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Using television shows to teach communication skills in internal medicine residency Wong, Roger Y; Saber, Sadra S; Ma, Irene; Roberts, J M Feb 3, 2009

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ralssBioMed CentBMC Medical EducationOpen AcceResearch articleUsing television shows to teach communication skills in internal medicine residencyRoger Y Wong*, Sadra S Saber, Irene Ma and J Mark RobertsAddress: Postgraduate Medical Education, Department of Medicine, University of British Columbia, Vancouver, CanadaEmail: Roger Y Wong* - rymwong@interchange.ubc.ca; Sadra S Saber - sadra@interchange.ubc.ca; Irene Ma - ima@interchange.ubc.ca; J Mark Roberts - james.roberts@vch.ca* Corresponding author    AbstractBackground: To address evidence-based effective communication skills in the formal academichalf day curriculum of our core internal medicine residency program, we designed and delivered aninteractive session using excerpts taken from medically-themed television shows.Methods: We selected two excerpts from the television show House, and one from Gray'sAnatomy and featured them in conjunction with a brief didactic presentation of the Kalamazooconsensus statement on doctor-patient communication. To assess the efficacy of this approach aset of standardized questions were given to our residents once at the beginning and once at thecompletion of the session.Results: Our residents indicated that their understanding of an evidence-based model of effectivecommunication such as the Kalamazoo model, and their comfort levels in applying such model inclinical practice increased significantly. Furthermore, residents' understanding levels of the sevenessential competencies listed in the Kalamazoo model also improved significantly. Finally, theresidents reported that their comfort levels in three challenging clinical scenarios presented tothem improved significantly.Conclusion: We used popular television shows to teach residents in our core internal medicineresidency program about effective communication skills with a focus on the Kalamazoo's model.The results of the subjective assessment of this approach indicated that it was successful inaccomplishing our objectives.BackgroundEffective communication skills are integral to patient careas they enhance patient satisfaction, adherence to treat-ment and health outcomes [1]. It is therefore inherent thatteaching communication skills is an important compo-nent in undergraduate and postgraduate medical educa-United States [2] and the CanMEDS framework mandatedby the Royal College of Physicians and Surgeons (RCPSC)in Canada [3] have declared communication as one of thecore competencies and roles of physicians. Several guide-lines [4-6], models [7,8], and consensus statements [9-11]have been developed to guide medical educators, learnersPublished: 3 February 2009BMC Medical Education 2009, 9:9 doi:10.1186/1472-6920-9-9Received: 3 September 2008Accepted: 3 February 2009This article is available from: http://www.biomedcentral.com/1472-6920/9/9© 2009 Wong et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 8(page number not for citation purposes)tion. In fact, accreditation bodies such as the AccreditationCouncil for Graduate Medical Education (ACGME) in theand physicians in developing sound communicationskills. However, challenges still remain in addressingBMC Medical Education 2009, 9:9 http://www.biomedcentral.com/1472-6920/9/9patient-physician communication in medical education.These include inadequate attention and time given to edu-cating undergraduate and postgraduate learners on com-munication skills, difficulties in implementingstandardized programs of communication skills in formalmedical curricula, as well as lack of objective evaluation ofthe efficacy of such programs [12-16]. These challenges, inturn, have resulted in deficiencies in patient-physiciancommunication in medical practice. Discussing end-of-life issues, delivering bad news, attending to psychosocialaspects of patients, and disclosing errors or adverse eventsare some examples of areas where pitfalls in physiciancommunication have been documented [17-19].Recognizing many of those issues, in 1999 representativesfrom major medical educational and professional organi-zations gathered in a conference in Kalamazoo, Michigan,with the objective of outlining a set of universal guidelinesby which effective communication skills can be taught,evaluated, and utilized in medical education and practice[9]. By the end, the collaboration of the experts from avariety of backgrounds and disciplines in medical educa-tion and practice produced a comprehensive and evi-dence-based model which outlines seven essentialelements in doctor-patient communication, and is nowwidely used in medical education. The seven elementslisted in the model, in brief, are: building a relationship,opening the discussion, gathering information, under-standing the patient's perspective, sharing information,reaching agreement on problems and plans, and finally,providing closure [9].So far, no formal structured teaching methods of theKalamazoo model exist in the literature. We intended toreinforce the importance of effective communication withparticular attention to the Kalamazoo model by means ofcinemeducation. This innovative approach was firstreported in 1994 and involves the use of clips from popu-lar films and television shows in education [20]. Sincethen, this approach has been successfully used in differentareas of medical education including psychiatry [21-23],family medicine [24], internal medicine residency pro-grams [25] as well as in undergraduate medical [26,27]and nursing [28] education.Our objective was to assess the efficacy of cinemeducation(television shows in our case) for teaching communica-tion skills using the Kalamazoo model, which has notbeen included in previous studies. The primary endpointwas the self-rated understanding of the evidence-basedKalamazoo model on communication. The secondaryendpoint was the self-rated comfort levels of residents inthree challenging clinical scenarios. These were: address-to psychosocial aspects of illness, and disclosing errorsand adverse events.MethodsSettingThe core internal medicine residency training program atthe University of British Columbia (UBC) is a 3-year pro-gram with 115 residents. These residents had not receivedformal instruction on the Kalamazoo model of communi-cation. In addition to clinical rotations, formal curriculumdelivery is done through academic half days (AHD) whichare held weekly for four hours and aimed to cover the top-ics in various medical specialties as well as the non-medi-cal expert competencies such as communication,collaboration, bioethics, evidence-based medicine, andquality improvement, etc. On average, about 70 residentsattend any AHD whereas the remainder is excused due topost-call days, out of town rotations, vacations, etc. Wereceived approval from the UBC residency training com-mittee to develop and implement the communicationcurriculum/testing and publish our experience.The Communication Skills Seminar and Viewing SessionWe organized a one-hour interactive session on commu-nication during AHD teaching time that targeted residentsin all three post-graduate years (PGY). Prior to initiatingthe AHD session, a baseline assessment (pre test) wascompleted by the residents, which contained questionson the various aspects of communication skills based onthe essential elements in the Kalamazoo consensus state-ment on communication. Then a brief didactic presenta-tion was given on effective communication competencies.Subsequently, we featured two scenarios excerpted fromthe first season of the television show House, and one fromthe first season of Gray's Anatomy. The episodes wereselected by one of the chief medical residents who screenplayed the entire first season of both shows. The nature ofthe episodes were carefully chosen to depict importantand sensitive situations with respect to doctor-patientcommunication. These excerpts represented 3 clinical sce-narios that are articulated in the core competencies ofeffective communication as documented by the educa-tional accreditation body, namely, addressing end-of lifeissues, attending to psychosocial aspects of illness, anddisclosing medical errors. Each feature presentation wasfollowed by 7 questions that mirrored the seven elementsin the Kalamazoo's model (see Appendix). This was fol-lowed by an interactive reflection period where residentswere encouraged to input their ideas on the excerpts ver-bally and discuss what they would have done differentlyin each of the featured scenarios. Finally a post-test wasadministered.Page 2 of 8(page number not for citation purposes)ing end-of life issues with terminally ill patients, attendingBMC Medical Education 2009, 9:9 http://www.biomedcentral.com/1472-6920/9/9Data CollectionThe standardized questions were designed by the AHDdirector and peer-reviewed by faculty members and seniorresidents to establish face and content validity. The ques-tions were specifically devised to address the end-pointswe previously defined (see Appendix).The residents' responses throughout the academic session(with the exception of the reflection segment) were col-lected via Personal Response System (PRS) transmitters[29]. We explained to the residents that, by respondingthrough the PRS, they have granted their verbal consent tosubmit their data for group analysis and reporting. Allquestions and potential responses were programmed intoa central notebook computer prior to the session. Eachresident was handed a PRS transmitter. A 10-seocnd inter-val per question was included for residents to key in theirresponses. All responses were based on a five-point Likertscale (1 = poor, 2 = fair, 3 = good, 4 = very good, 5 = excel-lent).The collected data was then statistically analyzed by com-paring the median values of all Likert responses (scorerange 0–5) before and after the AHD session using Wil-coxon paired signed ranked tests. Paired proportions werecompared using McNemar's tests. These non-parametrictests were chosen because our data did not follow the nor-mal distribution. All analyses were performed using SASstatistical software, version 9.1 (SAS Institute Inc, Cary,NC).ResultsA total of 64 residents attended the communication ses-sion, and 43 (67%) responded using the PRS transmitters(21 PGY-1, 15 PGY-2, 7 PGY-3).The residents who responded demonstrated significantimprovements in their self-rated understanding of effec-tive communication (Figure 1). At baseline (pre test), only23% of respondents indicated that they had a good, verygood or excellent understanding of an evidence-basedcommunication model such as the Kalamazoo, whereasafter the session, this proportion improved to 93% in thepost test (P < 0.0001). Similarly, the residents' self-reported comfort in applying an evidence-based commu-nication model to actual clinical encounters improvedsubstantially (Figure 2), from 23% who indicated good,very good or excellent level in the pre test to 88% post test(P < 0.0001).The AHD session also had positive effects in reinforcing toour residents the seven individual communication com-petencies listed in the Kalamazoo model. In fact, the resi-in 6 out of 7 competencies in the Kalamazoo (Table 1).Resident understanding improved from a median of 3(good) to 4 (very good) in every competency.Furthermore, the comfort levels of our residents in allthree challenging clinical scenarios also increased signifi-cantly after the AHD session (Table 2). Specifically, com-fort levels in addressing end-of-life issues and disclosureof adverse events/errors increased from a median of 2(fair) to 3 (good).Finally resident satisfaction at the completion of the ses-sion was encouraging as 80% indicated that they wouldlike to participate in this form of communication teachingin the future.DiscussionWe developed and implemented a focused teaching ses-sion on evidence-based and effective communicationskills as part of the formal academic half day curriculumusing clips from popular television shows. This was donein conjunction with a brief discussion of the Kalamazooconsensus statement. We observed significant improve-ments in the residents' understanding of the essential ele-ments of effective communication and their comfortlevels in selected clinical scenarios that were deemed chal-lenging.Cinemeducation is an effective tool that can enhanceteaching as it provides a dynamic and humanistic depic-tion of clinical situations to audiences, captures theirattention, and engages them in the emotional experience[20]. This tool has become increasingly popular in medi-cal education with the majority of its use in teachingabout psychosocial aspects of illnesses and specific symp-tom presentations as well as other areas such as profes-sionalism and therapeutic managements. Doctor-patientcommunication in medicine is also a key area thatinvolves a great deal of art, emotion, and humanistic fac-ets. While others have addressed interview skills and com-munication through cinemeducation in more specificclinical contexts [25,26,30,31] our session focused ongeneric communication competencies. The selected clipswell complemented the didactic portion of the seminar bydepicting clinical scenarios where the communicationskills of doctors and residents were at play. In other words,each scenario featured an encounter where patient-physi-cian communication was deficient in one or more compe-tencies of the Kalamazoo model. This made it possible torealize the importance of effective communication, andenabled the residents to visualize realistic situationswhere the Kalamazoo model's competencies that wereintroduced in the preceding section could be applied. ThisPage 3 of 8(page number not for citation purposes)dents' self-rated understanding of all the seven skillsimproved after the session, with statistical improvementnovel approach proved to be a success as it provided forboth an effective and an enjoyable experience, and helpedBMC Medical Education 2009, 9:9 http://www.biomedcentral.com/1472-6920/9/9in accomplishing our objectives of reinforcing the under-standing and application of an evidence-based model ofsound communication skills, according to the residents'feedback.We recognize our educational intervention was brief (aone-hour session including presentation of the Kalama-zoo model and some video excerpts). The long termimpact of our intervention is unclear. Future studies areneeded to compare cinemeducation with other educa-tional approaches (such as role-playing and/or standard-While this project had promising results, there are somelimitations in the study that should be noted. This studyis not a randomized controlled trial, lacked a controlgroup, and is based on subjective assessments of respond-ents. Future work should consider more objective assess-ments. Also, since our AHD session involved acombination of introducing the Kalamazoo model didac-tically and cinemeducation, it is difficult for us to defini-tively attribute impact to the individual components ofthe AHD session that might have contributed to the pre-post differences observed. Furthermore, the study wasResidents' self-rated understanding of an evidence-based model of effective communication before and after the academic half day (AHD) sessionFigure 1Residents' self-rated understanding of an evidence-based model of effective communication before and after the academic half day (AHD) session. Page 4 of 8(page number not for citation purposes)ized patient encounters) in improving communicationskills.done in one site with a relatively small sample size, andthe response rates were less than ideal. In fact, the post testBMC Medical Education 2009, 9:9 http://www.biomedcentral.com/1472-6920/9/9data was collected immediately after the intervention,making the observed gains potentially more optimistic.There could also be potential baseline differences betweenresponders and no responders. While our residents indi-cated that this approach was useful in reinforcing effectivecommunication skills, the study assessment was onlydone in an educational setting, and its efficacy withregards to real clinical situations remains unknown. Theexpansion of the study in the future to include more resi-dents from upcoming years, and possibly the involvementstep would be to take our study further into broader andmore practical contexts such as clinical rotations in theinternal medicine curriculum as well as clinical practicesof the program graduates. In other words, while the resultsof our subjective assessment by the residents was encour-aging, developing ways to assess the efficacy of ourapproach in real clinical encounters objectively, forinstance by OSCE-style assessments, would further vali-date our findings. Finally, it might be interesting to collectqualitative data during the open-ended reflection periodResidents' self-rated comfort levels in applying evidence-based and effective communication skills to patient encounters before and after th  ac d mic half day (AHD) sess onFigure 2Residents' self-rated comfort levels in applying evidence-based and effective communication skills to patient encounters before and after the academic half day (AHD) session. Page 5 of 8(page number not for citation purposes)of other programs or sites could help improve the gener-alizability of our findings. In addition, a desirable futurewhereby residents interactively discussed the communica-tion scenarios.BMC Medical Education 2009, 9:9 http://www.biomedcentral.com/1472-6920/9/9ConclusionTo address effective communication skills and present theKalamazoo's evidence-based model of doctor-patientcommunication in our academic half day curriculum, wedesigned a seminar which utilized three excerpts from thepopular television shows House and Gray's Anatomy. Thecomparison of the survey results taken from the residentsbefore and after the session showed that their understand-ing in the Kalamazoo model improved significantly, asdid their comfort in all three selected challenging clinicalscenarios.Competing interestsThe authors declare that they have no competing interests.Authors' contributionsRYW was the principal investigator of the study, devel-oped and delivered the seminar, and supervised the datacollection, analysis, and drafting of the paper. SSS wasresponsible for literature review and drafting the paper.IM was responsible for data analysis and producing theresults. Both IM and JMR also contributed by reviewingand improving the paper. All authors read and approvedthe final manuscript.AppendixStandardized questions used during academic half day(AHD) session:Pre AHD assessment:Please rate your comfort level on:1. Understanding of an evidence-based model of soundcommunication skills.2. Application of an evidence-based model of sound com-munication skills to actual patient encounters.Please rate your understanding of the skills to:3. Build a relationship during interview.4. Open the discussion.5. Gather information.6. Understand the patient's perspective.7. Share information.8. Reach agreement on problems and plans.9. Provide Closure.Please rate your comfort level on:10. Addressing end-of-life issues.11. Attention to psychosocial aspects of illness.12. Disclosure of error or adverse event.Assessment after showing each television clip:How well did the doctor(s) do to:Table 1: Self-reported understanding of the essential elements in the Kalamazoo model of communication pre and post the academic half day (AHD) session.Competencies in the Kalamazoo Model Pre-AHD: Median (IQR) Post-AHD: Median (IQR) P ValueBuild a relationship 3 (2–4) 4 (3–4) 0.005Open the discussion 3 (2–4) 4 (3–4) 0.001Gather information 3.5 (3–4) 4 (3–4) 0.13Understand the patient's perspective 3 (3–4) 4 (3.5–4) <0.001Share information 3 (3–4) 4 (4–4) <0.001Reach agreement on problems and plans 3 (3–4) 4 (3–4) 0.005Provide closure 3 (2–4) 4 (3–4) <0.001IQR = interquartile range.Table 2: Self-reported comfort levels in 3 clinical scenarios pre and post the academic half day (AHD) session.Clinical Scenarios Pre-AHDMedian (IQR)Post-AHDMedian (IQR)P ValueAddress end-of-life issues 2 (1–3) 3 (3–4) <0.001Attention to psychosocial aspects of illness 3 (2–3) 3 (3–4) 0.001Disclosure of error or adverse event 2 (2–3) 3 (2–4) 0.001Page 6 of 8(page number not for citation purposes)IQR = interquartile range.BMC Medical Education 2009, 9:9 http://www.biomedcentral.com/1472-6920/9/91. Build a relationship.2. Open the discussion.3. Gather information.4. Understand the patient's perspective.5. Share information.6. Reach agreement.7. Provide closure.Post AHD assessment:Please rate your comfort level on:1. Understanding of an evidence-based model of soundcommunication skills.2. Application of an evidence-based model of sound com-munication skills to actual patient encounters.Please rate your understanding of the skills to:3. Build a relationship during interview.4. Open the discussion.5. Gather information.6. Understand the patient's perspective.7. Share information.8. Reach agreement on problems and plans.9. Provide Closure.Please rate your comfort level on:10. Addressing end-of-life issues.11. Attention to psychosocial aspects of illness.12. Disclosure of error or adverse event.Please rate your level of agreement:13. I would like to participate in this kind of communica-tion teaching in the future.2. ACGME outcome project general competencies. 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