Introduction
Evidence-based medicine (EBM) requires that every aspect related to treatment effectiveness be operationalized and measurable [1, 2]. This assumption also applies to clinical communication, which until recently in Poland was treated exclusively as an art — and therefore not subject to a rigorous didactic process or systematic scientific research. Meanwhile, for more than 40 years it has been treated around the world as a set of skills used in the widely understood professional communication in medicine, in which the participants are all healthcare professionals involved in the treatment process, the patient and his family [3, 4]. Initially based on theory, then based on ongoing research, communication models were built that detail the skills necessary for effective and mutually satisfying clinical communication, for example history-taking, communicating information to the patient and sharing decision-making.
Given this variety, it seems all the more important to ensure that healthcare professionals have the right skills to communicate effectively. Communication skills are teachable and learnable [5, 6]. These skills allow physicians to be more effective when taking a medical history. Their use is also known to provide tangible benefits for both physicians and patients. Teaching and developing clinical communication is important not only for physicians but for all medical professionals. It is emphasized that proper, effective conversation allows proper collaboration in the interprofessional team in treating and caring for patients. Team communication skills also affect the quality of collaboration with patients [6]. An important element in communication skills training is to recognize the needs in this area among practising physicians in Poland — especially with regard to their mentoring role in educating future generations of physicians [7]. Exploration of the area of clinical communication was carried out during the empirical research. The study aimed to investigate the level of physicians’ communication skills, their educational needs in this area and the effectiveness of teaching in Poland.
Participants and methods
The clinical communication training needs of 123 physicians have been assessed. Physicians from various specialties were asked what they would like to learn in the area of communication skills. Physicians were invited to participate in the survey in two ways. 108 respondents were University Hospital employees who completed an online questionnaire. The survey was published on a separate page that did not require logging in and provision of personal data, and could only be accessed from the Hospital’s internal website. The remaining 15 participants took part in the survey during a conference (paper-pencil method).
The questionnaire contains items that explore physicians’ communication skills and their training needs in this area and consists of 25 items and personal data. The questionnaire items are shown in Table 1. The respondents’ answers were categorized and presented in the form of frequency distributions, both for the needs identified and in terms of prioritizing the areas of detailed competence training. The question was an open-ended question to which respondents wrote their answers and then their answers were assigned to specific categories. The survey received the approval of the Bioethics Committee.
|
No. |
|
|
1. |
Were you taught communication skills? |
|
2. |
Did you study communication together with students in any of the fields of study listed below? |
|
3. |
What kind of teaching methods were used during your teaching if you were learning communication skills? Please tick |
|
4. |
Were your communication skills assessed? |
|
5. |
There are many models of communication. Please indicate whether any of the following are known to you |
|
6. |
There are many models of the physician-patient relationship. Please indicate whether you use any of the following at work. Please write YES or NO next to each statement |
|
7. |
There is a lot of content to focus on when teaching communication skills. Please list what you were taught |
|
8. |
Are there issues in the area of communication skills that you would like to focus on in particular? What would you like to learn from the training? |
|
9. |
Please indicate in which clinic/department you work |
|
10. |
How often do you participate in training to improve your technical professional skills? |
|
11. |
Do you search for interesting courses and training to improve your technical professional skills by yourself? |
|
12. |
How far do you rate your commitment to further training in technical skills? |
|
13. |
How far do you rate your involvement in finding courses and training in technical skills? |
|
14. |
Please circle the answer that best enables you to answer the question: I am training in technical skills because… |
|
15. |
How many courses/workshops on communication with patients have you attended throughout your career? |
|
16. |
How often do you participate in training in communicating with patients? |
|
17. |
Do you search for interesting courses and training in the field of communication with patients? |
|
18. |
How far do you rate your commitment to further training in communicating with patients? |
|
19. |
How far would you rate your involvement in finding courses and training in communicating with patients? |
|
20. |
Please circle the answer that best enables you to answer the question: I am training in patient communication skills because… |
|
21. |
Using the scale, please indicate how interested you are in attending a workshop to develop |
|
22. |
Please rate your professional development needs from 1 to 6 and rank them in order of importance |
|
23. |
Please write down below any comments you can think of |
|
24. |
The questions below refer to the reasons why you choose to participate in workshops on communication skills with patients. Different people have different reasons for participating in such educational activities, so the authors of this survey would like to find out to what extent each of these reasons is true for you. They are grouped into three groups of issues, and each refers to the sentence that begins that group. Please indicate how true each sentence is for you, using the scale below |
Statistical analysis of the results used descriptive statistics (mean, standard deviation) and frequency distributions. Deviations from the independence of variable distributions were tested by using the chi-square likelihood ratio test.
Results
Among the surveyed 123 physicians there were 46% males and 54% females, aged 36.23 ± 10.36; seniority M = 10.32 ± 9.5. The distribution of answers is shown in Table 2.
|
Category |
N |
Percentage of valid answers |
|
Developing the ability to inform |
17 |
20.48 |
|
Communicating difficult news, to a patient in crisis, about dying |
27 |
32.53 |
|
Dealing with an aggressive patient/aggressive family |
22 |
26.51 |
|
No need (I am already sufficiently educated) |
10 |
12.05 |
|
Other (legal aspects, time management, dealing with one’s own emotions) |
4 |
04.82 |
|
All competencies (full course) |
3 |
03.62 |
|
No answer |
40 |
48.19 |
Almost half of the respondents did not answer the following question asked: “Are there issues in the area of communication skills that you would like to particularly focus on? What would you like to learn from the training?” It is most likely that the respondents could not identify their own needs because they do not know what they could learn. The answers to the open questions included the following statements: “Yes, however, I don’t know of any so far”. “I don’t quite know yet”; “I don’t know”. Furthermore, 12% of physicians take the view that they have such a high level of communication competencies (both in their own eyes and their assessment of how they are perceived by patients) that they do not need to practice them. In terms of declared needs, respondents most frequently indicated: “Communicating difficult news, with a particular focus on communicating about dying” (to both the patient and the patient’s family) — that need was reported by one in three physicians of all respondents. Other important skills that were highlighted by the respondents were the need to deal with patients and/or the patient’s family behaving aggressively, as well as the need to learn skills to inform about treatment — those needs were reported by one in four and one in five respondents, respectively. Respondents’ answers were analysed, which are included in Table 3.
|
Category |
Specialties of the surveyed physicians |
|||
|
Surgical [n (%)] |
Conservative [n (%)] |
Mixed [n (%)] |
Without specialty [n (%)]) |
|
|
Developing the ability to inform |
4 (30.77) |
6 (15) |
6 (14.29) |
1 (3.57) |
|
Communicating difficult news, to a patient in crisis, about dying |
0 |
8 (20) |
11 (26.19) |
8 (28.57) |
|
Dealing with an aggressive patient/aggressive family |
0 |
8 (20) |
5 (11.90) |
9 (32.14) |
|
No need (I am already sufficiently educated) |
0 |
0 |
10 (23.81) |
0 |
|
Other (legal aspects, time management, dealing with one’s own emotions) |
0 |
3 (7.5) |
0 |
1 (3.57) |
|
All competencies (full course) |
0 |
1 (2.5) |
0 |
2 (7.14) |
|
No answer |
9 (69.23) |
14 (35) |
10 (23.81) |
7 (2%) |
A further stage of the study examined the importance, in the opinion of physicians, of the need to develop communication skills. Respondents were asked to rank the areas according to their need for communication skills training. To do this, respondents created a hierarchy of importance, where “1” represented the most important need for communication skills training, and “7” was the least important need.
The results of the hierarchy distribution obtained are shown in Table 4. The obtained results identified that the need that was most recognized by respondents was the need related to the informative nature of the consultation — one in three respondents felt the need to train “skills to initiate consultations” and for almost half of them this relates to developing “information-gathering skills”. While “skills for structuring consultations” as a need was assigned the third rank by almost every second respondent, “relationship-building skills with patients” resulted in a greater dispersion of respondents’ answers — almost every third physician assigned it the fourth rank in the hierarchy of needs, the distribution of the rank assigned by most respondents oscillated between 3–5 (for more than 60% of respondents). At the same time, it was apparent that a large group of individuals (almost one in five respondents) gave the need to develop “relationship–building skills with patients” the highest priority. By far the lowest importance for the surveyed physicians was given to the development of “explaining, planning, consultation closure and variation skills in the content and process of medical history taking” — the final positions in the hierarchy were attributed to them by between 50 and 7% of the respondents (positions 5 to 7 of the hierarchy). Three (2.5%) physicians did not prioritize their needs.
|
Area |
Hierarchy of importance [%] |
||||||
|
1 |
2 |
3 |
4 |
5 |
6 |
7 |
|
|
A. Skills to initiate consultations |
33.33 |
14.16 |
11.66 |
8.33 |
6.67 |
16.66 |
9.16 |
|
B. Information-gathering skills |
19.16 |
41.66 |
13.33 |
13.33 |
4.16 |
3.33 |
5 |
|
C. Skills for structuring consultations |
7.5 |
7.5 |
41.66 |
16.66 |
15 |
8.33 |
3.33 |
|
D. Relationship-building skills |
18.33 |
11.66 |
14.16 |
35.83 |
11.66 |
4.16 |
4.16 |
|
E. Explaining and planning skills |
9.16 |
19.16 |
6.66 |
11.67 |
41.66 |
7.5 |
4.16 |
|
F. Consultation closure skills |
10 |
4.16 |
4.16 |
3.33 |
7.5 |
50 |
20.8 |
|
G. Possible options during the explanation and planning stage — taking into account skills regarding the content and process of medical history taking |
2.5 |
1.66 |
8.33 |
10.83 |
13.33 |
10 |
53.33 |
Discussion
The results of the study confirmed that there is a tendency to develop those skills whose deficits have been identified. According to Graf et.al. [8], the self-perception of communication skills improved, while the external perception of these skills worsened between the first (summer semester 2011) and the last cohort (summer semester 2014). Other studies also suggest differences between self- and external perceptions of medical students’ communication skills [9, 10]. Unfortunately, the physicians surveyed in the present study were not taught the “explaining, planning, consultation closure and variation skills in the content and process of medical history taking”, and in this respect, they have the least need for education. And the earlier the stage of training/shorter the working period, the lower the needs of physicians in this area. At the same time, studies indicate that only 44% of patients in Poland considered themselves to be sufficiently informed about their own health status [11], and insensitive and inadequate communication on end-of-life issues can cause the patient’s family long-term emotional trauma [12].
The survey included physicians representing various specialties and non-specialists. The respondents did not include physicians with a specialization in palliative medicine, but their interest in communication in the field of palliative medicine was evident in the results presented earlier. To see if the path of specialty training taken differentiates the respondents, specialties were divided into 3 types: conservative treatment (e.g., internal medicine, allergology, rheumatology), surgical treatment and mixed treatment (gastroenterology, orthopaedics), and a group without specialization was distinguished.
The highest need for developing the ability to inform was characteristic of the surgical group, and this was their only need. At the same time, doctors in this group very often (69.23%) did not answer the question asked. Physicians with a specialty requiring a combination of invasive procedures and conservative treatment almost to the same extent as physicians without a specialty indicated the need for training in breaking bad news skills — one in four respondents indicated this. Surprisingly, it seems that in the surgical and conservative groups combined, almost half of the respondents could not indicate a need or did not see one (no need and no answer — both 23.81%). The physicians beginning their professional path (without specialization) most often indicated the need to acquire competence in dealing with aggressive patients, while the aspects related to developing the ability to inform and “Other” (legal aspects, time management, dealing with one’s own emotions) are the least frequent.
Limitations of the study include a modest study sample recruited mostly from one clinical hospital. However, this is the first empirical study conducted in Poland exploring physicians’ communication. It would be worthwhile to repeat it with a larger sample and in several centres, among other things, because changes were made to the healthcare system and the training of physicians during the project period. Moreover, experience from clinical practice in the context of the SARS-CoV-2 pandemic indicates that teaching effective communication is particularly important for the quality of work and performance of healthcare workers and the quality of patient care. Then it will be possible to educate according to the words of Professor Jan Nielubowicz “Great is the power of the physician's word, as it allows healing and teaching. Medical doctors need words like any other tool to practice their profession. A doctor's words that are derived from true knowledge and willingness to help the sick has real power” [7].
Conclusions
Physicians in Poland struggle to accurately identify their training needs in clinical communication. This is due to the fact that until now these skills have not been taught in a systematic method. Hence, doctors do not know what to expect in this area and what they should be taught and learn. The clarification of issues that occurred in the process of prioritizing needs caused doctors to reevaluate the importance of the areas that should be taught — they recognized the importance of basic competencies, which are the basis for building effective communication with the patient. Therefore, a fundamental step in effective curricula building, including teaching clinical communication, is to assess the needs of learners.
Declaration of conflict of interests
The authors declare that there is no conflict of interest.
Funding
This study is supported by the Ministry of Science and Higher Education of the Republic of Poland, Project DIALOG, 0259/DLG/2018/10: Improving doctors’ communication skills with patients as an innovative way to ensure a higher quality of health care, better patient outcomes and lower treatment costs.
