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Contents lists available at ScienceDirect

Patient Education and Counseling

journal homepage: www.elsevier.com/locate/pateducou

Communication training: Skills and beyond

Myriam Deveugele
Department of Family Medicine and Primary Health Care, Ghent University, Campus UZ – 6K3 De Pintelaan 185, B 9000 Gent, Belgium

A R T I C L E I N F O A B S T R A C T

Objectives: As communication is a central part of every interpersonal meeting within healthcare and research
Keywords: reveals several benefits of effective communication, we need to teach students and practitioners how to
Communication training
communicate with patients and with colleagues. This paper reflects on what and how to teach.
Teaching
Skills training
Methods: In the previous century two major changes occurred: clinical relationship between doctor and
Reflective practice patient became important and patients became partners in care. Clinicians experienced that outcome and
especially compliance was influenced by the relational aspect and in particular by the communicative skills
of the physician. This paper reflects on teaching and defines problems. It gives some implications for the
future.
Results: Although communication skills training is reinforced in most curricula all over the word, huge
implementation problems arise; most of the time a coherent framework is lacking, training is limited in
time, not integrated in the curriculum and scarcely contextualized, often no formal training nor teaching
strategies are defined. Moreover evidence on communication skills training is scarce or contradictory.
Conclusions: Knowing when, what, how can be seen as an essential part of skills training. But students need
to be taught to reflect on every behavior during every medical consultation.
Practice implications: Three major implications can be helpful to overcome the problems in communication
training. First research and education on healthcare issues need to go hand in hand. Second, students as
well as healthcare professionals need a toolkit of basic skills to give them the opportunity not only to tackle
basic and serious problems, but to incorporate these skills and to be able to use them in a personal and
creative way. Third, personal reflection on own communicative actions and dealing with interdisciplinary
topics is a core business of medical communication and training.
ã 2015 Elsevier Ireland Ltd. All rights reserved.

1. Introduction communication. He said: “The patient, though conscious that his

condition is perilous, may recover his health simply through his
This paper is based on the keynote lecture given at the AACH contentment with the goodness of the physician” [1]. A strong
conference in Montréal October 1 2013. sentence intuitively referring to the healing aspects of the doctor
Communication is a central part of every interpersonal meeting patient relationship.
within healthcare. As research reveals that effective communication In the mid 50s of the previous century huge criticism to the
is connected with satisfaction, compliance and to some extend with biomedical model came apparent and the psycho-biomedical
medical outcomes it is widely acknowledged that we need to teach model was born. Balint groups, with as most important aim
students and practitioners how to communicate with patients and support of doctors in their demanding task to deal with biomedical
with colleagues. This paper reflects on what and how to teach. and psychosocial problems of patients, were installed [2]. The
quote of Engel in 1998 is in that perspective well known: “patients
2. What to teach need to know and understand and feel known and understood” [3].
Moreover patients became partners in care; they no longer
2.1. Brief historical perspective and comments passively had to undergo the treatment. They got the right to be
informed, to ask questions, to deal with their own disease and even
Thoughts on communicating with patients are not new, there to decide together with the doctor about the treatment. In some
are as old as medicine. Hippocrates, in fact, had some quotes on countries like Belgium and the Netherlands, this right got a legal
format as it became one of the topics in the ‘law on patients’ rights’
[4,5]. In the US, the Health Insurance Portability Accountability Act
E-mail address: [email protected] (M. Deveugele). HIPAA (1996) is intended to protect patients' medical records.

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0738-3991/ ã 2015 Elsevier Ireland Ltd. All rights reserved.

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It is important to notice that these principles are rooted in Beckman and Frankel stated that theory might diverge from day
humanity and in the belief that good communication leads to more to day reality, pointing at transfer from what is learned to how to
autonomy of the patient. Patient-centred communication puts behave in practice [12]. Makoul stressed the importance of the
these values at its centre. interplay between research and teaching, by saying: ‘Research on
In the same period research on communicative aspects of the patient–provider communication is most useful and necessary when it
medical consultation has been started and as a result the above recognizes the importance of clinical work, can be translated into
described ideology of patient autonomy was picked up politically practice, and incorporates outcome measures such as clinical
all over the world. The most important were, the statement of the endpoints, provider and/or patient perceptions, behavior as adher-
American Medical Colleges in 1984 [6], of the Canadian Medical ence, quality of care, and practice patterns’ [13].
schools in 1992 [7] and the international consensus statement in Education will only be valuable if linked to the daily practice of
1999 about communication teaching and assessment in medical health care providers. Moreover teaching must draw on evidence,
education [8]. All these statements have several issues in common: both on content and process of communication. Frameworks used
they all see doctor patient communication as an integral for teaching and assessing communication skills need to be
component of quality medical care; they highlight the need for studied, to determine reliability and validity, and to gauge their
formal training programs at the undergraduate, postgraduate and feasibility in real-life practice. So there is the need for evidence in
continuing education levels. They all state that teaching strategies medical communication, a model of goals and functions need to
can be defined to significantly change students’ communication be clear, and we need to think about theory and outcomes. Only
knowledge, skills and attitudes. Moreover the consensus state- then communication research and training will be in the
ment in 1999, in Amsterdam at the conference of what later attention of polity makers in different countries. But the most
became the European association for communication in healthcare and ultimate reason is to improve the health and the lives of
(EACH), completed the previous statements with the following patients.
advices: communication skills teaching should be planned and a
coherent framework should be made; teaching skills and clinical 2.3. Evidence on ‘what to teach’
teaching should be consistent and complementary; teaching
communication should foster personal and professional growth; Although the research field is rapidly growing and as a result
students’ communication skills should be assessed as well as the the body of evidence on communicative issues in healthcare is
teaching program should be evaluated; faculty development increasing, the evidence remains limited.
should be supported and adequately resourced [8]. First, communication has been and still is used as a container
concept; this concept became so overwhelming that almost
2.2. Problems to be solved everything fits into and relates to communication. The quote
‘without communication no medicine’ is a nice illustration. The
Although a lot of effort has been made by countries all over the concept ‘communication’ definitively needs to be disentangled.
world, we are far away from these important advices. The Second, we have a variety of endpoints, without justification or
implementation of communication training in medical schools priority. Some research reveals contradictory results like a positive
has encountered a number of problems. The training mostly effect of a patient centred intervention on satisfaction on the one
addresses specific items/topics like breaking bad news, genetic hand and at the same time a negative effect on medical outcome
counseling, handling psychosocial problems or stop-smoking parameters [14]. Until now it is not clear how to evaluate these
advice, but a coherent framework is lacking. Moreover training outcomes. And of course this has huge consequences for
is often limited in time, not integrated in the curriculum and communication training, what do we need to train if we know
scarcely contextualized; no formal training or teaching strategies that positive and satisfying communication skills may hamper or
are defined. On the contrary the didactical techniques are often not negatively influence the medical health outcomes [15]. Another
adapted to the nature of the subject: ex-cathedra lectures on problem may occur if the intended communicative behavior like
communication can teach the students that communication is posing open questions e.g. is not connected to the improvement of
useful and necessary but is not solely suited to confront them with patient outcomes due to the fact that the content of that open
their own communicative behavior or to help them to incorporate question is unrelated to the important issues in the eyes of the
new communicative techniques in their consultation style. patient.
Students’ communication skills are rarely reinforced when they Third, what do we know about short and long term endpoints?
enter the hospital for clerkships. Hospital care is diagnosis e.g. if we study communication in relation to breaking bad news,
oriented, doctor centred and often related to acute interventions. do we look at reactions shortly after the consultation, like anxiety,
Students are seldom stimulated to look for patient's ideas, or do we have attention for the quality of life of the patient and the
concerns and emotions at the bedside [9]. And although the next of kin during the whole period of disease, including death? As
advice is given that formal training programs have to be installed De Haes et all stated we need to define the goals of medical
not only at the undergraduate, but at postgraduate and continuing communication training [15].
education levels as well, research shows that these programs often
suffer from the same problems as described above, didactical 3. How to teach
principles are badly defined, assessment is seldom reported and
the content is not always transparent [10]. 3.1. Effectiveness of training
In this broad field, there is little connection between research,
teaching and implementation in practice for the benefit of the Looking at how, the most important problem to face is the
patient. effectiveness of training and teaching. Two recent papers, by
The problems described above stayed of course not unre- Veldhuijzen et al. and by Van Den Eertwegh et al., address these
marked. Warnings and advices were given by several authors at the problems [16,17]. They give a summary of gaps and challenges
end of the previous century and later on. Cegala pointed at the low within communication training. In their view the most important
priority for theoretical frameworks in communication research are: how to assess the effectiveness of training; how to deal with
[11]. He stated that communication theory is essential for the context and the transfer of the training into practice; how to
communication skills training to be effective. systematically implement the skills at organizational level.

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Assessing the effectiveness of communication training still never deal with the complexity of human communication which is
remains difficult. There is an absence of consensus how to define context specific, or subjectively shaped. The answer to this
and capture effectiveness. Effectiveness has been defined in criticism can be formulated as follow: skills represent a toolkit
numerous ways by many different theorists and researchers. that provides tools appropriate for every consultation task like
The well-known levels of evaluation developed by Kirkpatrick are building a save and workable relationship, clarification of the
one of the most prominent [18]. The model consists of four levels. patient's story, testing of diagnostic hypotheses, negotiation on
Level 1 deals with the satisfaction of the learner with the training; management with the patient and many other aims. One of the
level 2 with the extent to which the participants change most important goals of skills training has to be learning to use the
knowledge, skills and/or attitudes; level 3 evaluates the change tools in a context specific appropriate way to help the individual
of the participants' behavior-on-the-job based on what they patient and to strive for the best outcome.
learned; level 4 assesses change in behavior in relation to the effect Another criticism is that communicative behavior must be
on the organization. learned in practice [21]. It is obvious that every student and every
Although the model of Kirkpatrick has been criticized [19], it professional learn skills in the medical context. Since transfer is
remains interesting to notice that organizations still prefer to not self-evident, we might want to take during training examples
measure the first two levels rather than the last two, which are from medicine, with patients. As a result it is sometimes
harder to define. Levels three and four are however most mentioned that communication training should start at the time
interesting to know, since they measure whether real change of internships, or at least when the student gets access to hospital.
has occurred due to the intervention. Looking at effectiveness of Although logic at first sight, this idea might be dangerous, the
communication skills training, what we are striving for is an skills might be learned too late. Skills should be learned in
observable change in the communication behavior of clinicians in discrete parts, and if the learning process starts early in the
their daily practice. Ways to assess level 3 and 4 need to be defined carrier, skills can be internalized before entering the clinic.
to ensuring systematic and lasting implementation of the effects of Research showed that students with good communication skills
communication training. often lose their skills when confronted with real patients, in
hospital, due to anxiety. To overcome this problem, basic skills
3.2. Skills? must have been trained early in the curriculum and training the
supervisors is inevitable [22].
The Calgary Cambridge guide is probably the most comprehen- The problem with the critics might be the definition of the word
sive and useful framework for instruction in provider communi- ‘skills’. Do skills only refer to simple actions, like posing open
cation [20]. The Calgary Cambridge is constructed of five basic questions? Or can they be defined as complex behavior like
tasks healthcare providers routinely attempt to accomplish in conducting a bad news consultation. The concept ‘skills training’
clinical practice of everyday. In this way this framework solves at can be defined as series of discrete elements that can build
least one of the criticisms namely to resemble daily practice. It complex behavior and that can lead to, or help to build a
follows a natural flow of a consultation; it takes ‘relationship’ into relationship between patient and doctor. Skills can build complex
account, structure and efficiency. But most of all it is skill based. behavior, and skills are complex behavior. But most important is to
Skills are very fundamental; every health care professional needs raise the awareness about what, when and how to use which skill.
to master core skills to be able to tackle specific communicative Silverman et al. [20] confirmed that, without nurturing and
challenges such as breaking bad news, cultural issues, emotion integration, improvements as a result of communication training
handling, etc (Fig. 1). are often likely to flounder in the face of pressures from workload,
Of course some critical notes on skills training have been time issues, inappropriate modeling, and apparent failure to
formulated [21]. Sometimes it is mentioned that simple skills can recognize the value of this central clinical skill.

Fig. 1. Calgary Cambridge model of medical consultation.

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Core skills are of fundamental importance. A secure platform of people, more and more will the norm be working together with
core skills that will serve as the primary resource for dealing with other professionals for the sake of the patient. Actions all over the
all communication challenges is important. We need to deepen our world are taken to tackle this relatively new situation. Pype
understanding of these core skills and the level of mastery with addresses this topic in his PhD dissertation with other profes-
which we apply them. sionals the norm [25]. He looked at the co-operation of palliative
nurses and GPs in the context of palliative home care. His
4. Beyond? The way forward conclusions are promising for the collaboration: a survey of the
charts showed that GPs and nurses learn from each other.
Although knowing when, what, how can still be seen as part of Moreover focus groups revealed that GPs accept the fact that they
skills training, we need to teach the students to reflect on every can and have to learn from nurses. In a randomized controlled
behavior during every medical consultation. During the medical setting training was performed to make this collaboration more
curriculum this awareness needs to be raised. Often this is referred effective in terms of learning outcomes for professionals.
to as ‘reflective practice’ or ‘reflective education’. It is an area that The results, at this moment still subjective and close to the
needs to be developed, students need to see what they learn, what training, are positive and show that this way of working is
is taught, they need to know why they behave in the way they do feasible. So there seem to be no barriers to the development of
and they need to recognize the aims of the communication inter-disciplinary work. It will be, it has to be a domain within
training. While at the start of the communication training years medical communication are seem but [25].
ago, we needed to drift away from ‘theory’ lessons on communi-
cation towards a model of skills training. Now it is time to make the 5. Conclusions
circle and with skills training return to theory and explanation of
why, what and how. Three major conclusions can be drawn:
It is no longer good enough to just teach students how to First, research and education on healthcare issues need to go hand
communicate in certain situations. Students need to be aware of in hand. Content as well as process of what and how to teach need
the theories underlying these skills; they need to build a good to be the topic of research. It is important that the results of these
knowledge base about communication research, not only to have research efforts lead to implementation so that research and
insight in their own behavior and that of others but to be able to teaching can have a positive influence on the health of the patient
reflect and to start to become creative in communicating with on the one hand, but influence the policy makers to put medical
others. Going beyond skills calls for flexible, creative and authentic communication at the centre of all healthcare services, on the
use of skills in the appropriate situation. Sometimes skills training other hand.
and mindful reflection are seen as a dichotomy. But communica- Second, teaching students as well as healthcare professionals a
tion teaching embraces the integration of both skills training and a toolkit of basic skills is important to give them the opportunity not
holistic view on conducting a medical consultation. Good medical only to tackle basic and complex problems, but to incorporate
communication training encourages learners to reflect and to take these skills and to be able to use them in a personal and creative
into account the context, the patient’s needs and the learners own way.
needs. Third, personal reflection on own communicative actions
Some important issues need to be cared for. The first is the and interdisciplinary collaboration is a core business of medical
emotion of the caregiver. We need to take into account the emotion communication and training.
of the caregiver during the whole education and especially during
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