Intensive Communication Skills Teaching for Specialist Training in Palliative Medicine: Development and Evaluation of an Experiential Workshop

Abstract

Background:

The Australasian Chapter of the Palliative Medicine (AChPM) Curriculum Development Group identified communication as a core skill that trainees in palliative medicine need to acquire, and proposed the development of a communication skills workshop that should become a compulsory part of training to achieve accreditation as a palliative medicine specialist in Australia and New Zealand. This paper describes the development and subsequent evaluation of this module.

Methods:

A three-day communication workshop was developed in collaboration with expert communication skills facilitators from the United States and Australia. The teaching consists of: (1) brief plenary presentations providing an evidence-based framework for communication and a demonstration of suggested strategies; (2) small group experiential learning providing opportunities to practice communication skills with clinically relevant simulated patients, self-appraisal, constructive feedback, and reflective exercises; and (3) accompanying course-specific written material. Participants completed de-identified questionnaires before, after, and three months following completion of the workshop.

Results:

Forty-one participants completed the training in two workshops held in 2008 and 2009. Participants said in their questionnaire responses that the training was useful, would be helpful for their communication with patients, and that they would recommend the training to others. Qualitative feedback was highly positive. Self-assessed confidence in communication skills significantly increased following the workshop (p<.001) and was sustained at three months (p<.001).

Conclusion:

The training is highly valued by participants and increases confidence in communication skills. Facilitator training and capacity planning will be critical for the ongoing success of the communication workshop.

Introduction

Communication has been identified as one of the most important aspects of care for patients diagnosed with advanced life limiting illnesses.^1–2 For specialists practicing in palliative medicine, defined as “the study and management of patients with active, progressive, far-advanced disease for whom the prognosis is limited and the focus of care is the quality of life,”³ communication with patients and their families is a core and fundamental skill.

Communication skills of physicians do not reliably improve with experience alone.⁴ Training involving communication skills workshops of three or more days' duration has been shown to improve doctors' communication skills^5–6 and may potentially improve outcomes for patients.⁷

The particular importance of communication skills training for palliative medicine specialists is recognized by the AChPM and the Royal Australasian College of Physicians (RACP).⁸ In 2006, when the curriculum for trainees in palliative medicine was revised, it was proposed that trainees be required to complete a compulsory workshop in communication skills. This paper describes the development of the communication skills workshop for palliative medicine trainees in Australia and New Zealand and its subsequent evaluation.

Methods

Development of the communication skills training workshop

The development of the workshop was led by a working party of the AChPM, consisting of five palliative medicine specialists from Australia and New Zealand (JC, JA, AO'C, PM, JH) and one Australian communications skills expert (PB, a clinical psychologist). Australia and New Zealand have a long history of medical specialists providing training and education to specialist trainees on a voluntary basis as part of their public hospital and/or university appointments. While supporting the development costs of the workshop, the AChPM briefed the working party that it expected the workshop to be facilitated in the long term by fellows (known as faculty members in the United States) of the AChPM on a voluntary basis and that other costs and materials for running the workshops would be borne by the trainees on a cost recovery, not-for-profit basis. It was also proposed that the workshop be available to already qualified palliative medicine physicians as a continuing professional development activity.

The content and delivery of the workshop was based on a review of the best available evidence for communication skills training, sound educational principles, consultation with the deanery of the RACP, and a worldwide search for the most applicable models. The communication intervention developed by the Oncotalk^® group⁹ for medical oncology fellows in the United States¹⁰ was selected as the most relevant evidence-based model available.

The communication workshop and an accompanying train-the-trainer workshop for future facilitators were developed in collaboration with three U.S.-based expert communications skills facilitators from the Oncotalk group (AB, RA, JT).^9–10 The pedagogic approach and program design is similar to that used by the Oncotalk^® group⁹ and previously well described by Back and colleagues.¹⁰ The content of the presentations, written materials, and clinical cases was developed by the AChPM communication module working party with assistance from the Oncotalk^® group, in order to ensure the relevance to the cultural context of Australian and New Zealand palliative medicine practice and the learning objectives of the AChPM training curriculum.¹¹

Intervention setting

Intensive workshops were held in Sydney, Australia. In the first year (2008) the workshop was held over two days. In the second year (2009) the workshop length was increased to three days with similar content following feedback from participants that they would value more time for reflection and longer small group sessions.

Participants

Trainees and fellows of the AChPM were invited to undertake the workshop on a fee paying basis. In addition the workshop was available to medical practitioners who were completing a six-month AChPM diploma course in palliative medicine (completion of this diploma does not give palliative medicine specialist status) and, if space was available, to trainees in related disciplines, such as radiation oncology, medical oncology, and respiratory medicine. The workshop was advertised in AChPM and RACP newsletters and conferences and through not-for-profit palliative care organizations in Australia and New Zealand.

Communication module design and curriculum

The workshop is comprised of four learning modules, each targeting a different communication challenge, with specific learning objectives (for example, discussing prognosis and dealing with conflicting expectations) (Appendix 1). Each module consists of (1) a brief plenary session, including a didactic presentation providing an evidence-based framework for communication and specific skills for that module, and a role-play demonstration by the facilitators of suggested strategies; and (2) small group experiential learning (which takes up the majority of workshop time) providing opportunities to practice communication skills with simulated patients with clinically relevant diseases and concerns. In addition to the four modules, three reflective exercises are undertaken in the small groups over the course of the workshop. Finally, a course-specific, evidence-based manual is sent to participants prior to each workshop outlining a communication framework and describing key strategies for all four modules.

The small groups comprise five to six learners and a facilitator. In the first small group session, ground rules are established regarding role play procedures, confidentiality, and how to give constructive feedback (both through self-appraisal and group feedback) to ensure a safe, constructive, and learner-centered learning environment. In each of the subsequent four sessions, experiential learning relevant to one learning module is covered.

Each simulated patient visits each small group for 30 minutes during each module. Participants interact with the simulated patient individually, and reflect on and refine their communication through self-appraisal; constructive group feedback; and “replays,” where they reenact small segments of the interaction with a revised strategy. Three of the simulated patients have a diagnosis of malignancy (breast, lung, and lymphoma) and one has advanced heart failure. They each present at four consecutive periods in their illness, reflecting the module being taught. Thus participants can interact with four different simulated patients, practicing skills relevant to that module, with a growing familiarity with each case over the workshop. Actors experienced in medical roleplays rehearsed their roles in the weeks prior to the workshop; their characters were further refined with respect to learner needs in conjunction with the facilitator group, the day before the workshop and during the workshop at regular briefing sessions.

The reflective exercises aimed to promote awareness and group discussion of emotions and beliefs that influence physicians' communication behaviors during interactions with patients¹⁰ and covered aspects such as ‘What surprises you about what you learned today?’ and ‘When was the last time you felt like a healer?’

Evaluation

All participants were invited to participate in an evaluation of the course consisting of de-identified questionnaires before, after, and three months following completion of the workshop. All participants received an information sheet about the study and gave written consent. The study was approved by the University of Sydney Human Ethics committee. Nonrespondents of the follow-up questionnaire were sent one reminder. The participant evaluation consisted of the following measures:

Satisfaction with and impact of the course was assessed immediately following the course and at three months follow-up using a 4-point Likert scale (1=strongly agree to 4=strongly disagree) adapted from previous studies^10,12 (Tables 2 and 3). At three months participants were asked whether they had implemented trained skills in their practice (yes/no) and whether their personal practice of palliative medicine had changed as a result of participating in the workshop (yes/no). Qualitative feedback about positive and negative aspects of the course was also elicited with open-ended questions.

Self-assessed confidence in communication skills in areas specifically relevant to the practice of palliative medicine and to the course curriculum was assessed at baseline, immediately following the course, and at the three-month follow-up using 26-item, 5-point Likert scales (1=not at all confident to 5=very confident) adapted from Lenzi and colleagues.¹³ Total scores range from 26 to 130 (with higher scores reflecting greater confidence) (Table 4). The reliability of the overall scale was assessed using Cronbach's alpha. The current scale possessed an alpha of 0.965, which is considered excellent reliability and internal consistency.

Attitudes to psychosocial aspects of care were assessed at baseline and at the three-month follow-up using a 20-item questionnaire adapted from Jenkins and colleagues¹⁴ and Ashworth and colleagues.¹⁵ The questionnaire uses a 5-point Likert scale ranging from strongly disagrees (1) to strongly agrees (5). Scores range from 20 (minimal psychosocial orientation) to 100 (maximum psychosocial orientation).

Stress and burnout was assessed at baseline and at three months using the Maslach Burnout Inventory (MBI) as used by Rameriz and colleagues.¹⁶ The 22-item scale includes three subscales: emotional exhaustion, depersonalization and personal accomplishment. A high degree of stress and burnout is indicated by high scores on the emotional exhaustion and depersonalization subscales and low scores on the personal accomplishment scale.

Statistical analysis

Data analyses were conducted using Predictive Analytics SoftWare (PASW) version 17.0. Prior to conducting any statistical analyses, data were screened for accuracy and missing values. Descriptive statistics were used to characterize the sample. Due to the small sample size and restricted range of the data, nonparametric tests were utilized. To analyze differences between physicians' pretraining and posttraining self-report scale responses, including the Confidence in Communication Skills Scale, the Psychosocial Aspects of Cancer Care Scale, and the Human Services Inventory, the Wilcoxon Signed Ranks Test were utilized.

Results

Forty-one participants completed the training in two workshops held in 2008 and 2009; all participated in the evaluation. Demographic characteristics of participants are shown in Table 1. All participants completed the questionnaire immediately following the course and 31 participants returned the three-month follow-up questionnaire (76%).

Table 1.

Demographic Characteristics of Participants (n=41)

Characteristic	n=41
Age (years)	Range 31-60 years, mean 42
Gender
Male	11
Female	30
Type of participant
1^st year specialist trainee in PM	11
2^nd year specialist trainee in PM	6
3^rd year specialist trainee in PM	6
1 year diploma of PM trainee	2
PM specialist	14
Trainees in a related specialty	2
Years of practice in palliative medicine
<2 years	13
2-5 years	14
6-10 years	10
>10 years	4
Average hours of patient contact per week
0-10 hours	5
11-20 hours	9
21-30 hours	10
31-40 hours	13
>40 hours	4
Previous formal communication skills training involving skills practice
Yes	19
No	22

PM, palliative medicine.

Satisfaction with the course

Overall feedback about the course is shown in Tables 2 and 3. All participants said the training was useful, would be helpful for their communication with patients, and that they would recommend the training to others. At three months follow-up, all but one participant (who had been on maternity leave since the course) said they had implemented skills taught in the course during conversations with patients or their families; and all felt they had changed in their personal practice of palliative medicine as a result of participating in the training. Qualitative feedback was highly positive (Appendix 2).

Table 2.

Overall Ratings of Course in the Questionnaire Immediately following Completion of the Workshop (n=41)

Item	Strongly agree (n)	Agree (n)	Disagree (n)	Strongly disagree (n)	Missing (n)
The training was effective	32	7	1	0	1
The training was enjoyable	25	15	1	0	0
The training provided me with useful skills	35	6	0	0	0
The training will be helpful for my communication with patients	36	5	0	0	0
I would recommend this training to others	34	7	0	0	0
This communication module should be compulsory for palliative medicine trainees	33	8	0	0	0
The cost of this training module is too high for trainees	6	24	5	0	6
It is reasonable for palliative medicine trainees to have to pay to attend a communication workshop as part of their training	3	24	11	2	1

Table 3.

Overall Ratings of the Course at 3 Months Follow-up (n=31)

	Strongly agree (n)	Agree (n)	Missing (n)
The training was effective	20	11	0
The training provided me with useful skills	21	10	0
I have utilized skills from the training during my consultations with patients	12	18	1
The training has helped me in my discussions with patients	15	15	1
I would recommend this training to others	26	5	0

Self-assessed confidence

Self-assessed confidence in communication skills significantly increased from a baseline mean score of 89 to 105 immediately following the workshop (Z=−5.284, p<.001) and this improvement was sustained at three months (mean score 106, p<.001). Improvements were also seen in nearly all of the individual items (Table 4).

Table 4.

Participants' Self-Assessed Confidence in Communication Skills

	Pre		Post			3-month follow-up
	n=41		n=41			n=31
	Mean	(SD)	Mean	(SD)	p	Mean	(SD)	p
1. Introduce your role as a palliative care clinician to a patient	3.9	.75	4.2	.53	.007	4.2	.54	.001
2. Elicit a patient's concerns during a consultation	3.7	.72	4.3	.52	.000	4.4	.50	.000
3. Negotiate the agenda for a consultation with a patient	3.4	.91	4.2	.54	.000	4.2	.62	.000
4. Give bad news to a patient about his/her illness	3.7	.64	4.2	.48	.000	4.3	.51	.000
5. Elicit a patient's emotional reaction to what is being discussed	3.4	.7.0	4.3	.50	.000	4.3	.53	.000
6. Respond when a patient becomes upset during a consultation	3.6	.71	4.2	.65	.000	4.3	.45	.000
7. Respond when a patient becomes angry during a consultation	3.0	.76	3.9	.557	.000	4.0	.52	.000
8. Express empathy	3.9	.67	4.4	.58	.000	4.4	.50	.001
9. Elicit a patient's information needs regarding his/her illness and prognosis	3.6	.73	4.3	.56	.000	4.3	.58	.001
10. Discuss life expectancy	3.6	.74	4.1	.51	.000	4.1	.47	.000
11. Discuss treatment options, eg, palliative chemotherapy vs. best supportive care	3.3	.72	3.8	.60	.000	3.9	.67	.000
12. Discuss discontinuing disease specific treatments once they are no longer effective, eg, cessation of palliative chemotherapy	3.5	.74	4.0	.69	.000	4.0	.61	.001
13. Discuss potential future symptoms	3.9	.71	4.1	.57	.039	4.2	.65	.033
14. Respond to patients who deny the seriousness of their illness	3.0	.68	4.0	.47	.000	3.9	.51	.000
15. Respond to patients who want treatments that you believe are medically futile	3.1	.74	4.0	.47	.000	4.0	.41	.000
16. Deal with conflicts between patient and health care team	2.9	.89	3.9	.54	.000	3.9	.55	.000
17. Advise parents what to tell their children	2.6	.97	3.1	.893	.002	3.3	.77	.001
18. Explore a patient's wishes about his/her future medical care	3.4	.77	4.0	.74	.000	4.0	.58	.000
19. Discuss DNR with a patient	3.7	.60	4.3	.55	.000	4.2	.56	.000
20. Discuss discontinuing disease-specific treatments	3.7	.71	4.1	.60	.000	4.1	.60	.011
21. Discuss the dying process and what to expect in the final days of life?	3.9	.71	4.1	.66	.087	4.4	.55	.002
22. Elicit a patient's fears about the end of life	3.4	.86	4.3	.64	.000	4.3	.47	.000
23. Elicit a patient's hopes for the end of life	3.3	.90	4.2	.74	.000	4.0	.58	.000
24. Discuss how a patient can maintain hope	3.0	.83	3.8	.89	.000	3.7	.70	.000
25. Respond to concerns about potential complications	3.3	.79	3.7	.58	.007	4.0	.63	.001
26. Discuss a patient's request to hasten death	3.0	.96	3.8	.67	.000	3.9	.68	.000
TOTAL SCORE	88.6	14.30	105.3	10.84	.000	105.9	9.37	.000

No significant pre/post differences were observed on the other measured variables (psychosocial beliefs, and stress and burnout). There were small nonsignificant improvements in the emotional exhaustion and personal accomplishment subscales of the MBI three months following completion of the course, and no changes in the depersonalization subscale.

Discussion

This paper reports on the development of a binational communication workshop developed specifically for doctors training to be specialists in palliative medicine in Australia and New Zealand. We believe this represents a unique milestone for specialty development in palliative medicine worldwide. The course was highly rated by participants and appears to improve self-assessed confidence in communication skills.

Back and colleagues¹⁰ reported similarly positive participant satisfaction levels in their evaluation of a four-day communication module for giving bad news and discussing transitions to palliative care for 115 oncology fellows from various institutions in the United States. In addition, they showed significant improvements in participants' actual communication skills during audiotaped standardized patient encounters, assessed by blinded coders, in a pre/post course design.⁶

Of note in this study, the course did not seem to impact on participants' levels of stress and burnout or attitudes to psychosocial care. This contrasts with the findings of Jenkins and colleagues¹⁴ who found significantly improved attitudes towards psychosocial care among medical, radiation or surgical oncology physicians (n=48) attending a three-day communication workshop in the United Kingdom compared with controls (n=45). The current sample reported highly positive attitudes towards psychosocial issues at baseline; hence there may have not been much room for improvement. With regards to stress and burnout, the current sample reported low depersonalization, average emotional exhaustion, and fairly high personal accomplishment at baseline. The fact that this sample had relatively low stress and burnout levels, despite regular exposure to dying patients in their daily work, may reflect collegial support from within multidisciplinary palliative care teams as well as the fact that the majority of our sample had five or less years experience in palliative care. One Australian study suggests that more years of exposure to palliative care may be associated with higher burnout levels in palliative medicine specialists.¹⁷ In addition, the relatively low burnout levels may reflect mentoring from supervisors, which is incorporated into the three-year palliative medicine training program in Australia and New Zealand. Of note, Periera and colleagues¹⁸ reported that burnout levels in palliative care physicians and nurses does not appear higher than in other medical specialties despite frequent contact with dying patients.

We believe that development of the facilitators' skills has been fundamental for the success and sustainability of this communication workshop. The Oncotalk investigators provided an initial two-day facilitator training course to faculty members in 2008 and a further two-day consolidation facilitator training workshop in 2009. Three of the local lead facilitators also attended the Oncotalk course in the United States. The Oncotalk investigators (AB, RA, JT) and a local communication skills expert (PB) silently observed the local facilitators during the communication workshops and provided mentoring and feedback. Further consolidation of facilitator training for new faculty members was then run by local faculty members in 2010 and 2011 based on the teaching approach and materials developed by the Oncotalk group. This has enabled capacity planning with a critical mass of properly trained facilitators. In subsequent courses it is proposed that new faculty members act as cofacilitators to the local lead facilitators before taking on the lead facilitator role themselves. New lead facilitators will then be silently observed by more experienced facilitators to provide ongoing mentoring and support.

Annual workshops of this course are planned for trainees of the AChPM, and will be increased as demand requires. A further workshop was held in 2011, again with highly positive feedback from participants. The education committee and specialist advisory committee for the AChPM have recommended that the course now become a compulsory part of training in palliative medicine in Australia and New Zealand, as well as an optional continuing professional development activity for specialists already practicing in palliative medicine.

Limitations

Limitations of this project include pre/post design of the evaluation rather than a randomized study and lack of objective assessment of participants' communication skills and knowledge pre- and posttraining. We also did not assess the impact of the training on patient outcomes. In addition, our sample had disparate characteristics with a wide range of years of practicing palliative medicine, inclusion of both trainees and doctors who are already specialists in palliative medicine, as well as trainees in various years of the training program (year 1 to year 3). Our sample was not big enough to do subgroup analysis.

Areas for future research

Areas for future research include assessing the impact of this workshop on participants' objective communication skills in standardized patient encounters before and after completion of training. We view development of the teaching model described in this paper as an important step in implementing a novel training program that specifically addresses learning processes in the domain of communication skills. An important next step would be to assess the performance of learners after workshop completion to understand if they are able to use communication skills in practice at the level of competency required to be an effective palliative medicine specialist. The American Academy of Hospice and Palliative Medicine (AAHPM) has developed a set of core competencies for hospice and palliative medicine subspecialists, including assessment tools for interpersonal and communication skills (www.aahpm.org/fellowship/default/competencies.html).

Tools such as the AAHPM competencies may potentially be adapted for the AChPM communication skills curriculum and/or utilized in a mini clinical evaluation exercise (mini-CEX) currently being introduced into training programs through the AChPM and RACP (www.racp.edu.au/page/mini-cex). Other areas for future research include exploring optimal ways of providing ongoing facilitator training and development of a competency framework for facilitators. This course could readily be adapted for other specialty groups who frequently care for patients with advanced life limiting illnesses and this warrants further exploration.

Conclusions

In conclusion, formal incorporation of communications skills training as part of specialty training for palliative medicine physicians is feasible and acceptable in Australia and New Zealand. The training is highly valued by participants and increases confidence in communication skills. A sustainable training model for communication skills teaching must include training of future facilitators. This Australasian model may serve as an example for other countries and other relevant disciplines.

Footnotes

Acknowledgments

We would like to thank all of the participants who kindly volunteered to take part in the evaluation of this module; the AChPM for supporting the development of the module; the Pam McLean Communication Centre for training and supplying the simulated patients who were excellent; the additional new faculty members for this course–Jennifer Philip, Amy Waters, and Derek Eng; the administration staff at the RACP, in particular Kathrine Taunton and Joanna Van-Lane; and Will Cairns for his encouragement and leadership of the curriculum review process, which led to the development of this communication module.

Author Disclosure Statement

No conflicting financial interests exist.

Appendix 1. A ChPM Communication Workshop Curriculum: Learning Modules and Objectives *

Appendix 2. Qualitative Feedback from Participants

“I can see skills developing that I will use for years.”

“This kind of training changes practice and changes outcomes for patients.”

“The combination of fine actors and experienced facilitators was invaluable to facilitate learning, honing in to real situations in our working life.”

“The skills learned (from this course) have the capacity to dramatically change my practice.”

“It was the best course I have ever participated in – hungry for more.”

“Uplifting and tantalizing invitation to continue developing these skills. Immediately rewarding.”

“Great to experience ‘growth’ in a short period of time for oneself and others participating in this process.”

“Everyone practicing in palliative medicine should do it [this course]!”

“Eye opener into the value of good communication in day to day work!”

“This course was outstanding! Such education should be offered to all Fellows [of the ACP].”

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