Teaching consultation skills in higher specialist training: experience of a workshop for specialist registrars in rheumatology

V. Cooper and A. Hassell1

Keele University School of Medicine, Thornburrow Drive, Hartshill, Stoke on Trent ST4 7QB and
1 Staffordshire Rheumatology Centre, The Haywood Hospital, Burslem, Stoke on Trent ST6 7AG, UK

Abstract

Objectives. To design, implement and evaluate an initial communication skills workshop for higher specialist trainees in rheumatology, and to determine their prior experience of and attitude towards such training.

Methods. The setting for this study was a rheumatology specialist registrar study day in the West Midlands region of the UK. The workshop was jointly facilitated by a hospital specialist and a general practitioner educationist, providing both the credibility of subject expertise and experience of teaching consultation skills to groups of doctors. Simple, structured observations of pre-recorded consultations and simulations, based on scenarios from within the specialist field, were used.

Results. There was strong agreement amongst the trainees that the workshop was enjoyable and useful, that prior training and experience in this area was inadequate, and that it is feasible and important to develop the communication skills of hospital specialists.

Conclusions. Undergraduate teaching in communication skills has been inadequate in the past and it receives little or no attention in most specialist training. There is a compelling argument for the inclusion of communication skills teaching in higher medical training within rheumatology. More work is required to research the optimum methods of delivering teaching in this area in a postgraduate setting, and to assess the impact of communication skills teaching on clinical practice.

KEY WORDS: Communication, Communication skills, Physician–patient relationship, Medical education.

The importance of communication skills teaching in the context of undergraduate medical education has increasingly been recognized over the past decade. Within postgraduate medical education, its role in the curriculum is stressed in the training of general practitioners (GPs). It can also be argued that teaching in this area should continue in the postgraduate setting in secondary care, particularly as the content of many secondary care consultations requires a high level of specialist knowledge.

Successful consultations are the foundation of good medical practice and demand competent communication skills from all doctors. In a publication entitled ‘Tomorrow's doctors' the General Medical Council has listed, among essential attributes of every independent practitioner regardless of speciality, possession of consultation skills, which include ‘skills in sensitive and effective communication with patients and their families...’ [1].

Patients rightly expect their doctors to be effective communicators, and communication failure has been cited as the commonest cause of complaint by patients [2, 3]. Specific areas of complaint centre on: failure to gather adequate and accurate information; failure to provide sufficient, comprehensible information; failure to listen to patients' concerns; neglect of patients' psychosocial needs; and failure to develop a mutually acceptable relationship with patients [4].

There is evidence that patients benefit from consultations with doctors possessing good interpersonal skills, not only in terms of satisfaction but also through improved compliance with treatment and better health outcomes [4]. Even when the physician has no effective therapy to offer, demonstrating understanding and empathy and providing adequate information reduces patient anxiety and distress [2].

Consultation skills can be taught and assessed [5], and there is a significant evidence base to inform the context, content and methods of such teaching [2, 6, 7]. Even taking a biomedical view of the consultation, in which eliciting all relevant information and reaching a clear diagnosis is the paramount goal, there is evidence that specific teaching of communication skills improves the performance of medical students and that this improvement is sustained [8].

Prior to 1991, there seems to have been very little undergraduate teaching of communication skills in UK medical schools [9], and there is evidence that implementation is still patchy and poorly integrated, with departments of psychiatry and general practice being the prime movers [4]. Therefore, it is to be expected that many UK doctors currently undergoing specialist training will not have experienced any communication skills training and would benefit from this, both for their own clinical practice and as teachers and supervisors of their juniors.

In the UK, the specialist registrar has been established as a higher-grade training post that leads to accreditation for eligibility to become a consultant [10]. Within the medical specialities, the post is started after completion of the Royal College of Physicians membership examination. Specialist registrars in rheumatology in West Midlands have monthly joint educational workshops, lasting a full day. Until the advent of the workshop reported here, the emphasis had tended to be on specialist skills and knowledge.

The consultation skills workshop

We planned a half-day introductory workshop on communication skills for this group of specialist registrars. With no prior knowledge of their experience in this field and a suspicion that few, if any, would have been exposed to video recording before, we were careful to design a non-threatening workshop format. We considered it important that facilitation of the workshop should be conducted jointly by a hospital specialist and a general practitioner. Evaluation included an attitudinal questionnaire and asked for suggestions about preferences for further teaching.

Objectives
As an introductory workshop, we set limited and rather general objectives:

Structure and process
A key element in planning the workshop was to demonstrate cooperation between a consultant, with subject-specific knowledge and skills, and a general practitioner educationist, with generic skills in consultation teaching and practice. The latter was responsible for the overall format of the workshop, whilst the former constructed the case scenarios and led discussion on these.

The workshop took place in a postgraduate medical centre, away from everyone's usual place of work. It was planned as a half-day session for 14 registrars. Following a brief introduction, it consisted of the following three main components.

(i) Small group discussion to address the following questions:

(ii) Videotape of consultations. Consultations were selected from videotape recorded by the facilitators and shown to the groups after a short introduction, emphasizing important ‘rules' for handling this material.

Using different consultations, groups experimented with simple behavioural observations such as body language, who did most talking, and what was the style of questioning. Next, they tried using some models of the consultation [11, 12] to explore whether this increased their understanding of the process.

(iii) Simulation exercise, using ‘triads’. Groups were given some typical scenarios from their own speciality and asked to give suitable explanations to a ‘patient’; they then received feedback from an observer. The use of ‘triads' or ‘trios' is well established in general practice education [13], allowing each member the chance to be doctor, ‘patient’ and observer in a relatively non-threatening environment. There is no need for complex role-play planning because the doctor assumes his or her normal role and the ‘patient’ is a passive recipient.

Scenarios were chosen to reflect different aspects of hospital rheumatological practice. The scenarios were: (i) explaining to a patient with a mechanical back problem that no further medical interventions will be helpful or appropriate; (ii) explaining to a young woman with lupus nephritis that she requires treatment with potent cytotoxic therapy; and (iii) explaining to a new patient that he or she has rheumatoid arthritis.

Evaluation questionnaire

At the end of the workshop, participants were given a questionnaire and asked to complete this individually and leave it in the room. The first seven questions involved evaluation of the workshop in terms of its objectives, enjoyment and relevance. A statement was followed by a 40 mm visual analogue scale to represent level of agreement or disagreement. The next four questions used the same scale to test response to a series of statements about consultation skills teaching and the use of videotape. Participants were asked to rate elements of the presentation as below, equal to or above their expectation. The final section of the questionnaire included questions on prior experience of communication skills teaching, at what level of training it is appropriate, and some open-ended questions on the workshop.

Measurement of the mark along the visual analogue scale (mm from the appropriate end) was converted into scores and used to tabulate responses.

Results of evaluation

Fourteen specialist registrars took part in the workshop and all completed an evaluation form. Six registrars had experienced no prior teaching of communication skills. Of the eight who reported prior experience, three cited minimal undergraduate teaching, three had spent time as GP trainees after graduation, and two mentioned organized undergraduate teaching during the general practice or psychiatry components.

Responses indicated that all had enjoyed the workshop and that the overall objectives had been achieved (Table 1Go). Objective 4 received the lowest rating, with several participants commenting that a follow-up workshop using their own videotape would be helpful.


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TABLE 1. Achievement of workshop objectives

 
Responses to the attitudinal questions showed a high level of agreement that GP and specialist consultations are comparable in terms of communication skills, that such skills can be taught and learned, and that the workshop had improved their skills. There was a very strong feeling that good communication is not merely the province of general practice and that, as professionals, we should spend more time discussing what to tell patients and how to do it. The majority of participants perceived videotape (implicitly of their own consultations) as threatening (Table 2Go).


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TABLE 2. Attitude survey

 
Specific features of the workshop attracting favourable comment were: non-threatening use of small groups; integration of theory and practice; and informal and interactive approach.

Suggestions for how the workshop could have been improved centred on more role-play, use of video recording in the workshop and more time for small group work.

Discussion

We have described successful implementation of an initial consultation skills workshop for rheumatology specialist registrars. We found that the trainees' prior experience of consultation skills training was meagre, that they enjoyed the workshop and that they considered it relevant to their current practice. Nearly half of the participants had no prior teaching in communication skills and few reported any systematic teaching, except in general practice attachments. This confirms the reported survey findings. The majority felt strongly that communication skills could be improved with education and that this is important for all specialists. The Toronto Consensus [2] suggested that: ‘Communication skills training should be taught at all levels of the curriculum: further development of skills is needed as students encounter more complex situations and interpersonal skills, like other skills, benefit from reinforcement’. The response of this group supports this recommendation and suggests that there is an urgent need to teach consultation skills during postgraduate specialist training and not merely to wait until future cohorts emerge from the new undergraduate curriculum. Moreover, it is highly likely that even doctors completing the new undergraduate curriculum will benefit from further consultation skills training. Whilst generic consultation skills might be learned as an undergraduate, skills around the discussion with patients of sophisticated issues requiring specialist knowledge may surely only be dealt with in the context of higher medical training. A recent study by Donovan and Blake drew particular attention to one crucial aspect of communication, the nature of reassurance given to patients with rheumatological problems [13]. It is clearly essential that such research impacts upon rheumatology higher specialist training. The Royal College of Physicians has recognized the importance of communication skills in the postgraduate setting by incorporating ‘practical assessment of clinical examination skills (PACES)’ into the new membership examination, which includes two stations (out of six) in which communication skills are observed by the examiners.

The finding that most participants would feel threatened by the use of videotape confirms that we were right to be cautious in planning this initial workshop and to use only pre-recorded tape as an introduction. Those who commented felt safe and supported in the workshop and would like to venture further, with more role-play and use of personal video recording. Joint facilitation by an established specialist and a general practitioner experienced in consultation skills teaching provides a credible framework for teaching senior trainees, using complex situations from the speciality. This addresses some of the objections to teaching of ‘soft’ material and the problem of lack of integration [4].

The ‘triad’ exercise generated a lively theoretical discussion about broader ethical issues (informed consent, involving patients in decisions about risks and benefits, having no more therapy to offer) as well as communication problems. Informal feedback revealed that most of the registrars (12 out of 14) had had no opportunity to discuss such issues with peers or supervisors. Interactive case-based learning [14] may be a useful addition to formal specialist education, as it is in postgraduate education for general practice.

We believe that regular systematic teaching and evaluating of communication skills should be a core component of all specialist training programmes, to fill the gaps in undergraduate training, to complement development of new specialist knowledge and skills, and as a means of reinforcing and extending prior skills. There is a compelling argument for further work in this area, in particular to explore the prior experience of specialist registrars in all disciplines, the efficacy of consultation skills training in this group, and mechanisms for assessing these skills during higher specialist training.

Notes

Correspondence to: V. Cooper. Back

References

  1. General Medical Council. Tomorrow's doctors: recommendations on undergraduate medical education. London: General Medical Council,1993.
  2. Simpson M, Buckman R, Stewart M et al. Doctor–patient communication: the Toronto consensus statement. Br Med J 1991;303:1385–7.[ISI][Medline]
  3. HMSO. Health Services Commissioner for England, for Scotland and for Wales, Annual Report for 1992–93. London: HMSO,1993.
  4. Hargie O, Dickson D, Boohan M, Hughes K. A survey of communication skills training in UK Schools of Medicine: present practices and prospective proposals. Med Educ 1998;32:25–34.[ISI][Medline]
  5. Cooper C, Mira M. Who should assess medical students' communication skills: their academic teachers or their patients? Med Educ 1998;32:419–21.[ISI][Medline]
  6. Kurtz S, Silverman JD. The Calgary–Cambridge Referenced Observation Guides: an aid to defining the curriculum and organizing the teaching in communication training programmes. Med Educ 1996;30:83–9.[ISI][Medline]
  7. 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.[ISI]
  8. Evans BJ, Coman GJ, Goss B. Consulting skills training and medical students' interviewing efficiency. Med Educ 1996;30:121–8.[ISI][Medline]
  9. Whitehouse CR. The teaching of communication skills in United Kingdom medical schools. Med Educ 1991;25:311–8.[ISI][Medline]
  10. Calman KC, Temple JG, Naysmith R, Cairncross RG, Bennett SJ. Reforming higher specialist training in the United Kingdom—a step along the continuum of medical education. Med Educ 1999;33:28–33.[ISI][Medline]
  11. Pendleton D, Schofield T, Tate P et al. The consultation: an approach to learning and teaching. Oxford: Oxford University Press,1992.
  12. Neighbour R. The inner consultation. Lancaster, UK: Kluwer,1987.
  13. Donovan JL, Blake DR. Qualitative study of interpretation of reassurance among patients attending rheumatology clinics: ‘Just a touch of arthritis, doctor?’. Br Med J 2000;320:541–4.[Abstract/Free Full Text]
  14. McEvoy P. Educating the future GP. Oxford: Radcliffe Medical Press,1998.
Submitted 16 November 2001; Accepted 15 March 2002