assess communication skills and attitudes but rather, how to do so most efficiently and effectively. In order to enhance the development of communication curricula at all levels, we first provide a brief look at how communication education has become widely encouraged in many parts of the globe, and we set out the underlying assumption that frame the teaching and learning communication in medicine. We then summarize critical components common to many established communication curricula and identify a series of specific strategies for teaching communication skills. We include a chart that describes a sample of the wide variety of resources available to assist in the development and teaching of communication curricula in medicine. Finally we consider gaps in current communication curricula and suggest the next steps and ideas for moving forwards.
Reprinted with permission by Cancer Prevention and Control
- Maguire P. Can communication skills be taught? Br J Hosp Med 1990; 43(3):215-16.
Abstract: Basic interviewing skills can be learned at undergraduate and postgraduate level, providing effective methods are used. These include demonstration of key skills, practice under controlled conditions, and audiotape or videotape feedback of performance by a tutor within small groups. More complex skills can also be learned but may not be used or maintained without ongoing training and supervision.
- Mansfield F. Supervised role-play in the teaching of the process of consultation. Med Educ 1991;25:485-90.
Abstract: Supervised role-play is presented as a method for teaching the process of the medical consultation. The process of the consultation is reviewed and a brief description of supervised role-play is given with some of its advantages and disadvantages. Some simple devices used in the method are explained with examples. The 'living' nature of the consultation is emphasized and an active method of teaching is advocated.
Reprinted with permission by
Blackwell Science, Inc.
- Morgan ER, Winter RJ. Teaching communication skills. An essential part of residency training. Arch Pediatr Adolesc Med 1996; 150:638-642.
Abstract: OBJECTIVE: To design a structured curriculum concerning issues of communication with patients and families for use during training of pediatric residents. BACKGROUND: The stimulus for this initiative arose from residents perceived need for such a program and the realization that a structured approach to communication techniques did not currently exist in our residency and, in fact, in many undergraduate and graduate medical education curricula. METHODS: Our program was designed to address complex and difficult areas in physician-patient interaction, including how to deliver "bad news," deal with hostile parents, and speak to children about serious illness; the psychosocial aspects of death and dying were also covered in the program. Various teaching techniques were used. We attempted to assess residents' response and alteration in behavior consequent to the program. RESULTS: The program was successfully incorporated into the training of our residents and was carried out by using existent personnel; minimal expense was incurred. The residents thought the course was valuable and effective, although no statistically significant change in the communication skills of residents could be demonstrated. CONCLUSIONS: The area of physician-patient communication can be taught in a structured fashion during residency. Programs should be devised to meet the changing needs of training during residency and should incorporate the unique strengths of individual institutions.
Reprinted with permission by Arch Pediatr Adolesc Med 1996, 150:638-42, Copyrighted 1996, American Medical Association.
- Roter DL, Hall JA, Kern DE, Barker LR, Cole KA, Roca RP. Improving physicians' interviewing skills and reducing patients' emotional distress. A randomized clinical trial. Arch Intern Med 1995;155:1877-84.
Abstract: BACKGROUND: Despite high prevalence, emotional distress among primary care patients often goes unrecognized during routine medical encounters. OBJECTIVE: To explore the effect of communication-skills training on the process and outcome of care associated with patients' emotional distress. METHODS: A randomized, controlled field trial was conducted with 69 primary care physicians and 648 of their patients. Physicians were randomized to a no-training control group or one of two communication-skills training courses designed to help physicians address patients' emotional distress. The two training courses addressed communication through problem-defining skills or emotion- handling skills. All office visits of study physicians were audiotaped until five emotionally distressed and five nondistressed patients were enrolled based on patient response to the General Health Questionnaire. Physicians were also audiotaped interviewing a simulated patient to evaluate clinical proficiency. Telephone monitoring of distressed patients for utilization of medical services and General Health Questionnaire scores was conducted 2 weeks, 3 months, and 6 months after their audiotaped office visits. RESULTS: Audiotape analysis of actual and simulated patients showed that trained physicians used significantly more problem-defining and emotion-handling skills than did untrained physicians, without increasing the length of the visit. Trained physicians also reported more psychosocial problems, engaged in more strategies for managing emotional problems with actual patients, and scored higher in clinical proficiency with simulated patients. Patients of trained physicians reported reduction in emotional distress for as long as 6 months. CONCLUSIONS: Important changes in physicians' communication skills were evident after an 8-hour program. The training improved the process and outcome of care without lengthening the visits.
Reprinted with permission by Arch Intern Med 1995,155:1877-84, Copyrighted 1995, American Medical Association.
- Schmidt TA, Norton RL, Tolle SW. Sudden death in the ED: educating residents to compassionately inform families. J Emerg Med 1992;10:643-7.
Abstract: We describe a program used in our emergency medicine residency to help teach residents new skills in interacting with survivors following a patient's sudden death in the emergency department. This teaching module requires about two and a half hours to complete. It includes a brief presentation of new skills, videotapes of family notification, resident role play experiences, and a summary. Trained volunteers are used as simulated survivors in the role plays. Although labor intensive and time consuming, the program offers educational advantages. The residents have an opportunity to practice their communication skills in a protected setting. In addition, they receive immediate and specific feedback from the faculty facilitator, fellow residents, and, most importantly, the simulated survivor. Following the role play sessions, residents feel they are more skillful in meeting survivors' needs.
- Smith RC, Lyles JS, Mettler J, Stoffelmayr BE, Van Egeren LF, Marshall AA et al. The effectiveness of intensive training for residents in interviewing. A randomized, controlled study. Ann Intern Med 1998; 128:118-126.
Abstract: BACKGROUND: Interviewing and the physician-patient relationship are crucial elements of medical care, but residencies provide little formal instruction in these areas. OBJECTIVE: To determine the effects of a training program in interviewing on 1) residents' attitudes toward and skills in interviewing and 2) patients' physical and psychosocial well- being and satisfaction with care. DESIGN: Randomized, controlled study. SETTING: Two university-based primary care residencies. PARTICIPANTS: 63 primary care residents in postgraduate year 1. INTERVENTION: A 1- month, full-time rotation in interviewing and related psychosocial topics. MEASUREMENTS: Residents and their patients were assessed before and after the 1-month rotation. Questionnaires were used to assess residents' commitment to interviewing and psychosocial medicine, estimate of the importance of such care, and confidence in their ability to provide such care. Knowledge of interviewing and psychosocial medicine was assessed with a multiple-choice test. Audiotaped interviews with real patients and videotaped interviews with simulated patients were rated for specific interviewing behaviors. Patients' anxiety, depression, and social dysfunction; role limitations; somatic symptom status; and levels of satisfaction with medical visits were assessed by questionnaires and telephone interviews. RESULTS: Trained residents were superior to untrained residents in knowledge (difference in adjusted post-test mean scores, 15.7% [95% CI, 11% to 20%]); attitudes, such as confidence in psychological sensitivity (difference, 0.61 points on a 7-point scale [CI, 0.32 to 0.91 points]); somatization management (difference, 0.99 points [CI, 0.64 to 1.35 points]); interviewing of real patients (difference, 1.39 points on an 11-point scale [CI, 0.32 to 2.45 points]); and interviewing (data gathering) of simulated patients (difference, 2.67 points [CI, 1.77 to 3.56 points]). Mean differences between the study groups were consistently in the appropriate direction for patient satisfaction and patient well-being, but effect sizes were too small to be considered meaningful. CONCLUSION: An intensive 1-month training rotation in interviewing improved residents' knowledge about, attitudes toward, and skills in interviewing.
Reprinted with permission by Ann Intern Med, 1998, 128:118-26, Copyrighted 1998, American Medical Association.
- Stephens PA, Campbell JM. Scientific writing and editing: a new role for the library. Bull Med Libr Assoc 1995; 83:478-82.
Abstract: Traditional library instruction programs teach scientists how to find and manage information, but not how to report their research findings effectively. Since 1990, the William H. Welch Medical Library has sponsored classes on scientific writing and, since 1991, has offered a fee-based editing service for affiliates of the Johns Hopkins Medical Institutions. These programs were designed to fill an educational gap: Although formal instruction was offered to support other phases of the scientific communication process, the medical institutions had no central resource designed to help scientists develop and improve their writing skills. The establishment of such a resource at Welch has been well received by the community. Attendance at classes has grown steadily, and in 1993 a credit course on biomedical writing was added to the curriculum. The editing service, introduced in late 1991, has generated more requests for assistance than can be handled by the library's editor. This service not only extends the library's educational outreach but also generates a revenue stream. The Welch program in scientific writing and editing, or elements of it, could provide a model for other academic medical libraries interested in moving in this new direction.
The online version of this abstract was derived from the author's final submission to the Bullentin of the Medical Library Association and is used with permission of the Medical Library Association, Chicago.
- Williams GC, Deci EL. The importance of supporting autonomy in medical education. Ann Intern Med 1998;129:303-8.
Abstract: Many thoughtful leaders in medicine have asserted their belief that when physicians are more humanistic in their interactions with patients, their patients have more positive health outcomes. Consequently, many advocates have called for the practice of teaching students and residents to provide more humanistically oriented care. This article reviews research from motivational psychology, guided by self-determination theory, that suggests that when medical educators are more humanistic in their training of students, the students become more humanistic in their care of patients. Being humanistic in medical education can be achieved through support of the autonomy of students. Autonomy support means working from the students' perspectives to promote their active engagement and sense of volition with respect to learning. Research suggests that when educators are more supportive of student autonomy, students not only display a more humanistic orientation toward patients but also show greater conceptual understanding and better psychological adjustment.
Reprinted with permission by Ann Intern Med, 1998, 129:303-8, Copyright 1998, American Medical Association.
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