Communication skills training in paediatrics
- Declaration of conflict of interest: The authors have no conflicts of interests to declare.
Correspondence: Dr Amy Keir, Division of Neonatology, Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8, Canada. Fax: +1 416 813 5245; email: firstname.lastname@example.org
Clinical communication skills are central to good clinical practice and even expert communicators are able to acquire additional skills to improve their practice. The ability to communicate effectively is a core skill required in all areas of medicine. Clinical communication is defined as any interaction between health professionals or between health professionals and patients, and relatives. Effective communication occurs when these interactions are clear and sensitive, and characterised by trust, respect and empathy.[1, 2]
Effective communication by medical practitioners can increase diagnostic accuracy, increase adherence to treatment, minimise litigation, enhance patient satisfaction and improve health outcomes. However, communication skills are not necessarily intuitive but can be, and should be, learned.[4-8]
Communication skills training for some subspecialties, for example, palliative care and oncology trainees, has been long recognised as crucial to their clinical practice. Communication skills are also arguably fundamental for paediatricians and paediatric trainees, yet this has not always been reflected in training programs. The Royal Australasian College of Physicians' (RACP) Professional Qualities Curriculum states that to provide high-quality care for patients, ‘it is essential that Physicians establish and foster effective relationships with patients and their families’. The curriculum emphasises that ‘it is important to develop effective communication strategies early on in training’. However, how should paediatric trainees learn how to develop effective communication strategies? How could paediatricians best support their trainees to acquire these necessary communication skills? What evidence is there to support and guide teaching of communication skills to paediatric trainees? Moreover, what evidence is there that communication skills training makes a difference for patients and their families?
Teaching Communication Skills
Paediatric trainees usually learn communication skills from observing others. Where actual teaching occurs, it usually focuses on medical knowledge and clinical care, with little emphasis on the importance of learning how to talk and listen to families. However, communication problems of medical practitioners are not necessarily resolved by time or clinical exposure and experience alone is inadequate for medical practitioners to be truly effective communicators. To avoid such problems, trainees require evidence-based communication skills training, early on in their specialty training, to provide them with the best set of skills to care for their patients and families. To develop these skills, they require timely, relevant and clinically useful communication skills training programs. Communication skills training is not only about addressing communication problems, it is also about assisting already experienced, high-level communicators to further extend, and refine, their skills. The more effective a communicator a medical practitioner is, the better care they can potentially offer to their patients and their families. Many senior medical practitioners, despite having not received formal communication skills training themselves, still perceive these programs as useful.
Communication Skills Learning Strategies
The most effective method of communication skills training[13-15] is experiential learning – learning by doing. This form of training is generally undertaken within a workshop model, using simulated patients and role play, including constructive feedback on individual performances, supported by oral presentations, modelling and written information.[3, 13] Workshops tend to be resource intensive and expensive, and are usually a minimum of 1–3 days duration.[13-15] Brief educational interventions are less likely to be effective.[10, 13, 17, 18] Effective communication skills workshops include a cognitive component or evidence base for suggested skills, a behavioural component that allows participants to practice the actual communication skills learned through role playing and an affective component allowing participants to explore the feelings raised by communicating about difficult issues.[7, 13, 14]
Does Communication Skills Training Make a Difference?
A recent systematic review and meta-analysis of the efficacy of communication skills workshops in oncology found that communication skills training for health professionals yielded improved generic and specific communication skills, as well as altered attitudes towards death and dying. A small study of Dutch paediatricians found that those who had undertaken a 5-day intensive training course asked more psychosocial questions, looked at their patients and their parents more often and were seen to be more attentive to parents' and their patients' needs than a control group of paediatricians who were yet to complete the course. Another intervention study, designed for health professionals working on a paediatric inpatient ward, used a 3-day communication skills course including role play and feedback on video recordings. Parents' perceptions of feeling understood and their opportunities to explain their concerns were improved after the course.
A crossover randomised controlled trial involving hospital employed medical practitioners across a number of specialties found a significant improvement in communication behaviour after a 2-day communication skills course using role play, which allowed doctors to apply a more patient-centred approach to their communication. A 1-day experiential learning program, focusing on communication skills and relational abilities for paediatric critical care practitioners, found that the program was highly valued, clinically useful and logistically feasible. Communication skills training for paediatricians working in the paediatric outpatient setting has also been found to improve self-reported perceptions of ability and confidence. Video recorded material in combination with individualised feedback in small groups has been found to have significant impact on communication behaviour.
A number of studies have demonstrated that communication skills training for physician trainees result in short-term behavioural changes, such as increased use of empathic statements. Following communication skills training, there is also evidence that long-term behavioural changes occur; in one study, there was a measurable and sustained improvement in the use of summarising statements, assessed at 12 months after a communication skills intervention. In another, medical residents were found to have retained their patient-centred interviewing skills for at least 2 years.
The effect size of communication skills training interventions is difficult to measure and much of the research focuses on self-report of behavioural change. However, there is evidence to indicate that significant positive behavioural change can occur after formal training, including development of superior skills in building relationships with parents and improvements in self-efficacy.
However, the ultimate test of whether communication skills training is truly useful in improving communication and patient interactions is the impact on the patients themselves. There has been relatively little study of the effect of communication skills training on patient outcomes.[25, 26]
In summary, communication skills training programs have been shown to improve communication skills uptake and practitioners' confidence. There is compelling evidence that communication skills training makes a positive difference to medical practitioners' (including paediatric trainees) abilities to communicate effectively and that these changes can be maintained.[18, 23]
Communication Skills Training for Specialist Trainees in Australasia
A number of communication skills courses have been developed in Australia and New Zealand for medical practitioners undertaking specialty training. Details of a sample of these programs are shown in Table 1. They aim to assist medical practitioners to become more competent and prepared to engage in difficult conversations with patients and families. However, aside from oncology and palliative care trainees, there are no specialty communication skills training programs for adult or paediatric physician trainees. Hospital-based programs exist in some centres in Australia and New Zealand and have been well received.
Table 1. Selection of communication skills training courses available for specialty trainees in Australia and New Zealand 2010/2011
|The Chapter of Palliative Care: Royal Australasian College of Physicians||2.5-day course for palliative care trainees covering areas such as breaking bad news, dealing with mismatched expectations and end-of-life choices||Small group practice with simulated patients and demonstration||$1600 each|
|College of Intensive Care Medicine of Australia and New Zealand||1-day course for intensive care trainees launched in April 2011 covering areas such as breaking bad and catastrophic news, end-of-life treatment choices, open disclosure and advance care planning||Blend of demonstration, small group practice and scenarios||$200 each|
|The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG)||1-day communication skills workshops for all RANZCOG trainees||Lectures, video scenarios and exercises||$540 each|
|Medical Oncology Specialty Society||Half-day training program for Australian medical oncology trainees 2008–2010 for 5–10 participants||Focus on breaking bad news, discussing prognosis and transition to palliation, delivered by a professional Communications Training provider (for example, the Pam McClean Centre at the University of Sydney)||Free of charge|
|Royal Australasian College of Surgeons||2-day Training in Professional Skills (TIPS) course launched in July 2011 for 12 participants||Interactive lectures, small group tutorials and role playing in a simulated environment with actors||Free of charge|
To assess the current exposure of trainees to formal or informal communication skills training, we recently surveyed a subgroup of Australasian paediatric trainees, those training under the Neonatal/Perinatal Medicine Specialist Advisory Committee. Neonatal intensive care is an area where good communication, particularly in relation to treatment goals and end-of-life decisions, is clearly vital. The results are shown in Table 2. The majority of respondents had received no training in communication skills relating to critically ill newborn infants. Trainees overwhelming expressed a desire for more training relating to communication skills and goals of care. Although the response rate was 50%, the results from this Australasian survey were similar to those found in a North American survey, which is the only other survey of its kind to date. It appears likely that the views of these trainees would be similar to those in the wider Australasian paediatric trainee body.
Table 2. Results of a 2011 Web-based survey† of RACP Neonatal-Perinatal Medicine (NPM) trainees' perceptions and experiences of communication skills training‡
|During your training, have you received didactic teaching on the topic of negotiating goals of care with families of critically ill newborns?||No||76.3|
|During your NPM training, have you participated in role play or simulated patient scenarios with the goal of developing communication skills to help families make decisions about critically ill newborns?||No||73|
|>5 sessions ||0|
|During your NPM training, when you lead family meetings to discuss treatment goals for critically ill newborns currently in the intensive care unit, how often was the consultant in the room?||Never||32.4|
|How often did the consultant give you feedback about the way you led the meeting?||Never||30.6|
|Do you think that your training to discuss treatment goals and decision making should be improved?||Yes||100|
Proposed Development of a Communication Skills Training Program in Paediatrics
Most of the research on communication skills training relates to end-of-life decision making and has emerged from palliative care and oncology. The relative rarity of death in children may be one reason why, to date, communication skills training has not been a formal part of paediatric training. However, the ability to communicate well with patients and parents is valuable in a much broader range of contexts. It is also about improving the impact of these routine interactions. Communication skills training in paediatrics could be expanded to include the teaching of reflective listening skills, sensitivity to nonverbal cues and information giving skills. Important behaviours to focus on as part of training include the use of appropriate body language and tone of voice, use of first names, use of plain language to explain situations and encouraging parents, and the child if able, to ask questions.
Learning objectives of a communication skills training program should be specific and ideally integrated with the RACP Professional Qualities Curriculum. Objectives already identified in the curriculum include the ability to engage and reassure the patient in first encounters, history taking, counselling and breaking bad news. These objectives could be further expanded to include the use of specific behaviours, identified as important to good clinical practice.
There are no current frameworks for communication skills training in paediatrics, although there are several adult frameworks that could be modified, including the OncoTalk modules (see Table 3) and the Calgary-Cambridge referenced observation guides. A consultation tool to assess paediatric consultations has recently been developed based on the Calgary-Cambridge guides and this could be used to guide development of a framework. An option in Australasia would be to modify the existing RACP facilitated communication skills course for palliative care trainees based on the OncoTalk Learning Modules. It would need to include aspects of communication skills used in routine paediatric practice to be relevant to all paediatric trainees.
Table 3. A framework† for breaking bad news in Paediatric Medicine
|Step 1: Preparing for the Family Meeting||The meeting should occur in a private area with minimal chances for interruption. Both parents should generally be present and additional support persons as desired by the family.|
|Use of the infant's or child's name, sitting with the family and maintaining eye contact are important steps in establishing rapport with the family.|
|Step 2: Assessing the Family's Understanding of the Situation||The importance of understanding the family current perceptions of the situation is necessary.|
|An open-ended question such as How do you think things are going at the moment? can be useful.|
|Step 3: Delivering the Information||Information should be delivered in a step-by-step manner, with frequent opportunities for questions and time to allow the family to absorb the difficult news. Direct and straightforward information needs to be given using simple language, avoiding medical jargon.|
|Use of I wish statements can be used in the discussion of very bad news, such as I wish I had some better news for you and things had worked out the way we had all hoped. These statements can provide a verbal expression of empathy.|
|Step 4: Responding to the Family's Emotions||Empathic responses to the family's emotions are necessary. Gentle questioning may be used to explore the feelings of the family. Powerful statements can include This is so hard for you, just when our hopes were so high, for your daughter to have this complication. I wish it had been otherwise.|
|Step 5: Discussing the Implications and Future Directions||If the family is ready, shared discussion and decision about future medical care can be undertaken. This may need to be discussed at another stage to allow the family to deal with the powerful emotions associated with receiving difficult news.|
|Step 6: Summarising the Discussion||A summary of the discussion may help the family understand the situation more clearly. Clarifying the family's understanding of discussion is also necessary.|
|Availability for future meetings and support should be stressed to the family.|
The ideal program would have clear learning objectives and be based on experiential teaching methods – encompassing small group learning, direct observation, detailed and individualised feedback and practice of learned skills. It would need to run for at least 1 full day, as any shorter duration has not been proven to be of benefit.[13-15]
Who Would Teach and How Would These Programs Be Facilitated?
For communication training skills programs to be effective, it is important to have trained facilitators. Paediatricians, and other interested medical educators, could be trained to facilitate communication skills courses: through a train-the-trainer type course. Another option would be privately facilitated communication skills courses for paediatric trainees, such as those run for The Royal Australian and New Zealand College of Obstetricians and Gynaecologists trainees. Alternatively, courses could be developed or existing courses expanded at a local paediatric training network level. Expansion of existing hospital-based communication skills courses is an additional option. For example, the courses could be made available to trainees early on in their training and then on a 5 yearly repeat basis to assist in maintenance of skills.
The development of communication skills training courses for paediatric trainees would also allow for further research to be conducted, in particular, in the area of the impact of parents' perceptions of trainees' communication skills, which is currently limited.
Whatever option is feasible, it is likely that the financial cost to the trainee would be significant. The resources, both time and financial based, required to run these courses are substantial and are the most difficult aspects needed to overcome for their implementation.
How Can Paediatricians and Trainees Put These Ideas into Practice Now?
In the meantime, those passionate about communication skills training can make a difference at their local departmental level. Even with limited time and resources, effective learning can occur when supported by minimally formally trained teachers. Structured sessions, run at 3–6 monthly intervals, focusing on the skills of interviewing, information giving and planning treatment and dealing with issues such as breaking bad news, would be invaluable for trainees.
This article highlights the value of an evidence-based communication skills program, with clearly stated learning objectives for paediatric trainees. Paediatricians are well positioned to advocate for formal communication skills training for their trainees and may even find benefit themselves from additional training. It also helps to focus attention on the types of communication skills that require attention in paediatric training and on the importance of providing context-specific and credible learning experiences.
Development and implementation of formal communication skills training programs for paediatric trainees may face some challenges; however, the rewards of such programs are likely to be significant. The existence of communication skills training programs for other specialty trainees in Australasia indicates that these programs are logistically possible. It is hoped that this article will generate discussion on the implementation of such programs for paediatric trainees.
Communication skills training has the potential to bring significant benefits not only to participants but also to their patients and families. It is time to ensure that all training paediatricians have access to such a program.
No financial grants or other sources of funding were used for this project.
Thank you to all the RACP Neonatal-Perinatal Medicine trainees who participated in the survey.
Thank you to Assistant Professor Renee Boss (Johns Hopkins University, Baltimore, MD, USA) for allowing the reproduction, with alterations, of the original survey published in 2009.