Research Web exclusive
Abstract
Objective To assess the communication and interviewing skills of incoming residents and provide formative feedback to residents early in their training.
Design New residents completed a 15-minute objective structured clinical examination (OSCE) assessing communication skills and a 12-question, self-administered content quiz at the start of their residency. Each resident was directly observed by a family physician in the OSCE and provided with 15 minutes of structured feedback, with an opportunity for questions and discussion. The entire process remained private and did not affect summative evaluations.
Setting Family medicine residency training program at the University of Alberta in Edmonton.
Participants First-year family medicine residents.
Main outcome measures Residents’ scores on the OSCE and the content quiz; residents’ rating of the usefulness of the assessment and the likelihood it would lead to practice change.
Results A total of 61 residents (93.8%) completed the skills assessment (50 Canadian graduates, 11 international graduates). The mean score for the content quiz was 20.6 out of a total possible score of 24. Resident scores ranged from 8 to 24. The mean score on the OSCE practice interview was 21.1 out of 30, with a range of 13 to 29. Learner feedback indicated that the skills assessment was useful (4.68 out of 6) and would lead to a change in practice (4.43 out of 6).
Conclusion The introductory communication OSCE and quiz offer new residents an opportunity to gauge their baseline skill level, become aware of program expectations early in their training, and garner specific suggestions in a nonthreatening environment. This tailored approach helps orient residents while taking into account their previous experiences.
Assessment of communication skills in family medicine
Douglas Klein
MD MSc CCFPAlim Nagji
MD CCFPEDITOR’S KEY POINTS
• The diverse backgrounds and previous experience of residents creates the potential for unequal footing during training. This study aimed to assess the communication and interviewing skills of incoming residents and provide early formative feedback.
• New residents completed an online quiz and an objective structured clinical examination assessing communication skills and received structured feedback from experienced family medicine faculty. Generally, residents performed well on both assessments, with similar
performance among Canadian and international medical graduates.
• The residents found the assessment useful and indicated that it offered the opportunity for introspective learning and had the potential to change their practice.
This article has been peer reviewed.
Can Fam Physician 2015;61:e412-6
Résumé
Objectif Vérifier la capacité de communiquer et de faire des entrevues chez les nouveaux résidents et leur fournir un feed-back formatif en début de formation.
Type d’étude Les résidents ont répondu à un examen clinique objectif structuré (ECOS) de 15 minutes vérifiant leur capacité de communiquer et à un quiz de contenu auto-administré de 12 questions au début de leur résidence.
Chaque résident était directement observé par un médecin de famille durant l’ECOS et avait droit à un feed-back structuré de 15 minutes, avec possibilité de questions et de discussion. Tout ce processus demeurait privé et n’affectait en rien les évaluations finales.
Contexte Le programme de résidence en médecine familiale de l’Université de l’Alberta à Edmonton.
Participants Des résidents-1 en médecine familiale.
Principaux paramètres à l’étude Les scores des résidents à l’ECOS; leur évaluation de l’utilité de cette évaluation;
et la probabilité qu’elle affecte leur pratique.
Résultats Un total de 61 résidents (93,8 %) ont complété cette évaluation de leurs compétences (50 diplômés au Canada et 11 à l’étranger). Les scores pour le queiz de contenu variaient entre 8 et 24, avec une moyenne de 20,6 sur un total possible de 24. Les scores à l’entrevue simulée de l’ECOS allaient de 13 à 29, pour une moyenne de 21,1 sur 30. En rétrospective, les résidents ont indiqué que cette évaluation de leurs compétences était utile (4,68 sur 6) et qu’elle entraînerait des changements dans leur pratique (4,43 sur 6).
Conclusion L’ECOS initial et le quiz offrent au participant une occasion de mesurer ses compétences de base en communication, de prendre connaissance des attentes du programme tôt dans sa formation et de profiter de suggestions spécifiques dans un contexte non menaçant. Une telle approche personnalisée contribue à orienter le résident tout en tenant compte de ses expériences antérieures.
Évaluation de l’habileté à
communiquer en médecine familiale
Douglas Klein
MD MSc CCFPAlim Nagji
MD CCFPPOINTS DE REPèRE Du RéDacTEuR
• Parce qu’ils ont eu des conditionnements et des expériences différents, les résidents risquent de commencer leur formation sur des bases inégales. Cette étude voulait évaluer la capacité des nouveaux résidents de communiquer et d’effectuer des entrevues, tout en leur offrant un feed-back précoce.
• Les nouveaux résidents ont répondu à un quiz en ligne et à un examen clinique objectif structuré qui évaluaient leur habileté à communiquer pour ensuite profiter d’un feed-back structuré de la part de professeurs expérimentés en médecine familiale. Les résidents ont généralement bien performé à ces deux évaluations, les diplômés canadiens et étrangers obtenant des résultats semblables.
• Les résidents ont trouvé cette évaluation utile et souligné qu’elle leur offrait une occasion d’apprentissage introspectif susceptible de modifier leur pratique.
Cet article fait l’objet d’une révision par des pairs.
Can Fam Physician 2015;61:e412-6
Research | Assessment of communication skills in family medicine
T
he doctor-patient relationship is the cornerstone of medical care1 and has been shown to affect treat- ment outcomes and patient satisfaction.2-6 The need for strong communication skills has been well explored.7,8 As such skills are an essential component of medical school and postgraduate curricula, further advances are necessary to ensure the development of competent clinicians and communicators.A variety of assessment tools have been devel- oped to evaluate the doctor-patient relationship,9 with a particular emphasis on communication.9,10 With the shift to competency-based curricula, there will be an increased need for evaluation tools that can offer for- mative and constructive feedback via observed inter- actions. Formalized communication will therefore be necessary11,12 and will require trained observers and checklists, with the possible addition of multiple observ- ers or videorecording.13-15 Objective structured clinical examinations (OSCEs) remain the cornerstone of clinical examination, despite offering poor reliability in evaluat- ing communication skills alongside clinical acumen.16-18
Many individuals change cities or countries when tran- sitioning from medical school to residency. The result- ing diverse backgrounds and previous experience create the potential for unequal footing during residency. In the family medicine program at the University of Alberta in Edmonton, we piloted an initial evaluative OSCE to ascertain the baseline characteristics of residents while offering a structured and formalized avenue for feed- back specifically on communication skills. Given the pau- city of observed interactions noted in many residency programs, it is essential that residents are offered the opportunity to have direct, specific feedback targeting their style, technique, and execution in patient inter- views. As the patient history is key to medical diagnosis and the patient encounter is a critical component of the doctor-patient relationship, investing time and resources to ensure development of baseline expectations might enhance the communication skills of residents.
METhODS
In 2012, the Department of Family Medicine at the University of Alberta introduced a skills assessment at the beginning of residency. The purpose was to assess residents’ baseline skills in order to better support their training.
The skills assessment involved 2 components: an online written quiz and an observed OSCE practice interview. The online quiz evaluated the resident’s knowledge of communication microskills, such as para- phrasing and use of open-ended questions. Behaviour relating to personal well-being and resiliency was also assessed. The practice interview was observed live on camera by experienced faculty. Oral and written
feedback were provided to the resident on listening skills, verbal and nonverbal communication, and the overall effectiveness of the interview. All the residents completed a formal evaluation of the process following the assessment, rating elements of the assessment on a 6-point Likert scale.
The content of the online written quiz and the evalu- ation criteria for the observed practice interview were determined by a community of family medicine faculty and reflect some basic competencies in interviewing and communication necessary for doctor-patient inter- action. This 2-part skills assessment was based on an evaluation framework used by the College of Family Physicians of Canada.19,20 The skills assessment was then piloted with both faculty and residents in family medicine to ensure acceptability and feasibility. Ethics approval was obtained through the University of Alberta Health Research Ethics Board.
RESuLTS
A total of 61 residents completed the skills assessment process, representing 93.8% of the first-year residents.
Of the residents who completed the assessment, 26 were female (42.6%); 50 (82.0%) were Canadian medi- cal graduates, while the remaining 11 were international medical graduates (IMGs). Some residents could not participate owing to scheduling conflicts with manda- tory service-based rotations.
Residents scored well on the online quiz (Table 1).
The mean (SD) score was 20.6 (3.05) out of a total pos- sible score of 24 (range 8 to 24). The mean (SD) score on the observed practice interview was 21.1 (4.32) out of 30 (range 13 to 29). Table 2 shows the results of the prac- tice interviews broken down by types of skills observed.
In addition to scoring the resident, the faculty observer looked for specific behaviour during the practice inter- view. Elements of FIFE (feelings, ideas, function, expec- tations) were demonstrated by only half of the residents.
Table 3 lists the behaviour observed and the frequency with which each was observed among the residents.
Overall, the residents found the 2-part skills assess- ment quite valuable (Table 4), citing introspective learn- ing and potential future integration of feedback, and believed it was an appropriate measure of their skill.
Table 1. Results of the online assessment of communication skills
SKill (MAxiMuM PoSSible SCoRe) MeAN (SD) SCoRe
Communication skills (12) 10.0 (1.87)
Feedback knowledge (5) 4.4 (1.54) Doctor-patient relationship knowledge (7) 6.3 (0.92)
Total (24) 20.6 (3.05)
DIScuSSION
As in previous studies, residents’ skills assessment scores were highly varied, likely owing to their dif- ferent experiences before commencing training.21,22 Therefore, the skills assessment can offer educators insight into the trends and baseline characteristics of the incoming cohort. Further, it creates an organized avenue for residents to receive targeted feedback in an area that will likely go unsupervised for most of their training.
Although the online assessment was unsupervised, it is an emerging avenue for assessing knowledge of foundational concepts, including definitions and frameworks. Determining the value of such assess- ment will require further research to elucidate pos- sible relationships with the skills assessment and with resident performance.
Residents who might not have been aware of these key concepts beforehand were able to take the oppor- tunity to supplement their knowledge before commenc- ing their training. It is interesting to note that some residents still performed poorly in the online quiz. We hypothesize 2 possible reasons: either residents thought that they were not able to use resources while complet- ing the quiz, or perhaps they trained at institutions that used alternate methods to impart these skills, as these individuals seemed to perform as well as their peers in the observed OSCE practice interviews.
Fortunately, most residents demonstrated solid foun- dational knowledge in their interviews, possibly owing to the increasing emphasis placed on communication skills in medical schools. Of note, individuals seemed to perform poorest in the FIFE domain, an interesting development given the relative ease of scoring points in this category. Feedback given after the interviews was well received by residents, with by far most indicating that it would lead to practice change and also noting that it offered introspective discovery.
limitations
Comparing IMGs to graduates of the Canadian system poses an interesting challenge, given the relative differ- ences in curriculum designs and the heterogeneity of the former group. Previous literature has documented the need for communication training in IMG populations.23,24 In our study the groups scored similarly on both assess- ments (t test, P = .52 for the quiz and P = .81 for the OSCE);
Table 3. behaviour demonstrated by residents during the communication oSCe: N = 61 residents.
behAviouR obSeRveD N (%)
Allows time for appropriate silences 24 (39.3)
Paraphrases 32 (52.5)
Responds to patient cues 43 (70.5)
Clarifies jargon when used by the patient 5 (8.2) Uses eye contact appropriate for culture and
patient comfort 57 (93.4)
Is focused on the conversation 49 (80.3)
Adjusts demeanour to be appropriate to the
patient‘s context 25 (41.0)
Uses physical contact appropriate to the patient’s
comfort 2 (3.3)
Responds appropriately to the patient’s discomfort 32 (52.5) Verbally checks the meaning of body language,
actions, and behaviour 5 (8.2)
Uses language adequate to be understood by the
patient 49 (80.3)
Is able to converse at an appropriate level for the patient’s age and education
46 (75.4) Uses appropriate tone for the situation 43 (70.5) Asks open-ended and closed-ended questions
appropriately 31 (50.8)
Checks back with patient to ensure understanding 21 (34.4) Facilitates the patient’s story 32 (52.5) Provides clear and organized information in a
way the patient understands 16 (26.2)
Clarifies how the patient would like to be addressed 13 (21.3) Understands the patient‘s feelings regarding the
medical illness
30 (49.2) Learns of the patient‘s ideas regarding the
medical illness 25 (41.0)
Learns about the effect of the illness on function 30 (49.2) Understands the patient‘s expectations for the visit 30 (49.2)
Displays empathy 40 (65.6)
Is genuine in the interaction with the patient 40 (65.6) Is respectful in dealing with the patient 39 (63.9) Demonstrates appropriate time management 16 (26.2) Demonstrates smooth interview flow 21 (34.4) OSCE—objective structured clinical examination.
Table 2. Results of the communication oSCe
assessment: Each skill is scored out of 5 and the total is scored out of 30.
SKill MeAN (SD) SCoRe
Listening skills 3.7 (0.87) Nonverbal expressive 3.6 (0.85) Nonverbal receptive 3.2 (0.95) Verbal skills 3.8 (0.83)
FIFE 3.1 (1.01)
Overall 3.6 (0.83)
Total 21.1 (4.32)
FIFE—feelings, ideas, function, expectations; OSCE—objective structured clinical examination.
Research | Assessment of communication skills in family medicine
however, the small sample size and single-site design are notable limitations. In Alberta, IMGs must first com- plete a longitudinal observership and are prescreened with communication OSCEs before receiving acceptance into our residency program.25 It is plausible that this leads to a selection bias when considering how this cohort performs on a downstream assessment, and our results might not be generalizable to other programs.
Conclusion
An introductory assessment of communication skills through observed interviews and an online quiz might be a valuable tool to stratify the baseline characteristics of new trainees. Country of training might not play a pivotal role or might be minimized by the varying entry requirements for IMGs and Canadian graduates. Residents found this to be a useful exercise with the potential to change prac- tices as a result of the specific feedback offered. Further research can examine if these assessments can be used to identify residents who might struggle in the future.
Dr Klein is Associate Professor in the Department of Family Medicine at the University of Alberta in Edmonton. Dr Nagji was a third-year resident in family and emergency medicine at the University of Alberta at the time of writing.
Contributors
Both authors contributed to the concept and design of the study; data gathering, analysis, and interpretation; and preparing the manuscript for submission.
Competing interests None declared Correspondence
Dr Douglas Klein; e-mail Doug.klein@ualberta.ca references
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Table 4. Results from the resident evaluation of the combined skills assessment
vARiAble MeAN (SD) SCoRe
(ouT oF 6)
The skills assessment was useful 4.68 (1.08) The feedback will change my interviewing 4.43 (1.06) The skills assessment represents my true
performance 4.45 (1.20)
I learned about myself during the assessment 4.66 (1.10) The online quiz showed my knowledge 3.77 (1.11) Overall, the skills assessment was worthwhile 4.57 (1.12)
