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PEC-4793; No. of Pages 6 Patient Education and Counseling xxx (2014) xxx–xxx
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Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
Resident physicians’ attitudes and confidence in communicating with patients: A pilot study at a Japanese university hospital Hirono Ishikawa a,*, Masato Eto b, Kiyoshi Kitamura b,d, Takahiro Kiuchi a a
Department of Health Communication, The University of Tokyo, Tokyo, Japan General Education Center, University of Tokyo Hospital, Tokyo, Japan d International Research Center for Medical Education, The University of Tokyo, Tokyo, Japan b
A R T I C L E I N F O
A B S T R A C T
Article history: Available online xxx
Objective: This study aimed to explore the relationships among physicians’ confidence in conducting medical interviews, their attitudes toward the patient–physician relationship, and undergraduate training in communication skills among resident physicians in Japan. Methods: Participants were 63 first-year resident physicians at a university hospital in Tokyo. The Physician Confidence in the Medical Interview scale (PCMI) was constructed based on the framework of the Calgary–Cambridge Guide. Additionally, participants’ attitudes toward the patient–physician relationship (Patient–Practitioner Orientation Scale; PPOS), undergraduate experience of communication skills training, and demographic characteristics were assessed through a self-reported questionnaire. Results: The internal consistency of the PCMI and PPOS scales were adequate. As expected from the undergraduate curriculum for medical interviews in Japan, residents had relatively higher confidence in their communication skills with respect to gathering information and building the relationship, whereas less confident about sharing information and planning treatment. The PCMI was associated with a more patient-centered attitude as measured by the PPOS. Conclusion: These scales could be useful tools to measure physicians’ confidence and attitudes in communicating with patients and to explore their changes through medical education. Practice implications: Residency programs should consider including systematic training and assessment in communication skills related to sharing information and planning treatment. ß 2014 Elsevier Ireland Ltd. All rights reserved.
Keywords: Patient-centered Attitude Confidence Communication skills Graduate medical education
1. Introduction Numerous studies have confirmed the importance of communication skills for medical professionals. Communication skills training is now internationally accepted as an essential component of medical education [1]. With increasing attention to communication skills in medical education, physician characteristics that may influence the quality of communication have been intensively studied. Traditionally, behavioral theories have paid close attention to one’s attitudes (or beliefs) and self-efficacy (i.e., confidence in one’s ability to successfully execute the behavior required to produce the desired outcomes) as important predictors of one’s intentions and actual behavior [2]. Previous studies have explored the effect of * Corresponding author at: Department of Health Communication, School of Public Health, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo 113-8655, Japan. Tel.: +81 3 5800 8781; fax: +81 3 5689 0726. E-mail address: [email protected] (H. Ishikawa).
physicians’ attitude and confidence regarding communication with patients on their actual communication behaviors and on patient outcomes. It has been reported that physicians’ attitudes toward patient-centered and shared decision-making was related to more favorable communication behaviors, such as more engagement in emotional exchanges and the use of fewer closed-ended questions, as well as better patient outcomes, such as higher satisfaction and treatment adherence [3,4]. Also, physicians’ self-efficacy or confidence was associated with better ability to recognize patients’ needs for information and with higher patient satisfaction [5]. Although some studies have found that physician attitudes and confidence may not predict actual performance [6], these characteristics have been considered important from an educational standpoint because they can be changed through education, unlike many other physician characteristics, such as age, gender, and race. Additionally, selfreflection, i.e., the process of assessing one’s confidence and attitude in communicating with patients per se, may provide an important educational benefit for physicians.
http://dx.doi.org/10.1016/j.pec.2014.05.012 0738-3991/ß 2014 Elsevier Ireland Ltd. All rights reserved.
Please cite this article in press as: Ishikawa H, et al. Resident physicians’ attitudes and confidence in communicating with patients: A pilot study at a Japanese university hospital. Patient Educ Couns (2014), http://dx.doi.org/10.1016/j.pec.2014.05.012
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Until recently, especially in Japanese culture, communication competence was considered primarily to be an inherent ability or character trait rather than a set of skills to be acquired through education and practice. In 2001, the Report of the Coordinating Council on the Reform of Medical and Dental Education advocated guidelines for innovative changes to Japanese medical education, proposing an exemplary model of an undergraduate medical education curriculum [7], in which interpersonal relationships with patients and medical interview skills were included as important components. Furthermore, in 2005, the Objective Structured Clinical Examination (OSCE) was officially introduced as a method of assessing clinical competencies achieved through the preclinical core curriculum. Since then, many medical schools in Japan have undergone major curriculum reforms and have started to provide at least some lectures on and practice in medical interviews. Specific competence in communication skills expands as physicians advance from novice to expert in the practice of their specialty [8]. Most courses for undergraduate students emphasize training in basic interviewing skills, whereas courses for physicians are directed toward more complex skills [9]. Among the three functions of the medical interview (i.e., gathering data to understand the patient’s problems, developing rapport and responding to patients’ emotions, and educating and encouraging patients to adhere to treatment recommendations) [10], the focus of communication skills training in undergraduate medical education in Japan has been on the first two. However, before completion of a residency, physicians should demonstrate competence in applying the essential communication skills to the full range of clinical situations relevant to their specialty [8]. However, the extent to which resident physicians have confidence in their communication skills is unclear. Furthermore, communication skills training in postgraduate education has not been as well established as that in undergraduate programs. Residents are expected to learn from their everyday interactions with patients
and from observation of more senior physicians. Thus, it seems likely that what they learn during the residency program will vary depending on their attitude or motivation regarding communication with patients. Assessing the current status and relationship of physician’s confidence and attitude would be useful in considering communication skills training in postgraduate education. This study aimed to explore resident physicians’ confidence in medical interviews and its relationship to their attitude toward the patient–physician relationship and their previous experience of communication skills training at medical school in Japan. 2. Methods 2.1. Participants and procedures A total of 72 resident physicians entered a junior residency program at a university hospital in Tokyo in 2013. They were invited to participate in this questionnaire survey during the orientation sessions just before starting the residency program. Residents were informed both orally and in writing that participation was voluntary and would not influence their evaluation in the residency program. Participants received an Amazon gift certificate of 500 yen (approximately $5) in return. In total, 67 resident physicians returned a completed consent form and the questionnaire (response rate: 93.1%). Study procedures were approved by the Institutional Review Board of Graduate School of Medicine, the University of Tokyo. 2.2. Measures 2.2.1. Physician Confidence in the Medical Interview (PCMI) Based on the Calgary–Cambridge Guide to the medical interview [11] and the Macy Model of doctor–patient communication [12], a framework of physicians’ communication competence required for medical interviews was introduced in a Japanese textbook on the
Table 1 Physicians’ Confidence in the Medical Interview (PCMI): item content and means.
Initiating the session (1) Establish initial rapport (greet the patient, obtain the patient’s name, introduce oneself, etc.) (2) Elicit all of patient’s problems or reasons for the consultation (3) Negotiate an agenda taking both patient’s and physicians’ needs into account Gathering information (4) Encourage patient to tell the detailed story of the problem(s) in his/her own words (5) Actively listen, facilitating patient’s responses verbally and non-verbally (6) Clarify patient’s statements that are unclear, and periodically summarize to organize the information Providing structure (7) Share the flow of the interview with the patient (8) Summarize at appropriate points and structure the interview in a logical sequence (9) Attend to timing and keep the interview on task Building the relationship (10) Demonstrate appropriate non-verbal behavior (showing empathy, note taking, etc.) (11) Actively respond to patient emotions verbally (12) Encourage patient to participate in the decision-making process (share own thought processes, intent of the question, and the flow of the consultation) Explanation (13) Provide the correct amount and type of information (14) Share information in a way that aids accurate recall and understanding (15) Achieve shared understanding about the problems Planning (16) Encourage patient to participate in decision-making process to the level that they wish (17) Negotiate a mutually acceptable plan (18) Check with patient about whether he/she agrees and is comfortable with the plan Closing the session (19) Summarize the session briefly and clarify the plan of care (20) Assure that there is a plan for unexpected outcomes and follow-up (21) Thank the patient with appropriate parting statements Overall, achieve an interview that is fully satisfactory and accepted by the patient
Mean
SD
2.83 3.12 2.64 2.72 2.86 2.88 3.07 2.63 2.59 2.79 2.58 2.40 2.75 2.94 2.67 2.63
0.40 0.44 0.54 0.57 0.47 0.56 0.59 0.60 0.51 0.62 0.65 0.65 0.46 0.57 0.66 0.52
2.51 2.33 2.54 2.66 2.63 2.61 2.61 2.67 2.94 2.90 2.96 2.96 2.69
0.49 0.59 0.59 0.59 0.49 0.63 0.58 0.61 0.41 0.50 0.56 0.53 0.56
Note: Each item was rated on a 4-point scale with higher scores indicating greater confidence.
Please cite this article in press as: Ishikawa H, et al. Resident physicians’ attitudes and confidence in communicating with patients: A pilot study at a Japanese university hospital. Patient Educ Couns (2014), http://dx.doi.org/10.1016/j.pec.2014.05.012
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medical interview [13]. Using this framework and behavioral objectives, we developed a scale to measure physicians’ confidence in communicating with patients during the medical interviews. Residents were asked about their confidence in achieving 21 specific behavioral objectives under seven communication tasks in the medical interview: (1) initiating the session, (2) gathering information, (3) sharing information, (4) planning, (5) closing the session, (6) providing a structure, and (7) building a relationship. All scale items are presented in Table 1. Additionally, a single item asked about their overall confidence in conducting a medical interview that would be considered satisfactory and acceptable by the patient. Each item was rated on a 4-point Likert scale ranging from ‘‘not confident at all’’ to ‘‘very confident,’’ with higher scores indicating greater confidence in communicating with the patient. 2.2.2. Patient–Practitioner Orientation Scale (PPOS) The PPOS is a well-validated instrument to assess the individual’s attitude toward the patient–physician relationship [14,15]. The scale contains 18 items that reflect two domains of patient-centered practice, namely Sharing and Caring. The Sharing subscale assesses the extent to which the individual believes that the patient should receive information and be involved in decision making, and the Caring subscale assess the extent to which the patient’s expectations, feelings, and lifestyle should be taken into consideration during the medical consultation. Scoring is based on a 6-point Likert scale ranging from ‘‘strongly agree’’ to ‘‘strongly disagree,’’ with higher scores indicating a more patient-centered orientation. The scale has been translated and validated in nonWestern countries as well [16–21]. Translation into Japanese was performed following the standard procedure of translating scales [22]. First, the scale items were independently translated into Japanese by two researchers (native Japanese speakers). The two translations were reconciled by the first author through discussion with co-researchers. The reconciled version was back-translated by a bilingual Englishspeaking professional translator. The back-translated version was then sent to the author of the scale for review and comment. Based on his feedback, the wording of some items was further refined. 2.2.3. Other variables Previous communication skills education in medical schools (lectures regarding interpersonal communication or the medical interview, medical interview training sessions with simulated patients or role-play, and the OSCE), and demographic characteristics (age, gender, specialty orientation, and work experience before entering medical school) were also obtained through the self-reported questionnaire.
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Table 2 Participant characteristics and communication skills education in medical school: relationship with the PCMI and PPOS scores. N
%
PCMI
Age (years) Mean SD: 26.8 3.3 Gener Male 36 53.7 Female 31 46.3 Specialty orientation Internal 31 46.3 Surgical 17 25.4 Other/not decided 19 28.4 Studying at other universities Yes 20 29.9 No 46 68.7 Previous work experience Yes 9 13.4 No 57 85.1 Communication skills training (CST) in medical school Lectures 11 16.4 Never 1–5 lectures 27 40.3 6–10 lectures 14 20.9 11 times or more 15 22.4 CST in general Never 31 46.3 1–5 times 23 34.3 6 times or more 13 19.4 CST specific to medical interview 1–5 times 42 62.7 6–10 times 10 14.9 11 times or more 15 22.4 OSCE Once 29 43.3 Twice 22 32.8 3 times or more 16 23.9
Mean
SD
2.75 2.71
0.34 0.39
2.74 2.66 2.76
0.38 0.43 0.27
2.65 2.76
0.34 0.37
2.69 2.73
0.33 0.37
2.82 2.64 2.68 2.87
0.35 0.37 0.34 0.35
2.70 2.83 2.61
0.33 0.41 0.33
2.74 2.71 2.70
0.38 0.24 0.39
2.79 2.68 2.68
0.31 0.41 0.38
Note: PPOS: Patient–Practitioner Orientation Scale; PCMI: Physician Confidence in the Medical Interview.
school. A total of 36 male and 31 female residents (mean age, 26.8 years) completed the survey. Twenty residents (29.9%) had studied at other universities before entering medical school, and nine (13.4%) had previous work experience. During the 6 years in medical school, all participants had experienced communication skills training and assessment in the medical interview and had experienced the OSCE at least once. However, the amount of the undergraduate communication skills training varied widely among participants, suggesting differences in the curriculum of the medical schools from which they had graduated. 3.2. Physician Confidence in the Medical Interview
2.3. Statistical analysis Cronbach’s a coefficients were calculated to examine internal consistency. Exploratory factor analysis with promax rotation was performed to examine the factor structure of the PCMI. To determine the relationship between the PCMI and PPOS scales, Pearson’s correlation coefficient was calculated. A t-test was used to examine gender differences. Cases with missing values were excluded from the respective analyses. The analyses were conducted with Stata 12.0 software (Stata Corporation, TX).
The scores on each item of the scale are presented in Table 1. The items related to the tasks of providing a structure, providing explanations, and planning resulted in relatively lower scores compared with the tasks related to initiating and closing the session and gathering information. The internal consistency of the total scale was high (a = 0.92). The item–total correlations were all positive and ranged from 0.42 Table 3 PCMI and PPOS scores.
3. Results 3.1. Participant characteristics and undergraduate communication skills education Table 2 shows the participant characteristics and previous communication skills education during the 6 years in medical
PCMI total PPOS total Sharing Caring
Cronbach’s a
Mean
SD
0.92 0.71 0.64 0.56
2.73 4.55 4.35 4.76
0.36 0.41 0.54 0.42
Note: PPOS: Patient–Practitioner Orientation Scale; PCMI: Physician Confidence in the Medical Interview.
Please cite this article in press as: Ishikawa H, et al. Resident physicians’ attitudes and confidence in communicating with patients: A pilot study at a Japanese university hospital. Patient Educ Couns (2014), http://dx.doi.org/10.1016/j.pec.2014.05.012
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4 Table 4 Relationship of PCMI with PPOS.
Sharing
PPOS
PCMI Initiating the session Gathering information Providing structure Building the relationship Explanation Planning Closing the session
Caring
r
p-Value
r
p-Value
r
p-Value
0.252 0.200 0.101 0.216 0.291 0.138 0.157 0.305
0.040 0.104 0.416 0.079 0.017 0.264 0.206 0.012
0.200 0.196 0.070 0.164 0.265 0.097 0.087 0.246
0.106 0.112 0.572 0.185 0.030 0.434 0.483 0.045
0.235 0.139 0.107 0.211 0.227 0.145 0.193 0.279
0.056 0.264 0.391 0.087 0.065 0.243 0.118 0.022
Note: PPOS: Patient–Practitioner Orientation Scale; PCMI: Physician Confidence in the Medical Interview.
to 0.75. Exploratory factor analysis was performed to explore underlying factors and to determine each item’s loading on the factors. Although the initial factor solution showed three factors with eigenvalues >1 (8.0, 1.4, and 1.1), the eigenvalues declined sharply between the first and second factors, and the first factor accounted for 61.1% of the variance, followed by 10.9 and 8.4% for the second and third factors, respectively. Additionally, many items loaded on two or more factors. Given that the internal consistency of the total scale was high, we considered that it was more reasonable to use it as a total scale than to form subscales based on these factors. There was no difference in the scale scores by participant characteristics and previous communication skills training. On the other hand, a single item measuring overall confidence in performing the medical interview was significantly lower for female residents (2.52 0.57 vs. 2.83 0.51, p = 0.019). 3.3. Patient–Practitioner Orientation Scale The internal reliability, as determined by the Cronbach’s a coefficient, was adequate for the total scale and Sharing subscale, but was slightly lower for the Caring subscale (Table 3). The mean scores and SDs are presented in Table 3. The Caring score was slightly higher for female than for male residents, but the difference was not statistically significant (4.83 vs. 4.69, p = 0.199). No significant difference was found in any other scale scores by participant characteristics and previous communication skills training. 3.4. Relationship between PCMI and PPOS Overall, the physicians’ confidence in communication was associated with a more patient–centered orientation (r = 0.252, p = 0.04) (Table 4). In particular, physicians’ confidence in their communication skills related to building the relationship and closing the session were positively associated with total PPOS total scores and scores on the Sharing subscale.
4. Discussion and conclusion 4.1. Discussion The PCMI and PPOS scales were used successfully to assess physician confidence and attitudes regarding communication with patients in this survey with the Japanese resident physicians. Generally, residents had relatively high confidence in their communication skills with respect to gathering information and building a relationship, but were less confident about sharing information and planning treatment. Also, residents with more patient-centered attitudes had more confidence in their ability in medical interviews.
The internal consistency of the PCMI scale was high. The scores in the areas of sharing information and planning were relatively lower, as expected from the undergraduate curriculum addressing the medical interview in Japan. Traditionally, undergraduate medical education has concentrated on teaching students how to gather information from the patient, emphasizing the value of listening and responding as well as asking the right questions, and the training has less frequently extended to the second part of the medical interview in which the physician explains and discusses findings and treatment plans [23,24]. A previous study reported that communication skills training in interviewing skills did not necessarily improve physicians’ communication of information and advice [23]. Undergraduate education regarding the medical interview in most Japanese medical schools has focused on gathering information and building rapport with the patient in the setting of a first-visit outpatient consultation. Thus, the finding that resident physicians had greater confidence in their communication skills related to gathering information and building a relationship suggests that the educational objectives of undergraduate education have been achieved to a certain extent. However, no significant association was found between physician’s confidence and the quantity of communication skills training in medical school. Because the residents were graduates of different medical schools, the content and quality of their communication skills training would have varied greatly, although we were unable to provide details about this from the questionnaire. Further quality management and improvement in communication skills training in undergraduate medical education may still be needed. At the same time, more training during the residency program needs to be directed toward communication skills required for sharing information and negotiating treatment plans with the patient. There was a major reform of the postgraduate medical education in Japan in 2004 [25]. A mandatory 2-year postgraduate clinical rotation system was implemented to compensate for weaknesses in undergraduate clinical education. This 2-year residency program is the last mandatory educational opportunity for physicians. However, many institutions do not have a systematic training and assessment program in the area of communication skills. Communication skills training during the residency program should be considered to meet the needs of patients and to establish the competence required of resident physicians in Japan. The internal consistency of the PPOS was adequate, comparable to that in previous studies. The mean scores were similar to those reported in previous studies with post-clerkship medical students in the US [26,27] and higher than those reported in previous studies in Asian countries [16,18,19,21]. It has been suggested that attitudes toward a patient-centered approach involve a complex interplay of social tradition and culture [16]. Japanese medical schools have learned a great deal from US medical education including theories and concepts as well as educational methods
Please cite this article in press as: Ishikawa H, et al. Resident physicians’ attitudes and confidence in communicating with patients: A pilot study at a Japanese university hospital. Patient Educ Couns (2014), http://dx.doi.org/10.1016/j.pec.2014.05.012
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and programs. This may partly explain why our participants had patient-centered attitudes similar to those in the US. On the other hand, social and cultural differences may be greater between Japanese and US patients than between Japanese and US physicians [28]. Further study is needed to explore attitudes among Japanese patients and their fit with those of their physicians. No significant difference by physician characteristics was found in physician confidence regarding specific components of the medical interview, except that female residents were less confident than males that they could conduct a medical interview that would be satisfactory to the patient overall. It has been suggested that women tend to underestimate their abilities [29,30], although they may actually conduct better medical interviews with the patient, engaging in more patient-centered communication [31]. In assessing physician confidence and its relationship with actual communication behaviors, physician gender should be considered. In general, the residents with more patient-centered attitudes were more confident about their communication with patients. They may have been more motivated to learn communication skills during their undergraduate education. Further investigation is needed to determine whether and how attitudes toward the patient–physician relationship might influence the process of learning the communication skills needed for the medical interview. These scales may be a useful tool for measuring physicians’ attitudes and their confidence about the medical interview and for exploring how these factors change as a result of communication skills training. Several limitations should be noted in interpreting our study findings. First, we recognize that our sample was small and may not be representative of resident physicians in Japan. On the other hand, this university hospital has one of the largest groups of residents in a junior residency program, and the proportion of the residents who graduated from its own university medical school is lower compared with other university hospitals in Japan. Thus, it was considered a reasonable sample for a pilot study. Second, sociocultural context and practice style may differ between Japanese and Western cultures, and our findings may be specific to the Japanese sociocultural context. At minimum, however, our results were basically consistent with previous studies in the US, and the scores on the PPOS were quite similar. Third, it has been widely acknowledged that physicians’ self-assessment of their competence does not necessarily reflect their actual competence [6,32]. Further investigation is needed to explore the meaning of physicians’ confidence and to confirm the validity and applicability of the scales by testing their relationship with observed communication skills. 4.2. Conclusion As expected from the undergraduate curriculum addressing the medical interview in Japan, residents had relatively higher confidence in their communication skills for gathering information and building the relationship, and they were less confident about their ability to share information and plan treatment. Training in communication skills appropriate to explanation and treatment planning may be needed during the residency program. The internal consistency of the PCMI and PPOS scales were adequate, and both were successfully used in this survey with the Japanese resident physicians. The scales could be useful tools for measuring physicians’ confidence in and attitudes toward communicating with patients and for exploring changes in these domains as a result of communication skills training. Further investigation is needed to confirm the validity and applicability of the scales by testing their relationship with the observed communication skills.
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4.3. Practice implications The residency program should consider including systematic training in and assessment of communication skills focusing on explaining results and planning treatment. The scales used in this study could be used to measure physicians’ confidence and attitudes in communicating with patients and to explore changes in these resulting from communication skills training. Conflict of interest The authors have no conflicts of interest to report. Acknowledgments We sincerely thank Dr. Kei Mukohara at National Hospital Organization Nagasaki Medical Center for his help in developing the PCMI scale. We are also grateful to Dr.Edward Krupat at Harvard Medical School for his valuable advice regarding the PPOS. This study was supported by JSPS KAKENHI Grant Number 24390163. References [1] Core Committee, Institute for International Medical Education. Global minimum essential requirements in medical education. Med Teach 2002;24:130– 5. [2] Glanz K, Rimer BK, Viswanath K, editors. Health behavior and health education: theory, research, and practice. 4th ed., California: Jossey-Bass Publishers; 2008. [3] Roter DL, Hall JA. Doctors talking with patients/patients talking with doctors: improving communication in medical visits. 2nd ed. Westport, CT: Praeger Publishers; 2006. [4] Stewart M, Brown JB, Weston WW, McWhinney IR, McWilliam CL, Freeman TR. Patient-centered medicine transforming the clinical method. 2nd ed. Oxford, UK: Radcliffe Medical Press; 2003. [5] De Vries AM, de Roten Y, Meystre C, Passchier J, Despland JN, Stiefel F. Clinician characteristics, communication, and patient outcome in oncology: a systematic review. Psychooncology 2014;23:375–81. [6] Davis DA, Mazmanian PE, Fordis M, Van Harrison R, Thorpe KE, Perrier L. Accuracy of physician self-assessment compared with observed measures of competence: a systematic review. J Amer Med Assoc 2006;296:1094–102. [7] Kozu T. Medical education in Japan. Acad Med 2006;81:1069–75. [8] Duffy FD, Gordon GH, Whelan G, Cole-Kelly K, Frankel R, Buffone N, et al. Assessing competence in communication and interpersonal skills: the Kalamazoo II report. Acad Med 2004;79:495–507. [9] Aspegren K. BEME Guide No. 2: teaching and learning communication skills in medicine-a review with quality grading of articles. Med Teach 1999;21:563– 70. [10] Cohen-Cole SA. The medical interview: the three function approach. St. Louis, MO: Mosby-Year Book, Inc.; 1991. [11] Kurtz S, Silverman J, Benson J, Draper J. Marrying content and process in clinical method teaching: enhancing the Calgary-Cambridge guides. Acad Med 2003;78:802–9. [12] Kalet A, Pugnaire MP, Cole-Kelly K, Janicik R, Ferrara E, Schwartz MD, et al. Teaching communication in clinical clerkships: models from the Macy initiative in health communications. Acad Med 2004;79:511–20. [13] Mukohara K. Medical interview: evidence-based approach. Tokyo: Bunkyodo; 2006 [in Japanese]. [14] Krupat E, Hiam CM, Fleming MZ, Freeman P. Patient-centeredness and its correlates among first year medical students. Int J Psychiatry Med 1999;29:347–56. [15] Krupat E, Rosenkranz SL, Yeager CM, Barnard K, Putnam SM, Inui TS. The practice orientations of physicians and patients: the effect of doctor–patient congruence on satisfaction. Patient Educ Couns 2000;39:49–59. [16] Lee KH, Seow A, Luo N, Koh D. Attitudes towards the doctor–patient relationship: a prospective study in an Asian medical school. Med Educ 2008;42:1092–9. [17] Pereira CM, Amaral CF, Ribeiro MM, Paro HB, Pinto RM, Reis LE, et al. Crosscultural validation of the Patient–Practitioner Orientation Scale (PPOS). Patient Educ Couns 2013;91:37–43. [18] Moore M. What does patient-centred communication mean in Nepal? Med Educ 2008;42:18–26. [19] Al-Bawardy R, Blatt B, Al-Shohaib S, Simmens SJ. Cross-cultural comparison of the patient-centeredness of the hidden curriculum between a Saudi Arabian and 9 US medical schools. Med Educ Online 2009;14:19. [20] Chan CM, Azman WA. Attitudes and role orientations on doctor–patient fit and patient satisfaction in cancer care. Singapore Med J 2012;53:52–6.
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PEC-4793; No. of Pages 6 Patient Education and Counseling xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
Resident physicians’ attitudes and confidence in communicating with patients: A pilot study at a Japanese university hospital Hirono Ishikawa a,*, Masato Eto b, Kiyoshi Kitamura b,d, Takahiro Kiuchi a a
Department of Health Communication, The University of Tokyo, Tokyo, Japan General Education Center, University of Tokyo Hospital, Tokyo, Japan d International Research Center for Medical Education, The University of Tokyo, Tokyo, Japan b
A R T I C L E I N F O
A B S T R A C T
Article history: Available online xxx
Objective: This study aimed to explore the relationships among physicians’ confidence in conducting medical interviews, their attitudes toward the patient–physician relationship, and undergraduate training in communication skills among resident physicians in Japan. Methods: Participants were 63 first-year resident physicians at a university hospital in Tokyo. The Physician Confidence in the Medical Interview scale (PCMI) was constructed based on the framework of the Calgary–Cambridge Guide. Additionally, participants’ attitudes toward the patient–physician relationship (Patient–Practitioner Orientation Scale; PPOS), undergraduate experience of communication skills training, and demographic characteristics were assessed through a self-reported questionnaire. Results: The internal consistency of the PCMI and PPOS scales were adequate. As expected from the undergraduate curriculum for medical interviews in Japan, residents had relatively higher confidence in their communication skills with respect to gathering information and building the relationship, whereas less confident about sharing information and planning treatment. The PCMI was associated with a more patient-centered attitude as measured by the PPOS. Conclusion: These scales could be useful tools to measure physicians’ confidence and attitudes in communicating with patients and to explore their changes through medical education. Practice implications: Residency programs should consider including systematic training and assessment in communication skills related to sharing information and planning treatment. ß 2014 Elsevier Ireland Ltd. All rights reserved.
Keywords: Patient-centered Attitude Confidence Communication skills Graduate medical education
1. Introduction Numerous studies have confirmed the importance of communication skills for medical professionals. Communication skills training is now internationally accepted as an essential component of medical education [1]. With increasing attention to communication skills in medical education, physician characteristics that may influence the quality of communication have been intensively studied. Traditionally, behavioral theories have paid close attention to one’s attitudes (or beliefs) and self-efficacy (i.e., confidence in one’s ability to successfully execute the behavior required to produce the desired outcomes) as important predictors of one’s intentions and actual behavior [2]. Previous studies have explored the effect of * Corresponding author at: Department of Health Communication, School of Public Health, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo 113-8655, Japan. Tel.: +81 3 5800 8781; fax: +81 3 5689 0726. E-mail address: [email protected] (H. Ishikawa).
physicians’ attitude and confidence regarding communication with patients on their actual communication behaviors and on patient outcomes. It has been reported that physicians’ attitudes toward patient-centered and shared decision-making was related to more favorable communication behaviors, such as more engagement in emotional exchanges and the use of fewer closed-ended questions, as well as better patient outcomes, such as higher satisfaction and treatment adherence [3,4]. Also, physicians’ self-efficacy or confidence was associated with better ability to recognize patients’ needs for information and with higher patient satisfaction [5]. Although some studies have found that physician attitudes and confidence may not predict actual performance [6], these characteristics have been considered important from an educational standpoint because they can be changed through education, unlike many other physician characteristics, such as age, gender, and race. Additionally, selfreflection, i.e., the process of assessing one’s confidence and attitude in communicating with patients per se, may provide an important educational benefit for physicians.
http://dx.doi.org/10.1016/j.pec.2014.05.012 0738-3991/ß 2014 Elsevier Ireland Ltd. All rights reserved.
Please cite this article in press as: Ishikawa H, et al. Resident physicians’ attitudes and confidence in communicating with patients: A pilot study at a Japanese university hospital. Patient Educ Couns (2014), http://dx.doi.org/10.1016/j.pec.2014.05.012
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Until recently, especially in Japanese culture, communication competence was considered primarily to be an inherent ability or character trait rather than a set of skills to be acquired through education and practice. In 2001, the Report of the Coordinating Council on the Reform of Medical and Dental Education advocated guidelines for innovative changes to Japanese medical education, proposing an exemplary model of an undergraduate medical education curriculum [7], in which interpersonal relationships with patients and medical interview skills were included as important components. Furthermore, in 2005, the Objective Structured Clinical Examination (OSCE) was officially introduced as a method of assessing clinical competencies achieved through the preclinical core curriculum. Since then, many medical schools in Japan have undergone major curriculum reforms and have started to provide at least some lectures on and practice in medical interviews. Specific competence in communication skills expands as physicians advance from novice to expert in the practice of their specialty [8]. Most courses for undergraduate students emphasize training in basic interviewing skills, whereas courses for physicians are directed toward more complex skills [9]. Among the three functions of the medical interview (i.e., gathering data to understand the patient’s problems, developing rapport and responding to patients’ emotions, and educating and encouraging patients to adhere to treatment recommendations) [10], the focus of communication skills training in undergraduate medical education in Japan has been on the first two. However, before completion of a residency, physicians should demonstrate competence in applying the essential communication skills to the full range of clinical situations relevant to their specialty [8]. However, the extent to which resident physicians have confidence in their communication skills is unclear. Furthermore, communication skills training in postgraduate education has not been as well established as that in undergraduate programs. Residents are expected to learn from their everyday interactions with patients
and from observation of more senior physicians. Thus, it seems likely that what they learn during the residency program will vary depending on their attitude or motivation regarding communication with patients. Assessing the current status and relationship of physician’s confidence and attitude would be useful in considering communication skills training in postgraduate education. This study aimed to explore resident physicians’ confidence in medical interviews and its relationship to their attitude toward the patient–physician relationship and their previous experience of communication skills training at medical school in Japan. 2. Methods 2.1. Participants and procedures A total of 72 resident physicians entered a junior residency program at a university hospital in Tokyo in 2013. They were invited to participate in this questionnaire survey during the orientation sessions just before starting the residency program. Residents were informed both orally and in writing that participation was voluntary and would not influence their evaluation in the residency program. Participants received an Amazon gift certificate of 500 yen (approximately $5) in return. In total, 67 resident physicians returned a completed consent form and the questionnaire (response rate: 93.1%). Study procedures were approved by the Institutional Review Board of Graduate School of Medicine, the University of Tokyo. 2.2. Measures 2.2.1. Physician Confidence in the Medical Interview (PCMI) Based on the Calgary–Cambridge Guide to the medical interview [11] and the Macy Model of doctor–patient communication [12], a framework of physicians’ communication competence required for medical interviews was introduced in a Japanese textbook on the
Table 1 Physicians’ Confidence in the Medical Interview (PCMI): item content and means.
Initiating the session (1) Establish initial rapport (greet the patient, obtain the patient’s name, introduce oneself, etc.) (2) Elicit all of patient’s problems or reasons for the consultation (3) Negotiate an agenda taking both patient’s and physicians’ needs into account Gathering information (4) Encourage patient to tell the detailed story of the problem(s) in his/her own words (5) Actively listen, facilitating patient’s responses verbally and non-verbally (6) Clarify patient’s statements that are unclear, and periodically summarize to organize the information Providing structure (7) Share the flow of the interview with the patient (8) Summarize at appropriate points and structure the interview in a logical sequence (9) Attend to timing and keep the interview on task Building the relationship (10) Demonstrate appropriate non-verbal behavior (showing empathy, note taking, etc.) (11) Actively respond to patient emotions verbally (12) Encourage patient to participate in the decision-making process (share own thought processes, intent of the question, and the flow of the consultation) Explanation (13) Provide the correct amount and type of information (14) Share information in a way that aids accurate recall and understanding (15) Achieve shared understanding about the problems Planning (16) Encourage patient to participate in decision-making process to the level that they wish (17) Negotiate a mutually acceptable plan (18) Check with patient about whether he/she agrees and is comfortable with the plan Closing the session (19) Summarize the session briefly and clarify the plan of care (20) Assure that there is a plan for unexpected outcomes and follow-up (21) Thank the patient with appropriate parting statements Overall, achieve an interview that is fully satisfactory and accepted by the patient
Mean
SD
2.83 3.12 2.64 2.72 2.86 2.88 3.07 2.63 2.59 2.79 2.58 2.40 2.75 2.94 2.67 2.63
0.40 0.44 0.54 0.57 0.47 0.56 0.59 0.60 0.51 0.62 0.65 0.65 0.46 0.57 0.66 0.52
2.51 2.33 2.54 2.66 2.63 2.61 2.61 2.67 2.94 2.90 2.96 2.96 2.69
0.49 0.59 0.59 0.59 0.49 0.63 0.58 0.61 0.41 0.50 0.56 0.53 0.56
Note: Each item was rated on a 4-point scale with higher scores indicating greater confidence.
Please cite this article in press as: Ishikawa H, et al. Resident physicians’ attitudes and confidence in communicating with patients: A pilot study at a Japanese university hospital. Patient Educ Couns (2014), http://dx.doi.org/10.1016/j.pec.2014.05.012
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medical interview [13]. Using this framework and behavioral objectives, we developed a scale to measure physicians’ confidence in communicating with patients during the medical interviews. Residents were asked about their confidence in achieving 21 specific behavioral objectives under seven communication tasks in the medical interview: (1) initiating the session, (2) gathering information, (3) sharing information, (4) planning, (5) closing the session, (6) providing a structure, and (7) building a relationship. All scale items are presented in Table 1. Additionally, a single item asked about their overall confidence in conducting a medical interview that would be considered satisfactory and acceptable by the patient. Each item was rated on a 4-point Likert scale ranging from ‘‘not confident at all’’ to ‘‘very confident,’’ with higher scores indicating greater confidence in communicating with the patient. 2.2.2. Patient–Practitioner Orientation Scale (PPOS) The PPOS is a well-validated instrument to assess the individual’s attitude toward the patient–physician relationship [14,15]. The scale contains 18 items that reflect two domains of patient-centered practice, namely Sharing and Caring. The Sharing subscale assesses the extent to which the individual believes that the patient should receive information and be involved in decision making, and the Caring subscale assess the extent to which the patient’s expectations, feelings, and lifestyle should be taken into consideration during the medical consultation. Scoring is based on a 6-point Likert scale ranging from ‘‘strongly agree’’ to ‘‘strongly disagree,’’ with higher scores indicating a more patient-centered orientation. The scale has been translated and validated in nonWestern countries as well [16–21]. Translation into Japanese was performed following the standard procedure of translating scales [22]. First, the scale items were independently translated into Japanese by two researchers (native Japanese speakers). The two translations were reconciled by the first author through discussion with co-researchers. The reconciled version was back-translated by a bilingual Englishspeaking professional translator. The back-translated version was then sent to the author of the scale for review and comment. Based on his feedback, the wording of some items was further refined. 2.2.3. Other variables Previous communication skills education in medical schools (lectures regarding interpersonal communication or the medical interview, medical interview training sessions with simulated patients or role-play, and the OSCE), and demographic characteristics (age, gender, specialty orientation, and work experience before entering medical school) were also obtained through the self-reported questionnaire.
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Table 2 Participant characteristics and communication skills education in medical school: relationship with the PCMI and PPOS scores. N
%
PCMI
Age (years) Mean SD: 26.8 3.3 Gener Male 36 53.7 Female 31 46.3 Specialty orientation Internal 31 46.3 Surgical 17 25.4 Other/not decided 19 28.4 Studying at other universities Yes 20 29.9 No 46 68.7 Previous work experience Yes 9 13.4 No 57 85.1 Communication skills training (CST) in medical school Lectures 11 16.4 Never 1–5 lectures 27 40.3 6–10 lectures 14 20.9 11 times or more 15 22.4 CST in general Never 31 46.3 1–5 times 23 34.3 6 times or more 13 19.4 CST specific to medical interview 1–5 times 42 62.7 6–10 times 10 14.9 11 times or more 15 22.4 OSCE Once 29 43.3 Twice 22 32.8 3 times or more 16 23.9
Mean
SD
2.75 2.71
0.34 0.39
2.74 2.66 2.76
0.38 0.43 0.27
2.65 2.76
0.34 0.37
2.69 2.73
0.33 0.37
2.82 2.64 2.68 2.87
0.35 0.37 0.34 0.35
2.70 2.83 2.61
0.33 0.41 0.33
2.74 2.71 2.70
0.38 0.24 0.39
2.79 2.68 2.68
0.31 0.41 0.38
Note: PPOS: Patient–Practitioner Orientation Scale; PCMI: Physician Confidence in the Medical Interview.
school. A total of 36 male and 31 female residents (mean age, 26.8 years) completed the survey. Twenty residents (29.9%) had studied at other universities before entering medical school, and nine (13.4%) had previous work experience. During the 6 years in medical school, all participants had experienced communication skills training and assessment in the medical interview and had experienced the OSCE at least once. However, the amount of the undergraduate communication skills training varied widely among participants, suggesting differences in the curriculum of the medical schools from which they had graduated. 3.2. Physician Confidence in the Medical Interview
2.3. Statistical analysis Cronbach’s a coefficients were calculated to examine internal consistency. Exploratory factor analysis with promax rotation was performed to examine the factor structure of the PCMI. To determine the relationship between the PCMI and PPOS scales, Pearson’s correlation coefficient was calculated. A t-test was used to examine gender differences. Cases with missing values were excluded from the respective analyses. The analyses were conducted with Stata 12.0 software (Stata Corporation, TX).
The scores on each item of the scale are presented in Table 1. The items related to the tasks of providing a structure, providing explanations, and planning resulted in relatively lower scores compared with the tasks related to initiating and closing the session and gathering information. The internal consistency of the total scale was high (a = 0.92). The item–total correlations were all positive and ranged from 0.42 Table 3 PCMI and PPOS scores.
3. Results 3.1. Participant characteristics and undergraduate communication skills education Table 2 shows the participant characteristics and previous communication skills education during the 6 years in medical
PCMI total PPOS total Sharing Caring
Cronbach’s a
Mean
SD
0.92 0.71 0.64 0.56
2.73 4.55 4.35 4.76
0.36 0.41 0.54 0.42
Note: PPOS: Patient–Practitioner Orientation Scale; PCMI: Physician Confidence in the Medical Interview.
Please cite this article in press as: Ishikawa H, et al. Resident physicians’ attitudes and confidence in communicating with patients: A pilot study at a Japanese university hospital. Patient Educ Couns (2014), http://dx.doi.org/10.1016/j.pec.2014.05.012
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4 Table 4 Relationship of PCMI with PPOS.
Sharing
PPOS
PCMI Initiating the session Gathering information Providing structure Building the relationship Explanation Planning Closing the session
Caring
r
p-Value
r
p-Value
r
p-Value
0.252 0.200 0.101 0.216 0.291 0.138 0.157 0.305
0.040 0.104 0.416 0.079 0.017 0.264 0.206 0.012
0.200 0.196 0.070 0.164 0.265 0.097 0.087 0.246
0.106 0.112 0.572 0.185 0.030 0.434 0.483 0.045
0.235 0.139 0.107 0.211 0.227 0.145 0.193 0.279
0.056 0.264 0.391 0.087 0.065 0.243 0.118 0.022
Note: PPOS: Patient–Practitioner Orientation Scale; PCMI: Physician Confidence in the Medical Interview.
to 0.75. Exploratory factor analysis was performed to explore underlying factors and to determine each item’s loading on the factors. Although the initial factor solution showed three factors with eigenvalues >1 (8.0, 1.4, and 1.1), the eigenvalues declined sharply between the first and second factors, and the first factor accounted for 61.1% of the variance, followed by 10.9 and 8.4% for the second and third factors, respectively. Additionally, many items loaded on two or more factors. Given that the internal consistency of the total scale was high, we considered that it was more reasonable to use it as a total scale than to form subscales based on these factors. There was no difference in the scale scores by participant characteristics and previous communication skills training. On the other hand, a single item measuring overall confidence in performing the medical interview was significantly lower for female residents (2.52 0.57 vs. 2.83 0.51, p = 0.019). 3.3. Patient–Practitioner Orientation Scale The internal reliability, as determined by the Cronbach’s a coefficient, was adequate for the total scale and Sharing subscale, but was slightly lower for the Caring subscale (Table 3). The mean scores and SDs are presented in Table 3. The Caring score was slightly higher for female than for male residents, but the difference was not statistically significant (4.83 vs. 4.69, p = 0.199). No significant difference was found in any other scale scores by participant characteristics and previous communication skills training. 3.4. Relationship between PCMI and PPOS Overall, the physicians’ confidence in communication was associated with a more patient–centered orientation (r = 0.252, p = 0.04) (Table 4). In particular, physicians’ confidence in their communication skills related to building the relationship and closing the session were positively associated with total PPOS total scores and scores on the Sharing subscale.
4. Discussion and conclusion 4.1. Discussion The PCMI and PPOS scales were used successfully to assess physician confidence and attitudes regarding communication with patients in this survey with the Japanese resident physicians. Generally, residents had relatively high confidence in their communication skills with respect to gathering information and building a relationship, but were less confident about sharing information and planning treatment. Also, residents with more patient-centered attitudes had more confidence in their ability in medical interviews.
The internal consistency of the PCMI scale was high. The scores in the areas of sharing information and planning were relatively lower, as expected from the undergraduate curriculum addressing the medical interview in Japan. Traditionally, undergraduate medical education has concentrated on teaching students how to gather information from the patient, emphasizing the value of listening and responding as well as asking the right questions, and the training has less frequently extended to the second part of the medical interview in which the physician explains and discusses findings and treatment plans [23,24]. A previous study reported that communication skills training in interviewing skills did not necessarily improve physicians’ communication of information and advice [23]. Undergraduate education regarding the medical interview in most Japanese medical schools has focused on gathering information and building rapport with the patient in the setting of a first-visit outpatient consultation. Thus, the finding that resident physicians had greater confidence in their communication skills related to gathering information and building a relationship suggests that the educational objectives of undergraduate education have been achieved to a certain extent. However, no significant association was found between physician’s confidence and the quantity of communication skills training in medical school. Because the residents were graduates of different medical schools, the content and quality of their communication skills training would have varied greatly, although we were unable to provide details about this from the questionnaire. Further quality management and improvement in communication skills training in undergraduate medical education may still be needed. At the same time, more training during the residency program needs to be directed toward communication skills required for sharing information and negotiating treatment plans with the patient. There was a major reform of the postgraduate medical education in Japan in 2004 [25]. A mandatory 2-year postgraduate clinical rotation system was implemented to compensate for weaknesses in undergraduate clinical education. This 2-year residency program is the last mandatory educational opportunity for physicians. However, many institutions do not have a systematic training and assessment program in the area of communication skills. Communication skills training during the residency program should be considered to meet the needs of patients and to establish the competence required of resident physicians in Japan. The internal consistency of the PPOS was adequate, comparable to that in previous studies. The mean scores were similar to those reported in previous studies with post-clerkship medical students in the US [26,27] and higher than those reported in previous studies in Asian countries [16,18,19,21]. It has been suggested that attitudes toward a patient-centered approach involve a complex interplay of social tradition and culture [16]. Japanese medical schools have learned a great deal from US medical education including theories and concepts as well as educational methods
Please cite this article in press as: Ishikawa H, et al. Resident physicians’ attitudes and confidence in communicating with patients: A pilot study at a Japanese university hospital. Patient Educ Couns (2014), http://dx.doi.org/10.1016/j.pec.2014.05.012
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and programs. This may partly explain why our participants had patient-centered attitudes similar to those in the US. On the other hand, social and cultural differences may be greater between Japanese and US patients than between Japanese and US physicians [28]. Further study is needed to explore attitudes among Japanese patients and their fit with those of their physicians. No significant difference by physician characteristics was found in physician confidence regarding specific components of the medical interview, except that female residents were less confident than males that they could conduct a medical interview that would be satisfactory to the patient overall. It has been suggested that women tend to underestimate their abilities [29,30], although they may actually conduct better medical interviews with the patient, engaging in more patient-centered communication [31]. In assessing physician confidence and its relationship with actual communication behaviors, physician gender should be considered. In general, the residents with more patient-centered attitudes were more confident about their communication with patients. They may have been more motivated to learn communication skills during their undergraduate education. Further investigation is needed to determine whether and how attitudes toward the patient–physician relationship might influence the process of learning the communication skills needed for the medical interview. These scales may be a useful tool for measuring physicians’ attitudes and their confidence about the medical interview and for exploring how these factors change as a result of communication skills training. Several limitations should be noted in interpreting our study findings. First, we recognize that our sample was small and may not be representative of resident physicians in Japan. On the other hand, this university hospital has one of the largest groups of residents in a junior residency program, and the proportion of the residents who graduated from its own university medical school is lower compared with other university hospitals in Japan. Thus, it was considered a reasonable sample for a pilot study. Second, sociocultural context and practice style may differ between Japanese and Western cultures, and our findings may be specific to the Japanese sociocultural context. At minimum, however, our results were basically consistent with previous studies in the US, and the scores on the PPOS were quite similar. Third, it has been widely acknowledged that physicians’ self-assessment of their competence does not necessarily reflect their actual competence [6,32]. Further investigation is needed to explore the meaning of physicians’ confidence and to confirm the validity and applicability of the scales by testing their relationship with observed communication skills. 4.2. Conclusion As expected from the undergraduate curriculum addressing the medical interview in Japan, residents had relatively higher confidence in their communication skills for gathering information and building the relationship, and they were less confident about their ability to share information and plan treatment. Training in communication skills appropriate to explanation and treatment planning may be needed during the residency program. The internal consistency of the PCMI and PPOS scales were adequate, and both were successfully used in this survey with the Japanese resident physicians. The scales could be useful tools for measuring physicians’ confidence in and attitudes toward communicating with patients and for exploring changes in these domains as a result of communication skills training. Further investigation is needed to confirm the validity and applicability of the scales by testing their relationship with the observed communication skills.
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