Training surgical residents to communicate effectively with patients in specific scenarios -- for example, when a patient has cancer -- may enhance their communication skills for specific cases, but not their general communication skills, according to a report in the August issue of Archives of Surgery, one of the JAMA/Archives journals. The article is part of the In Evolution: Surgical Training theme issue.
According to background information in the article, surgical residents in general do not have a formal curriculum for patient education and, instead, are expected to learn these skills in practice. The Accreditation Council for Graduate Medical Education considers communication skills a core competency and requires residency programs to provide documentation of formal processes to assess residents' communication abilities, provide them with feedback and utilize the assessment results to improve residents' competence in this skill. The use of standardized patients (SPs, typically actors trained to play the role of patients, evaluators and sometimes instructors in clinical examinations) is a widely accepted way of teaching and assessing clinical as well as communication skills. Previous research has examined the use of this practice for testing surgical residents in scenarios such as end-of-life family conferences and disclosure of complications.
"The goal of this project," explain the authors, "was to teach surgical residents to incorporate patient-centered communication skills into their practice, providing emotional support, transition, and continuity of care, as well as information and education, involving family and friends and respecting patient values and differences."
Rajiv Y. Chandawarkar, M.D., from the University of Connecticut School of Medicine, Farmington, and colleagues conducted a three-step study that involved 44 general surgery residents. In step one, residents underwent a simulation that involved giving SPs a diagnosis of breast cancer or rectal cancer. Their skills with condition-specific content (such as delivering the diagnosis and helping the patient understand it) and general communication were scored by the SPs. Step two involved a three-part interactive program comprising principles of patient communication, a surgeon's experience in various roles (physician, patient and patient's spouse) and role-playing in which residents played patient, physician and observer and self-rated their performances. In step three, residents were reassessed by SPs using the same tools as in step 1, with the type of cancer switched so that residents who first encountered a breast cancer simulation later encountered a rectal cancer simulation and vice versa.
A significant improvement was seen in residents' case-specific performance, from an initial median (midpoint) score of 8.5 (on a scale of 0 to 13) to a final median score of 11. Significant differences were not seen between pretest and posttest scores of participants' general communication skills. Scores did not appear to vary by type of cancer, indicating a lack of inherent bias with regards to performance comparisons in either case.
"Our results show that case-specific improvements seem more amenable to measurable improvement than general communications skills, at least with the limited short-term training that we used," write the authors. "Such skills can be assessed over a longer period, perhaps by incorporating this model and assessments from year to year." They add that the methods used in this study could be adopted by other teaching hospitals or community health centers, with modifications as needed by each program. "Without communication skills," the authors conclude, "even the best surgical training would be rendered ineffective."
- R. Y. Chandawarkar, K. A. Ruscher, A. Krajewski, M. Garg, C. Pfeiffer, R. Singh, W. E. Longo, R. A. Kozol, B. Lesnikoski, P. Nadkarni. Pretraining and Posttraining Assessment of Residents' Performance in the Fourth Accreditation Council for Graduate Medical Education Competency: Patient Communication Skills. Archives of Surgery, 2011; 146 (8): 916 DOI: 10.1001/archsurg.2011.167
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