Anaesthesia, 2004, 59, pages 166–172 .....................................................................................................................................................................................................................
SPECIAL ARTICLE
Improving anaesthetists’ communication skills C. Harms,1 J. R. Young,5 F. Amsler,2 C. Zettler,3 D. Scheidegger4 and C. H. Kindler1 1 Staff Anaesthetist, 2 Consultant Psychologist, 3 Resident, 4 Professor and Chairman, Department of Anaesthesia, University Clinics Basel, 5 Biostatistician, Basel Institute of Clinical Epidemiology, University Clinics Basel, Kantonsspital, CH-4031 Basel, Switzerland Summary
The attitude, behaviour and communication skills of specialised doctors are increasingly recognised as important and they have been identified as training requirements. We designed a programme to teach communication skills to doctors in a University Department of Anaesthesia and evaluated its effect on patient outcomes such as satisfaction and anxiety. The 20 h programme was based on videotaped reviews of actual pre-operative visits and role-playing. Effects on patient satisfaction and pre-operative anxiety were assessed using a patient questionnaire. In addition, all participating anaesthetists assessed the training. We provide evidence that the training increased patient satisfaction with the pre-operative anaesthetic visit. Training also decreased anxiety associated with specific aspects of anaesthesia and surgery, but the effect was rather small given the intense programme. The anaesthetists agreed that their interpersonal skills increased and they felt better prepared to understand patients’ anxieties. Communication skills training can increase patient satisfaction and decrease specific anxieties. The authors conclude that in order to better demonstrate the efficacy of such a training programme, the particular communication skills of anaesthetists rather than indirect patient outcome parameters should be measured. Keywords
Patient satisfaction. Anxiety. Pre-operative care. Physician-patient relations. Communication. Clinical competence. Education.
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Correspondence to: C. H. Kindler E-mail:
[email protected] Accepted: 31 August 2003
Effective communication between doctor and patient improves patient satisfaction, patient recall of information and medical outcome, and can even protect doctors against malpractice litigation [1]. Although interest in teaching communication skills in medical schools has increased over the years, most postgraduate medical education still focusses on the technical and biomedical aspects of medicine [2]. However, the importance of non-technical skills in the daily work of doctors is now increasingly recognised, even in subspecialties such as anaesthesia [3]. Anaesthesia residency review committees in different countries now demand documentation of training in communication skills. For example, the Royal College of Anaesthetists requires an assessment of communication skills, attitudes to patients and behaviour for its Certificate of Completion of Specialist Training [4]. The American Accreditation Council for Graduate Medical Education (ACGME) has endorsed six general 166
competencies including interpersonal and communication skills for residents in all specialties [5]. The ACGME and the American Board of Medical Specialties are now collaborating to implement and evaluate these general competencies. The impact of doctors’ personal skills has therefore become an area of clinical interest and research. Most medical training programmes that teach communication skills are designed for general practitioners, but a few have been designed for surgeons [1] or for Accident and Emergency Department doctors [6]. Apart from personal observations, there are no data available on how anaesthetists communicate with their patients [7, 8]. We designed a programme to teach communication skills to anaesthetists using videotaped reviews of their pre-operative visits and role-play. Communication skills that are effective for general practitioners are not necessarily effective for other specialists [1]. Our programme was therefore tailored to the particular 2004 Blackwell Publishing Ltd
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Anaesthesia, 2004, 59, pages 166–172 C. Harms et al. Improving anaesthetist communication skills . ....................................................................................................................................................................................................................
situation of the anaesthetist and patient in the preoperative setting. The objectives of the training programme were to improve the receptive and affective behaviour and interpersonal skills of anaesthetists and to increase patient participation in informed or shared decision-making with respect to the planned anaesthetic technique. Despite the resources invested in communication skills training, few programmes seem to have been assessed in terms of patient outcome [2, 9]. Using a patient questionnaire, we assessed whether our training programme increased patient satisfaction and decreased patient anxiety before surgery. In addition, the training programme was assessed by a questionnaire distributed to all participating anaesthetists. Methods
The Local Research Ethics Committee of the University of Basel approved the communication skills training programme and its assessment by questionnaires. A clinical psychologist (F.A.) led the training. Anaesthetists in a University Department of Anaesthesia were trained in small groups of 7–10 with a similar mixture of residents and faculty within each group. Each group received 10 training sessions, one each month, and each session lasted about 2 h. Participation in the training was mandatory for all 59 anaesthetists involved in patient care during the study period, although not all received the full 20 h of training. Training started with a short theoretical introduction to interpersonal communication and its effect on patient outcomes such as patient satisfaction. After this, training consisted firstly of reviewing videotaped pre-operative visits. Each trainee had to record two of his ⁄ her preoperative visits and these videos were discussed and analysed within each group. Trainees were asked to observe themselves, recognise their own emotions, recognise their patients’ expressions and listen actively to what their patients were saying. Second, role-playing was used to prepare for difficult situations. Trainees were asked to apply four behaviours of effective clinicians, adapted to the pre-operative situation: 1 establish a welcoming atmosphere for the pre-operative visit and agree with the patient on an agenda; 2 elicit the patient’s concerns about anaesthesia and surgery; 3 demonstrate empathy both verbally and non-verbally; 4 actively involve the patient in making decisions about the planned anaesthetic technique whenever possible, and appropriately conclude the visit by reassuring the patient of ongoing care. The training programme was assessed using a pre- and postintervention design. Patient satisfaction and patient 2004 Blackwell Publishing Ltd
pre-operative anxiety were defined as appropriate measures of improvement in communication skills. We constructed a questionnaire using a modified Delphi procedure [10] to measure patient satisfaction with the pre-operative visit, patient pre-operative anxiety [11] and patient perception of the anaesthetist [12]. The final version of the questionnaire contained 86 items. Inclusion criteria for patients were: age over 18 years; fluency and literacy in the German language; written informed consent. Patients with a seriously impaired mental status were excluded. Anaesthetists were informed verbally and in writing about the purpose of the study and asked to participate. They were told that they did not have to distribute questionnaires to patients if they did not wish to do this and they also signed a physician questionnaire containing patient and physician demographic data. Preintervention data were collected for a period of 3 months from all patients undergoing elective surgery, the intervention consisted of training in communication skills for a period of 10 months using videotape reviews and roleplaying, and postintervention data were collected for a 3-month period after the training finished. At the end of the programme, all participating anaesthetists also assessed it. Summary response variables Six response variables were used to summarise patients’ satisfaction with the pre-operative anaesthetic visit and pre-operative anxiety. Satisfaction with the pre-operative anaesthetic visit was summarised by ‘overall satisfaction’ in the form of each patient’s response to a general question on overall satisfaction, and by ‘median satisfaction’ in the form of each patient’s median response to 10 specific questions on satisfaction with different aspects of the preoperative anaesthetic visit. All 11 questions used the same five ordered categories (insufficient, fair, appropriate, very good, excellent). Pre-operative anxiety was summarised by using the German version of the Spielberger-StateAnxiety-Score (STAI-G Form X1) [13], by ‘overall anxiety about anaesthesia’ and ‘overall anxiety about surgery’ in the form of each patient’s response to two general questions on overall anxiety, and by ‘median anxiety’ in the form of each patient’s median response to 10 specific questions on different aspects of anxiety about anaesthesia and surgery [11]. These 12 questions on anxiety all used a 10-cm visual analogue scale (VAS). Predictor variables The predictor variables used to model each summary response variable were: age, gender, level of education, prior experience of anaesthesia, whether or not patients felt they were involved in choosing the type of anaesthesia they would receive, planned duration of 167
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C. Harms et al. Improving anaesthetist communication skills Anaesthesia, 2004, 59, pages 166–172 . ....................................................................................................................................................................................................................
combined and renamed ‘standard’. Overall and median satisfaction were assumed to follow underlying normal distributions, although each was measured on an ordinal scale [14]; the Spielberger score was assumed to follow a normal distribution; and the other anxiety responses were assumed to follow exponential distributions (Fig. 1). Models were fitted using the NLMIXED, MIXED and GENMOD procedures in SAS version 8.2. (SAS Institute Inc., Cary, NC). The NLMIXED procedure fits nonlinear models with both fixed and random effects; the MIXED procedure fits linear models with both fixed and random effects; the GENMOD procedure fits non-linear models with only fixed effects. Where possible, therefore, parameter estimates from NLMIXED were checked against estimates from other procedures: the MIXED procedure reproduced estimates for the Spielberger score with the random effect, the GENMOD procedure reproduced estimates for the other anxiety responses without the random effect. When using NLMIXED, models were first fitted without the random effect to provide suitable starting values for fitting with the random effect. Optimisation in NLMIXED was by the trust region method or, if this failed to converge, by quasi-Newton methods. The trust region method uses both first and second order partial derivatives and often provides stable estimates when a model has a small number of predictor variables. When a model has more variables, the trust region method may fail to converge, but quasi-Newton methods may converge as these use only the first order partial derivatives [15]. All confidence intervals were approximate 95%
surgery, the anaesthetist and the number of hours of training the anaesthetist had received before the anaesthetic visit. Age, planned duration of surgery and the number of hours of training were continuous variables; all other variables were categorical. The patients’ level of education was coded as one of three categories: at most primary or secondary school, apprenticeship or high school, college or university. Prior experience of anaesthesia was also coded as one of three categories: none, prior experience, prior bad experience. Models and model fitting The six summary response variables were modelled using analysis of covariance. ‘Mixed’ models were fitted with the anaesthetist as a random effect and all other predictors as fixed effects. As a fixed effect, each predictor variable or category of a predictor variable is represented by a single parameter. As a random effect, each anaesthetist is said to form a cluster; responses from patients with the same anaesthetist are correlated but responses from patients with different anaesthetists are independent. A single parameter, the between-cluster variance, describes the differences between clusters; cluster effects are assumed to be normally distributed with a mean of zero. In this way, variability between anaesthetists is modelled without needing additional predictor variables to describe the differences between them. Different distributions were assumed for the six summary response variables. For both overall and median satisfaction, < 1% of responses were ‘fair’ and none was ‘insufficient’. The lower three categories were therefore %
%
50
50
40
40
30
30
20
20
10
10
0
Standard
Very good
0
Excellent
Standard
Satisfaction - overall %
40
15
30
10
20
5
10 20 - 25 - 30 - 35 - 40 - 45 - 50 - 55 - 60 - 65 - 70 - 75
