- Email: [email protected]
Self-Assessment of Communication Skills Preparedness: Adult Versus Pediatric Skills
Self-Assessment of Communication Skills Preparedness: Adult Versus Pediatric Skills Catherine E. Dube´, EdD; Antoinette LaMonica, MSW; William Boyle, MD; Barbara Fuller, MPH; Gary J. Burkholder, PhD Purpose.—To characterize and compare incoming residents’ self-reported 1) amount and sufficiency of medical school training in clinical communication for patients of different ages, and 2) training experience and anticipated comfort level when breaking news of serious diagnoses with patients of different ages. Method.—A self-assessment tool was voluntarily completed by residents entering Brown- and Dartmouth-affiliated residencies. Descriptive statistics were generated and 2-tailed t tests were used to compare mean responses for patient age categories within each area of questioning. Results.—A total of 143 (78%) of 184 residents completed self-assessments. Estimates of training time with adult patients were greater than any other patient age category and were rated most sufficient. Twelve percent and 11% of respondents reported no formal training in pediatric and adolescent skills, respectively, and more than half reported that they had never observed a pediatric or adolescent ‘‘bad news’’ interaction. Half of the respondents had personally informed a patient or family of a serious diagnosis, most often concerning middle-aged or elderly patients. Respondents anticipated greatest discomfort discussing serious illness in younger patients and least discomfort discussing serious illness in adult and elderly patients. Conclusions.—Residents feel less prepared for and receive less training in general communication skills, particularly skills required for delivering bad news, in pediatric clinical interactions as compared with interactions with adult patients. Additional formalized training in communication skills and strategies for breaking bad news to pediatric and adolescent patients may be warranted. KEY WORDS:
communication; medical education; residency education
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T
he systematic training of medical students and residents in communication skills has burgeoned over the past 2 decades. Over 90% of US and Canadian medical schools have a communication skills requirement for medical student training.1 This phenomenon is due to the recognition that communication skills are key ingredients of effective patient care.2–4 Korsch and colleagues5 were among the earliest contributors to the scientific research on physician-patient communication. Their observations of thousands of pediatric encounters in the 1960s described the inherent challenges and provided guidance to physicians on skills that would improve parental satisfaction and patient outcomes.6 Since Korsch’s groundbreaking work, the greatest strides in both research and teaching have occurred in the disciplines of adult medicine,6–9 and most texts used in teaching physician-patient communication address adult medical practice.10–13 With a few notable exceptions,14–16 there is a lack of current stud-
ies of the pediatric interview, its content and its structure, and how it differs from the adult interview. The relative neglect of communication in pediatrics was illustrated recently the Journal of the Association for Teachers of Family Medicine (May 2002).17 This issue dedicated to physician-patient communication carried no articles addressing the unique aspects of pediatric medical interviewing. This represents a cause of concern to medical educators. The format, structure, and content of the pediatric interview differ fundamentally from those of the adult patient interview. The evolving cognitive abilities, emotional development, and dependent role of the child, as well as the unique intermediary role of the parent and family in the decision-making process, make pediatric interactions more complicated than those involving an adult patient.3,14,15,18 Among the most common challenging medical interactions, delivering ‘‘bad news’’ may be the most stressful for medical trainees.19 Structured educational interventions to improve bad news skills have been employed using standardized patient20–22 role play23 and/or seminar methodologies.19,24–26 Several of these methods were tested in pediatric settings,19,20,22,24,25 and 3 were conducted within medical school training.21,23,26 Yet most medical schools have not implemented systematic and formal training for breaking bad news.21 Many still rely on hit-or-miss opportunities found in traditional medical apprenticeship experiences where all students rarely have the same chance to observe and to perform.
From the Departments of Community Health and Family Medicine (Dr Dube´ and Ms Fuller) and Institute for Community Health Promotion (Dr Burkholder), Brown Medical School, Providence, RI; and Department of Pediatrics (Ms LaMonica and Dr Boyle), Dartmouth Medical School, Hanover, NH. Address correspondence to Catherine Dube´, EdD, Institute for Community Health Promotion, Brown University, 1 Hoppin St, Coro 4W, Providence, RI 02903 (e-mail: CatherinepDube@brown. edu). Received for publication January 27, 2003; accepted February 3, 2003. AMBULATORY PEDIATRICS Copyright q 2003 by Ambulatory Pediatric Association
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Current methods for teaching adult patient communication skills use systematic approaches, structured models and skill sets, research-based principles, and organized and standardized opportunities for observation, practice, reflection, and feedback.27–34 Do students receive equivalent structured learning opportunities in pediatric and adult interviewing skills training during medical school? Are bad news interactions in adult and pediatric settings observed by students and practiced? Competencies in patient care endorsed by the Accreditation Council for Graduate Medical Education include communication and respectful interactions with patients and their families.35 We carried out this study to help educators in residency programs gain an understanding of residents’ self-reported baseline preparation in both general and specialized communication skills. METHODS In the summer of 2000, residents entering Brown-affiliated residencies in internal medicine, family medicine, or pediatrics, and all incoming residents at Dartmouth-affiliated programs, were asked to voluntarily complete an educational self-assessment of their previous patient communication skills training. The purpose of this assessment was to further understand residents’ perceived level of cumulative prior training in pediatric communication skills compared with training with adult patients. Emphasis was placed on skills for delivering bad news. Questions of interest included: 1) Is formal communication skills training perceived as equivalent for both pediatric and adult patients? 2) Is training in adult and pediatric interactions perceived as equally sufficient? 3) Do equivalent opportunities exist for training (practice with observation and feedback) for interactions with both pediatric and adult patients? 4) Do equivalent opportunities exist for observation and practice of ‘‘breaking bad news’’ with both pediatric and adult patients? and 5) What level of discomfort do incoming residents feel when discussing bad news concerning patients of different ages? A 2-page instrument was distributed to 184 residents at program-sponsored orientation meetings. To protect anonymity, no information was collected about medical school attended. Demographic information included age, sex, ethnicity, partner status, number of children, and intended medical specialty. Five questions were presented concerning the amount and perceived sufficiency of communication skills training as well as the residents’ comfort with breaking the news of a serious diagnosis. Responses for categories of patient ages were collected for each question. Respondents were asked to estimate the number of hours of cumulative formal communication training they had received before residency (possible responses: 1 5 none; 2 5 1–3 h; 3 5 3–8 h; 4 5 8–16 h; 5 5 16–24 h; 6 5 .24 h) and to rate its sufficiency (on a scale of 1– 5 with 1 5 completely insufficient and 5 5 fully sufficient). Estimates of time and of sufficiency were requested for training experiences with patients of different ages: child (pediatric), adolescent, adult, and geriatric. Resi-
dents were asked to estimate the number of times they simultaneously interacted with patients of different ages and/or their families and were observed, subsequently receiving feedback from faculty. These estimates were recorded using a 5-point scale (1 5 Never, 2 5 1–2 times, 3 5 3–5 times, 4 5 5–10 times, 5 5 over 10 times). Age was categorized as infant/toddler, school-age child, adolescent, young adult, middle-aged adult, and elderly adult. Opportunities to observe a bad news interaction and to personally inform a patient or family of a serious diagnosis were reported using the same 5-point scale and the same 6 age categories. Residents were then asked to rate the level of comfort they would feel when discussing a serious medical illness or bad prognosis with patients and/or their families/caretakers in the 6 age categories. Comfort was reported using a 5-point Likert scale (from 1 5 extreme discomfort/ avoidance to 5 5 no discomfort). All analyses were completed using StatView statistical software (version 5.0 for Windows; SAS Institute Inc, Cary, NC). Descriptive statistics and frequency distributions were calculated for all responses, and paired t tests (2-tailed) were conducted to compare the means of different patient age groups. Missing data rate was low (3% average, with no question having a missing data rate higher than 8%). Items to which the response was ‘‘don’t know’’ were coded as missing and not included in any pairwise analysis requiring response. RESULTS A total of 143 self-assessments were collected from 184 residents asked to participate, for a 78% response rate (N 5 62 [Brown], and N 5 81 [Dartmouth]). Respondents were predominantly unmarried (58%), white (69%), and male (57%), and they ranged in age from 24 to 51 (M 5 29, SD 5 4.9). Nineteen respondents (13%) were parents. Intended practice included internal medicine (24%), pediatrics (19%), family medicine (7%), and general internal medicine (6%); others reported intention to enter psychiatry, radiology, surgery, obstetrics/gynecology, emergency medicine, and pathology. Thirty-one respondents (22%) planned subspecialty training. Time and Sufficiency of Communication Skills Training Formal training time for adult patient communication averaged 16–24 hours, and paired t tests indicated that this was significantly greater than that reported for pediatric (3–8 h), adolescent (3–8 h), or geriatric (3–16 h) patients (P , .0001). Adult patient communication training was rated most sufficient (M 5 4.1) compared with 3.0 for pediatric, 2.9 for adolescent, and 3.4 for geriatric patients (P , .0001). Twelve percent of residents reported no pediatric communication training, and 11% reported no training with adolescents. In comparison, only 1 respondent reported no formal training with adult patients (Table 1).
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Table 1. Formal Training Hours and Sufficiency of Training (n 5 143) Formal Training Hours Paired t test Adult Patients
Paired t test Geriatric Patients
Patient Age
Mean†
Mode†
% None
Mean Diff*
P
Mean Diff
P
Pediatric Adolescent Adult Geriatric
3.0 2.9 4.6 3.4
2/3 2 5 4
12% 11% ,1% 10%
21.55 21.68 — 21.16
,.0001 ,.0001 — ,.0001
20.38 20.54 1.16 —
,.01 ,.0001 ,.0001 —
Sufficiency of Training Paired t test Geriatric Patients
Paired t test Adult Patients
Patient Age
Mean‡
Mode‡
% Completely Insufficient
Mean Diff
P
Mean Diff
P
Pediatric Adolescent Adult Geriatric
3.0 2.9 4.1 3.4
3 3 5 3
10% 10% 7% 5%
21.08 21.21 — 20.66
,.0001 ,.0001 — ,.0001
20.42 20.55 0.66 —
,.001 ,.0001 ,.0001 —
*Mean Diff indicates mean differential. †Formal Training Hours: 1 5 none; 2 5 1–3h; 3 5 3–8h; 4 5 8–16h; 5 5 16–24h; 6 5 .24h. ‡Sufficiency of Training: 1 5 completely insufficient; 5 5 fully sufficient.
Faculty Observation of Student Interactions With Feedback Opportunities for students to conduct clinical interactions while faculty observed, providing subsequent feedback, were more frequent for middle-aged and elderly patients than for infants/toddlers or adolescent patients (P, .0001). Eleven percent of respondents reported that they were never observed with feedback in pediatric interactions, 15% were never observed with feedback with adolescent patients, and only 1 resident was never observed with feedback with middle-aged adult patients. Opportunities for Observation of Interactions and Practicing Breaking Bad News Most (94%) of the respondents had observed a physician informing a patient, family, or caretaker of a serious medical diagnosis. Among those who had, the interaction more commonly concerned a middle-aged or elderly patient rather than a pediatric, adolescent, or young adult patient (P , .0001); half of the 94% who had seen a bad news interaction reported never observing one concerning a pediatric or adolescent patient. About half of the respondents had personally informed a patient or family of a serious medical diagnosis, but this was more likely with a middle-aged or elderly adult patient (P , .0001) (Table 2). Discomfort Discussing Bad News With Patients of Different Ages Respondents reported greater discomfort discussing serious illness in younger patients and less discomfort in discussions about older patients. Ratings for adult and elderly patients were significantly higher (less uncomfortable, M 5 4.1 for both; P , .0001) compared with infants/toddlers (M 5 3.3), school-aged children (M 5 3.4), and adolescents (M 5 3.6). Forty-eight percent of respondents reported feeling very or extremely uncomfort-
able discussing bad news when patients were infants or toddlers; 43% when patients were school-aged children, and 32% when patients were adolescents. Only 7% of respondents reported feeling very or extremely uncomfortable discussing bad news concerning middle-aged or elderly patients. Most respondents, however, anticipated normal levels of discomfort regardless of patient age (Mode 5 4 [normal discomfort] for all age categories). DISCUSSION This self-reported assessment of training experiences before residency indicates that graduate medical students entering Brown- and Dartmouth-affiliated residency programs feel better prepared in communication skills for middle-aged adult patients and less prepared in communication skills for pediatric and adolescent practice. They reported less formal teaching in general communication skills and fewer opportunities for observed practice and faculty feedback with younger patients. For more challenging interactions that require informing the patient and/ or family of a serious medical diagnosis, respondents reported limited opportunities to observe faculty, particularly with pediatric and adolescent patients. Even fewer opportunities were provided for medical students to personally discuss a serious diagnosis with the patient and/ or family. In general, respondents anticipated greater discomfort discussing bad news concerning younger patients. Study limitations should be acknowledged. Findings are based on voluntary self-report from a limited sample of residents affiliated with 2 medical schools. The data are historical. Incoming residents started medical school 4 years earlier, and any interim curriculum changes would be undetectable. The study is retrospective and responses are subject to recall bias. Further study is warranted, including performance-based assessment of incoming resident communication skills and investigation of other in-
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Table 2. Frequency of Educational Activities Paired t test Middle-aged Patients Patient Age Infants/Toddlers School age Adolescents Young adults Middle-aged Elderly adults
Mean†
Mode†
% Never
Mean Diff*
Number of Times Students Were Observed Interviewing 2.6 2 12% 2.8 2 10% 2.6 2 15% 2.9 2 9% 3.7 4 ,1% 3.4 4 4%
P
Paired t test Elderly Patients Mean Diff
Patients & Given Faculty Feedback (n 5 143) 21.03 ,.0001 20.79 20.93 ,.0001 20.68 21.04 ,.0001 20.80 20.73 ,.0001 20.49 — — 0.24 20.24 ,.0001 —
P ,.0001 ,.0001 ,.0001 ,.0001 ,.0001 —
Of Students Who Had Observed a Physician Informing of a Serious Diagnosis (n 5 134) Number of Observations by Patient Age Infants/Toddlers 1.8 1 53% 21.44 ,.0001 21.63 ,.0001 School age 1.8 1 48% 21.38 ,.0001 21.57 ,.0001 Adolescents 1.8 1 50% 21.44 ,.0001 21.63 ,.0001 Young adults 2.2 1 34% 20.99 ,.0001 21.17 ,.0001 Middle aged 3.2 3 5% — — 0.19 ,.01 Elderly adults 3.4 4 4% 20.19 ,.01 — — Of Students Who Had Informed a Patient/Family of a Serious Diagnosis (n 5 72) Number of Interactions by Patient Age Infants/Toddlers 1.2 1 82% 21.26 ,.0001 21.32 ,.0001 School age 1.2 1 89% 21.33 ,.0001 21.39 ,.0001 Adolescents 1.3 1 77% 21.21 ,.0001 21.27 ,.0001 Young adults 1.8 1 54% 20.72 ,.0001 20.79 ,.0001 Middle-aged 2.5 2 13% — — 20.06 ns Elderly adults 2.6 4 15% 0.06 ns — — *Mean Diff indicates mean differential. †1 5 never; 2 5 1–2 times; 3 5 3–5 times; 4 5 5–10 times; 5 5 .10 times.
fluences that may affect resident discomfort when breaking bad news. It is widely known that in most medical schools, basic communication skills training focuses on interactions with the adult patient. Historically, many of the leaders in the field of physician-patient communication have emerged from the disciplines of internal medicine and adult psychiatry. Recently, pediatricians have become more active in professional associations devoted to teaching the skills of doctor-patient communication. Still, most formal communication skills training for medical students seems to focus predominantly on the adult patient. This is unfortunate, because interactions in pediatric practice are more complicated, as they are rarely one-on-one and are influenced by the changing developmental abilities of the child, evolving roles of parents and family, and influences of the legal system. One could argue that the seeming discrepancy in teaching skills for breaking bad news with young, generally healthy patients is due to lack of clinical opportunities. However, neglect of bad news skills in pediatric training is not simply to be expected. First, news does not have to be life-threatening to be bad or serious. Furthermore, students in academic medical settings have access to tertiary care hospitals where there is a concentration of very sick children. One clinical experience in a hematology/oncology service, for example, could provide multiple opportunities to witness bad news situations. Experiences included in the student’s education and how such experiences are handled can make a difference (eg, whether attendings invite students to observe when delivering bad news to a parent and/or patient; whether the student giving
bad news for the first time is observed, given feedback, and provided opportunities for reflection). With the exception of geriatricians, all practicing physicians can expect to interact with patients in later adolescence. Because adolescents are less likely to be seen in the medical setting, educational strategies to compensate for limited incidental exposure could be considered in both medical school and residency training. Educational strategies may include use of adolescent standardized patients and the expansion of adolescent medical practice in academic settings where trainees may observe and contribute to a variety of challenging interactions. REFERENCES 1. Association of American Medical Colleges. Number of US medical schools teaching selected topics 2000–01. Available at: http:// services.aamc.org/currdir/section2/LCMEHottopics.pdf. Accessed January 15, 2003. 2. Safran DG, Taira DA, Rogers WH, Kosinski M, Ware JE, Tarlov AR. Linking primary care performance to outcomes of care. J Family Practice. 1998;47:213–220. 3. Van Dulmen AM, Holl RA. Effects of continuing pediatric education in interpersonal communications skills. European J Ped. 2000;159:489–495. 4. von Gunten CF, Ferris FD, Emanuel LL. Ensuring competency in end-of-life care: communication and relational skills. JAMA. 2000;284:3051–3057. 5. Korsch BM, Gozzi EK, Francis V. Gaps in doctor-patient communication. I: doctor-patient interaction and patient satisfaction. Pediatrics. 1968;42:855–871. 6. Lipkin M Jr, Putnam SM, Lazare A, eds. The Medical Interview: Clinical Care, Education, and Research. New York, NY: Springer-Verlag; 1995. 7. Makoul G. Contemporary issues in medicine: communication in medicine. In: Association of American Medical Colleges, ed.
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Medical School Objectives Project, Report III: Contemporary Issues in Medicine: Communication in Medicine. Washington, DC: Association of American Medical Colleges; 1999. Novack DH, Dube´ CE, Goldstein MG. Teaching medical interviewing: a basic course on interviewing and the physician-patient relationship. Arch Intern Med. 1992;152:1814–1820. Roter DL, Hall JA, Meriscar, et al. Effectiveness of interventions to improve patient compliance: a meta-analysis. Med Care. 1998;36:1138–1161. Smith RC. The Patient’s Story: Integrated Patient-Doctor Interviewing. Boston: Little Brown; 1996. Billings JA, Stoekle JD. The Clinical Encounter: A Guide to the Medical Interview and Case Presentation. 2nd ed. St. Louis, Mo: Mosby; 1999. Coulehan JL, Block MR. The Medical Interview: Mastering Skills for Clinical Practice. 3rd ed. Philadelphia, Pa: FA Davis; 1997. Cole SA, Bird J. The Medical Interview: The Three Function Approach. St. Louis, Mo: Mosby; 2000. Pantell RH, Stewart TJ, Dias JK, et al. Physician communication with children and parents. Pediatrics. 1982;70:396–402. Mendelsohn JS, Quinn MD, McNabb WL. Interview strategies commonly used by pediatricians. Arch Pediatr Adolesc Med. 1999;153:154–157. Lewis CC, Pantell RH, Sharp L. Increasing patient knowledge, satisfaction, and involvement: randomized trial of a communication intervention. Pediatrics. 1991;88:351–358. Steele DJ, Marvel K, eds. Dedicated issue on physician-patient communication. Fam Med. 2002;34(5; theme issue):310–393. Boyle WE, Hoekelman RA. The pediatric history. In: Hoekelman RA, et al, eds. Primary Pediatric Care. 3rd ed. St. Louis, Mo: Mosby; 1997:57–66. Morgan ER, Winter RJ. Teaching communication skills: an essential part of residency training. Arch Pediatr Adolesc Med. 1996;150:638–642. Vaidya VU, Greenberg LW, Patel KM, et al. Teaching physicians how to break bad news: a 1-day workshop using standardized parents. Arch Pediatr Adolesc Med. 1999;153:419– 422.
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21. Colletti L, Gruppen L, Barclay M, Stern D. Teaching students to break bad news. Am J Surg. 2001;182:20–23. 22. Greenberger LW, Ochsenschlager D, O’Donnell R, et al. Communicating bad news: a pediatric department’s evaluation of a simulated intervention. Pediatrics. 1999;103:1210–1217. 23. Cushing AM, Jones A. Evaluation of a breaking bad news course for medical students. Med Educ. 1995;29:430–435. 24. Jewett LS, Greenberg LW, Champion LA, et al. The teaching of crisis counseling skills to pediatric residents: a one-year study. Pediatrics 1982;70:907–911. 25. Bagatell R, Meyer R, Herron S, et al. When children die: a seminar series for pediatric residents. Pediatrics. 2002;110:348– 353. 26. Magnani JW, Minor MA, Aldrich JM. Care at the end of life: a novel curriculum module implemented by medical students. Acad Med. 2002;77:292–298. 27. Kalpan CB, Siegel B, Madill JM, Epstein RM. Communication and the medical interview: strategies for learning and teaching. J Gen Intern Med. 1997;12(suppl 2):S49–S55. 28. DiBartola LM. Listening to patients and responding with care: a model for teaching communication skills. Joint Commission Journal on Quality Improvement. 2001;27:315–323. 29. Chou C, Lee K. Improving residents’ interviewing skills by group videotape review. Acad Med. 2002;77:744. 30. Hewson MG, Little ML. Giving feedback in medical education: verification of recommended techniques. J Gen Intern Med. 1998;13:111–116. 31. Benbassat J, Baumal R. A step-wise role playing approach for teaching patient counseling skills to medical students. Patient Educ Couns. 2002;46:147–152. 32. Kendrick T, Freeling P. A communication skills course for preclinical students: evaluation of general practice based teaching using group methods. Med Educ. 1993;27:211–217. 33. Dube´ CE, O’Donnell JF, Novack DH. Communication skills for preventive interventions. Acad Med 2000;75(7 suppl):S45–S54. 34. Kurtz S, Silverman J, Draper J. Teaching and Learning Communication Skills in Medicine. Abingdon, Oxon, UK: Radcliffe Medical Press; 1998. 35. Accreditation Council for Graduate Medical Education. Outcome Project, General Competencies. Washington, DC: Accreditation Council for Graduate Medical Education; 1999.
communication; medical education; residency education
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T
he systematic training of medical students and residents in communication skills has burgeoned over the past 2 decades. Over 90% of US and Canadian medical schools have a communication skills requirement for medical student training.1 This phenomenon is due to the recognition that communication skills are key ingredients of effective patient care.2–4 Korsch and colleagues5 were among the earliest contributors to the scientific research on physician-patient communication. Their observations of thousands of pediatric encounters in the 1960s described the inherent challenges and provided guidance to physicians on skills that would improve parental satisfaction and patient outcomes.6 Since Korsch’s groundbreaking work, the greatest strides in both research and teaching have occurred in the disciplines of adult medicine,6–9 and most texts used in teaching physician-patient communication address adult medical practice.10–13 With a few notable exceptions,14–16 there is a lack of current stud-
ies of the pediatric interview, its content and its structure, and how it differs from the adult interview. The relative neglect of communication in pediatrics was illustrated recently the Journal of the Association for Teachers of Family Medicine (May 2002).17 This issue dedicated to physician-patient communication carried no articles addressing the unique aspects of pediatric medical interviewing. This represents a cause of concern to medical educators. The format, structure, and content of the pediatric interview differ fundamentally from those of the adult patient interview. The evolving cognitive abilities, emotional development, and dependent role of the child, as well as the unique intermediary role of the parent and family in the decision-making process, make pediatric interactions more complicated than those involving an adult patient.3,14,15,18 Among the most common challenging medical interactions, delivering ‘‘bad news’’ may be the most stressful for medical trainees.19 Structured educational interventions to improve bad news skills have been employed using standardized patient20–22 role play23 and/or seminar methodologies.19,24–26 Several of these methods were tested in pediatric settings,19,20,22,24,25 and 3 were conducted within medical school training.21,23,26 Yet most medical schools have not implemented systematic and formal training for breaking bad news.21 Many still rely on hit-or-miss opportunities found in traditional medical apprenticeship experiences where all students rarely have the same chance to observe and to perform.
From the Departments of Community Health and Family Medicine (Dr Dube´ and Ms Fuller) and Institute for Community Health Promotion (Dr Burkholder), Brown Medical School, Providence, RI; and Department of Pediatrics (Ms LaMonica and Dr Boyle), Dartmouth Medical School, Hanover, NH. Address correspondence to Catherine Dube´, EdD, Institute for Community Health Promotion, Brown University, 1 Hoppin St, Coro 4W, Providence, RI 02903 (e-mail: CatherinepDube@brown. edu). Received for publication January 27, 2003; accepted February 3, 2003. AMBULATORY PEDIATRICS Copyright q 2003 by Ambulatory Pediatric Association
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Current methods for teaching adult patient communication skills use systematic approaches, structured models and skill sets, research-based principles, and organized and standardized opportunities for observation, practice, reflection, and feedback.27–34 Do students receive equivalent structured learning opportunities in pediatric and adult interviewing skills training during medical school? Are bad news interactions in adult and pediatric settings observed by students and practiced? Competencies in patient care endorsed by the Accreditation Council for Graduate Medical Education include communication and respectful interactions with patients and their families.35 We carried out this study to help educators in residency programs gain an understanding of residents’ self-reported baseline preparation in both general and specialized communication skills. METHODS In the summer of 2000, residents entering Brown-affiliated residencies in internal medicine, family medicine, or pediatrics, and all incoming residents at Dartmouth-affiliated programs, were asked to voluntarily complete an educational self-assessment of their previous patient communication skills training. The purpose of this assessment was to further understand residents’ perceived level of cumulative prior training in pediatric communication skills compared with training with adult patients. Emphasis was placed on skills for delivering bad news. Questions of interest included: 1) Is formal communication skills training perceived as equivalent for both pediatric and adult patients? 2) Is training in adult and pediatric interactions perceived as equally sufficient? 3) Do equivalent opportunities exist for training (practice with observation and feedback) for interactions with both pediatric and adult patients? 4) Do equivalent opportunities exist for observation and practice of ‘‘breaking bad news’’ with both pediatric and adult patients? and 5) What level of discomfort do incoming residents feel when discussing bad news concerning patients of different ages? A 2-page instrument was distributed to 184 residents at program-sponsored orientation meetings. To protect anonymity, no information was collected about medical school attended. Demographic information included age, sex, ethnicity, partner status, number of children, and intended medical specialty. Five questions were presented concerning the amount and perceived sufficiency of communication skills training as well as the residents’ comfort with breaking the news of a serious diagnosis. Responses for categories of patient ages were collected for each question. Respondents were asked to estimate the number of hours of cumulative formal communication training they had received before residency (possible responses: 1 5 none; 2 5 1–3 h; 3 5 3–8 h; 4 5 8–16 h; 5 5 16–24 h; 6 5 .24 h) and to rate its sufficiency (on a scale of 1– 5 with 1 5 completely insufficient and 5 5 fully sufficient). Estimates of time and of sufficiency were requested for training experiences with patients of different ages: child (pediatric), adolescent, adult, and geriatric. Resi-
dents were asked to estimate the number of times they simultaneously interacted with patients of different ages and/or their families and were observed, subsequently receiving feedback from faculty. These estimates were recorded using a 5-point scale (1 5 Never, 2 5 1–2 times, 3 5 3–5 times, 4 5 5–10 times, 5 5 over 10 times). Age was categorized as infant/toddler, school-age child, adolescent, young adult, middle-aged adult, and elderly adult. Opportunities to observe a bad news interaction and to personally inform a patient or family of a serious diagnosis were reported using the same 5-point scale and the same 6 age categories. Residents were then asked to rate the level of comfort they would feel when discussing a serious medical illness or bad prognosis with patients and/or their families/caretakers in the 6 age categories. Comfort was reported using a 5-point Likert scale (from 1 5 extreme discomfort/ avoidance to 5 5 no discomfort). All analyses were completed using StatView statistical software (version 5.0 for Windows; SAS Institute Inc, Cary, NC). Descriptive statistics and frequency distributions were calculated for all responses, and paired t tests (2-tailed) were conducted to compare the means of different patient age groups. Missing data rate was low (3% average, with no question having a missing data rate higher than 8%). Items to which the response was ‘‘don’t know’’ were coded as missing and not included in any pairwise analysis requiring response. RESULTS A total of 143 self-assessments were collected from 184 residents asked to participate, for a 78% response rate (N 5 62 [Brown], and N 5 81 [Dartmouth]). Respondents were predominantly unmarried (58%), white (69%), and male (57%), and they ranged in age from 24 to 51 (M 5 29, SD 5 4.9). Nineteen respondents (13%) were parents. Intended practice included internal medicine (24%), pediatrics (19%), family medicine (7%), and general internal medicine (6%); others reported intention to enter psychiatry, radiology, surgery, obstetrics/gynecology, emergency medicine, and pathology. Thirty-one respondents (22%) planned subspecialty training. Time and Sufficiency of Communication Skills Training Formal training time for adult patient communication averaged 16–24 hours, and paired t tests indicated that this was significantly greater than that reported for pediatric (3–8 h), adolescent (3–8 h), or geriatric (3–16 h) patients (P , .0001). Adult patient communication training was rated most sufficient (M 5 4.1) compared with 3.0 for pediatric, 2.9 for adolescent, and 3.4 for geriatric patients (P , .0001). Twelve percent of residents reported no pediatric communication training, and 11% reported no training with adolescents. In comparison, only 1 respondent reported no formal training with adult patients (Table 1).
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Table 1. Formal Training Hours and Sufficiency of Training (n 5 143) Formal Training Hours Paired t test Adult Patients
Paired t test Geriatric Patients
Patient Age
Mean†
Mode†
% None
Mean Diff*
P
Mean Diff
P
Pediatric Adolescent Adult Geriatric
3.0 2.9 4.6 3.4
2/3 2 5 4
12% 11% ,1% 10%
21.55 21.68 — 21.16
,.0001 ,.0001 — ,.0001
20.38 20.54 1.16 —
,.01 ,.0001 ,.0001 —
Sufficiency of Training Paired t test Geriatric Patients
Paired t test Adult Patients
Patient Age
Mean‡
Mode‡
% Completely Insufficient
Mean Diff
P
Mean Diff
P
Pediatric Adolescent Adult Geriatric
3.0 2.9 4.1 3.4
3 3 5 3
10% 10% 7% 5%
21.08 21.21 — 20.66
,.0001 ,.0001 — ,.0001
20.42 20.55 0.66 —
,.001 ,.0001 ,.0001 —
*Mean Diff indicates mean differential. †Formal Training Hours: 1 5 none; 2 5 1–3h; 3 5 3–8h; 4 5 8–16h; 5 5 16–24h; 6 5 .24h. ‡Sufficiency of Training: 1 5 completely insufficient; 5 5 fully sufficient.
Faculty Observation of Student Interactions With Feedback Opportunities for students to conduct clinical interactions while faculty observed, providing subsequent feedback, were more frequent for middle-aged and elderly patients than for infants/toddlers or adolescent patients (P, .0001). Eleven percent of respondents reported that they were never observed with feedback in pediatric interactions, 15% were never observed with feedback with adolescent patients, and only 1 resident was never observed with feedback with middle-aged adult patients. Opportunities for Observation of Interactions and Practicing Breaking Bad News Most (94%) of the respondents had observed a physician informing a patient, family, or caretaker of a serious medical diagnosis. Among those who had, the interaction more commonly concerned a middle-aged or elderly patient rather than a pediatric, adolescent, or young adult patient (P , .0001); half of the 94% who had seen a bad news interaction reported never observing one concerning a pediatric or adolescent patient. About half of the respondents had personally informed a patient or family of a serious medical diagnosis, but this was more likely with a middle-aged or elderly adult patient (P , .0001) (Table 2). Discomfort Discussing Bad News With Patients of Different Ages Respondents reported greater discomfort discussing serious illness in younger patients and less discomfort in discussions about older patients. Ratings for adult and elderly patients were significantly higher (less uncomfortable, M 5 4.1 for both; P , .0001) compared with infants/toddlers (M 5 3.3), school-aged children (M 5 3.4), and adolescents (M 5 3.6). Forty-eight percent of respondents reported feeling very or extremely uncomfort-
able discussing bad news when patients were infants or toddlers; 43% when patients were school-aged children, and 32% when patients were adolescents. Only 7% of respondents reported feeling very or extremely uncomfortable discussing bad news concerning middle-aged or elderly patients. Most respondents, however, anticipated normal levels of discomfort regardless of patient age (Mode 5 4 [normal discomfort] for all age categories). DISCUSSION This self-reported assessment of training experiences before residency indicates that graduate medical students entering Brown- and Dartmouth-affiliated residency programs feel better prepared in communication skills for middle-aged adult patients and less prepared in communication skills for pediatric and adolescent practice. They reported less formal teaching in general communication skills and fewer opportunities for observed practice and faculty feedback with younger patients. For more challenging interactions that require informing the patient and/ or family of a serious medical diagnosis, respondents reported limited opportunities to observe faculty, particularly with pediatric and adolescent patients. Even fewer opportunities were provided for medical students to personally discuss a serious diagnosis with the patient and/ or family. In general, respondents anticipated greater discomfort discussing bad news concerning younger patients. Study limitations should be acknowledged. Findings are based on voluntary self-report from a limited sample of residents affiliated with 2 medical schools. The data are historical. Incoming residents started medical school 4 years earlier, and any interim curriculum changes would be undetectable. The study is retrospective and responses are subject to recall bias. Further study is warranted, including performance-based assessment of incoming resident communication skills and investigation of other in-
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Table 2. Frequency of Educational Activities Paired t test Middle-aged Patients Patient Age Infants/Toddlers School age Adolescents Young adults Middle-aged Elderly adults
Mean†
Mode†
% Never
Mean Diff*
Number of Times Students Were Observed Interviewing 2.6 2 12% 2.8 2 10% 2.6 2 15% 2.9 2 9% 3.7 4 ,1% 3.4 4 4%
P
Paired t test Elderly Patients Mean Diff
Patients & Given Faculty Feedback (n 5 143) 21.03 ,.0001 20.79 20.93 ,.0001 20.68 21.04 ,.0001 20.80 20.73 ,.0001 20.49 — — 0.24 20.24 ,.0001 —
P ,.0001 ,.0001 ,.0001 ,.0001 ,.0001 —
Of Students Who Had Observed a Physician Informing of a Serious Diagnosis (n 5 134) Number of Observations by Patient Age Infants/Toddlers 1.8 1 53% 21.44 ,.0001 21.63 ,.0001 School age 1.8 1 48% 21.38 ,.0001 21.57 ,.0001 Adolescents 1.8 1 50% 21.44 ,.0001 21.63 ,.0001 Young adults 2.2 1 34% 20.99 ,.0001 21.17 ,.0001 Middle aged 3.2 3 5% — — 0.19 ,.01 Elderly adults 3.4 4 4% 20.19 ,.01 — — Of Students Who Had Informed a Patient/Family of a Serious Diagnosis (n 5 72) Number of Interactions by Patient Age Infants/Toddlers 1.2 1 82% 21.26 ,.0001 21.32 ,.0001 School age 1.2 1 89% 21.33 ,.0001 21.39 ,.0001 Adolescents 1.3 1 77% 21.21 ,.0001 21.27 ,.0001 Young adults 1.8 1 54% 20.72 ,.0001 20.79 ,.0001 Middle-aged 2.5 2 13% — — 20.06 ns Elderly adults 2.6 4 15% 0.06 ns — — *Mean Diff indicates mean differential. †1 5 never; 2 5 1–2 times; 3 5 3–5 times; 4 5 5–10 times; 5 5 .10 times.
fluences that may affect resident discomfort when breaking bad news. It is widely known that in most medical schools, basic communication skills training focuses on interactions with the adult patient. Historically, many of the leaders in the field of physician-patient communication have emerged from the disciplines of internal medicine and adult psychiatry. Recently, pediatricians have become more active in professional associations devoted to teaching the skills of doctor-patient communication. Still, most formal communication skills training for medical students seems to focus predominantly on the adult patient. This is unfortunate, because interactions in pediatric practice are more complicated, as they are rarely one-on-one and are influenced by the changing developmental abilities of the child, evolving roles of parents and family, and influences of the legal system. One could argue that the seeming discrepancy in teaching skills for breaking bad news with young, generally healthy patients is due to lack of clinical opportunities. However, neglect of bad news skills in pediatric training is not simply to be expected. First, news does not have to be life-threatening to be bad or serious. Furthermore, students in academic medical settings have access to tertiary care hospitals where there is a concentration of very sick children. One clinical experience in a hematology/oncology service, for example, could provide multiple opportunities to witness bad news situations. Experiences included in the student’s education and how such experiences are handled can make a difference (eg, whether attendings invite students to observe when delivering bad news to a parent and/or patient; whether the student giving
bad news for the first time is observed, given feedback, and provided opportunities for reflection). With the exception of geriatricians, all practicing physicians can expect to interact with patients in later adolescence. Because adolescents are less likely to be seen in the medical setting, educational strategies to compensate for limited incidental exposure could be considered in both medical school and residency training. Educational strategies may include use of adolescent standardized patients and the expansion of adolescent medical practice in academic settings where trainees may observe and contribute to a variety of challenging interactions. REFERENCES 1. Association of American Medical Colleges. Number of US medical schools teaching selected topics 2000–01. Available at: http:// services.aamc.org/currdir/section2/LCMEHottopics.pdf. Accessed January 15, 2003. 2. Safran DG, Taira DA, Rogers WH, Kosinski M, Ware JE, Tarlov AR. Linking primary care performance to outcomes of care. J Family Practice. 1998;47:213–220. 3. Van Dulmen AM, Holl RA. Effects of continuing pediatric education in interpersonal communications skills. European J Ped. 2000;159:489–495. 4. von Gunten CF, Ferris FD, Emanuel LL. Ensuring competency in end-of-life care: communication and relational skills. JAMA. 2000;284:3051–3057. 5. Korsch BM, Gozzi EK, Francis V. Gaps in doctor-patient communication. I: doctor-patient interaction and patient satisfaction. Pediatrics. 1968;42:855–871. 6. Lipkin M Jr, Putnam SM, Lazare A, eds. The Medical Interview: Clinical Care, Education, and Research. New York, NY: Springer-Verlag; 1995. 7. Makoul G. Contemporary issues in medicine: communication in medicine. In: Association of American Medical Colleges, ed.
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