1. Communication skills teaching – Can one size fit all?
Julie Rowlands
Dr Nikki Pease

2. It is now widely recognised that good communication is essential for the delivery of high quality care but this was not always the case…
Time of Hippocrates – Communication was of prime importance to doctors
Medicine advanced, focus changed to learning new skills, new techniques and treatments.
Communication remained integral to good medicine but doctors were not trained to communicate
Good communication between health professionals and patients is essential for the delivery of high quality care
To improve patients’ experience of care (Cancer plan 2000)
Good communication essential so that patients make informed choices.
Patient’s and carers complaints regarding healthcare frequently focus perceived failure of communication (DoH 2000)
Communication in healthcare is so absolutely essential it is as little noticed as water by fish
Mack Lipkin in Handbook of Communication in Oncology and palliative Care 2010
Between 1920s and 1960s there was recognition of the importance of taking a history and various clinical approaches taught.

3. 1960s onwards – attempts to analyse interview content
Interactional analysis of interviews – Korsch (1968)
RIAS – Roter interactional analysis scheme – Roter (1977)
MIPS – Medical interaction process system - Ford et al (2000)
Lipkin and Putnam (1979) set up an interest group to identify how to equip doctors with the necessary skills and attitudes to communicate effectively: Publication of a curriculum for effective medical interviewing in 1984 (General medicine).
1984 – current day. Several main players in CS research and teaching. Further evidence generated in cancer and palliative care
Core communication skills 3 day course in England for Cancer MDT members ‘Connected’ by NCAT – future unknown.
Korsch et al 1968 Gaps in doctor patient communication. Paediatrics
These interactional analysis tools were useful for analysing the content but not so good at recognising rich interactions, identifying nuances and meaning. There was a limitation to their use in helping to develop ways of teaching doctors to communicate better
Mack Lipkin
Lipkin M, Quill T, Napadano RJ. The medical interview: a core curriculum for residencies in internal medicine. Ann Int Med 100:
Roter DL (1977) Patient participation in the patient-provider interaction: the effects of patient question asking on the quality of interaction, satisfaction and compliance. Health Educ Monogr 2:

4. 1980s onwards - evidence suggests that teaching can improve communication skills but…
How should we teach for best effect?
What evidence exists already?

5. Immediate constructive feedback
The evidence provides many common themes with all models based on similar components
Learner centered
Patient centered interviewing
Face to face
Small groups
Facilitated Role play
Immediate constructive feedback
Trained actors
Personal awareness
The commonly used learner centered approach usually delivered in an intensive 2-3 day course was well described by Lipkin in 1995 and this has been replicated by many others – Lipkin model initially used in UK by Fallowfield
Much of the evidence in the oncology/palliative care literature has been generated using this approach .
The Cardiff University Postgraduate Diploma in Palliative Medicine is also a pioneer of communication skills teaching using a learner/patient centered method for over 20 years.
Evidence is usually reported as self-rated improvement in confidence and skills, and facilitator/researcher rated improvement in identified key skills.
Short course
1 ½ , 2, 3 days
Credible trainers

6. How robust is the evidence for a short intensive course?
1 ½ day courses demonstrated improvement in skills (Fallowfield 1998).
2 – 5 day intensive courses increase skills further (Fallowfield et al 2001, 2003).
Longer, less intensive courses demonstrated no additional improvements (Ravasi et al 1993, and 2002).
A recent consensus meeting of European experts (Steifel et al 2009) reported no conclusive results for the optimal length of course.
Fallowfield L, Lipkin M, Hall A, Teaching senior oncologists communication skills: results from phase 1 of a comprehensive longitudinal program in the UK. Journal of Clinical Oncology. 16:
Fallowfield L, Saul J, Gilligan B Teaching senior nurses how to teach communication skills in oncology. Cancer Nursing. 24: 3: 185 – 191
Fallowfield L, Jenkins V, Farewell V, Solis-Trapala I Enduring impact of communication skills training: results of a 12 month follow-up. British Journal of Cancer. 89: 1445 – 1449.
A longer course (5 days per month for 3 months (Ravasi 2002) provided no further significant improvements to a8 weekly 3 hour sessions (24 hours total) Ravasi 1993)
[1] Razavi D, Delvaux N, Marchal S, Bredart A, Farvacques C, Paesmans M,.(1993) The effects of a 24 hour psychological training program on attitudes, communication skills and occupational stress in oncology: a randomised study. European Journal of Cancer. 29A: 13: 1858 – 1863.
[1] Razavi D, Delvaux N, Marchal S, Durieux J.F, Farvacques C, Dubus L et al.(2002). Does training increase the use of more emotionally laden words by nurses when talking with cancer patients? A randomised study. British Journal of Cancer. 87: 1-7.
Stiefel F. Barth J. Bensing J, Fallowfield L, Jost L, Razavi D, Kiss A, 2009 Communication skills training in oncology: a position paper based on a consensus meeting among European experts in Annals of Oncology. 21:

7. Important! This is research evidence for greatest skills improvement.
What were the students’ starting points?
Previous training (2001)?
What is our aim in teaching
– some improvement?
- achievement of a set level?
- improve the student to the best they can achieve?
Is ‘good’ ‘good enough’?

8. MSc/Postgraduate Diploma in Palliative medicine/care
The history
Teaching communication skills since 1989
Students are assessed in order to gain credits towards MSc.
Developed a ‘toolkit’ that can be used in any situation regardless of profession, culture or clinical setting.
Evidence was collected by scoring students along the 2 year timeline of our postgraduate diploma.
The research

9. So how do we teach communication skills for the MSc?
A Blended Learning Approach
Teaching blocks yr 1 and yr 2
Face to face lecture – theory: ‘Cardiff communication skills 6 point toolkit ‘.
Facilitated role-play with and without professional actors
Electronic resources
Reading material, Podcasts and videos

10. The Cardiff Communication Skills 6 point Toolkit
Comfort
Language
Question style
Listening/Use of silence
Reflection
Summarising

11. What questions did we want our research to answer?
Did communication skills improve?
Were improved skills maintained over time? (12 month follow up assessment)
Were skills improved further with a second session of training? (16 month follow up assessment from initial training)
Were students’ self assessments reliable? (comparison of self assessment to tutor assessment)

12. Method and data collection
Data collected for 2 cohorts to allow comparison of results:
Cohort 1: 2008 – 2010
Cohort 2: – 2011
Triangulated approach to analysing data:
Self assessment and facilitator rated competence of ‘consultations’ at 6 points across 2 years

13. Cohort 1- N= 46 – 34 doctors, 12 nurses
Collection of data
Cohort 1- N= 46 – 34 doctors, 12 nurses
Cohort 2- N = doctors, 9 nurses
Assessment at RTB against 6 ‘tools’ by students and tutors
Assessment of DVD against 15 key performance indicators
Comparison of student/tutor scores

14. Data collection timeline
Cohort 1
Sept Jan/Feb Sept Feb/Mar 2010
Cohort 2
Sept Jan/Feb Sept Feb/Mar 2011

15. Findings for Cohort 1.

16. Were communication skills improved by training?
Yes
Student self-scoring at RTB against ‘tools’.
72% of the cohort scored themselves > 70% post training compared to 48% of cohort pre training.
Tutor scoring post training for comparison
87% of the cohort were scored >70% post training.

17. Did students feel their skills were maintained over time?
Post RTB year 1 score compared with pre RTB year 2 score
Students felt that their skill level had reduced over time to their original score or lower.
This is inconsistent with published evidence of follow up questionnaires which raises questions………………

18. Why did they score themselves lower?
Because they felt their skills had deteriorated?
Because they had more insight into their skills after practicing and having further written feedback?
Because they understood the assessment system better?
Because they completed the self-assessment immediately pre-training and wanted to ensure they could demonstrate improvement?
this data was collected immediately pre teaching

19. Were skills improved further with a second session of training
Were skills improved further with a second session of training? YES Cohort 1 data. N=46 - Self and tutor ratings at RTB

20. Did students feel that their skills/confidence had improved by the end of the course? Student self assessment of 2nd DVD:
YES
Students scoring 70% and above increased from 22% (n=7) in year 1 to 60% (n=19) in year 2
At the end of the 2 years of teaching most students were communicating at a very good or excellent level
Over 90% of Students were scored at 60% and over both by self assessment and by tutors
*The Number of students with full data across both years is 32

21. Are students self-assessments from teaching sessions reliable?
Both students and tutors felt that their competencies had improved overall but there was some difference of opinion in which areas the students had improved most.

22. Where were the greatest improvements perceived?
The students perceived their greatest improvement in Questioning and Listening
The tutors perceived greatest improvement in the students’ Reflecting and Summarising

23. Did the findings for Cohort 2 support those for Cohort 1?
Partly but not fully:
All students perceived their competence levels to be higher following training.
Most students reverted to the original scores after a year (self assessed)
However..
Students did not perceive their competence levels to be improved further after a 2nd session of training.
Tutors did not perceive that students improved further between year 1 and 2.

24. Can this be explained?
There were differences in the pre-course skills of the students (self assessed): The second cohort had less high scorers
The amount of improvement in skills was different:
- In high scorers the change was small but quick
- In lower scorers change was incremental over a longer time

25. What evidence can we use to guide future teaching/assessment?
ALL students and tutors felt teaching had improved skills
Students may need different lengths of teaching programmes
Assessments should be included as self-assessment scores are unreliable
Certificates of competence are more meaningful than certificates of attendance

26. The Take Home Message?
One size does NOT fit all!
Why design ‘standard’ length communication skills courses regardless of prior skills and try to make everyone fit?

27. Identifying high/mediocre/low scorers may be the key.
An assessment method that can be used after 1 day of training could do this.

28. Our Training proposal – progression by traffic light system
1 day of training which benefits all = cost effective
Some students will need more training to reach desired level
Students can be ‘traffic lighted’ at the end of day one and the most appropriate route and follow up offered.

29. Training for all: Theory + toolkit, facilitated role-play, assessment and allocated ‘Green’, ‘Amber’ or ‘Red’.
Day 1 assessment outcome
Green: Student exits with certificate of competence, returns within 5 years for update

30. Training for all: Theory +toolkit, facilitated role-play, assessment and allocated ‘Green’, ‘Amber’ or ‘Red’.
Day 1 assessment outcome
Amber and Red: Stays for a 2nd day and receives further training, role-play and reassessment.

31. Day 2 assessment outcome
Day 2. Further facilitated role-play, assessment and allocated ‘Green’, ‘Amber’ or ‘Red’.
Day 2 assessment outcome
Green: Student exits with certificate of competence, returns within 5 years for update

32. Day 2 assessment outcome
Day 2. Further facilitated role-play, assessment and allocated ‘Green’, ‘Amber’ or ‘Red’.
Day 2 assessment outcome
Amber: Given further advice/pointers advised to practice using the toolkit and returns for training within 2 years.

33. Day 2. Further facilitated role-play, assessment and allocated ‘Green’, ‘Amber’ or ‘Red’.
Day 2 assessment outcome
Red: Given further advice/pointers. Advised to practice using the toolkit. Given guidance on how to reflect on practice. Wherever possible partnered up with local colleague or team to mentor/support. Returns for training in 1 year.

34. The Future of communication skills teaching for HCPs - What do you think?
Comm skills training of benefit to all
One size does not fit all.
Assessment process- consideration to previous experience/ training.
Resource allocation/ use – sigmoid shoaped curve.