Original Research Article Panacea Journal of Medical Sciences, January-April,2016;6(1): 20-25 20 Effectiveness of Educational Intervention to Enhance Communication Skills among Interns Rajavel Murugan P.1,*, Padmavathi T2 1Senior Assistant Professor, Dept. of General Medicine, 2Senior Assistant Professor, Dept. of Pharmacology, Government Thoothukudi Medical College, Tamilnadu. *Corresponding Author E-mail: drrajavelmurugan8@gmail.com Abstract Communication skills are required for medical professionals to carry out multiple tasks in their daily practice. An effective doctor-patient communication is vital for satisfying needs and expectations of patients, lack of which leads to conflicts between patients and doctors. This skill is found to be deficient among practitioners and interns as teaching or training on communication skill is not included in the present curriculum. Studies have proved that many educational interventions including interactive workshops can enhance the skills of students in effectively communicating with patients. 25 interns were involved each in study and control groups after obtaining approval from Institutional Ethics Committee. After assessing levels of domains of communication for both groups by questionnaire, Workshop (lecture, video play, small group discussion, role play and feedback) was conducted for the study group for two hours. Assessment was done by OSCE for the study and control group. Prior to intervention, 24% interns had knowledge about communication skills and only 8% felt confident in communication. Comparison of overall scores of Post workshop OSCE between two groups by unpaired t test showed significant difference (p value < 0.0001). Of the 10 variables used in OSCE rating scale, four showed no significance. The levels of knowledge and confidence of interns are low in communicating with patients. Hence intervention like workshop can improve this skill if included in curriculum. Keywords: Communication skill, Interns, OSCE, Workshop. Introduction Communication is the process by which we exchange information between individuals or groups of people and is successful only when both the sender and the receiver understand the same information. Communication skills are required for medical professionals to carry out tasks such as medical interviewing, explaining a diagnosis or prognosis, giving instruction to undergo diagnostic or therapeutic procedures and providing counselling to motivate the patients in the course of treatment. An effective doctor- patient communication is vital for satisfying the needs and expectations of patients, lack of which leads to conflicts between them and doctors. This miscommunication also increases their symptoms of anxiety and depression. Unfortunately, only half of the complaints and concerns of patients are likely to be addressed by the doctors since the practitioners often falter to perceive fully the physical, emotional, and social impact of the problems of the patients. Good communication can influence biological, social and psychological outcomes of a patient such as decrease in the use of analgesics, reduction in the duration of hospital stay and improvement in recovery from any prolonged serious illnesses and surgeries. Moreover, poor communication often results in medical accidents and subsequent litigation. Efficient communication will provide greater job satisfaction, less work stress and will help in accurate identification of the problems of the patients. Hence excellent communication skills are essential for an Indian Medical Graduate to achieve successful medical professionalism(1). However, this skill is found to be deficient among practitioners and interns as the teaching on this skill is not included in the present curriculum(2-3). This knowledge deficiency of interns may be attributed to the fact that interns have never been trained to consult in the general practice setting, and their skills are limited to making value judgements(4). It is also clear that good communication skills in medical practice are not innate, can be learned, and can always be enhanced(5). Our present curriculum pays very little attention to ensure that our graduates acquire skills necessary to effectively communicate with patients. So far, medical graduates acquire communication skills only from hidden curriculum, that too very meagre. Since the ways to accomplish this mission are less defined, it is the responsibility of faculties in medical education to emphasise the importance of communication skill among medical students and to find newer methods to educate them. It is the need of the hour to instigate this into overt curriculum. Recent research has demonst- rated that training in communication skills is both feasible and effective. It should become an integral part of medical education. Studies have proved that educational interventions in the form of interactive workshops, interviews of Simulated Patients, role modelling, role-play, videotape review, and skills practice can enhance the skills of students in communicating with patients(6-7). Though Murugan Rajavel et al. Effectiveness of Educational Intervention to Enhance Communication Skills among…... Panacea Journal of Medical Sciences, January-April,2016;6(1): 20-25 21 many interventions have been proved to be effective individually, being a multimodal intervention, workshop which incorporates most of the teaching methods may enhance the skill still more. Based on this perspective, we intended to study the present level of knowledge and confidence of medical students about communication and the impact of workshop as an educational intervention in augmenting the skill. Material and Methods This prospective, comparative study was conducted in a tertiary care hospital during the month of August 2015 after obtaining approval from Institutional Ethics Committee. Among the 100 students undergoing internship in our hospital, the 25 interns posted in Department of General Medicine were included in the study group and the 25 posted in Department of General Surgery were assigned to the control group. Informed consent was obtained from all of them. A 10 point questionnaire graded by Likert scale was distributed to participants from the study and control groups for pre intervention assessment. Questions were framed giving value to three attributes of communication skill such as knowledge on communication, importance of communication, and confidence in communicating to patients (Table 1). Table 1: Questions in the pre/post questionnaire Sr. No. Questions Domains 1 I know all the steps in communicating with patients Knowledge 2 I introduce myself before starting history 3 I used to listen to what patients say and allow ample time for them to talk 4 I will explain in details pros and cons, necessity, steps of any procedure before doing it. Importance 5 I can build good rapport with patients in OP an IP. 6 I usually give details to patients and relatives about illness 7 I usually prefer to give counselling to patients and relatives about therapeutic options 8 I usually show good empathy to patients of serious illness? Confidence 9 I can handle situation of breaking bad news or DIL to patients or relatives with ease 10 I am confident in obtaining consent from patients or relatives. Source: A S Khan et al (8) The workshop for intervention was designed in multimodal way incorporating a power point lecture, role play, small group discussion based on case scenarios, video play and a open ended feedback(7,9)(Table 2). The session started with power point lecture detailing about Kalamazoo statement and SPIKES protocol on communication(10-11). Slides in power point were designed in accordance with Macy model of Doctor Patient communication. The didactic session was followed by role play depicting good communication between a doctor and patient which is an effective means of acquisition of knowledge of communication skills(6). Then the 25 participants were divided into small groups each comprising of eight and case scenarios expressing faltered communication between doctor and patient were distributed to each group. Time was allowed for discussion on the scenario among group members before presenting their final opinion to the forum. Workshop was completed with videos on effective and bizarre communication between doctor and patient. After the intervention, answers for post intervention questionnaire and written feedback were obtained from all participants of study group. Table 2: Workshop synopsis (2hours) Sr. No. Teaching method Duration 1 Lecture with power point 30 minutes 2 Role play 15 minutes 3 Small group discussion 15 minutes 4 Video play 30 minutes 5 Feedback 30 minutes Several reliable methods have been suggested to assess communication skill. Of all, we thought OSCE can be used effectively in our study, since it is already in use for routine summative evaluation. Even though reliability of global scoring by examiners as observers is debatable, OSCE has been proved to be successful tool in assessing physician – patient communication which is a highly complex process(12). Hence, we subjected the participants of both the groups to assessment by OSCE in the subsequent days following workshop. Other studies have used more number of stations and more than one examiner per station. But, being a pilot study in its aspect, and for the sake of feasibility we decided to have 10 stations of OSCE to evaluate the three domains of communication(7). Murugan Rajavel et al. Effectiveness of Educational Intervention to Enhance Communication Skills among…... Panacea Journal of Medical Sciences, January-April,2016;6(1): 20-25 22 Pre and post intervention questionnaire were analysed by descriptive statistics. The mean of OSCE scores obtained by the participants of both the groups were compared by unpaired student t test. The scores obtained for individual variables in OSCE rating scale were also compared by unpaired student t test. Results On analysing pre intervention questionnaire answered by the participants of study group, it was found that among three attributes stressed, 24% interns agreed that they possess some knowledge on communication, 56% felt the importance and only 8% expressed their confidence in communicating with patients (Table 3). Table 3: Interpretation of pre intervention questionnaire for both groups Measure Agree Not clear Disagree control Study Control Study Control Study Knowledge 5 (20%) 6 (24%) 7 (28%) 8 (32%) 13 (52%) 11 (44%) Importance 16 (64%) 14 (56%) 4 (16%) 5 (20%) 5 (20%) 6 (24%) Confidence 3 (12%) 2 (08%) 5 (20%) 7 (28%) 17 (68%) 16 (64%) Review of post workshop questionnaire revealed that the interns of study group expressed significant increase in their knowledge and confidence on communication skill. Only two of the interns were not clear about the importance of communication skill (Fig. 1). Fig. 1: Comparison of attributes between both groups in Questionnaire analysis On comparing mean OSCE scores obtained by control group (9.8) and study group (14.18), we found significant difference between both the groups (p = 0.001) (Fig. 2). Murugan Rajavel et al. Effectiveness of Educational Intervention to Enhance Communication Skills among…... Panacea Journal of Medical Sciences, January-April,2016;6(1): 20-25 23 Fig. 2: Comparison of Mean score in OSCE between both groups Individual scores obtained for each variable in 10 point rating scale was compared between both groups for significance. Of these 10 variables, except four (highlighted in the table), all others showed significant difference between the groups (Table 4). Table 4: Individual variables in OSCE check list- comparison of performance between study and control groups Sr. No Variable Control Study P value Mean SD Mean SD 1 Introduction of self to patient 0.48 0.71 1.64 0.64 <0.001 2 Consent taken for history taking 0.24 0.44 1 0.5 <0.001 3 Good listener (Didn’t interrupt patients) 1.16 0.55 1.28 0.68 >0.05 4 Understand effect of problem 1.2 0.41 1.56 0.51 <0.05 5 Able to explain diagnosis 1.52 0.51 1.85 0.37 <0.05 6 Communicate to patient about his/her concerns 0.60 0.76 0.88 0.6 >0.05 7 Patients can understand explanation 1.24 0.66 1.6 0.5 <0.05 8 Offer help in a polite way 1.04 0.69 1.25 0.45 >0.05 9 Share decision for management 0.84 0.55 1.12 0.44 >0.05 10 Eye to eye contact 1.36 0.57 1.88 0.33 <0.001 Discussion Though it has long been accepted that communication is of central importance and a core aspect of clinical practice, there is no proper training for students and interns. Since communication skills have not been embedded in the present curriculum, concerns over poor doctor - patient relation is increasing among stakeholders. Communication cannot be taught in one single step but many simple and complex skills like medical interviewing, empathy, breaking bad news, getting informed consent, and dealing with emotions of patients in terminal illnesses. Many of the studies have revealed that intervention like workshop proves to improve communication skill among students and interns. Our study proves that the knowledge level of interns on communication and their confidence in handling difficult situations like breaking bad news and declaring terminal illness are very low. Majority of interns agreed that they do not possess ample knowledge in this skill (76%) and felt poorly confident to deal with bad situations (92%). This fact goes in accordance with revelation of a study by Mohsen Tavakol et al(2) who used CSKS (communication skill knowledge scale) to assess knowledge level of interns about communication skills which was found to be limited. This deficit in knowledge has also been reported by researchers in other countries(11). The knowledge deficiency may be attributed to the fact that students are not properly trained in such skill and they have never been exposed to general practice setting. Our interns who participated in the study did not seem to know the importance of this skill in applying to their practice. Again this may be due to under exposure of interns to complex situations and real life problems which may arise because of lack of communication skill. The interns do not give due importance to this aspect since there is either absence of structured Murugan Rajavel et al. Effectiveness of Educational Intervention to Enhance Communication Skills among…... Panacea Journal of Medical Sciences, January-April,2016;6(1): 20-25 24 curriculum or scarcity of role models practicing good communication with patients. Post intervention questionnaire analysis clearly shows improvement in knowledge, importance and confidence levels of interns in communication. All the interns (100%) of study group reported that their knowledge of communication was very much boosted up after the workshop. They also felt that apart from improving their knowledge, the workshop made them very much confident to effectively communicate with patients. Some interns mentioned role play as very special one since it helped them to sort out so many unanswered questions in facing difficult patient encounters. A study by Majmin Sheikh Hamza et al(12) explained the effectiveness of workshop in improving communication skill among medical students, in which, majority of the students (81.4%) rated the workshop as useful and beneficial and about 84.3% of them rated that the workshop had achieved its objectives. Similarly study by Jong Won Jung et al(13) also concludes that communication skills training for interns facilitates their reflection and development of communication skills, as well as their competency of situational problem solving. A very significant improvement was observed in post graduates, in patient encounters of breaking bad news after communication skill workshop for 4 days in a cohort study by Anthony L. Back et al(14) involving 115 postgraduates. Coinciding with facts of above studies, our studyshows extreme significance in improving the communication skill which is expressed by comparison of overall score obtained in assessment by OSCE between control study groups. The efficacy of intervention like workshop proved by researchers across the world was reiterated in our study as the study group interns scored much higher than those of control group. Though overall score of study group was much higher over score of control group interns, four of ten skills assessed in OSCE such as listening, addressing emotions, politeness and sharing decision in management showed no significance between control and study group. This observation of non-significance of above parameters indirectly means that these four skills are being learnt by interns in hidden curriculum either from their teachers or peers through role modelling. Hence, while planning the module for communication training, other six parameters should be given priority. In the written, open ended feedback, the interns expressed higher interest in looking forward to more workshop in future or regular inclusion in curriculum to make them more comfortable and confident in communicating with patients. Overall, all the interns expressed their willingness to undergo more such workshop since they feel that it certainly will help in their day to day practice. On analysing effect of gender difference on communication skill, male interns scored higher (71%) than female interns (50%) due to unknown reason. One randomised study, two open effect studies and one descriptive study show that females score better than males after a training course in communication skills(9- 11). A recent meta-analysis indicated that female physicians are likely to perform more patient-centred communication behaviours such as collaborative communication, empathic communication and giving psychosocial information(15-16). On contrary, our study expresses preponderance in males who have scored more than 75%. We owe this contradictory finding of this study in gender effect to small number of participants included in the study. The limitations of our study are less number of interns, shorter duration of workshop and single examiner observing all stations per candidate. Conclusion Since levels of knowledge and confidence of interns are low in communicating with patients, intervention targeting affective learning of communica- tion skills, in conjunction with cognitive and behaviour- ral training, need to be developed to help medical students understand the importance of communication and the complexity of communication issues in health care. Intervention like workshop will help medical students to perceive these skills as important and retain knowledge of them. Inclusion of such workshop in curriculum will definitely help all the students to acquire the important competency of communication, a part of professionalism in practice. Conflict of Interest: None Source of Support: Nil References 1. Stern DT. Measuring medical professionalism pp15-39;. 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