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*Department of General Surgery and †Department of Preventive Medicine, Vanderbilt University Medical
Center, Nashville, Tennessee
BACKGROUND: The Accreditation Council for Graduate Residents were asked how frequently they received feedback
Medical Education (ACGME) requires that “residents must be specific to their communication skills during the past 6 months:
able to demonstrate interpersonal and communication skills Most residents reported 0 (39%) or 1 (21%) feedback episode.
that result in effective information exchange and teaming with Only 30% of resident respondents reported receiving feedback
patients, their patients’ families, and professional associates.” that they perceived helpful.
The authors sought to assess current methods of teaching and Attending surgeons reported that they did provide residents
attitudes regarding communication skills in their surgical feedback specific to their communication skills. When asked to
residency. estimate the number of feedback episodes in the last 6 months,
16 faculty members reported a total of 67 feedback episodes,
METHODS: After obtaining Institutional Review Board
(IRB) exemption, voluntary anonymous surveys were com- whereas 33 residents reported a total of only 24 episodes.
pleted by a sample of convenience at the Vanderbilt University Most faculty members rated their comfort with providing
Medical Center: surgical residents at Grand Rounds and at- feedback specific to communication skills as “very comfortable”
tending surgeons in a faculty meeting. Data were evaluated (56%) or “comfortable” (19%). “Time constraints” was the
from 49 respondents (33 of 75 total surgical residents, 16 rep- most frequently cited barrier to teaching communication skills.
resentative attending surgeons). CONCLUSIONS: Communication skills are valued as inte-
RESULTS: One hundred percent of respondents rated the im- gral to patient care by both residents and faculty in this study.
portance of communication to the successful care of patients as Residents are most receptive to teaching of communication
“4” or “5” of 5. Direct attending observation of residents com- skills in the clinical setting. Faculty members report they are
municating with patients/families was confirmed by residents providing feedback to residents. Although residents report di-
and faculty. rect observation by faculty, currently only a minority (30%) are
Residents reported varying levels of comfort with different types receiving feedback regarding communication that they consider
of conversations. Residents were “comfortable” or “very comfort- helpful. A need exists to facilitate the feedback process to resolve
able” as follows: obtaining informed consent, 91%; reporting op- this discrepancy. The authors propose that an evaluation instru-
erative findings, 64%; delivering bad news, 61%; conducting a ment regarding communication skills may strengthen the feed-
family conference, 40%; discussing do not resuscitate (DNR) or- back process. (Curr Surg 63:401-409. © 2006 by the
ders, 36%; and discussing transition to comfort care, 24%. Association of Program Directors in Surgery.)
Resident receptiveness to communication skills education
varied with proposed venues: 84% favored teaching in the
course of routine clinical care, 52% via online resources, and BACKGROUND
46% in workshops.
Program directors are well aware of the 6 core competencies
required by the Accreditation Council for Graduate Medical
Correspondence: Inquiries to Kimberly D. Lomis, MD, Assistant Professor of Surgery, Education (ACGME). These competencies include interper-
Vanderbilt University Medical Center, D-5203, Medical Center North, 1161 21st Avenue sonal and communication skills:
South, Nashville, TN 37232-2577; fax: (615) 343-9485; e-mail: kim.lomis@
vanderbilt.edu “Residents must be able to demonstrate interpersonal and
Presented March 22, 2006 at Surgical Education Week, Tucson, Arizona. communication skills that result in effective information ex-
CURRENT SURGERY • © 2006 by the Association of Program Directors in Surgery 0149-7944/06/$30.00 401
Published by Elsevier Inc. doi:10.1016/j.cursur.2006.06.016
change and teaming with patients, their patients’ families, and communication skills. These themes were value for communi-
professional associates. Residents are expected to: cation in clinical care, frequency of communication tasks, com-
fort levels with various tasks, prior learning experiences, oppor-
• create and sustain a therapeutic and ethically sound relation-
tunities for observation, feedback (frequency and quality), and
ship with patients;
future learning opportunities (Figs. 1 and 2).
• use effective listening skills and elicit and provide informa-
tion using effective nonverbal, explanatory, questioning, and
Value
writing skills
• work effectively with others as a member or leader of a health Residents and attendings were asked to rate the importance of
care team or other professional group.”1 communication skills in the care of patients.
In response to this requirement, the authors sought to assess
their own current methods of teaching and evaluating commu- Frequency
nication skills. Their program currently relies predominantly Residents were asked to describe the frequency of primary re-
on role modeling as a method of teaching communication tech- sponsibility for the communication process over the past 6
niques. It remained unclear to what extent residents are exposed months.
to a formal discussion of these skills.
Regarding documentation of competence, scores for inter- Comfort
personal and communication skills are assigned by individual
faculty members on subjective clinical evaluation forms. The Residents and attendings were asked to rate their personal com-
authors’ program participates in the ACS/APDS evaluation fort with various types of conversations. Attendings were asked
project. This evaluation provides limited behavioral anchors to rate their comfort with evaluating resident communication
upon which to base ratings of communication skills: skills.
Please estimate how often in the past 6 months you served as the PRIMARY source of
communication with the patient/family for these types of conversations:
Please rate your personal comfort level with each type of conversation:
uncertain adequate very comfortable
Admission dx/plan 1 2 3 4 5
Daily progress updates 1 2 3 4 5
Informed consent 1 2 3 4 5
Operative findings 1 2 3 4 5
Delivery of bad news 1 2 3 4 5
DNR orders 1 2 3 4 5
Family conference 1 2 3 4 5
Transition to comfort care 1 2 3 4 5
Other (please specify) ___________________________________________________________
comments:______________________________________________________________
______________________________________________________________________
FIGURE 1. Resident survey.
Have you had learning experiences explicitly regarding communication skills (workshops,
role plays, etc; not routine clinical care)? Yes No
If yes, please describe:
______________________________________________________________________
______________________________________________________________________
How many times in the past 6 months has an attending directly observed you
communicate with a patient/family?
1 2 3 4 5 6 7 8 9 10 >10
If directly observed, how many times in the past 6 months did you receive feedback
specific to your communication skills?
1 2 3 4 5 6 7 8 9 10 >10
If you did receive feedback about your communication skills, was this helpful?
Yes No
Explain____________________________________________________________
_________________________________________________________________
Would you welcome specific feedback regarding communication skills in the course of
routine clinical care? Yes No
PGY-level: _____________
Comments:
FIGURE 1. continued.
ident levels of training were as follows: PGY I: 13; II: 6; III: 7; ence was indicated by number of years on an academic faculty
and IV: 6. One respondent did not indicate PGY-level. The rather than rank. The distribution was as follows: 0 to 5 years: 6;
survey was administered at the end of the academic year during 6 to10 years: 4; and ⬎10 years: 6.
transition; therefore, these groups are effectively PGY2-5 in
experience. The eligible faculty pool was 40, of which 16 were
Value
present at the single faculty meeting during which the survey
was circulated and discussed. All faculty members present at the All respondents (attendings and residents) rated the importance
meeting did respond to the survey. Attending surgeon experi- of communication to the successful care of patients as “4” or “5”
How important do you feel communication skills are to the successful care of patients?
not important somewhat important very important
1 2 3 4 5
comments:______________________________________________________________
______________________________________________________________________
Please rate your personal comfort level with each type of conversation:
uncertain adequate very comfortable
Admission dx/plan 1 2 3 4 5
Daily progress updates 1 2 3 4 5
Informed consent 1 2 3 4 5
Operative findings 1 2 3 4 5
Delivery of bad news 1 2 3 4 5
DNR orders 1 2 3 4 5
Family conference 1 2 3 4 5
Transition to comfort care 1 2 3 4 5
Other (please specify) ____________________________________________________
comments:______________________________________________________________
_____________________________________________________________________
Are you familiar with any specific models of the communication process (Macy model,
Bayer method, etc)? Yes No
Have you had experience explicitly teaching communication skills (workshops, role plays,
etc; not routine clinical care)? Yes No
If yes, please describe: _______________________________________________
__________________________________________________________________
FIGURE 2. Attending survey.
1 2 3 4 5 6 7 8 9 10 >10
How many times in the past 6 months have you provided residents feedback specific to
their communication skills?
1 2 3 4 5 6 7 8 9 10 >10
Please rate your personal comfort with providing residents feedback specific to their
communication skills:
uncertain adequate very comfortable
1 2 3 4 5
comments:______________________________________________________________
______________________________________________________________________
Please check any factors that make teaching communication skills difficult for you:
____Time constraints
____Lack of vocabulary to discuss communication skills
____Not a priority
____Personal trait of the physician (not a teachable skill set)
____Viewed as a “soft” topic
____Other (please specify)
comments:______________________________________________________________
______________________________________________________________________
______________________________________________________________________
Would you welcome an evaluative tool (checklist) to help guide feedback regarding
communication skills? Yes No
of 5. Comments from attendings included “Absolutely critical” able with discussing DNR status, conducting a family confer-
and “This is as important as operative technical skills.” Resident ence, and discussing transition to comfort care (Fig. 3).
comments included “Patients won’t let you [operate on] them Attendings reported comfort with providing feedback spe-
unless they fully trust you. A good communicator is less likely to cific to communication skills, with 56% responding “very com-
be sued for malpractice compared to poor communicator what- fortable” and 19% responding “comfortable.”
ever the level of skill is” and “Communication among teams [is
important to patient care].” Observation
Attendings and residents confirmed that attending surgeons do
Prior Learning Experiences directly observe residents communicating with patients and fami-
Few attendings (2/16) had knowledge of specific models of lies. Residents reported an average of 9 episodes of direct observa-
communication or had prior training to teach communication. tion in the preceding 6 months, with only 2 residents reporting no
Although few residents reported knowledge of specific models observed communication episodes. Similarly, faculty reported an
of communication (2/33), the majority (21/33) had undergone average of 8 direct observations in the preceding 6 months.
some formal teaching of communication skills. As per the com-
ments, most of this training occurred during medical school. Feedback
Residents reported the following frequencies of feedback in the
Frequency preceding 6-month period: 0 feedback episodes, 13; 1 feedback
Residents reported ample opportunity to serve as the primary episode, 7; 2 feedback episodes, 3; 3 feedback episodes, 3; 4
communicator with patients and families. The total resident feedback episodes, 3; 5 feedback episodes, 1; and 6 feedback
group estimated 1764 communication episodes in the preced- episodes, 1 (Fig. 4). Comments from residents regarding pro-
ing 6 months. vision of feedback include “I have not received feedback from
any attendings, only nurses or the charge nurse.”
A discrepancy existed in estimates of feedback episodes pro-
Comfort
vided by residents and attendings: 16 attendings reported a total
Residents reported varying levels of comfort with different of 67 episodes, whereas the larger sample of 33 residents re-
types of conversations. A high level of comfort was evident in ported total of only 24 episodes.
obtaining informed consent, reporting operative findings, and Residents were asked to rate the quality of the feedback they
delivering bad news. Residents were progressively less comfort- did receive. Only 30% of resident respondents reported that