3A.09 Challenges

Training in communication skills is a regular part of undergraduate medical curricula nowadays, and most undergraduate communication-skills programs also teach patient-education skills. However, the effects of communication-skills training programs are not impressive. Small to moderate improvements have been found in students' communication competency after one or more communication courses [110-115], but deterioration in students' communication competency over time has also been reported [116-118]. Furthermore, although communication-skills training appears to be effective in improving targeted communication skills, the effects of CST on performance and outcomes in clinical practice remain obscure. Postgraduate communication courses also appear to have positive effects on the communication competency of practicing physicians [85,87,88,110,119-123], but these effects are limited [93,124,125]. Only interventions for residents and consultants, which specifically address communication behavior in clinical practice, seem to have some positive effects on behavior and outcomes [122,126,127]. Even the ample attention paid to communication skills in general-practice training has hardly any effect at all on clinical communication behavior [85,96]. Furthermore, the effects of patient-physician communication education on consultation outcomes, such as patient satisfaction, understanding, adherence, self-management, and health status, are nearly absent [39,128-131]. Veldhuijzen [14, page 15] therefore concluded that: "These findings points to the sobering conclusion that the vast effort to shape or change how doctors communicate with their patients has in fact been rather ineffective in practice." Apparently, an expert level of communication competency in clinical practice is difficult to attain. The transfer of communication competency, acquired in formal learning conditions, into clinical practice appears to be especially problematic [19,132-134]. The lack of transfer is often attributed to the inhibiting influence of clinical culture and supervisors' rejective behavior [64,135-143]. Continuing positive reinforcement of favorable communication behavior in clinical practice might diminish these negative effects [145]. However, even if the clinical culture supports the performance of learned communication behavior, the transfer of this behavior into clinical practice will not be clear-cut due to case-specificity. Case-specificity means that physicians' individual quality of communication performance varies depending on the content, type, and context of the consultation. Until recently, case-specificity was mainly regarded as an assessment problem, since the case-specific variation in performance jeopardized the assessment reliability and validity. By assessing communication competency in more than one consultation, such as in an Objective Structured Clinical Examination (OSCE), a reliable estimate of a trainee's average communication competency could be obtained. However, in a functional, outcomes-based approach to communication assessment physicians' performance variability should be limited, since a physician should demonstrate superior communication performance in all consultations regardless of the type and complexity of the consultations. Otherwise, performance quality could fall below standard in some consultations, and patients might suffer from physicians' inferior communication performance. Case-specificity implies that a set of generic or transferable communication skills that show a high level of stability and have applicability to a wide range of encounters does not exist. The effect of communication education will therefore be limited if the training is restricted to a predetermined set of skills in standardized and simulated situations. Thus, contextual learning as provided by workplace-based learning is considered essential nowadays for clinical communication

competency development [19,134,142,143]. However, the causes of case-specificity and its effects on physicians' communication behavior and on consultation outcomes have hardly been investigated at all until now