ORIGINAL REPORTS
Difficult Conversations: A National Course for Neurosurgery Residents in Physician-Patient Communication Michael M. Haglund, PhD,* Mariah Rudd, BS,† Alisa Nagler, JD,† and Neil S. Prose, MD‡ Duke Epilepsy Center, Duke University Medical Center, Durham, North Carolina; †Graduate Medical Education, Duke University Hospital, Durham, North Carolina; and ‡Duke Global Health Institute, Duke University School of Medicine, Durham, North Carolina *
OBJECTIVE: To describe the design, content, implementa-
tion, and evaluation of a national curriculum for teaching practical skills in empathic communication to residents in neurosurgery. DESIGN: Based on needs assessed through a national
survey of neurosurgery program directors, videotaped scenarios using standardized patients illustrating good and bad communication skills were developed. Presurveys and postsurveys were conducted querying participants on their level of competence and the specific behaviors they would attempt to change following participation. A subgroup of residents was evaluated before and after the training based on videotaped role-play exercises. SETTING: A pilot study was conducted at the authors’
physician-patient communication training. Presurvey and postsurvey results showed significant improvement in several of the communication scenarios. Those who participated in role-play showed significant improvement in “asking open-ended questions,” “listening,” “fire warning shot,” “allowing patient to absorb,” and “explaining in clear language.” CONCLUSIONS: Neurosurgeons frequently participate in
difficult conversations. Both residents and faculty note that exposure to this content is suboptimal. A hybrid approach to teaching communication skills is well received and enhances graduate medical education training of surgical C 2015 Association of subspecialists. ( J Surg 72:394-401. J Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)
institution and later implemented at National Neurosurgery Boot Camps.
KEY WORDS: communication, neuro-surgery, hybrid curriculum, graduate medical education, competency
PARTICIPANTS: A total of 14 Duke graduate medical
COMPETENCIES: Interpersonal and Skills, Professionalism, Patient Care
education neurosurgery residents agreed to participate in the pilot study. From across the country, 93 residents (representing 59 institutions) participated in the communication training as part of the Neurosurgery Boot camps, 11 of whom volunteered to participate in a role-playing session before and after the formal teaching session. RESULTS: Most of the neurosurgery program directors
responding to the survey indicated that an interactive online communication-training module would be of value (77%). A total of 93 residents participated in communication training as part of the Neurosurgery Boot Camps. Approximately half of the residents reported having no formal
Duke University GME Innovation Grant. Ethical Support/IRB. The study was granted an institutional review board exemption. The Institutional Review Board Policy ID # is Pro00043722. Correspondence: Inquiries to Neil S. Prose, MD, Duke Box 3252, Durham, NC 27710; e-mail: [email protected]
394
Communication
INTRODUCTION On an almost daily basis, neurosurgeons engage in conversations with patients and their families related to sudden and catastrophic illness.1 These might include discussions of severe brain or spinal cord trauma, the diagnosis and treatment of tumors of the central nervous system, or disappointing outcomes after high-risk complex neurosurgery procedures. Studies have shown that individuals choose a career in surgery for the income, prestige, and job opportunities and that surgeons have a distinct “surgical personality.”2-4 It is less likely that medical students choose a surgical career with the forward thought about the inevitable uncomfortable conversations they will need to have with patients and their families. The ability to
Journal of Surgical Education & 2015 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2014.11.014
communicate clearly and with empathy is a critical skill for neurosurgeons, and yet they may not be prepared for or trained in doing so. In July 2002, the American Council on Graduate Medical Education and the Residency Review Committee for surgery created a requirement for the teaching of interpersonal and communication skills in the training of all surgery residencies and fellowships.5-7 More recently, residency programs have incorporated milestones for teaching and assessment. With the extensive patient care and medical knowledge content necessary for successful neurosurgery training, it is said that 2 milestones are dedicated specifically to interpersonal and communication skills.8 The adoption and documentation of communication curricula within surgical subspecialties has been sporadic and difficult to achieve. There have only been a few successful efforts described in the medical education and surgery literature. These include the incorporation of exercises with standardized patients into a plastic surgery curriculum and a novel curriculum on delivering bad news in a urology training program.9 Recently, Harnof et al.,10 working with neurosurgery residents in Israel, published a small study on simulation-based interpersonal communication skills training for residents in neurosurgery. The 15 neurosurgery trainees found that simulation-based scenarios were like real patients, the cases presented were useful for training, and the videotaped debriefings contributed to their communication skills. The authors believe that, to meet requirements and provide critical communication training to residents, innovative methods are required and must occur at both a local and a national level. For this reason, the Principal Investigators (PIs) sought to develop an interactive hybrid approach to teach, reinforce, and evaluate communication skills that is accessible to both individual training programs and to national forums for resident training. This study describes for the first time the design, content, implementation, and evaluation of a national curriculum for teaching practical skills in empathic communication to residents in neurosurgery.
MATERIALS AND METHODS Program Director National Survey As part of a needs assessment, a survey was developed and disseminated electronically to all neurosurgery program directors via an existing LISTSERV. The survey, composed of 6 questions, was intended to determine current practices and gaps in communication training in graduate medical education (GME) programs. Questions were designed to elicit feedback on current teaching and evaluation practices addressing trainee communication competence. PIs also sought to gather feedback on whether new education tools, such as videos and specific workshop design, might be useful for individual training programs and in helping meet the new educational milestones.
Development of Educational Materials The PIs submitted (and were awarded) a GME (graduate medical education) innovation grant proposal to develop training videos addressing empathetic communication.11 A content expert (N.P.) in physician-patient communication worked with the Duke Neurosurgery Program Director (M.H.) to develop an educational curriculum. Based on the results of the program director survey and a review of relevant literature on communication skills in surgical specialties, the PIs created videotaped scenarios using standardized patients. The videos demonstrated (and highlighted) good and bad communication practices in 4 areas: (1) Taking a history (a patient with slurred speech from a brain tumor) (2) Obtaining informed consent (for excision of the tumor) (3) Delivering bad news (informing parents of a brain tumor diagnosis in a young child) (4) Delivering a disappointing outcome (surgical complication will now require tracheostomy and feeding tube) For each of the 4 conversations, an example of a poorly conducted interaction and a good physician-patient communication interaction were portrayed. Subtitles were used to highlight specific practices for effective and empathetic communication in the good scenarios, focusing on body language, the use of open-ended questions, and reflective listening. These videos were designed to be incorporated as part of a formal workshop at either a local or a national level. The Integrated Listening System method of physician-patient communication was used to guide the instruction. The Integrated Listening System includes an Invitation to start the communication, active Listening, and Summarizing what was discussed.12 A laminated card that lists useful phrases for difficult conversations in neurosurgery and suggests the mnemonic SOLS: “Sit,” “ask Open-ended questions,” “Listen,” and “Say back what you heard” was also developed. The SOLSþ for specific situations included “firing a warning shot,” “allowing patient to absorb information,” “asking permission to proceed,” “apologizing when appropriate,” “explaining in clear language,” “offering support,” and “What questions do you have?” (Appendix A). These same topics were tracked in the evaluation of the videos created, with a subgroup of residents, before and after the communication training at the boot camp. Duke GME Neurosurgery Resident Pilot Study As an initial pilot study, the videotapes were used in a 2-hour seminar on physician-patient communication for
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neurosurgery residents at the PI’s institution. Following a brief didactic session, the participants were required to watch the video that demonstrated “poor” communication techniques and to comment on what they would have done differently. The residents then watched the videos that modeled empathic communication. The individual techniques for empathic communication, identified by subtitles in the video, were discussed in detail. At the conclusion of the seminar, the residents were given laminated cards showing the SOLS method, and some suggested phrases for difficult conversations. Each participant was asked to identify (document and submit) a change they would make in their communication with patients following the training. The residents were asked to complete an evaluation form at the end of the session. In addition, 6 weeks following the session, participants were asked via e-mail if they had succeeded in incorporating the change they identified into their clinical practice. National Neurosurgery Resident Boot Camp Results of the National Program Director Survey and the PI’s (M.H.) experience at a local institution led him to recommend similar training at the national level. Thus, a patient-physician communication session, including the videos and SOLS checklist, was incorporated as a required component of the nationwide Society of Neurological Surgeons Annual Resident Boot Camps. Each year the Society of Neurological Surgeons offers 3 regional resident boot camps.13 In 2013, the PIs traveled to facilitate the training at 2 boot camp locations: St. Louis and New York. At each, resident participants attended a 45-minute lecture facilitated by the PI (M.H.) that incorporated the SOLS checklist. Boot camp participants were also required to attend a small group physician-patient skills discussion during which residents reviewed the videos and each engaged in a role-play communication scenario related to delivering bad news or dealing with a disappointing surgical outcome. All boot camp participants completed a pre-evaluation and postevaluation, rating the session (live workshop, videos, and small group discussion) and assessing their confidence in using appropriate communication skills with patients. A 5-point Likert scale was used with 1 being “novice” and 5 being “expert.” The analysis on the 4 measures of competence for communication measures (Table 3) was evaluated using a 1-sided p value using the t test for the a priori assessment that the aggregate postintervention means would be higher than the aggregate preintervention means. The significance level was set at p ¼ 0.05. The before and after scores for 11 measures of communication training (Fig. 2) were analyzed using a 1-tailed t test to test the a priori hypothesis that posttraining means would be higher than pretraining means. The significance level was set at p ¼ 0.05. The analyses were conducted using SAS v 9.3. 396
Role-Playing Before and After Communication Teaching Session These sessions were enhanced with the incorporation of an optional video-recorded simulated role-play for participants using standardized patient scenarios. Those registered were contacted by e-mail and offered an Amazon gift card to “practice” their empathetic communication skills with a realistic scenario (developed by N.P. and M.H.). They were asked to commit to video-recording before and after the educational session. Using the SOLS checklist, we assessed participant communication skills before and after the educational intervention.14 The following open-ended questions were included in the boot camp communication seminar postsurvey, and responses were analyzed using qualitative study methods. (1) If you feel your ability to communicate improved because of the workshop, how? (2) As a result of this presentation, one change I will make in the care of patients is:_________.
RESULTS Program Director National Survey Of 102 GME neurosurgery program directors, 87 (85%) completed the electronic survey. Many program directors indicated that residents were only “somewhat” or “not” obtaining sufficient skills in these communication milestone areas: delivery bad news, 59.7%; obtaining surgical consent, 32.1%; and managing a disappointing outcome, 64.3% (Fig. 1). Of the responding program directors, 77% indicated that an interactive online training module would be of value, and 82% were in favor of incorporating this content into the National Neurosurgery Boot Camps developed by the Senior Society of Neurological Surgeons. Most responders indicated that that they rely on institutional experts (38%) or institutional offerings (25%) for communication skills training for their residents. Others stated that their residents receive this training as part of a current conference series (22%) or required readings (21%) (Table 1). Duke GME Neurosurgery Resident Pilot Study Of 17 Duke GME neurosurgery residents, 14 participated in the pilot seminar and completed evaluations before and after the training and 6 weeks later. Self-reported survey outcomes suggest that the educational intervention resulted in a large improvement in proficiency. Before the training, 36% reported being “proficient” or “expert,” whereas 86% reported being “proficient” or “expert” after the training (Table 2).
Journal of Surgical Education Volume 72/Number 3 May/June 2015
FIGURE 1. Neurosurgery GME Program Director reporting of communication skills training (n ¼ 87).
Participants were asked to identify a change they were committed to making in their communication with patients following the seminar. Participants’ responses were focused on taking more time with patients, repeating what they heard patients say or ask, and sitting when having a conversation with the patient. Within the 6-week period, 89% of the residents reported meeting their goal of a changed behavior. Time (40%) and opportunity (20%) were the barriers most often reported to implementing their self-identified change in communication behavior. When queried regarding whether the videos were realistic and engaging, 21% of responders reported “fairly often” and 79% of responders reported “very often.”
TABLE 1. Methods for Teaching Communication Skills to Neurosurgery Residents Reported by Program Directors Across the Country (n ¼ 87) How are Those Skills Currently Being Taught in Your Program?
Count (%)
Part of current conference series—session dedicated to communication Part of current conference series—components worked into a number of sessions Online module—elective Online module—required Institutional offering (across disciplines) Reading material available Reading material required Experts within the institution assist with providing this content Experts outside the institution assist with providing this content Other None of the above
19 (22) 18 (21) 4 5 22 13 5 33
(5) (6) (25) (15) (6) (38)
1 (1) 17 (20) 14 (16)
National Neurosurgery Resident Boot Camp From across the country, 93 residents (representing 59 institutions) participated in the communication training as part of the Neurosurgery Boot Camps developed by the Society of Neurological Surgeons. The PI was one of the members of the planning committee. Overall, 73 participants completed the presurvey and 68 participants completed the postsurvey. In the presurvey, 49.3% of the responders reported having no formal training in physician-patient communication in their program, and only 13.7% reported having formal training. The postsurvey aggregate scores for self-reported competence were greater than that of the presurvey scores, thus illustrating improvement in all the 4 communication skills milestones covered in the lecture and seminar. For “obtaining informed consent,” the difference was statistically significant at p ¼ 0.009, and for “delivering a disappointing outcome,” the change was significant at p ¼ 0.049 (Table 3). Overall, the participants reported that their communication skills improved following the training, with 56% reporting that it “greatly” or “extremely” improved, 34% reporting that it “moderately” improved, and 10% reporting that it “slightly” improved, and no one reported “not at all.” A number of themes were identified from the open-ended question—“If you feel your ability to communicate improved because of the workshop, how?” (Table 4). When asked about a change they would make following the session, most of the responses included the following:
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Be brief with less jargon in explanations to patients Pause and allow time for questions from patients Sit down while speaking with the patient Ask open-ended questions 397
TABLE 2. Self-Reported Skill/Knowledge Competence of Participants Before and After Seminar Rate Your Skill/Knowledge in This Area Novice Advanced beginner Competent Proficient Expert
Before 0 4 5 5 0
After
(0%) 0 (0%) (28.60%) 1 (7.10%) (35.70%) 1 (7.1%) (35.70%) 11 (78.6%) (0%) 1 (7.1%)
Be quiet and listen Minimize sounding defensive in response to patient questions Use SOLS!
Role-Play Before and After Communication Teaching Session At the first 2 National Neurosurgery Boot Camps, 11 residents volunteered to participate in a role-playing session before and after the formal teaching session. The videotapes were reviewed and compared with the SOLS and the SOLSþ criteria on a 5-point Likert scale. A chair was provided for all the sessions, so the “Sit” portion had 100% completion. All the other portions of the SOLS and the SOLSþ showed trends of improvement, except “Apologizing” and “Offering support.” Several of the measurements showed significant improvement, including “asking openended questions,” “listening,” “fire warning shot,” “allowing them to absorb,” and “explaining in clear language” (Fig. 2).
DISCUSSION With the introduction of competency-based education in the early 2000s and, more recently, the Next Accreditation System Milestones, the Accreditation Council for Graduate Medical Education (ACGME) has identified communication as an important skill for physicians in training. Interpersonal communication is 1 of 6 core competencies for all physicians and comprises 2 of the 24 milestones for neurosurgery training programs. The training that occurs at the National Neurosurgery Boot Camp covers 8 of the 24 individual milestones over the first 4 levels for one of the Interpersonal Communication Milestones. Neurosurgeons
are frequently called upon to engage in difficult conversations with patients and their families. Unfortunately, there is little published literature on the successful implementation of the communication curricula in the surgical subspecialties. Not surprisingly, more than 75% of neurosurgery program directors who responded reported that a formal communication skills curriculum would be valuable to their program and residents. A question that remains is whether a curriculum such as this should be repeated during the duration of a program lasting up to 7 years. The PIs intend to analyze trainee evaluation results (completed by faculty, patients, and team members) specific to communication skills to determine whether another required offering would be beneficial. Although program directors and residents report a need for additional training in this area, there was a disconnect regarding the amount of communication training residents are already receiving. Program directors reported that their trainees are already acquiring skills in 3 areas noted in the ACGME communication milestones (obtaining surgical consent, 67.8%; delivering bad news, 40.2%; and managing a disappointing outcome, 32.2%). However, only 13.7% of resident participants at the National Neurosurgery Boot Camp reported receiving formal physician-patient communication training. The reasons for this disconnect are not clear. It is possible that trainees do not recognize ways in which communication skills training is embedded in the resident experience, in which case programs would benefit from more clearly labeling this training and pointing out its significance. However, if 86% of residents are truly not receiving this required and critical content, there is a major need for changes in the resident education curriculum to include formal teaching in communication skills. Delivering communication skills in the surgical subspecialty residencies can be challenging. The availability of content and content experts, scheduling, and duty hour limitations are potential difficulties. The PIs have developed a successful communication skills educational intervention that is based on an interactive video series demonstrating good and bad communication. Using brief videos to portray real-life communication encounters is an innovative and creative way to engage learners and incorporate skills training for busy residents. Although used as part of a seminar (both at the program and the national level), videos can also be used as an individual learning activity. Thus, brief videos with standardized patients and realistic scenarios illustrating bad and good
TABLE 3. Participant-Reported Competence for Communication on a 5-Point Likert Scale Before and After the Workshop Taking a history Obtaining informed consent Delivering bad news Delivering a disappointing outcome
398
Before Workshop
After Workshop
p Value
3.5 3.29 3.26 3.03
3.67 3.61 3.46 3.3
0.0779 0.0091 0.0939 0.0490
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TABLE 4. Themes and Representative Comments From Open-Ended Responses Regarding How Workshop Improved Communication Skills Theme Improved confidence Gained key tools/techniques
Importance of Language
Representative Comments “I am more comfortable with breaking bad news and how to respond to various patient reactions to bad news” “Learned key phrases on how to effectively communicate” “Being given specific phrases and tips was very helpful” “It was useful to see how others approach these situations and I plan on using some of their strategies in the future” “Important to use less jargon and technical language” “Learned key phrases on how to effectively communicate” “More useful language….” “Useful catch phrases to keep in mind”
behavior are multifunctional and a convenient way of delivering key content. Those who participated in the seminars with the videos reported them to be realistic and engaging. More importantly, participants noted an improvement in their skill and confidence. Survey results and open-ended comment themes reveal that participants believe their communication competence improved following the training. Residents also identified plans to change their current practices based on skills acquired from the videos and the seminar. Evaluation of video recordings of those who participated in the optional simulated role-play using standardized patient scenarios
showed a trend toward greater proficiency after the training. The participants were provided a SOLS checklist handout, and these practical steps were emphasized during training, reinforced with the card, and highlighted in the video. A number of benefits have resulted from this educational intervention. The authors believe most, if not all, of Kirkpatrick’s 4 levels of evaluation has been achieved. The postsurvey outcomes demonstrate learner satisfaction with the process (level 1). They report that the videos are engaging and realistic. Participants were able to identify key takeaway points, suggesting that new knowledge was learned (level 2). They identified an opportunity to change
FIGURE 2. Comparison before and after communication training (n ¼ 11). Journal of Surgical Education Volume 72/Number 3 May/June 2015
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and improve their current patient communication (level 3), and most pilot participants were able to reach their individual goal for communication change within 6 weeks (level 4).15 Not surprisingly, these levels are similar to the progressive milestones and signify that learners are moving from left to right on the milestone table. The authors acknowledge that bias may exist in the pilot study because the program director was also the PI. This seminar proved to be influential at both the local and the national level. The authors wish to emphasize the important role that the Senior Society of Neurological Surgeons National Boot Camps played in this process. Such national programs also have the potential to leverage resources and relieve individual programs from burdens and challenges such as identifying content experts, cost, and time. In the most recent series of the Senior Society National Neurosurgery Boot Camps chaired by Richard Byrne, MD, all finishing postgraduate year 1 residents in neurosurgery training programs in the United States participated in the communication skills training sessions.
CONCLUSION AND NEXT STEPS
REFERENCES 1. Ptacek JT, Eberhardt Tara L. Breaking bad news. J Am
Med Assoc. 1996;276(6):496-502. 2. McGreevy J, Wiebe D. A preliminary measurement of
the surgical personality. Am J Surg. 2002;184(2): 121-125. 3. Scott I, Gowans M, Wright B, Brenneis F. Determi-
nants of choosing a career in surgery. Med Teach. 2011;33(12):1011-1017. 4. Deedar-Ali-Khawaja Ranish, Sadaf Mumtaz Khan.
Trends of surgical career selection among medical students and graduates: a global perspective. Journal of Surg Educat. 2010;67(4):237-248. 5. Clayton Josephine M, et al. Evaluation of a novel
Communication skills is an ACGME core competency and is embedded in the milestones for residency training programs. In surgical subspecialties, the lack of content expertise and time has caused serious limitations and created difficulty in meeting these requirements. Both residents and faculty note that exposure to this content is suboptimal, and residents perceive receiving less communication education than faculty believe that they are providing. A hybrid approach to teaching communication skills, including the distribution of a simple SOLS checklist, is well received and enhances GME training of surgical subspecialists. This training could easily be adapted and adopted by other specialties at the program or the national level to meet the required and critical need for training to effectively communicate with patients. Future studies might include the analysis of patient evaluation data to gauge resident communication skills performance either with a presurvey and postsurvey or control group.
individualized communication-skills training intervention to improve doctors’ confidence and skills in end-of-life communication. Palliat Med. 2013;27 (3):236-243. 6. Schell JO, Green JA, Tulsky JA, Arnold RM. Com-
munication skills training for dialysis decision-making and end-of-life care in nephrology. Clin J Am Soc Nephrol. 2013;8(4):675-680. 7. Nguyen Tien V, Hong Judith, Prose Neil S.
Compassionate care: enhancing physician–patient communication and education in dermatology: part I: patient-centered communication. J Am Acad Dermatol. 2013;683:353-e1. 8. Neurological Surgery Milestones. Available at: 〈https://
www.acgme.org/acgmeweb/Portals/0/PDFs/Milestones/ NeurologicalSurgeryMilestones.pdf〉; Accessed 12.07. 2014. 9. Davis D, Lee G. The use of standardized patients
ACKNOWLEDGMENTS The authors would like to acknowledge and thank Richard Sloane of Duke University Hospital for the statistical analysis and his thoughtful contributions to organizing the outcomes. The authors thank Sandra Serafini, PhD for her statistical support. The authors would also like to acknowledge the generous funding from the Duke Graduate Medical Education QuasiEndowment that made this study possible. In 2006, Dr Victor Dzau, chancellor for health affairs at Duke University Health system, and the Board of Directors 400
created and deployed a quasiendowment with health system reserves (the Duke Graduate Medical Education Quasi-Endowment) for the support of Duke GME.
in the plastic surgery residency curriculum: teaching core competencies with objective structured clinical examinations. Plast Reconstr Surg. 2011;128:291-297; Gettman MT, Karnes RJ, Arnold JJ, et al. Urology resident training with an unexpected patient death scenario: experiential learning with high fidelity simulation. J Urol. 2008;180(1):283-288. 10. Harnof S, Hadani M, Ziv A, Berkenstadt H.
Simulation-based interpersonal communication skills training for neurosurgicall residents. Isr Med Assoc J. 2013;15(9):557-560.
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11. Andolsek K, Murphy G, Nagler A, et al. Fostering
creativity: Duke Medicine Quasi-Endowment encourages Graduate Medical Education Innovation. Acad Med. 2013;88(2):185-191. 12. Boyle Dennis, Dwinnell Brian, Frederic Platt. Invite,
listen, and summarize: a patient-centered communication technique. Acad Med. 2005;80(1):29-32. 13. Selden NR, Origitano TC, Burchiel KJ, et al. A
national fundamentals curriculum for neurosurgery
PGY1 residents: the 2010 Society of Neurological Surgeons boot camp courses. Neurosurgery. 2012;70 (4):971-981. 14. Makoul Gregory. The SEGUE Framework for teach-
ing and assessing communication skills. Patient Educ Couns. 2001;45(1):23-34. 15. Kirkpatrick DL. Techniques for evaluating training
programs. J Am Soc Train Dir. 1959;13(3): 21-26.
SUPPORTING INFORMATION Supplementary material cited in this article is available online at doi:10.1016/j.jsurg.2014.11.014.
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Difficult Conversations: A National Course for Neurosurgery Residents in Physician-Patient Communication Michael M. Haglund, PhD,* Mariah Rudd, BS,† Alisa Nagler, JD,† and Neil S. Prose, MD‡ Duke Epilepsy Center, Duke University Medical Center, Durham, North Carolina; †Graduate Medical Education, Duke University Hospital, Durham, North Carolina; and ‡Duke Global Health Institute, Duke University School of Medicine, Durham, North Carolina *
OBJECTIVE: To describe the design, content, implementa-
tion, and evaluation of a national curriculum for teaching practical skills in empathic communication to residents in neurosurgery. DESIGN: Based on needs assessed through a national
survey of neurosurgery program directors, videotaped scenarios using standardized patients illustrating good and bad communication skills were developed. Presurveys and postsurveys were conducted querying participants on their level of competence and the specific behaviors they would attempt to change following participation. A subgroup of residents was evaluated before and after the training based on videotaped role-play exercises. SETTING: A pilot study was conducted at the authors’
physician-patient communication training. Presurvey and postsurvey results showed significant improvement in several of the communication scenarios. Those who participated in role-play showed significant improvement in “asking open-ended questions,” “listening,” “fire warning shot,” “allowing patient to absorb,” and “explaining in clear language.” CONCLUSIONS: Neurosurgeons frequently participate in
difficult conversations. Both residents and faculty note that exposure to this content is suboptimal. A hybrid approach to teaching communication skills is well received and enhances graduate medical education training of surgical C 2015 Association of subspecialists. ( J Surg 72:394-401. J Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)
institution and later implemented at National Neurosurgery Boot Camps.
KEY WORDS: communication, neuro-surgery, hybrid curriculum, graduate medical education, competency
PARTICIPANTS: A total of 14 Duke graduate medical
COMPETENCIES: Interpersonal and Skills, Professionalism, Patient Care
education neurosurgery residents agreed to participate in the pilot study. From across the country, 93 residents (representing 59 institutions) participated in the communication training as part of the Neurosurgery Boot camps, 11 of whom volunteered to participate in a role-playing session before and after the formal teaching session. RESULTS: Most of the neurosurgery program directors
responding to the survey indicated that an interactive online communication-training module would be of value (77%). A total of 93 residents participated in communication training as part of the Neurosurgery Boot Camps. Approximately half of the residents reported having no formal
Duke University GME Innovation Grant. Ethical Support/IRB. The study was granted an institutional review board exemption. The Institutional Review Board Policy ID # is Pro00043722. Correspondence: Inquiries to Neil S. Prose, MD, Duke Box 3252, Durham, NC 27710; e-mail: [email protected]
394
Communication
INTRODUCTION On an almost daily basis, neurosurgeons engage in conversations with patients and their families related to sudden and catastrophic illness.1 These might include discussions of severe brain or spinal cord trauma, the diagnosis and treatment of tumors of the central nervous system, or disappointing outcomes after high-risk complex neurosurgery procedures. Studies have shown that individuals choose a career in surgery for the income, prestige, and job opportunities and that surgeons have a distinct “surgical personality.”2-4 It is less likely that medical students choose a surgical career with the forward thought about the inevitable uncomfortable conversations they will need to have with patients and their families. The ability to
Journal of Surgical Education & 2015 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2014.11.014
communicate clearly and with empathy is a critical skill for neurosurgeons, and yet they may not be prepared for or trained in doing so. In July 2002, the American Council on Graduate Medical Education and the Residency Review Committee for surgery created a requirement for the teaching of interpersonal and communication skills in the training of all surgery residencies and fellowships.5-7 More recently, residency programs have incorporated milestones for teaching and assessment. With the extensive patient care and medical knowledge content necessary for successful neurosurgery training, it is said that 2 milestones are dedicated specifically to interpersonal and communication skills.8 The adoption and documentation of communication curricula within surgical subspecialties has been sporadic and difficult to achieve. There have only been a few successful efforts described in the medical education and surgery literature. These include the incorporation of exercises with standardized patients into a plastic surgery curriculum and a novel curriculum on delivering bad news in a urology training program.9 Recently, Harnof et al.,10 working with neurosurgery residents in Israel, published a small study on simulation-based interpersonal communication skills training for residents in neurosurgery. The 15 neurosurgery trainees found that simulation-based scenarios were like real patients, the cases presented were useful for training, and the videotaped debriefings contributed to their communication skills. The authors believe that, to meet requirements and provide critical communication training to residents, innovative methods are required and must occur at both a local and a national level. For this reason, the Principal Investigators (PIs) sought to develop an interactive hybrid approach to teach, reinforce, and evaluate communication skills that is accessible to both individual training programs and to national forums for resident training. This study describes for the first time the design, content, implementation, and evaluation of a national curriculum for teaching practical skills in empathic communication to residents in neurosurgery.
MATERIALS AND METHODS Program Director National Survey As part of a needs assessment, a survey was developed and disseminated electronically to all neurosurgery program directors via an existing LISTSERV. The survey, composed of 6 questions, was intended to determine current practices and gaps in communication training in graduate medical education (GME) programs. Questions were designed to elicit feedback on current teaching and evaluation practices addressing trainee communication competence. PIs also sought to gather feedback on whether new education tools, such as videos and specific workshop design, might be useful for individual training programs and in helping meet the new educational milestones.
Development of Educational Materials The PIs submitted (and were awarded) a GME (graduate medical education) innovation grant proposal to develop training videos addressing empathetic communication.11 A content expert (N.P.) in physician-patient communication worked with the Duke Neurosurgery Program Director (M.H.) to develop an educational curriculum. Based on the results of the program director survey and a review of relevant literature on communication skills in surgical specialties, the PIs created videotaped scenarios using standardized patients. The videos demonstrated (and highlighted) good and bad communication practices in 4 areas: (1) Taking a history (a patient with slurred speech from a brain tumor) (2) Obtaining informed consent (for excision of the tumor) (3) Delivering bad news (informing parents of a brain tumor diagnosis in a young child) (4) Delivering a disappointing outcome (surgical complication will now require tracheostomy and feeding tube) For each of the 4 conversations, an example of a poorly conducted interaction and a good physician-patient communication interaction were portrayed. Subtitles were used to highlight specific practices for effective and empathetic communication in the good scenarios, focusing on body language, the use of open-ended questions, and reflective listening. These videos were designed to be incorporated as part of a formal workshop at either a local or a national level. The Integrated Listening System method of physician-patient communication was used to guide the instruction. The Integrated Listening System includes an Invitation to start the communication, active Listening, and Summarizing what was discussed.12 A laminated card that lists useful phrases for difficult conversations in neurosurgery and suggests the mnemonic SOLS: “Sit,” “ask Open-ended questions,” “Listen,” and “Say back what you heard” was also developed. The SOLSþ for specific situations included “firing a warning shot,” “allowing patient to absorb information,” “asking permission to proceed,” “apologizing when appropriate,” “explaining in clear language,” “offering support,” and “What questions do you have?” (Appendix A). These same topics were tracked in the evaluation of the videos created, with a subgroup of residents, before and after the communication training at the boot camp. Duke GME Neurosurgery Resident Pilot Study As an initial pilot study, the videotapes were used in a 2-hour seminar on physician-patient communication for
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neurosurgery residents at the PI’s institution. Following a brief didactic session, the participants were required to watch the video that demonstrated “poor” communication techniques and to comment on what they would have done differently. The residents then watched the videos that modeled empathic communication. The individual techniques for empathic communication, identified by subtitles in the video, were discussed in detail. At the conclusion of the seminar, the residents were given laminated cards showing the SOLS method, and some suggested phrases for difficult conversations. Each participant was asked to identify (document and submit) a change they would make in their communication with patients following the training. The residents were asked to complete an evaluation form at the end of the session. In addition, 6 weeks following the session, participants were asked via e-mail if they had succeeded in incorporating the change they identified into their clinical practice. National Neurosurgery Resident Boot Camp Results of the National Program Director Survey and the PI’s (M.H.) experience at a local institution led him to recommend similar training at the national level. Thus, a patient-physician communication session, including the videos and SOLS checklist, was incorporated as a required component of the nationwide Society of Neurological Surgeons Annual Resident Boot Camps. Each year the Society of Neurological Surgeons offers 3 regional resident boot camps.13 In 2013, the PIs traveled to facilitate the training at 2 boot camp locations: St. Louis and New York. At each, resident participants attended a 45-minute lecture facilitated by the PI (M.H.) that incorporated the SOLS checklist. Boot camp participants were also required to attend a small group physician-patient skills discussion during which residents reviewed the videos and each engaged in a role-play communication scenario related to delivering bad news or dealing with a disappointing surgical outcome. All boot camp participants completed a pre-evaluation and postevaluation, rating the session (live workshop, videos, and small group discussion) and assessing their confidence in using appropriate communication skills with patients. A 5-point Likert scale was used with 1 being “novice” and 5 being “expert.” The analysis on the 4 measures of competence for communication measures (Table 3) was evaluated using a 1-sided p value using the t test for the a priori assessment that the aggregate postintervention means would be higher than the aggregate preintervention means. The significance level was set at p ¼ 0.05. The before and after scores for 11 measures of communication training (Fig. 2) were analyzed using a 1-tailed t test to test the a priori hypothesis that posttraining means would be higher than pretraining means. The significance level was set at p ¼ 0.05. The analyses were conducted using SAS v 9.3. 396
Role-Playing Before and After Communication Teaching Session These sessions were enhanced with the incorporation of an optional video-recorded simulated role-play for participants using standardized patient scenarios. Those registered were contacted by e-mail and offered an Amazon gift card to “practice” their empathetic communication skills with a realistic scenario (developed by N.P. and M.H.). They were asked to commit to video-recording before and after the educational session. Using the SOLS checklist, we assessed participant communication skills before and after the educational intervention.14 The following open-ended questions were included in the boot camp communication seminar postsurvey, and responses were analyzed using qualitative study methods. (1) If you feel your ability to communicate improved because of the workshop, how? (2) As a result of this presentation, one change I will make in the care of patients is:_________.
RESULTS Program Director National Survey Of 102 GME neurosurgery program directors, 87 (85%) completed the electronic survey. Many program directors indicated that residents were only “somewhat” or “not” obtaining sufficient skills in these communication milestone areas: delivery bad news, 59.7%; obtaining surgical consent, 32.1%; and managing a disappointing outcome, 64.3% (Fig. 1). Of the responding program directors, 77% indicated that an interactive online training module would be of value, and 82% were in favor of incorporating this content into the National Neurosurgery Boot Camps developed by the Senior Society of Neurological Surgeons. Most responders indicated that that they rely on institutional experts (38%) or institutional offerings (25%) for communication skills training for their residents. Others stated that their residents receive this training as part of a current conference series (22%) or required readings (21%) (Table 1). Duke GME Neurosurgery Resident Pilot Study Of 17 Duke GME neurosurgery residents, 14 participated in the pilot seminar and completed evaluations before and after the training and 6 weeks later. Self-reported survey outcomes suggest that the educational intervention resulted in a large improvement in proficiency. Before the training, 36% reported being “proficient” or “expert,” whereas 86% reported being “proficient” or “expert” after the training (Table 2).
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FIGURE 1. Neurosurgery GME Program Director reporting of communication skills training (n ¼ 87).
Participants were asked to identify a change they were committed to making in their communication with patients following the seminar. Participants’ responses were focused on taking more time with patients, repeating what they heard patients say or ask, and sitting when having a conversation with the patient. Within the 6-week period, 89% of the residents reported meeting their goal of a changed behavior. Time (40%) and opportunity (20%) were the barriers most often reported to implementing their self-identified change in communication behavior. When queried regarding whether the videos were realistic and engaging, 21% of responders reported “fairly often” and 79% of responders reported “very often.”
TABLE 1. Methods for Teaching Communication Skills to Neurosurgery Residents Reported by Program Directors Across the Country (n ¼ 87) How are Those Skills Currently Being Taught in Your Program?
Count (%)
Part of current conference series—session dedicated to communication Part of current conference series—components worked into a number of sessions Online module—elective Online module—required Institutional offering (across disciplines) Reading material available Reading material required Experts within the institution assist with providing this content Experts outside the institution assist with providing this content Other None of the above
19 (22) 18 (21) 4 5 22 13 5 33
(5) (6) (25) (15) (6) (38)
1 (1) 17 (20) 14 (16)
National Neurosurgery Resident Boot Camp From across the country, 93 residents (representing 59 institutions) participated in the communication training as part of the Neurosurgery Boot Camps developed by the Society of Neurological Surgeons. The PI was one of the members of the planning committee. Overall, 73 participants completed the presurvey and 68 participants completed the postsurvey. In the presurvey, 49.3% of the responders reported having no formal training in physician-patient communication in their program, and only 13.7% reported having formal training. The postsurvey aggregate scores for self-reported competence were greater than that of the presurvey scores, thus illustrating improvement in all the 4 communication skills milestones covered in the lecture and seminar. For “obtaining informed consent,” the difference was statistically significant at p ¼ 0.009, and for “delivering a disappointing outcome,” the change was significant at p ¼ 0.049 (Table 3). Overall, the participants reported that their communication skills improved following the training, with 56% reporting that it “greatly” or “extremely” improved, 34% reporting that it “moderately” improved, and 10% reporting that it “slightly” improved, and no one reported “not at all.” A number of themes were identified from the open-ended question—“If you feel your ability to communicate improved because of the workshop, how?” (Table 4). When asked about a change they would make following the session, most of the responses included the following:
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Be brief with less jargon in explanations to patients Pause and allow time for questions from patients Sit down while speaking with the patient Ask open-ended questions 397
TABLE 2. Self-Reported Skill/Knowledge Competence of Participants Before and After Seminar Rate Your Skill/Knowledge in This Area Novice Advanced beginner Competent Proficient Expert
Before 0 4 5 5 0
After
(0%) 0 (0%) (28.60%) 1 (7.10%) (35.70%) 1 (7.1%) (35.70%) 11 (78.6%) (0%) 1 (7.1%)
Be quiet and listen Minimize sounding defensive in response to patient questions Use SOLS!
Role-Play Before and After Communication Teaching Session At the first 2 National Neurosurgery Boot Camps, 11 residents volunteered to participate in a role-playing session before and after the formal teaching session. The videotapes were reviewed and compared with the SOLS and the SOLSþ criteria on a 5-point Likert scale. A chair was provided for all the sessions, so the “Sit” portion had 100% completion. All the other portions of the SOLS and the SOLSþ showed trends of improvement, except “Apologizing” and “Offering support.” Several of the measurements showed significant improvement, including “asking openended questions,” “listening,” “fire warning shot,” “allowing them to absorb,” and “explaining in clear language” (Fig. 2).
DISCUSSION With the introduction of competency-based education in the early 2000s and, more recently, the Next Accreditation System Milestones, the Accreditation Council for Graduate Medical Education (ACGME) has identified communication as an important skill for physicians in training. Interpersonal communication is 1 of 6 core competencies for all physicians and comprises 2 of the 24 milestones for neurosurgery training programs. The training that occurs at the National Neurosurgery Boot Camp covers 8 of the 24 individual milestones over the first 4 levels for one of the Interpersonal Communication Milestones. Neurosurgeons
are frequently called upon to engage in difficult conversations with patients and their families. Unfortunately, there is little published literature on the successful implementation of the communication curricula in the surgical subspecialties. Not surprisingly, more than 75% of neurosurgery program directors who responded reported that a formal communication skills curriculum would be valuable to their program and residents. A question that remains is whether a curriculum such as this should be repeated during the duration of a program lasting up to 7 years. The PIs intend to analyze trainee evaluation results (completed by faculty, patients, and team members) specific to communication skills to determine whether another required offering would be beneficial. Although program directors and residents report a need for additional training in this area, there was a disconnect regarding the amount of communication training residents are already receiving. Program directors reported that their trainees are already acquiring skills in 3 areas noted in the ACGME communication milestones (obtaining surgical consent, 67.8%; delivering bad news, 40.2%; and managing a disappointing outcome, 32.2%). However, only 13.7% of resident participants at the National Neurosurgery Boot Camp reported receiving formal physician-patient communication training. The reasons for this disconnect are not clear. It is possible that trainees do not recognize ways in which communication skills training is embedded in the resident experience, in which case programs would benefit from more clearly labeling this training and pointing out its significance. However, if 86% of residents are truly not receiving this required and critical content, there is a major need for changes in the resident education curriculum to include formal teaching in communication skills. Delivering communication skills in the surgical subspecialty residencies can be challenging. The availability of content and content experts, scheduling, and duty hour limitations are potential difficulties. The PIs have developed a successful communication skills educational intervention that is based on an interactive video series demonstrating good and bad communication. Using brief videos to portray real-life communication encounters is an innovative and creative way to engage learners and incorporate skills training for busy residents. Although used as part of a seminar (both at the program and the national level), videos can also be used as an individual learning activity. Thus, brief videos with standardized patients and realistic scenarios illustrating bad and good
TABLE 3. Participant-Reported Competence for Communication on a 5-Point Likert Scale Before and After the Workshop Taking a history Obtaining informed consent Delivering bad news Delivering a disappointing outcome
398
Before Workshop
After Workshop
p Value
3.5 3.29 3.26 3.03
3.67 3.61 3.46 3.3
0.0779 0.0091 0.0939 0.0490
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TABLE 4. Themes and Representative Comments From Open-Ended Responses Regarding How Workshop Improved Communication Skills Theme Improved confidence Gained key tools/techniques
Importance of Language
Representative Comments “I am more comfortable with breaking bad news and how to respond to various patient reactions to bad news” “Learned key phrases on how to effectively communicate” “Being given specific phrases and tips was very helpful” “It was useful to see how others approach these situations and I plan on using some of their strategies in the future” “Important to use less jargon and technical language” “Learned key phrases on how to effectively communicate” “More useful language….” “Useful catch phrases to keep in mind”
behavior are multifunctional and a convenient way of delivering key content. Those who participated in the seminars with the videos reported them to be realistic and engaging. More importantly, participants noted an improvement in their skill and confidence. Survey results and open-ended comment themes reveal that participants believe their communication competence improved following the training. Residents also identified plans to change their current practices based on skills acquired from the videos and the seminar. Evaluation of video recordings of those who participated in the optional simulated role-play using standardized patient scenarios
showed a trend toward greater proficiency after the training. The participants were provided a SOLS checklist handout, and these practical steps were emphasized during training, reinforced with the card, and highlighted in the video. A number of benefits have resulted from this educational intervention. The authors believe most, if not all, of Kirkpatrick’s 4 levels of evaluation has been achieved. The postsurvey outcomes demonstrate learner satisfaction with the process (level 1). They report that the videos are engaging and realistic. Participants were able to identify key takeaway points, suggesting that new knowledge was learned (level 2). They identified an opportunity to change
FIGURE 2. Comparison before and after communication training (n ¼ 11). Journal of Surgical Education Volume 72/Number 3 May/June 2015
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and improve their current patient communication (level 3), and most pilot participants were able to reach their individual goal for communication change within 6 weeks (level 4).15 Not surprisingly, these levels are similar to the progressive milestones and signify that learners are moving from left to right on the milestone table. The authors acknowledge that bias may exist in the pilot study because the program director was also the PI. This seminar proved to be influential at both the local and the national level. The authors wish to emphasize the important role that the Senior Society of Neurological Surgeons National Boot Camps played in this process. Such national programs also have the potential to leverage resources and relieve individual programs from burdens and challenges such as identifying content experts, cost, and time. In the most recent series of the Senior Society National Neurosurgery Boot Camps chaired by Richard Byrne, MD, all finishing postgraduate year 1 residents in neurosurgery training programs in the United States participated in the communication skills training sessions.
CONCLUSION AND NEXT STEPS
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ACKNOWLEDGMENTS The authors would like to acknowledge and thank Richard Sloane of Duke University Hospital for the statistical analysis and his thoughtful contributions to organizing the outcomes. The authors thank Sandra Serafini, PhD for her statistical support. The authors would also like to acknowledge the generous funding from the Duke Graduate Medical Education QuasiEndowment that made this study possible. In 2006, Dr Victor Dzau, chancellor for health affairs at Duke University Health system, and the Board of Directors 400
created and deployed a quasiendowment with health system reserves (the Duke Graduate Medical Education Quasi-Endowment) for the support of Duke GME.
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SUPPORTING INFORMATION Supplementary material cited in this article is available online at doi:10.1016/j.jsurg.2014.11.014.
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