Medical Education and Training Programs

Researchers have found that institution­alization of improved communication is impeded by organizational and professional culture, status inequities, gendered roles and expectations, and patient health literacy.

Physician Education Programs. Training programs for physicians focus on commu­nication skills, patient-centered communica­tion, and delivering bad news. Studies that have evaluated the effectiveness of these programs have reported mixed results. One conceptual model for physician communi­cation skills training, the Comskil model (Brown & Bylund, 2008), consists of six categories: (1) establishing the consultation framework (negotiating the agenda with the patient), (2) checking patient understanding, (3) questioning, (4) empathic communica­tion, (5) information organization, and (6) shared decision making. Brown et al. (2010) evaluated the impact of Comskil training for oncology fellows through self-report surveys and videos of patient communication before and after the training. The authors found a significant increase in use of the skills after training, mostly in the category of establish­ing the consultation framework. Self-report data suggested that participants had increased confidence in their communication skills.

Other investigators have also found posi­tive impacts of communication skills training for physicians. Penticuff and Arheart (2005) reported on a program designed to improve information sharing in a neonatal intensive care unit. They found parents’ comprehen­sion and satisfaction improved significantly (including less decision conflict) as a result of the program. Similarly, Helitzer et al. (2011) reported that primary care providers who were trained in patient-centered communica­tion, general communication skills, and meth­ods for discussing adverse childhood events evidenced significant differences in these areas over the control group and maintained these improvements over a 24-month period.

Another training framework, COMFORT, is a patient-centered communication model for sharing bad news (Villagran, Goldsmith, Wittenberg-Lyles, & Baldwin, 2010).

Nurse Education Programs. Brinkert’s (2010) review of the nursing profession suggests that effective communication and collaboration has been identified as an important indicator of motivation, satisfaction, and perceptions of job effectiveness. He reports on several profes­sional development programs in nursing that have led to improved conflict communication, including those designed specifically to teach conflict management strategies (Haraway & Haraway, 2005) or performance of specific roles and protocols (Davies & Lynch, 2007). Brinkert’s (2010) review highlighted several mentoring and support programs that pro­vided evidence of success, including a 3-year study of a nurse mentor-mentee program in an academic hospital. Nurses served as men­tors and advocates, and the study reported improved perceptions of nurses by others, increased nurse retention, and improved patient care.

An intervention that blends the concepts of training and mentoring is conflict coach­ing (Brinkert, 2011). Conflict coaching entails a coach working individually with a “cli­ent” to help him or her assess a conflict and consider alternative conflict management strategies and outcomes. Brinkert conducted a study in which 20 nurse managers in a hospital received 12 hours of training in con­flict coaching. Data were collected over an 8-month period to determine perceptions of effectiveness from the coaches and their 20 supervisees.

Patient Education Programs. Cegala (2006) identified and reviewed 18 studies of patient communication training. He found that most training programs focus on information-seeking skills and question asking; and while some pro­grams report large gains, most studies indicated that the impact of the training was moderate. A smaller training topic focused on providing information and helping patients clearly and completely express their concerns and report symptoms. Cegala and colleagues (1996) have included these skills in their interventions and have experienced success, noting improved diagnosis and treatment decision making on the part of providers. Last, some training programs focus on patient-verifying skills by directing them to check their understanding, request repetitions and summaries, and encourage fore­casts that indicate what information may be sought or provided at some later point. These programs have found improved patient recall and immediate understanding. Cegala (2006) concluded that few studies have examined the influence of patient training on health out­comes (see Kaplan, Greenfield, & Ware, 1989, for exception) and that more research is needed to determine if patient outcomes persist beyond the immediate training and can be transferred from one health care setting to another.

Cegala (2006) cautions that medical inter­ventions are most effective when they are tai­lored to patients’ individual needs.

In related research, Haskard et al. (2008) investigated whether training was more effec­tive when both physicians and their patients received training. They concluded that trained physicians, relative to the untrained physi­cians, demonstrated significantly improved health behavior counseling of patients and connected-sensitive communication. They also reported that patients of trained physicians indicated higher quality of care and indicated greater willingness to recommend their phy­sician to others. Patient training produced higher physician satisfaction with the data col­lection process but did not have concomitant effects on patient satisfaction, perhaps due to the brevity of the training. When only one party was trained (as compared with when both or neither parties were trained), physi­cians reported lower satisfaction, less interest in relational change, and greater stress.

Haskard et al.’s (2008) study points to the need to train both providers and patients, to evaluate the training and outcomes of the training from both participants’ perspec­tives, and to include short- and long-term evaluation measures in communication train­ing programs and studies. Moreover, the authors point to a confounding factor in that

organizational changes during the course of research may have contributed to outcomes. This leads us to conflict intervention at the organizational or systemic level.