When I think about my work on the acute medical unit, or my clinics, it is almost mind boggling, the number of interactions I have with other humans – trainees, consultant colleagues, radiographers, radiologists, professionals from other hospitals, biochemists, nurses, physios, therapists, and of course – patients. As Atul Gawande points out in this splendid article, medicine is now more about pit crews than cowboys, and this level of teamworking brings an inherent babble of communication.
The central point of all of this communication is to provide a service to patients – alleviating symptoms, diagnosing and curing disease, or helping patients to manage long term conditions. It would be incredibly difficult to do any of these core activities in healthcare without communicating effectively with patients.
A paper in the current issue of the PMJ reviews the literature relating to the assessment of communication skills within more senior postgraduate trainees (within two years of completion of training) and those who have already become established in practice.
The paper synthesises the evidence on assessment of communication skills, and draws the rather disappointing conclusion that currently there is little in the evidence to demonstrate benefit from educational initiatives, that there is no definitive, validated tool to evaluate communication skills, and that there is no defined standard of what constitutes good communication in the senior postgraduate, or consultant workforce.
The conclusion is disappointing from my point of view, as I consider communication to be such an important part of my day job; but when I think back to my own training, is really not all that surprising.
In my higher training I cannot think of one training session that used any of the methods reported in this paper to evaluate my communication skills. However, if the evidence is so heterogenous, and there is no clear basis on which to build educational efforts to improve communication skills in senior clinicians, is there any indication that such training is even required?
If we stick to the published evidence on this front, a mixed picture emerges again, with two of the referenced papers indicating that communication skills increase with increasing experience, whilst two others showed that communication skills worsen with increasing time in postgraduate training.
But if we go outside the published evidence on communication assessments, and look more at the outcomes of healthcare, we see that deficiencies of communication play a major role in almost all categories of incident that resulted in death of permanent loss of function investigated by the Joint Commission (an accreditation body in the US.) The Joint Commission estimates that breakdowns or errors in communication contributed to over 50% of post-operative complications, around 2/3 of wrong-patient/wrong-site/wrong procedure events, and 70% of medication error events.
These events are not the well controlled OSCE style scenarios that are traditionally used to evaluate one-on-one communication skills, but are real-life incidents that will have involved all of the complexity of current healthcare provision. Communication in these areas include so much more than those areas traditionally concentrated on in training programmes.
Email, pager, telephone, written notes, electronic health records – post-it notes, all of these forms of communication are used in real life, and perhaps the reason for the heterogeneity of evidence about what makes good communication, and the lack of clear path to improved communication skills is that we aren’t really looking at all the right areas of communication. Whilst using appropriate non-lexical utterances, empathetic questioning and establishing rapport with patients is very important, we perhaps also need to pay attention to the wider aspects of communication and start to improve outcomes and reduce the number of events where poor communication underpins the error.
There are some recommendations out there about closed loop communication techniques, standardised communication systems (eg SBAR) and other techniques to improve understanding within and across teams, many of which have their roots in the military and aviation industries. These are often resisted by medical practitioners, but as I sit here, watching 24 hours in A&E it is clear that in the critical pinchpoints of communication in medical emergencies, we have started to use more structured, team approaches to communication where the feedback from poor understanding can have an immediate and disastrous impact.
Whilst, as this systematic review shows, the evidence for improving communication skills in senior postgraduate trainees and consultants may be lacking in standardisation, and validation – the outcomes of poor communication are often plain to see.
There is undoubtedly a paucity of training around communication skills in the higher grades of training, and, just because there is an absence of evidence, we should not take this as evidence of an absence of benefit of paying attention to what is one of the core activities we all engage in every day.