Downloaded from http://pmj.bmj.com/ on May 31, 2015 - Published by group.bmj.com
Original article
Impact of a faculty development programme for teaching communication skills on participants’ practice Noelle Junod Perron,1,2 Stephane Cullati,3 Patricia Hudelson,4 Mathieu Nendaz,2,5 Diana Dolmans,6 Cees van der Vleuten6 1
Division of Primary Care, Department of Community Care, Primary Care and Emergency, Geneva University Hospitals, Geneva, Switzerland 2 Unit of Development and Research in Medical Education, University of Geneva Faculty of Medicine, Geneva, Switzerland 3 Quality of Care Service, Medical Directorate, Geneva University Hospitals, Geneva, Switzerland 4 Department of Community Care, Primary Care and Emergency, Geneva University Hospitals, Geneva, Switzerland 5 Department of Internal Medicine, Rehabilitation and Geriatric Medicine, Geneva, Switzerland 6 Department for Educational Development and Research, Maastricht University, Maastricht, The Netherlands Correspondence to Dr Noelle Junod Perron, Division of Primary Care, Department of community care, primary care and emergency, Geneva University Hospitals, 4 rue Gabrielle Perret-Gentil, 1211 Geneva 4, Switzerland; [email protected] Received 14 December 2012 Revised 10 February 2014 Accepted 14 February 2014 Published Online First 17 March 2014
ABSTRACT Purpose of the study A 6-month faculty development programme was designed to improve supervisors’ feedback to junior doctors on their clinical communication skills (CS) and included both CS and teaching skills training. The aim of this study was to assess supervisors’ views on the impact of the programme on their subsequent teaching and communication practice. Study design 28 clinical supervisors at the Geneva University Hospitals, from either inpatient or outpatient settings (general internists or primary care specialists), undertook a six-session faculty development programme, between 2009 and 2011, and each completed a short questionnaire before and 1 month after the course. Between 3 and 6 months after the course, the participants were interviewed about their views on the impact of the course on their practice using a semistructured interview. Interviews were audiotaped and transcribed verbatim and analysed thematically. Results The percentage of participants who reported teaching CS at least once a week had increased from 5/26 (19%) to 8/26 (30%), p=0.07. Participants reported using teaching skills, especially giving structured feedback. Use of newly acquired teaching skills was more likely when participants had protected time for teaching or were involved in formal teaching activities. Even participants who reported minimal teaching activity found the newly acquired CS to be useful, both with their own patients and in other professional situations. The few participants who explicitly reported teaching regularly CS in practice had generally become formal teachers in CS training. Conclusions A faculty development programme on how to teach CS is perceived to be useful by clinical supervisors to acquire new skills, but using them in the workplace appears to depend on creation of a supportive environment with protected time for teaching. Involving supervisors in formal communication teaching may be one way to ensure continued use of newly learned teaching skills.
INTRODUCTION
To cite: Junod Perron N, Cullati S, Hudelson P, et al. Postgrad Med J 2014;90:245–250.
Effective communication skills are of central importance in healthcare and have a positive impact on patient and physician’ satisfaction and patient outcomes.1 2 There is strong evidence that communication skills can improve and be retained with appropriate training.3 4 A majority of medical schools now offer formal communication skills training as part of their curricula. However, development of longitudinal training of communication skills after medical school remains difficult.
Junod Perron N, et al. Postgrad Med J 2014;90:245–250. doi:10.1136/postgradmedj-2012-131700
Clinical skills are best taught and learned in the clinical environment.5 Nonetheless, teaching of communication skills to medical students and junior doctors during clinical training remains insufficient6–8 and deficiencies in interviewing and communication skills have been observed among junior doctors in several countries, even after completion of postgraduate training.9 10 Supervisors do not systematically observe junior doctors taking a history11 and rarely give feedback on their communication skills7 12 despite the fact that junior doctors expect their supervisors to do so.13–15 Educators encounter several challenges when teaching communication skills to junior doctors.16 Formal training opportunities decrease after medical school and teaching and learning still rely heavily on a master–apprentice model where teaching is often unplanned and occurs through implicit role modelling.17 Clinical faculty are less likely to teach communication skills at the bedside or in the consultation room, and communication skills teaching has recently been described as highly variable, rarely explicit and relying primarily on role modelling.18 Several faculty development programmes have been developed and reported on in the last 20 years to help faculty improve their teaching skills.19 Despite the fact that supervisors express a need for additional training in physician–patient communication in order to teach these skills to others,20 only a few authors describe specific training programmes on how to teach communication skills.21–23 Little is known about their use and factors influencing their use in practice. At the University Hospitals of Geneva, we developed a training programme for clinical supervisors working in hospital medicine and in a primary care clinic (see box 1). The programme focused simultaneously on improving supervisors’ own clinical communication skills and their teaching skills. The overall aim of the programme was to increase the frequency and quality of communication skills teaching that occurred in the clinical context. The programme was effective in improving supervisors’ teaching skills, as assessed in simulated objective structured teaching encounters.26 In particular, supervisors learned to explore and adapt to the learning needs of junior doctors, stimulate junior doctors’ skills self-assessment and check their understanding of training content. However, actual use of these new teaching skills in the workplace (often referred to as ‘transfer’) was not evaluated. Training transfer is considered to be effective when the knowledge, skills and abilities acquired in the training context produce the 245
Downloaded from http://pmj.bmj.com/ on May 31, 2015 - Published by group.bmj.com
Original article
Box 1 Details of the training programme
Box 2 Study setting and participants’ role
The 6-month training programme consisted of
Setting The University Hospitals of Geneva is a 1900-bed hospital serving a population of 470 000. The General Internal Medicine Service offers 3 years of training in internal medicine to about 80 junior doctors a year. Of these, 40 work on the general internal medicine wards for 12–18 months and are supervised by 15 clinical supervisors. The other 40 rotate in different settings such as the intensive care unit, the emergencies or subspecialty units. The Division of Primary Care offers 1–2 years of training in ambulatory care to 40 junior doctors nearing the end of their postgraduate training, most of whom have completed 2– 4 years of training in inpatient internal medicine. They are supervised by 18 clinical supervisors. Participants’ role Clinical supervisors in both services usually have a minimum of 4–5 years of postgraduate training. They work as clinical supervisors for 2–5 years before either moving into private practice, specialising in a medical subspecialty or taking on more academic and management responsibilities within the hospital service.
▸ 4–5 small group sessions (6–7 h in total) over a period of 3 months where participants would simultaneously learn communication and teaching skills. It was based on clinical supervisors’ and junior doctors’ needs and adapted to institutional constraints.24 25 Communication skills: – to explain a procedure, to break bad news, to conduct a family discussion in the inpatient setting. – to explain a diagnosis, to manage time consultation with a talkative patient and to manage a difficult consultation with an angry patient in the outpatient setting. Teaching skills: – to give feedback. – During these sessions, participants had to alternatively play the role of a clinician interacting with a simulated patient, a supervisor giving feedback and an observer analysing the communication and/or the teaching process. ▸ 2 individual coaching sessions (2 h in total) 3 months following the training course during which participants watched and discussed two self-videotaped feedback sessions on junior doctors’ communication skills made before the training. After training, they were offered to take part in formative assessment sessions for second and third year medical students where they could practice their feedback skills on students’ history taking, communication and physical exam skills. desired behavioural change in the workplace context.27 The aim of the present study was to explore participants’ perceptions of the impact of our faculty development programme on their teaching and communication practice post-training, and to identify factors that facilitate transfer of skills to practice.
METHODS Design We used a short pre-post self-report questionnaire to evaluate the frequency of communication skills teaching in the workplace. We conducted semistructured interviews with participants to explore the perceived impact of the training programme on their teaching and communication practices, and the factors that facilitated skills transfer.
Setting
Semistructured interviews Participants were interviewed 3–6 months after completion of the training programme. These interviews were conducted by either a medical anthropologist (PH) or a sociologist (SC) who had no prior involvement in the development, implementation and evaluation of the training programme. Interviews lasted 20– 40 min and explored participants’ perceptions about which teaching and communication skills they were able to transfer into practice and what factors facilitated such transfer (see interview guide in box 3). Interviews were audiorecorded and transcribed ad verbatim.
Box 3 Interview guide
The study was conducted in the inpatient service of general internal medicine and the outpatient division of primary care of the University Hospitals of Geneva, Switzerland (box 2).
Participants All 28 clinical supervisors who took part in the faculty development programme were invited to participate. They all worked as clinical supervisors in either the inpatient or the outpatient setting during 2009–2010 or 2010–2011 (box 2).
Data collection Self-report questionnaire A pre-training and post-training self-report questionnaire was completed twice by all training programme participants, once 246
before and once a month after the end of the training. In addition to sociodemographic questions, the questionnaire asked, “How often do you teach communication skills in clinical practice?” and “Did you supervise formative assessment sessions for medical students this year?”.
▸ What do you remember about the training programme on how to teach communication skills to junior doctors? ▸ What did you get out of the training programme? What did you learn? ▸ What was less useful or lacking in the training programme? ▸ What did you learn that you now apply in your daily work? ▸ What did you learn that you do not apply in your daily work? Why not? ▸ To what extent did you find support in your division to apply what you learned? ▸ In your opinion, what could be done to help you put into practice what you learned?
Junod Perron N, et al. Postgrad Med J 2014;90:245–250. doi:10.1136/postgradmedj-2012-131700
Downloaded from http://pmj.bmj.com/ on May 31, 2015 - Published by group.bmj.com
Original article Data analysis Survey We used MacNemar tests to analyse potential differences in communication skills teaching frequency before and after training, with a p value
Original article
Impact of a faculty development programme for teaching communication skills on participants’ practice Noelle Junod Perron,1,2 Stephane Cullati,3 Patricia Hudelson,4 Mathieu Nendaz,2,5 Diana Dolmans,6 Cees van der Vleuten6 1
Division of Primary Care, Department of Community Care, Primary Care and Emergency, Geneva University Hospitals, Geneva, Switzerland 2 Unit of Development and Research in Medical Education, University of Geneva Faculty of Medicine, Geneva, Switzerland 3 Quality of Care Service, Medical Directorate, Geneva University Hospitals, Geneva, Switzerland 4 Department of Community Care, Primary Care and Emergency, Geneva University Hospitals, Geneva, Switzerland 5 Department of Internal Medicine, Rehabilitation and Geriatric Medicine, Geneva, Switzerland 6 Department for Educational Development and Research, Maastricht University, Maastricht, The Netherlands Correspondence to Dr Noelle Junod Perron, Division of Primary Care, Department of community care, primary care and emergency, Geneva University Hospitals, 4 rue Gabrielle Perret-Gentil, 1211 Geneva 4, Switzerland; [email protected] Received 14 December 2012 Revised 10 February 2014 Accepted 14 February 2014 Published Online First 17 March 2014
ABSTRACT Purpose of the study A 6-month faculty development programme was designed to improve supervisors’ feedback to junior doctors on their clinical communication skills (CS) and included both CS and teaching skills training. The aim of this study was to assess supervisors’ views on the impact of the programme on their subsequent teaching and communication practice. Study design 28 clinical supervisors at the Geneva University Hospitals, from either inpatient or outpatient settings (general internists or primary care specialists), undertook a six-session faculty development programme, between 2009 and 2011, and each completed a short questionnaire before and 1 month after the course. Between 3 and 6 months after the course, the participants were interviewed about their views on the impact of the course on their practice using a semistructured interview. Interviews were audiotaped and transcribed verbatim and analysed thematically. Results The percentage of participants who reported teaching CS at least once a week had increased from 5/26 (19%) to 8/26 (30%), p=0.07. Participants reported using teaching skills, especially giving structured feedback. Use of newly acquired teaching skills was more likely when participants had protected time for teaching or were involved in formal teaching activities. Even participants who reported minimal teaching activity found the newly acquired CS to be useful, both with their own patients and in other professional situations. The few participants who explicitly reported teaching regularly CS in practice had generally become formal teachers in CS training. Conclusions A faculty development programme on how to teach CS is perceived to be useful by clinical supervisors to acquire new skills, but using them in the workplace appears to depend on creation of a supportive environment with protected time for teaching. Involving supervisors in formal communication teaching may be one way to ensure continued use of newly learned teaching skills.
INTRODUCTION
To cite: Junod Perron N, Cullati S, Hudelson P, et al. Postgrad Med J 2014;90:245–250.
Effective communication skills are of central importance in healthcare and have a positive impact on patient and physician’ satisfaction and patient outcomes.1 2 There is strong evidence that communication skills can improve and be retained with appropriate training.3 4 A majority of medical schools now offer formal communication skills training as part of their curricula. However, development of longitudinal training of communication skills after medical school remains difficult.
Junod Perron N, et al. Postgrad Med J 2014;90:245–250. doi:10.1136/postgradmedj-2012-131700
Clinical skills are best taught and learned in the clinical environment.5 Nonetheless, teaching of communication skills to medical students and junior doctors during clinical training remains insufficient6–8 and deficiencies in interviewing and communication skills have been observed among junior doctors in several countries, even after completion of postgraduate training.9 10 Supervisors do not systematically observe junior doctors taking a history11 and rarely give feedback on their communication skills7 12 despite the fact that junior doctors expect their supervisors to do so.13–15 Educators encounter several challenges when teaching communication skills to junior doctors.16 Formal training opportunities decrease after medical school and teaching and learning still rely heavily on a master–apprentice model where teaching is often unplanned and occurs through implicit role modelling.17 Clinical faculty are less likely to teach communication skills at the bedside or in the consultation room, and communication skills teaching has recently been described as highly variable, rarely explicit and relying primarily on role modelling.18 Several faculty development programmes have been developed and reported on in the last 20 years to help faculty improve their teaching skills.19 Despite the fact that supervisors express a need for additional training in physician–patient communication in order to teach these skills to others,20 only a few authors describe specific training programmes on how to teach communication skills.21–23 Little is known about their use and factors influencing their use in practice. At the University Hospitals of Geneva, we developed a training programme for clinical supervisors working in hospital medicine and in a primary care clinic (see box 1). The programme focused simultaneously on improving supervisors’ own clinical communication skills and their teaching skills. The overall aim of the programme was to increase the frequency and quality of communication skills teaching that occurred in the clinical context. The programme was effective in improving supervisors’ teaching skills, as assessed in simulated objective structured teaching encounters.26 In particular, supervisors learned to explore and adapt to the learning needs of junior doctors, stimulate junior doctors’ skills self-assessment and check their understanding of training content. However, actual use of these new teaching skills in the workplace (often referred to as ‘transfer’) was not evaluated. Training transfer is considered to be effective when the knowledge, skills and abilities acquired in the training context produce the 245
Downloaded from http://pmj.bmj.com/ on May 31, 2015 - Published by group.bmj.com
Original article
Box 1 Details of the training programme
Box 2 Study setting and participants’ role
The 6-month training programme consisted of
Setting The University Hospitals of Geneva is a 1900-bed hospital serving a population of 470 000. The General Internal Medicine Service offers 3 years of training in internal medicine to about 80 junior doctors a year. Of these, 40 work on the general internal medicine wards for 12–18 months and are supervised by 15 clinical supervisors. The other 40 rotate in different settings such as the intensive care unit, the emergencies or subspecialty units. The Division of Primary Care offers 1–2 years of training in ambulatory care to 40 junior doctors nearing the end of their postgraduate training, most of whom have completed 2– 4 years of training in inpatient internal medicine. They are supervised by 18 clinical supervisors. Participants’ role Clinical supervisors in both services usually have a minimum of 4–5 years of postgraduate training. They work as clinical supervisors for 2–5 years before either moving into private practice, specialising in a medical subspecialty or taking on more academic and management responsibilities within the hospital service.
▸ 4–5 small group sessions (6–7 h in total) over a period of 3 months where participants would simultaneously learn communication and teaching skills. It was based on clinical supervisors’ and junior doctors’ needs and adapted to institutional constraints.24 25 Communication skills: – to explain a procedure, to break bad news, to conduct a family discussion in the inpatient setting. – to explain a diagnosis, to manage time consultation with a talkative patient and to manage a difficult consultation with an angry patient in the outpatient setting. Teaching skills: – to give feedback. – During these sessions, participants had to alternatively play the role of a clinician interacting with a simulated patient, a supervisor giving feedback and an observer analysing the communication and/or the teaching process. ▸ 2 individual coaching sessions (2 h in total) 3 months following the training course during which participants watched and discussed two self-videotaped feedback sessions on junior doctors’ communication skills made before the training. After training, they were offered to take part in formative assessment sessions for second and third year medical students where they could practice their feedback skills on students’ history taking, communication and physical exam skills. desired behavioural change in the workplace context.27 The aim of the present study was to explore participants’ perceptions of the impact of our faculty development programme on their teaching and communication practice post-training, and to identify factors that facilitate transfer of skills to practice.
METHODS Design We used a short pre-post self-report questionnaire to evaluate the frequency of communication skills teaching in the workplace. We conducted semistructured interviews with participants to explore the perceived impact of the training programme on their teaching and communication practices, and the factors that facilitated skills transfer.
Setting
Semistructured interviews Participants were interviewed 3–6 months after completion of the training programme. These interviews were conducted by either a medical anthropologist (PH) or a sociologist (SC) who had no prior involvement in the development, implementation and evaluation of the training programme. Interviews lasted 20– 40 min and explored participants’ perceptions about which teaching and communication skills they were able to transfer into practice and what factors facilitated such transfer (see interview guide in box 3). Interviews were audiorecorded and transcribed ad verbatim.
Box 3 Interview guide
The study was conducted in the inpatient service of general internal medicine and the outpatient division of primary care of the University Hospitals of Geneva, Switzerland (box 2).
Participants All 28 clinical supervisors who took part in the faculty development programme were invited to participate. They all worked as clinical supervisors in either the inpatient or the outpatient setting during 2009–2010 or 2010–2011 (box 2).
Data collection Self-report questionnaire A pre-training and post-training self-report questionnaire was completed twice by all training programme participants, once 246
before and once a month after the end of the training. In addition to sociodemographic questions, the questionnaire asked, “How often do you teach communication skills in clinical practice?” and “Did you supervise formative assessment sessions for medical students this year?”.
▸ What do you remember about the training programme on how to teach communication skills to junior doctors? ▸ What did you get out of the training programme? What did you learn? ▸ What was less useful or lacking in the training programme? ▸ What did you learn that you now apply in your daily work? ▸ What did you learn that you do not apply in your daily work? Why not? ▸ To what extent did you find support in your division to apply what you learned? ▸ In your opinion, what could be done to help you put into practice what you learned?
Junod Perron N, et al. Postgrad Med J 2014;90:245–250. doi:10.1136/postgradmedj-2012-131700
Downloaded from http://pmj.bmj.com/ on May 31, 2015 - Published by group.bmj.com
Original article Data analysis Survey We used MacNemar tests to analyse potential differences in communication skills teaching frequency before and after training, with a p value
