Abstract
Objective:
To assess the impact of a 1-hour communication skills workshop highlighting the “ask more and summarize technique” (AMST) to teach residents an effective way to respond to emotionally charged questions.
Methods:
From December 2015 to January 2017, residents on an inpatient oncology or palliative medicine rotation attended a mandatory 1-hour workshop on AMST involving a short introduction to the technique followed by skills practice. A survey (S1) was administered to the residents during the first session to assess their self-reported attitudes and practices. A follow-up survey (S2) was e-mailed at the end of the rotation to assess the usefulness of AMST.
Results:
Twenty-one participants completed S1, and 12 participants completed S2. A total of 62% (13/21) reported the workshop was “very useful.” There was a reported increased frequency of “summarizing back” between surveys (P = .01). Addressing fear and anxiety (75%, 9/12) and responding to patients who were angry/upset (67%, 8/12) were the situations where AMST was found to be the most useful. Fifty-four percent of respondents (7/12) felt they could have used AMST more.
Conclusion:
A 1-hour communication skills workshop targeting residents on an inpatient oncology or palliative rotation increased the use of summary statements in challenging situations.
Practice Implications:
A short skills practice workshop can be incorporated into a busy clinical curriculum to achieve changes in trainee behaviors and attitudes.
Introduction
Positive interactions have been demonstrated to enhance patient’s perceptions of the treating doctor’s competence, 1 while negative communication behaviors have been linked to adverse outcomes including higher rates of malpractice lawsuits and claims. 2 Perceived failure of communication and a lack of ability to convey a sense of care are often the focus of patients’ complaints. 1 Breakdown in communication at various levels has been shown to be a major underlying factor in medical errors. 3 Poor quality communication and inadequate training in effective communication have also been shown to influence physicians’ stress levels, job satisfaction, and emotional burnout. 4,5
Communication in the arena of cancer has special challenges related to navigating complex patient emotions while delivering bad news, explaining prognosis, and describing complicated treatment options. 6 Recognizing contextual, cognitive, and emotional barriers and tailoring the delivery of information according to individual needs are a sophisticated and difficult task, often requiring skill and training. Communication skills training in cancer care has been shown to be effective in improving caregiver’s abilities in both information gathering and providing support. 7 In a study of 206 health professionals, patient disclosure about psychological and social perceptions of their illness was better achieved by open direct questions, empathic statements, and summarizing back to the patient. 8 Fostering competence in clinical communication and professionalism is a well-recognized focus in medical training today. It is endorsed widely by several national organizations, and various approaches toward the assessment and execution of this aspect of medical education have been recognized. 9 Communication and interpersonal skills find their place among core competencies in graduate medical education outlined by the Accreditation Council for Graduate Medical Education and is a recognized area of improvement for training programs. 10,11
Our project aimed to assess the logistics and impact of a 1-hour communication skills workshop focusing on the novel “ask more and summarize technique” (AMST) for residents on an inpatient oncology or palliative medicine rotation. We assessed changes in perceived knowledge, attitudes, and practice by utilizing a survey administered during the workshop and a follow-up survey toward the end of the rotation.
Methods
Setting and Participants
Residents assigned to 2- to 4-week inpatient oncology and palliative rotations attended a mandatory 1-hour workshop on communication. Ten workshops, each with 4 to 6 residents, were held from December 2015 to January 2017. A recognized expert (author K.N.) conducted the workshop that focused on the AMST. This technique has been designed to help clinician’s when they are faced with an unanticipated, emotionally charged or sensitive question during patient encounters. The AMST steps are: Discover the patient’s motivation behind the emotionally charged question (“ask more”). Summarize back to the patient what you heard them say (“summarize”). Respond with empathy, information, more questions, silence, or a combination of the above.
The 1-hour workshop started by asking the residents what emotionally charged questions they had been asked on their rotation or were worried that they might be asked. The steps of AMST were then explained to the residents. The instructor then played the role of a patient or family member by asking a resident one of the questions identified at the beginning of the session. The resident responded by using AMST, and then the steps were repeated with the next resident. The structure of the session is outlined in Figure 1. Steps 3 through 5 were repeated for each resident in the session. Figure 2 illustrates an example.
Structure of workshop.
Example of a scenario in which ask more and summarize technique (AMST) is used to respond to a patient’s question.
Study Design
All residents on their oncology or palliative rotation were eligible to participate in the study. A survey was administered to the residents immediately following the workshop to assess their perceptions in the utility and impact of the exercise. Additionally, a link to a follow-up survey was sent directly to the original responders via e-mail through Research Electronic Data Capture. 12 The follow-up survey was sent toward the end of the rotation to assess the following: the usefulness of the technique during the rotation, the situations for which the technique was useful, and perceived barriers to its use. The institutional review board (IRB) of Cleveland Clinic determined that this project involved an internal quality assessment and improvement activity that was part of standard health-care operations in the local setting rather than research and did not require IRB approval.
Survey Questionnaires
Survey 1 consisted of 2 components (Table 1). The first included demographic information including age, sex, and year of training. The second component addressed residents’ assessment of the perceived utility, need, and impression of the workshop utilizing a Likert scale.
Resident Responses to Surveys Regarding the Utility and Impact of the Workshop.a
Abbreviation: AMST, ask more and summarize technique.
a Pre- and postsurvey for participants in the AMST Workshop.
b Wilcoxon signed ranks test.
The follow-up questionnaire, Survey 2, assessed how useful the technique was during the rotation, the situations for which it was useful, and perceived barriers to its use (Table 1).
Statistical Analysis
Categorical data are summarized as number and percentage. Continuous variables are reported as mean and standard deviation. Categorical data were compared with a χ2 test, and continuous data with a paired samples t test or a Wilcoxon-Signed Rank test for nonparametric data. All tests were 2-tailed with an α of less than 0.05. Statistical analysis was performed using IBM SPSS Statistics 22.
Results
Baseline characteristics of participants who completed S1 (n = 21) are shown in Table 1. Seventy-one percent (15/21) of participants were 25 to 30 years old, 57% (12/21) male, and 67% (14/21) PGY1, whereas for S2 (n = 12); 58% (7/12) were 25 to 30 years old, 58% (7/12) male, and 90% (11/12) post-graduate year (PGY)1. Although there was no difference in the reported frequency of “asking more information of patients questions” between the surveys (P = .73), there was a reported increased frequency of “summarizing back” between surveys (P = .01).
Approximately 62% (13/21) of participants reported the workshop to be “very useful.” Situations where participants felt AMST was most useful in addressing fear and anxiety (75%, 9/12) and managing patients who are feeling angry or upset (67%, 8/12). Just over half (54%, 7/12) felt they could have used AMST more during their inpatient oncology or palliative rotation. Specific comments are shown in Table 2. Using more role-play scenarios and working in pairs after the group exercise were suggestions from participants on how to improve the workshop.
Participants’ Response to the Workshop and Suggestions for Improvement.
Discussion and Conclusion
Discussion
Effective patient communication is the basis of a strong patient–physician relationship and its importance is well recognized today in health care. 13 Indeed, communication is a focus for competency in physician training modules but competing time constraints pose unique challenges during residency training. The workshop in this pilot study was created to maximize communication skills practice around 1 specific effective technique when an emotionally charged question is asked. By creating an “AMST drill,” residents spent the majority of the hour practicing the technique and had the chance to strengthen their use of the technique through repetition as well as through observation of their peers.
Using structured communication curricula has been shown to be effective in improving communication skills among residents. 14 -18 Methods of training and assessment have included didactic seminars, role-playing, direct observation by supervising physicians, patient surveys, standardized patient encounters, and reflective learning. 19 -22 Small group communication skills courses, with role-play among participants, have been recognized as an effective method of teaching communication skills. 23 Time spent practicing communication skills individually and observing others has been successfully shown to increase comprehension and application. 24 The Serious Illness Care Program trains physicians on the use of a structured guide for advanced care planning discussion with patients facing a limited prognosis. 25 Such interventions are effective and may not require an all-day skills practice session. Unfortunately, interventions such as these often require an institutional or cultural shift and may be less practical in the education of trainees entering specialties that do not commonly discuss prognosis. In addition, when focusing on 1 specific topic of conversation, such as patients with a limited prognosis, residents may miss the communication techniques that are generalizable to common communication challenges. Moreover, patient communication competes with other clinical curricula in a training program and must be delivered in a time-efficient manner. Our workshop, delivered in just 1 hour, introduced a structured yet practical, easy to utilize technique to face emotionally charged questions, and it was well received among participants. There was an increase in the reported frequency of summarizing back patients’ responses by the trainees and self-reported change in practice during the inpatient oncology or palliative care rotation.
Communication skills programs for oncologists often involve full-day or multiple-day programs that are expensive, resource heavy and would be difficult to integrate with clinical schedules. 26 -28 In fact, a systematic review of communication skills training programs suggests that sessions are more effective if they last for at least 1 day and preferably more. 29 In residency, this is difficult if not impossible. We therefore designed our intervention for a 1-hour time frame. A similar 1-hour curriculum for oncology fellows has previously been shown to be well received. 30 In order to maximize the time frame allotted to this intervention, we focused on 1 specific area of communication—facing an emotionally charged question. At least 40 minutes were dedicated to skills practice, as practicing skills in role-play has been identified as a key component of communication skills training. 26 Even with this brief session, most residents perceived the workshop to be “very useful” and anticipated near daily use of the AMST technique.
The communication skills literature has not clarified whether changes achieved through training sessions can be sustained over time. Some evidence suggests that the changes are only transient without an additional sustaining influence. 31 One advantage of a 1-hour workshop integrated into the residency curriculum is that it can be repeated throughout the year. In fact, in our program, several residents have attended the lecture multiple times as they return to the oncology or palliative service. Repeated exposure may serve as a method of reinforcing and enhancing skill retention, especially because it affords opportunities for additional practice and reflection. 21
Recognizing the importance and potential for improvement in communication, especially when caring for patients who have cancer, has led to the implementation and even enforcement of communication skills training programs. 26,32 Residents and other trainees working with patients with cancer have been shown to have high burnout rates, 33 and self-perceived failings in effective communication strategies, such as breaking bad news or handling stressful conversations, have been recognized as contributing factors. 34 Our pilot study suggests that a single 1-hour workshop can be implemented in a way that residents report is both meaningful and helpful. Because residents in our program have a strong representation from multiple foreign medical schools, it would be interesting to note in a future study whether the effectiveness of the intervention is sustained across various cultural and training backgrounds.
Certain limitations to our study should be recognized. Although we attempted to maximize recruitment, not all eligible residents participated in the workshop due to urgent competing clinical obligations. In addition, not all attendees completed the voluntary surveys, thus the final number of study participants is small and limits interpretation of the results and generalizability of the utility of this study. Further, this pilot study was only conducted at a single institution. A subsequent study expanding this pilot project to a broader group including multiple institutions and spanning different years of residency would be important to confirm the feasibility and utility of this technique and the workshop design. Moreover, although our study did utilize a follow-up survey toward the end of the rotation, it would be important and insightful to have been able to confirm sustainability of practice change, perhaps 6 months or a year after the workshop was attended. Residents reported their perceived use of the technique rather than being directly observed in clinical encounters or receiving patient feedback as to the effectiveness of their communication. We also recognize that although the 1-hour design was optimized to fit into work schedules, it did not allow time for more thorough debriefing or reflective writing that could augment the learning potential from such an intervention.
Conclusion
A 1-hour structured communication skills workshop for residents during an inpatient oncology or palliative rotation was well received. The AMST technique is a novel way to assist residents as they navigate communication challenges in the care of patients with oncology, especially when addressing patient’s fear, anxiety, and anger. Interventions focused on expanding and potentially broadening the use of this technique to foster competency through maximal time practicing skill would be important to confirm its utility and feasibility for more widespread incorporation into medical training.
Footnotes
Authors’ Note
The contents of this paper have not been published previously, but elements thereof were presented as a workshop at the October 2017 joint meeting for the International Conference on Communication in Healthcare & Health Literacy Annual Research Conference. The content of this paper was also presented at the April 2017 Society of General Internal Medicine annual meeting in Washington, D.C.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.