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How to Optimize Physicians’ Communication Skills in Cancer Care: Results of a Randomized Study Assessing the Usefulness of Posttraining Consolidation Workshops

Darius Razavi, Isabelle Merckaert, Serge Marchal, Yves Libert, Sandrine Conradt, Jacques Boniver, Anne-Marie Etienne, Ovide Fontaine, Pascal Janne, Jean Klastersky, Christine Reynaert, Pierre Scalliet, Jean-Louis Slachmuylder, Nicole Delvaux

From the Université Libre de Bruxelles, Faculté des Sciences Psychologiques et de l’Éducation and Institut Jules Bordet; C.A.M. (Training and Research Group); Université Catholique de Louvain, Faculté de Médecine, Brussels; Hôpital Universitaire Erasme, Service de Psychologie, Brussels; Université Catholique de Louvain, Faculté de Psychologie et des Sciences de l’Éducation, Louvain-la-Neuve; Université de Liège, Faculté de Psychologie and Faculté de Médecine, Liège, Belgium.

Address reprint requests to Darius Razavi, MD, PhD, Université Libre de Bruxelles, Av F Roosevelt, 50-CP 191, B-1050 Bruxelles, Belgium; email: drazavi{at}ulb.ac.be.

	ABSTRACT

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Purpose: Although there is wide recognition of the usefulness of improving physicians’ communication skills, no studies have yet assessed the efficacy of post-training consolidation workshops. This study aims to assess the efficacy of six 3-hour consolidation workshops conducted after a 2.5-day basic training program.

Methods: Physicians, after attending the basic training program, were randomly assigned to consolidation workshops or to a waiting list. Training efficacy was assessed through simulated and actual patient interviews that were audiotaped at baseline and after consolidation workshops for the consolidation-workshop group, and approximately 5 months after the end of basic training for the waiting-list group. Communication skills were assessed according to the Cancer Research Campaign Workshop Evaluation Manual. Patients’ perceptions of communication skills improvement were assessed using a 14-item questionnaire.

Results: Sixty-three physicians completed the training program. Communication skills improved significantly more in the consolidation-workshop group compared with the waiting-list group. In simulated interviews, group-by-time repeated measures analysis of variance showed a significant increase in open and open directive questions (P = .014) and utterances alerting patients to reality (P = .049), as well as a significant decrease in premature reassurance (P = .042). In actual patient interviews, results revealed a significant increase in acknowledgments (P = .022) and empathic statements (P = .009), in educated guesses (P = .041), and in negotiations (P = .008). Patients interacting with physicians who benefited from consolidation workshops reported higher scores concerning their physicians’ understanding of their disease (P = .004).

Conclusion: Consolidation workshops further improve a communication skills training program’s efficacy and facilitate the transfer of acquired skills to clinical practice.

	INTRODUCTION

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EFFECTIVE COMMUNICATION skills are the key to assessing, informing, and supporting patients adequately.^1–4 Unfortunately, physicians do not always possess those communication skills.⁵ In the last two decades, research efforts have focused on which communication skills are to be taught and on which training techniques are to be used.⁵ In this context, key communication skills (open directive questions; focus on and clarification of psychologic aspects; empathic statements; and educated guesses) have been shown to improve patients’ disclosure of psychosocial concerns, whereas other communication strategies (directive questions, general inquiries, and premature advice and reassurance) have been found to inhibit disclosure.⁶ Although studies have indicated that discussing psychologic concerns with patients is likely to have a beneficial effect on patient outcomes,^7–8 physicians still often address these concerns only when their patients bring up these topics.⁹

Communication skills training programs have shown their benefits in terms of changes in physicians’ attitudes and beliefs, improved physician recognition of patients’ psychosocial problems, and, most importantly, physicians’ acquisition of new skills.^10–14 There is now some indication that learner-centered, skills-focused, practice-oriented techniques are a good adjunct for conducting workshops.⁵ What still needs to be investigated is the impact of those changes on patient outcomes, such as satisfaction, perception of the physician’s performance, distress, and compliance. Recent results of a communication skills training program (two 4-hour sessions) stressed the difficulty of improving patient satisfaction with the interviews and the need to resort to longer and more intensive programs.¹⁵ Therefore, an important question concerns the optimal duration and time schedule of communication skills training programs. It has been shown that short training programs (4.5 hours) do not lead to significant behavioral changes.¹⁰ Moreover, it has been indicated that consolidation follow-up sessions are required to facilitate maintenance of newly acquired skills and their transfer into the clinical practice.¹⁶

Therefore, the aim of this study was to assess the improvement in physicians’ communication skills resulting from participation in consolidation workshops after attending a basic training program. The basic training program duration (2.5 days) was chosen to ensure communication skills improvements. The bimonthly consolidation workshops were spread over a 3-month period to allow physicians to test their newly acquired skills in their everyday practice and to be able to report difficulties encountered in their implementation. Workshops were thus designed to maintain the newly acquired skills, ensure further improvements, and promote the transfer of skills to the clinical practice. It was also hypothesized that communication skill improvements acquired during the consolidation workshops would be reflected in patients’ perceptions of and satisfaction with their physicians’ performance, as recorded in actual patient interviews.

	METHODS

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Subjects
To be included in the study, physicians had to be specialists in medical or surgical oncology, radiotherapy, hematology, gynecology, and so on. They also had to be working with cancer patients (part time or full time). Physicians were invited by mail to take part in the training program (n = 3,706), and all institutions devoted to cancer care were asked to deliver an internal letter of invitation (n = 2,741). Because of the low response rate—only 90 potentially interested physicians responded spontaneously to the mail—214 physicians, including the 90 potentially interested, were contacted by phone. One hundred sixty-three of the physicians were individually met. Twenty-one information sessions were also organized in institutions devoted to cancer care. A total of 173 physicians were met during those sessions.

Study Design and Assessment Procedure
The efficacy of the consolidation workshops was assessed in a study allocating physicians randomly, after a basic training program, to consolidation workshops or to a waiting list (Fig 1). The study was approved by the local ethics committee. The basic training program was spread over a 1-month period. The consolidation workshops started 2 months later for participants who were immediately assigned to the workshops. The bimonthly workshops were spread over a 3-month period. Subjects assigned to the waiting list were invited to take part in the consolidation workshops 6 months after the end of the basic training program.

View larger version (27K): [in this window] [in a new window]   Fig 1. Study design, with timing of assessments and interventions.

Consolidation Workshops
Each of the six consolidation workshops consisted of a 3-hour evening training session (limited to six participants). Each session was led by an experienced facilitator and was based on role plays, with systematic feedback based on clinical problems brought up by the participants. Sessions were spread over a 3-month period to allow physicians to further practice the communication skills they learned during the basic training program. These workshops were also aimed at evaluating the difficulties of transferring newly acquired skills to the workplace and at stimulating the use of those skills.

Simulated Interviews
Simulated interviews were audiotaped and videotaped. The same vignette was used at T1 and T2 (Table 1). The actress was asked to exhibit a high level of distress when bringing up concerns about the diagnosis and prognosis of her disease and the potential impact of her disease on her asthmatic daughter’s well being. The same actress, trained to exhibit a high level of distress, was used at T1 and T2 for all participants. Training included practicing the role play and participating in feedback sessions led by the study coordinators. An actress experienced in simulating interviews was chosen to ensure that she maintained the same behavior and high emotional level all across the interview situations. The fact that she maintained the same high emotional level was tested in a previous study.¹⁹ Before the simulated interview, physicians had enough time to learn the case description and the aims of the interview. They were then introduced to the actress in the recording room and told that after 20 minutes the interview would end. A clock helped time management.

Actual Patient Interviews
An actual patient interview was also audiotaped at each assessment time. Patients were chosen by physicians. Inclusion criteria for patients included breaking news (bad, neutral, or good), age older than 18 years, ability to speak French, absence of cognitive dysfunction, and written informed consent. Patients were different at T1 and T2.

Interview Rating System
All audiotapes were transcribed. Transcripts were assessed for their quality and then rated by trained psychologists. Rating was based on the French translation and adaptation of the Cancer Research Campaign Workshop Evaluation Manual.²⁰ Raters were blind to the trained or untrained status of the physicians and to the assessment time. The Cancer Research Campaign Workshop Evaluation Manual was used to assess the form, function, and emotional level of each utterance.

Interviews were rated by 14 intensively trained psychologists. Training included reading the manual, doing rating exercises, and being supervised by the rater coordinator. Before beginning to rate, raters had to reach at least the following concordance rate with a validating test: 85% for the rating of the form of the utterances, 67% for the functions, and 71% for the emotional level. Moreover, to ensure a quality control and to avoid rating conflicts, raters were systematically supervised by the rater coordinator to check the accuracy of their ratings. Finally, ratings were checked throughout the process for inconsistencies.

Questionnaires
Before actual patient interviews, each patient completed a sociodemographic questionnaire, the Hospital Anxiety and Depression Scale,^21–22 and the Ways of Coping Checklist^23–24 (Table 2). Each physician completed a sociodemographic and socioprofessional questionnaire (see Results). After the interviews, each patient and physician filled in the Perception of the Interview Questionnaire. Physicians also had to report oncologic information about patients’ disease and interview characteristics. Patient performance status was assessed with the Karnofsky performance status score.²⁵

	RESULTS

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Physician and Patient Sociodemographic Data
After the recruitment process, 113 physicians registered for the training program, and 72 attended the first training day. Principal barriers to participation were personal and institutional reasons, time limitations, training duration, and time-consuming assessment procedures. Four physicians who attended less than 15 hours of basic training and five physicians who took part in less than four workshops were not considered assessable. Sixty-three physicians completed the program. One physician did not complete the assessment procedure. Three physicians completed the simulated interviews but were not able to accrue a patient for the actual patient interview. Therefore, 62 physicians who completed the simulated interview and 59 who completed the actual patient interviews were assessable. Comparison of included and excluded physicians showed no statistically significant differences for age, sex, and number of years of practice. In regard to physicians’ demographic and socioprofessional characteristics, no statistically significant differences were found at baseline between physicians who participated in the consolidation workshops and physicians assigned to the waiting list.

Physicians in the consolidation-workshop group were a mean of 41 years old (SD, 6.6 years), 48% were female, 10% lived alone, 35 lived with a partner, and 55 had children. Physicians had a mean of 16.5 years (SD, 6.5 years) of medical practice and 13.5 years (SD, 6.8 years) of practice in oncology. Forty-one percent of the physicians worked in oncology and radiotherapy, and the rest worked in hematology, gynecology, and other specialities. Fourteen percent of the physicians worked with outpatients only. The mean number of cancer patients seen during the week before the assessment procedure was 28 (SD, 24 patients). None of the physicians had attended communication skills training workshops in the last year.

Physicians in the waiting-list group (no consolidation workshops) were a mean of 44 years old (SD, 7.7 years), 42% were female, 15% lived alone, 33 lived with a partner, and 52 had children. They had a mean of 18.2 years (SD, 7.3 years) of medical practice and 15.0 years (SD, 8.0 years) of practice in oncology. Forty-two percent of the physicians worked in oncology and radiotherapy, and the rest worked in hematology, gynecology, and other specialities. Twelve percent of the physicians worked with outpatients only. The mean number of cancer patients seen during the week before the assessment procedure was 25 (SD, 19 patients). Six percent of the physicians (n = 2) had attended a brief communication skills training workshop in the last year. As displayed in Table 2, no statistically significant differences were found in patient, disease, and interview characteristics over time and between the consolidation-workshop and waiting–list groups when comparison was possible.

Assessment of Consolidation Workshop Efficacy
As shown in Table 4, several significant MANOVA group-by-time changes in physicians’ communication skills were noted in simulated interviews. At T2, physicians in the consolidation-workshop group, compared with physicians in the waiting-list group, asked more open and open directive questions (F = 6.38, P = .014), used significantly more functions alerting patients to elements of reality they had not perceived before (F = 4.04, P = .049), and made significantly fewer premature reassurances (F = 4.32, P = .042).

In actual patient interviews, MANOVA time effects were found as well (Table 5). Over time, all physicians elicited and clarified more psychologic information (F = 14.80, P < .000). Actual patient interviews in both groups were of a higher emotional level over time because the number of utterances with feelings stated explicitly increased significantly (F = 5.97, P = .018).

Perception of and Satisfaction With the Actual Patient Interview
As shown in Table 6, no statistically significant differences were found between groups and over time in physicians’ perception and satisfaction with the way they conducted the actual patient interviews. Only one significant MANOVA group-by-time effect was observed in patients’ perception with the way physicians conducted actual patient interviews. Patients interacting with cancer specialists who benefited from the consolidation workshops reported that the physicians had a better perception of their understanding of the disease (F = 9.14, P = .004). One significant MANOVA group effect was found as well; physicians in the consolidation-workshop group gave less information about the diagnosis at both assessment times compared with the waiting–list group (F = 4.54, P = .037).

	DISCUSSION

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First, it should be noted that physicians participating in the basic training program improved their communication skills over time and that the emotional level of the interviews increased. In accordance with published studies,^10–14 our results thus confirm the efficacy of 2.5-day communication skills training programs. The powerful time effect observed both in simulated and in actual patient interviews may be explained, in part, by the fact that knowing that one is going to get further training can have a motivating effect.

Post-consolidation workshop changes in simulated interviews reflect a greater openness toward patients’ concerns and needs. Physicians use more strategies promoting patients’ disclosure of concerns⁶ (that is, more open and open directive questions) and fewer communication behaviors inhibiting disclosure of concerns (that is, fewer premature reassurances). Although the use of open and open directive questions increased over time in both groups, consolidation workshops had a further impact on the amplitude of the changes observed.

Post-consolidation workshop changes in actual patient interviews also reflect a greater interest in patients’ concerns and needs; there were more acknowledgments (showing that one has heard patients’ words by saying "Yes," "I see," and similar statements of acknowledgement), empathic statements (showing understanding of patients’ feelings by making brief statements such as "How upsetting for you. . ."), educated guesses (making sensible and warranted guesses at patients’ thoughts and feelings), and negotiations (discussing with patients which steps to take next). The increase in the use of empathy is an important finding because empathy is rarely used in the clinical setting before any communication skills training. It should be recalled that the lack of empathy or difficulty in maintaining empathy in the clinical setting may be explained by physicians’ significant workload.

Most importantly for the focus of this study, it is worthwhile to emphasize that, in simulated interviews, communication skills were acquired immediately after attending the basic training program and amplified by consolidation workshops. In actual patient interviews, new communication skills were used mainly after attendance of consolidation workshops. This reflects the usefulness of consolidation workshops in the transfer to the clinical practice of newly learned communication skills. It should be stressed that disparity in skills acquisition could also be related to the test-like structure of the simulated interview, as well as to the learning effect related to this context. Finally, it should be noted that the simulated interview was a first encounter that focused on diagnosis, whereas actual patient interviews mostly involved patients who had been seen previously and focused either on diagnosis or prognosis and treatment. Therefore, the disparity in skills acquisition could also be related to the fact that communication skills are dependent on situations.

Post-training changes in the use of communication skills were only reflected in one dimension of patients’ perceptions of the interviews. Patients interacting with physicians who attended the consolidation workshops reported that they had a better perception of their understanding of their disease. Therefore, newly acquired communication skills are not fully perceived by patients. This may be because the improvements in communication skills did not reach the level that would allow perception of a higher level of skills by patients. Furthermore, no changes were observed in patient satisfaction with the interview. This is similar to previous results of a communication skills training program that consisted of two 4-hour sessions.¹⁵ Although our training program was longer and more intensive, it also did not lead to an increase in patient satisfaction. These limited results may be a result of the ceiling responses to the questions already noticeable before training. Some patient variables (age, prognosis, performance status, type of physician-patient relationship, etc) and the fact that patients were invited to participate by their physicians could explain why most patients perceived their physicians’ communication skills as quite good before any training. Therefore, physician communication style could be more important than the newly acquired communication skills that may take years to be integrated into a general interpersonal style. Moreover, most patients knew their physicians and might not have been able to perceive subtle changes. They saw their physicians as a whole rather than in terms of specific skills. This does not indicate, however, that good communication skills and improvements in these skills do not matter to patients. This simply may indicate that patients are extremely tolerant of their trusted physicians. In this regard, it would be interesting in future studies to collect more precise data that monitored the intensity and familiarity of physician-patient relationship to examine to what extent these variables may influence a patient’s detection of physician communication-skills changes.

The fact that physicians were voluntarily enrolled and were mainly experienced clinicians could limit the generalizability of our results. It could be argued that the motivation of those physicians was high and that this could have an impact on the changes observed. However, the fact that the physicians were experienced could also mean that their communication strategies were more rooted in habits and that improvements in this context could be more difficult to achieve.

The aim of our randomized training program designed for medical specialists dealing with cancer patients was to evaluate the specific benefits of consolidation workshops after a short basic training program. Our findings emphasize the usefulness of consolidation workshops to optimize learning of new communication skills and their transfer to clinical practice. As expected, consolidation workshops had a positive impact not only on the range of communication skills learned but also, in some cases, on their amplitude. These improvements highlight a trend toward a physician-patient relationship that is more centered on the patient.

It should be emphasized that only four of the 22 communication skills were affected by consolidation workshops. Changing the way physicians talk to patients is a challenging task because communication involves habitual and automatic patterns of relating. Further improvements might be expected by pursuing consolidation workshops or by implementing training programs during medical school.

To our knowledge, this is the first study assessing the usefulness of consolidation workshops for physicians who completed a basic training program. The transfer of learned skills to the clinical practice seems to be related to these workshops. Spreading the workshops over a 2-month period may allow physicians to further practice learned skills and to discuss the difficulties encountered in their implementation. However, more research is necessary to design consolidation workshops that promote the transfer to the clinical practice of a broader range of truly mastered skills that enable physicians to respond adequately to patients’ needs.

	ACKNOWLEDGMENTS

 
We thank all the physicians and patients who participated in the study. For their contribution to the data collection, we thank Laurence Dubus, Jean-François Durieux, and Angélique Moucheux. For her contribution to the quality control of the transcripts, we thank Christine Farvacques. For his contribution to the coordination of the raters and the quality control of the transcripts, we thank Michel De Cock. For their contribution to the rating of the interviews, we thank Nicolas Beauloye, Véronique Beddegenoots, Youri Caels, Anne Chevalier, Caroline Dhozot, Michel De Cock, Emilie Harcq, Sandrine Kranich, Christophe Luthy, Maggie Oda, Fiona Roe, and Fiona Vandenbossche. We also thank Viviane De Beer, Maria Del Pilar Pato Fernandez, Fabienne Hubert, Immaculée Mukarwego, Françoise Odou, Claudia Ortega, and Monique Toussaint for the transcription of the interviews.

	NOTES

 
Supported by the Fonds National de la Recherche Scientifique-Section Télévie of Belgium and by the C.A.M., Training and Research Group, Brussels, Belgium.

	REFERENCES

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Submitted August 7, 2002; accepted June 3, 2003.

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