communication skills for medical residents

Patient Education and Counseling 102 (2019) 1104–1110

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Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou

Effectiveness of a brief training program in relational/communication skills for medical residents Miguel Barbosaa,* , Lidia Del Piccolob , António Barbosaa a b

Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Italy

A R T I C L E I N F O

A B S T R A C T

Article history: Received 11 July 2018 Received in revised form 18 December 2018 Accepted 20 January 2019

Objective: To assess the effectiveness of a brief training program in relational/communication skills (RCS) for medical residents. Methods: This longitudinal study enrolled 64 medical residents who participated in a RCS training program in small groups. Teaching was based on interviews with standardized patients and reflective practice. Video-recorded consultations were coded according to the Verona-Coding-Definitions-ofEmotional-Sequences (VR-CoDES) and a coding system developed to assess ten communication skills for breaking bad news. The outcome measures were: independent raters’ score in RCS for breaking bad news and the percentage of providing space and empathic responses, by comparing baseline (T1) skills with those after three-days (T2) and three-months (T3). Results: After the training program residents provided more space for further disclosure of cues and concerns according to VR-CoDES definitions. There were significant improvements in seven of the ten communication skills for breaking bad news. All of these improvements were observed either at T2 or at T3. Conclusion: This study demonstrates the effectiveness of a brief RCS training program designed to improve medical residents’ ability to respond appropriately to patients’ cues and concerns and to conduct a breaking bad news encounter. Practice implications: Brief RCS training programs adopting multiple approaches, should be offered as mandatory during residency programs. © 2019 Elsevier B.V. All rights reserved.

Keywords: Breaking bad news Communication skills training Relationship-centered care Standardized/simulated patient Residents VR-CoDES

1. Introduction Relational and communication skills are a central component of clinical competence and a cornerstone of quality of care [1,2]. They are the building blocks for communicating effectively with patient and family members. An effective communication is a process of a mutual interaction that effectively facilitates patient involvement in healthcare decision making and treatment adherence, increases patient satisfaction and compliance, optimizes health care utilization, and positively influences patients’ health outcomes [3–5]. Considering the positive impact of skillful communication, research on the effective and efficient educational strategies for improving clinicians’ relational and communication skills is paramount.

* Corresponding author at: Av. Prof. Egas Moniz, 1649-028, Lisboa, Portugal. E-mail addresses: [email protected] (M. Barbosa), [email protected] (L. Del Piccolo), [email protected] (A. Barbosa). https://doi.org/10.1016/j.pec.2019.01.013 0738-3991/© 2019 Elsevier B.V. All rights reserved.

Research has shown that communication skills training programs designed for physicians and medical residents in different specialties and health contexts can be successful [6–8]. However, there is substantive heterogeneity of these training programs and little is known about the ideal length of both the training sessions and the programs, and the particular contribution of the educational strategies included in the programs [7]. Merckaert, Libert, and Razavi [9] recommend low trainees-tofacilitator ratios and the use of multiple methods for practice and feedback. In their meta-analytic study, Barth and Lannen [10] recommend training courses of at least 3 days’ length, the inclusion of booster training sessions at a later date, and the use of role-play exercises to practice and assess communication skills. Video, real demonstrations, role play, and standardized patients encounters have proved to be effective educational tools in facilitating communication skills across multiple health professions [11,12]. Additional educational strategies may enhance the effectiveness of the training programs, including trainees’ self-analysis of their own performance recorded by video and reflective practice on challenging cases from clinical practice. A combination of multiple

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educational modalities, in a brief and intensive format of training, would be useful in the clinical context where clinicians are overloaded and time constrained. Relational/communication skills (RCS) courses should be organized in clinician’s place of work, during working hours in order to balance maximum effect and workload [7]. On the basis of these aforementioned assumptions, we designed and implemented a brief (10-hours) relational/communication skills training program based on a relationship-centered care (RCC) framework [13–17]. The program consists of multimodality educational strategies, including didactic lectures, standardized patients encounters, constructive feedback, and individual reflective practice. The aim of the current study was to assess the effectiveness of this brief RCS training program. To address this aim, we evaluated whether trainees on completion of the program (a) spent more time exploring patient’s perspective/ psychosocial issues; (b) improved their ability to acknowledge, explore, and address patients’ emotional cues and concerns; and (c) enhanced their communication skills in breaking bad news encounters.

fear of not being able to follow the growth of the grandchild, and issues relating to body image and sexual health. During the period between T2 and T3, each resident developed a written reflective report in which he/she described and reflected on four challenging communication situations he/she had to manage during his/her own clinical practice and which communication strategies he/she used to deal with the patient.

2. Methods

2.4. Measures

2.1. Study design

2.4.1. Demographic and occupational/training information Age, sex, medical specialty, average hours of patient contact per week and previous communications skills training. Three measures of residents’ communicative behavior were analyzed:

In a longitudinal study, we followed a cohort of residents in different specialties of medicine. The study sample consisted of ninety-two medical residents (76.1% were female) who formed a consecutive sample among those who undertook a regular RCS training program at the Faculty of Medicine of the University of Lisbon. 2.2. The relational and communication skills training program The RCS training program is a regular program developed at the Faculty of Medicine of the University of Lisbon for medical residents. The training was free of charge and was comprised of the following: a one-hour lecture, three three-hour practical sessions and individual reflective practice. Each session addressed specific topics of breaking bad news and palliative care (e.g., cancer diagnosis, discussing prognosis, conducting a family conference, dealing with conflicting expectations, and transition to palliative care) and included: (a) the use of standardized patients to practice RCS in small groups (3–4 participants), and (b) constructive feedback from professional actors, resident peers, and an experienced facilitator, including questions to promote residents’ selfawareness of the relational dynamic between them and the patient. During the first session, residents participated in a onehour lecture on the framework for RCS and relationship-centered care and received a manual on communication skills. Training sessions were arranged at baseline (T1) and at three-days (T2) and three-months (T3) thereafter. During each training session, each resident performed two standardized interviews: the first one was conducted alone, with no presence of any colleague, and was followed by the feedback from the facilitator; the second one was conducted in the presence of the resident’s peers, and each resident was required to reflect on his/her performance, having received feedback from the actor, the peers, and the facilitator. Each resident then received his/her own videos to review and selfanalyze on the basis of the feedback received. The two standardized patients were a male and a female. Each patient had a diagnosis of malignancy (prostate in the case of the male and breast cancer in the female) at the same clinical phase and they exhibited similar psychosocial and spiritual/existential concerns. Therefore, residents faced up to similar challenges: responding to strong emotions, how to tell the news to family members, intense

2.3. Procedure During the first session, residents were randomly assigned to interviewing either the male or the female standardized patient. During the second session, they were assigned to the other standardized patient, and in the third session, they were again randomly assigned to one of the two standardized patients. The facilitator was a highly experienced psychiatrist, trained in psychooncology and palliative care, and was the same for all small groups. All videos of the interviews were analyzed by two independent coders, who were blinded to the time and sequence of the assessments.

2.4.2. Patient’s perspective Patient and residents’ utterances were coded as biomedical (e.g., symptoms, diagnosis, prognostic, treatments) or psychosocial (e.g., feelings, thoughts, concerns, needs, and expectations). The percentage of time (seconds) that residents devoted to each perspective was then calculated. 2.4.3. Residents’ responsiveness to patient’s emotional cues and concerns Standardized patients’ and residents’ utterances were coded using the Verona Coding Definitions of Emotional Sequences and Health Provider Responses (VR-CoDES) [18,19]. This system classifies health provider responses to patient cues and concerns through sequence analysis and a detailed description of how providers handle patient’s expressions of emotion. Given the total number of residents’ responses during the standardized patients encounters, the percentage of five composite sets of responses were created by using the VR-CoDES categories: (a) the reducing space category was created by summing up the total percentage of non-explicit and explicit responses that reduced space for further disclosure, including: ignoring, shutting down, giving information advice, switching, post-poning, and active blocking; (b) the nonexplicit provision of space category was derived by summing up the total percentage of silence, back-channel, non-explicit acknowledgement, and active invitation; (c) the content exploration category assessed whether residents explicitly acknowledged and requested further information on the content related to the cue or the concern and was created by summing up the total percentage of explicit acknowledgement and exploration of content; (d) the affect acknowledgement/exploration category assessed whether residents explicitly referred to the emotional aspect of the cue or concern (i.e., acknowledge) or whether the residents’ explicitly picked up the affective aspect of the cue or concern (i.e., explore) and was derived by summing up the total percentage of explicitly acknowledgement and exploration of affect; and (e) the empathy category assessed whether residents legitimized or shared the patient’s emotion and was created by

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summing up the total percentage of non-explicit and explicit empathic responses. The use of percentages allowed for a common metric to compare residents’ responses to cues and concerns during the different sessions of the training. Two coders, blinded to the time of assessment, independently coded 30 consultations in random order. Inter-coder agreement was calculated by Cohen’s kappa coefficient and indicated good agreement: 0.87 for space reduction, 0.81 for non-explicit provision of space, .82 for content exploration, .80 for affect Acknowledgement/exploration, and 0.86 for empathy. 2.4.4. Communication skills for breaking bad news Inspired by the SPIKES protocol [20], ten communication skills were rated on a 4-points Likert scale that defined the quality of residents’ responses: (a) to understand patient’s perspective; (b) to respond to patient’s emotional cues; (c) to explore what patient already knows before giving the bad news; (d) to transmit information step-by-step; (e) to explain diagnosis and symptoms; (f) to discuss treatment alternatives; (g) to plan and orient; (g) to offer partnership; (i) to check for understanding/questions; and (j) to summarize information and establish a follow-up plan. Inter-coder reliability was evaluated by computing the intra-class correlation coefficient (ICC) of the ratings of two coders [21]. The average ICCs obtained were consistently high and above 0.86 for all communication skills. 2.5. Statistical analysis We carried out repeated analyses of variance (ANOVA) to determine: (a) the percentage of time devoted to paying attention to patient’s perspective, (b) the frequency of each category of residents responses to patients’ cues and concerns (i.e., space reduction, non-explicit provision of space, content exploration, affect acknowledgement/exploration, and empathy), (c) the score in each of the ten communication skills for breaking bad news across the three training sessions (T1, T2, T3). Tukey’s post hoc tests were used to discriminate differences between groups. All statistical analyses were carried out using SPSS for Windows, version 22. Findings were denoted as statistically significant at p < .05. 3. Results 3.1. Sample characteristics The sample comprised 64 residents who completed data at T1, T2, and T3. Of the 92 residents included in the study, 14 dropped out or could not be reached for follow-up at T2. Of the remaining 76, an additional 14 were excluded from analysis because there were video/audio problems (inaudible or stopped recording) in at least one of the assessment sessions. A comparison of baseline characteristics between participants and non-participants (Table 1) showed that the residents were comparable for all variables except the average number of patient contact hours per week, which was lower in those who completed all three sessions of the training compared to the non-participating group (t(90) = -3.20, p = .002).

Table 1 Baseline characteristics of medical resident sample. Characteristics

Initial sample n = 92

29.48 (6.22) Age in years, mean (SD) Female (%) 70 (76.1%) Medical specialty (%) Internal medicine 43 (46.7%) Oncology 28 (30.4%) Family practice 21 (22.8%) Average hours of patient contact per week(%) < 31 hours 9 (9.8%) 31-40 hours 37 (40.2%) > 40 hours 46 (50.0%) Previous communications skills training 21 (24.7%) (%)

Final sample n = 64 29.31 (6.34) 49 (76.6%) 31 (48.4%) 17 (26.6%) 16 (25%) 9 (14%) 28 (43.8%) 27 (42.2%) 15 (24.6%)

3.3. Residents’ responsiveness to the patient’s cues and concerns Patients expressed 678 cues and concerns at T1, 595 at T2, and 596 at T3, showing significant differences among the three sessions (F(2, 62) = 4.88, p = .015). Tukey’s post hoc tests showed that there were more cues and concerns per consultation at T1 (M = 10.69, SD = .47) than at T2 (M = 9.34, SD = .32; p = .014) and T3 (M = 9.61, SD = .38; (p = .036) Five categories of residents’ responses to patient’s cues and concerns were analyzed. Table 2 shows the mean percentage of residents’ responses to patient’s cues and concerns at T1, T2, and T3. ANOVA results revealed statistical significant differences among training sessions. Tukey’s post hoc tests showed a higher mean percentage of trainees’ responses that reduced space at T1 than T2 and T3. Trainees also showed a higher mean percentage of content exploration, affect acknowledgement/exploration and empathy at T2 and T3 than T1. There were no differences in the mean percentage of non explicit provision of space across time points. Box 1 reports an example of an improvement in a trainee’s ability to respond to patient’s emotions. 3.4. Communication skills for breaking bad news Table 3 shows the mean of the ten communication skills at T1, T2, and T3. Overall, trainees significantly improved their communication skills from T1 to T2 and this improvement was retained over three months (T3). ANOVA results revealed statistical significant differences between training sessions on all measures, except for explores what patient already knows, discusses treatment alternatives, and checks for understanding/questions. Tukey’s post hoc test showed that trainees’ abilities to understand patient’s perspective, respond to patient’s emotional cues, transmit information step-by-step, explain diagnosis and symptoms, plan and orient, offer partnership, and summarize information and follow-up plan were statistically higher at T2 and T3 than T1. There were no differences in the means of these communications skills between T2 and T3. 4. Discussion and conclusion

3.2. Percentage of time devoted to the patient’s perspective 4.1. Discussion ANOVA for repeated measures determined that the mean percentage of time devoted to the patient’s perspective differed significantly between time points (F(2, 64) = 3.37, p = .038). Tukey Post hoc tests showed that the mean percentage of time devoted to patient’s perspective was lower at T1 (M = 44.25, SD = 1.98) than T2 (M = 48.62, SD = 1.65, p = .043) and T3 (M = 50.16, SD = 1.98, p = .028).

The current study evaluated the effectiveness of a brief relational/communication skills training program for medical residents. The findings strongly support the hypothesis that multimodality training can significantly improve residents’ RCS during standardized patients’ encounters. Overall, residents spent

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Table 2 Mean percentage of residents’ responses to patient’s cues and concerns at T1, T2, and T3. T1

T2

T3

Variables

M

SD

M

SD

M

SD

F(2, 64)

p

Space reduction Non-explicit provision of space Content Exploration Affect Acknowledgement/Exploration Empathy

64.20a 20.84 5.18a 3.01a 6.76a

2.46 1.88 1.07 .81 1.13

34.03b 22.64 10.92b 11.54b 20.88b

2.52 2.03 1.45 1.83 2.00

37.15b 24.52 10.41b 9.07b 18.88b

3.10 2.30 1.63 1.17 2.02

48.84 .84 5.90 13.78 26.12

<.001 .429 .004 <.001 <.001

Note: Means sharing a common subscript are not statistically different at p < .05, Tukey HSD procedure. T1: baseline, T2: 3 days after, T3: 3 months after.

Box 1. Examples of expressions drawn from the standardized interviews carried out by residents. Response of a resident to a patient’s cue at T1 Patient: Cancer . . . Doctor? It cannot be one cancer . . . ihhhh . . . I don’t believe it! Resident: But look, it's not worth getting nervous because there are excellent treatments for this. Everything will be right, okay?! Patient: What will happen to my life Doctor?! Resident: No, no . . . Mr Manuel aaa . . . you will not be . . . very worried, okay? ... Please, you should think positively, at this point it is very important to be positive, okay? Response of a resident to a patient’s cue at T2 Patient: Cancer? Oh, cancer is very bad, very bad news. I didn’t, I really didn’t expect this news. Resident: I understand that is very difficult news to receive at this stage of your life. Patient: What am I going to do with my life?! And now Doctor?! Resident: What worries you most

Table 3 Communication skills scores at T1, T2, and T3. T1 Variables Understand patient’s perspective Respond to patient’s emotional cues Explore what patient already knows Transmit information step-by-step Explain diagnosis and symptoms Discuss treatment alternatives Plan and orient Offer partnership Check for understanding / questions Summarize information and follow-up plan

T2

M

SD a

2.05 2.27a 1.53 1.97a 2.30a 2.71 2.34a 2.79a 1.63 1.07a

.09 .08 .07 .10 .10 .09 .08 .12 .09 .03

T3

M

SD b

3.07 3.15b 1.71 2.79b 2.82b 3.00 2.77b 3.60b 1.87 1.39b

1.08 .09 .08 .12 .11 .10 .08 .09 .10 .08

M b

2.90 2.95b 1.77 2.66b 2.80b 2.92 2.79b 3.47b 1.73 1.32b

SD

F(2, 64)

p

1.05 .08 .10 .16 .10 .08 .08 .12 .10 .075

46.01 45.55 3.56 20.45 8.82 2.90 14.66 21.93 2.10 8.35

<.001 <.001 .032 <.001 <.001 .059 <.001 <.001 .127 <.001

Note: Means sharing a common subscript are not statistically different at p < .05, Tukey HSD procedure. T1: baseline, T2: 3 days after, T3: 3 months after.

more time exploring patient’s perspective/psychosocial issues and their RCS improved after attending the first training session in terms of ability to respond appropriately to both patients’ cues and concerns and in seven of the 10 key communication skills assessed in the context of breaking bad news. These improvements were maintained after three months. The study results corroborate the findings of other studies, which show that clinicians find difficult to respond to patients’ emotional distress [22–24]. At baseline 64.20% of the residents’ responses to patients’ cues and concerns reduced space for further disclosure. However, after the first training session (4-h.), 65.97% of the responses where devoted to providing space by exploring the patients’ expressed content and affects, inviting further discussion, and acknowledging and empathizing with patient’s expressed emotions. Responding to patients’ cues is crucial for building confidence and trust in a clinical relationship. Previous studies have shown that sensitive responses to emotional distress reduce psychological morbidity in cancer patients [25]. Moreover, empathic responses lead patients to feel acknowledged and encourage them to share their concerns and potentially important information, providing more opportunities

to address their emotions and potentially enhancing the clinical relationship. The significant improvement in resident responses to patients’ cues and concerns was further supported by the ten key communication skills for breaking bad news. After the first training session, residents significantly improved their ability to understand the patient’s perspective and to respond to patient’s emotional cues by active exploring patient’s ideas, concerns, emotions, desires, expectations, the impact of the symptoms and diagnosis on patient’s life, and by acknowledging their feelings and giving more empathic responses. Residents also improved their ability to transmit information step-by-step. As suggested in the SPIKES protocol for delivering bad news, it is important to explore the patient’s perception before discussing the medical findings, to clarify the role that the patient wants to have and to transmit the information step-by-step, including preparing the patient for bad news [20]. There were no differences in the skill named explore what patient already knows. The low mean scores obtained at the three assessment sessions suggest that trainees did not consolidate this crucial skill to respect the patient desires, correct misinformation, or evaluate if there is any variation

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of illness denial and accordingly adjust the way to deliver bad news. The improvements in explaining diagnosis and symptoms reflect a greater ability of residents to address the patient’s needs and emotions in a more attuned way. Along these lines, they introduced informative topics when the patient directly or indirectly asked for an explanation, instead of following a rigid agenda of their own. Residents were also more aware of the importance of offering partnership at a critical moment as in receiving the diagnosis of cancer. They expressed willingness to help by using expressions of partnership (e.g., “we’re going to go through this process together”) and identifying additional resources or involving significant others. Residents’ were also more able to manage the information during the encounter, including planning and orienting, and summarizing information and following-up the plan. The improvement in these two sets of skills reflects a better organization of the information, the use of explicit categorization or signposting, the establishment of next steps, dates and sequences of events [26]. There were no differences concerning the skill check for understanding/questions and the mean scores were low, showing that trainees rarely took the initiative of giving the opportunity to the patient to ask questions or express doubts, even at the end of the encounter. Finally, there were also no differences in the skill discussion of treatment alternatives and the mean scores were high, showing that trainees frequently addressed this topic. One possible reason for this could be that the discussion on treatments was more familiar for residents and they routinely exercised this ability in their daily practice. However, in comparing the baseline and the final session, there was a different timing in the use of this skill. At baseline, the discussion on treatment alternatives was adopted as a way to avoid the emergence of emotional topics [27], whereas at the end of the training, it was used in manner that accommodated shared decision making. Therefore, even if the ability score was similar, the timing of this skill use was different. The results of the current study confirm the findings of previous investigations of the effectiveness of training in changing healthcare professionals’ communicative behaviors [6,8,22,28–31]. Based on the current study findings, we hypothesize that the effectiveness of the current RCS training program may be attributed to the combination of educational modalities over the three months: a one-hour didactic lecture, three 3-hour highly interactive sessions (i.e., standardized patients encounters, feedback, questions to promote the residents’ self-awareness of the relational dynamic), followed by individual reflective practice (i.e., performance self-analysis by videos, written reflective report, selfstudy). Although the specific individual contribution of each educational modality was not measured, we speculate that all of these modalities might play a critical role in skill mastery and in building relational/communicative styles. The use of standardized patient encounters has proved to be an effective tool in promoting communication skills in a less threatening context [32]. The small groups also transformed the training environment in a less stressful setting and provided trainees with multiple opportunities for practice and feedback; they also helped to enhance the interactivity and promote deeper reflective discussions in which trainees exposed themselves more easily [33]. Additionally, the observation of others performance may have served as a model or contributed to the awareness of critical aspects discussed in the training sessions. The facilitator’s questions to promote residents’ self-awareness of the relational dynamic in the encounters may have also helped them to realize that some of their responses were strongly influenced by feelings and emotional reactions to the patient. All of these practical inputs were complemented by individual reflective practices. Trainees’ self-study on communication skills, self-reflection about their own performance recorded

by video and the written reflective report on their clinical practice may have facilitated the consolidation of what they learned during the interactive sessions and the transference of these knowledge/ skills to clinical practice. The three-month period enabled trainees to reflect on their relational and communicative style in real-life settings and to review and adjust behaviors they considered important. The retention of the improvements of residents’ RCS over a three months period may suggest changes in trainees’ communication style, raising the questions of whether the improvements would be transferred to the clinical practice and whether the improvements would be retained over a longer period of time. Accordingly, we are currently studying the longer-term effect of the RCS training and the residents’ perception of the contribution of each educational strategy. Answering these questions will helps us to better understand the optimal components and the ideal length of training programs for producing positive and solid changes, which is still to be determined [7]. 4.1.1. Strengths and limitation This is a longitudinal study which adopts multiple educational strategies (i.e., standardized patients encounters, feedback, reflective practice, written reflective report, self-analysis of own videos). Future research should assess trainees’ perception of each particular strategy in contributing to the improvement of RCSs. One of the limitations of our study is that the generalizability of results is impaired mainly by the sampling of residents from a single institution in a limited number of specialties. Participants were recruited by a sequential sample of those who undertook a regular training program to increase their communication skills, and females were over-represented. Most of the residents were attending internal medicine, oncology, and family practice courses in Lisbon. Thus, the results may not be generalized to residents coming from other medical specialties or other regions of the country and to residents who do not value or are not motivated to perform formal training in communication skills. Moreover, this was a non-randomized trial and there was no control group. Therefore we are unable to distinguish the specific effect of the RCS training program from more general effects of the residency experience. Finally, residents’ RCS were practiced and assessed using standardized patients. Therefore, the improvements in the RCS after training may be not transferable or may not completely reflect behavioral change into real patient consultations. However, the preselected scenarios/scripts intensely trained with actors allowed to standardize the actors’ performances making them very similar, in terms of the frequency and intensity of cues and concerns and the key psychosocial issues addressed, to a real patient. Future studies should assess the transfer of training to real patient encounters and the impact of the training in subsequent patient outcomes (e.g., patient satisfaction, treatment adherence, patient trust, emotional wellbeing and better health). 4.2. Conclusion This study provided several evidences that residents’ relational and communication skills can be improved with a brief training that included the use of standardized patient encounters, small groups, reflective practice, feedback, the adoption of a written reflective report, and self-analysis of performance by the use of personal videos. The first four-hours training session demonstrated to be effective in improving targeted relational/communication skills for breaking bad news. The improvements observed 3 days after the first training session (T2) were maintained over three months (T3). During the program residents appeared to integrate a relational model of care and thus became more able to explore and

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empathize with the emotional experience of the patient, and to conduct a bad news consultation.

[7]

4.3. Practice implications [8]

The current study highlights the importance of formal training for teaching and learning relational and communication skills. Furthermore, the effectiveness of this brief and multimodality training program provides evidence to support the benefits of implementing RCS training as mandatory in residency curricula. Introducing brief training sessions (3–4 h) and individual reflective practice can be easily integrated into a residency program. Although each medical setting has specific communication challenges, there are core issues shared across all settings, such as the ability to respond to the patient's needs and emotions and to enhance the quality of the encounter with the patient by an efficient exchange of information. Thus, there should be either a common level of core skills or specialized interventions peculiar to each context. Additionally, it might be useful to conduct part of the training at residents’ workplace locations, to facilitate the transference of the improvements to real practice. Accordingly, tutors can orient the training to particular skills and challenges related to the characteristics of the clinical setting. The regular performance of self-analysis by video and individual reflective practice workout also facilitates the transference of the relational and communications skills to everyday practice. Finally, we suggest implementing this brief training early in clinician’s medical training, as this might effectively contribute to the development of effective communication styles at a professional stage in which trainees are more amenable to change.

[9]

[10]

[11]

[12]

[13]

[14]

[15]

[16]

[17] [18]

Funding This work was supported by the Fundação Calouste Gulbenkian, Portugal. Conflict of interest

[19]

None. Acknowledgements [20]

The authors are grateful to Professor Peter Lawlor (University of Ottawa) for English review of this manuscript. [21]

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