Introduction of Module-based Training on Communication Skills among Interns in a Tertiary Care Teaching Hospital of Kolkata, India

1. Associate Professor, Department of Community Medicine, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India. 2. Statistician Cum Tutor, Department of Community Medicine, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India. 3. Resident, Department of Community Medicine, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India. 4. Resident, Department of Community Medicine, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India. 5. Resident, Department of Community Medicine, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India. 6. Associate Professor, Department of Community Medicine, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India. 7. Professor, Department of Community Medicine, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India.

Abstract

Introduction: Many of the problems in Indian healthcare settings resulting in mistrust, violence, allegations and litigations against doctors can be solved by effective communication between doctors and patients or their relatives. Interaction of the students as a community physician needs training in communication skills. A structured module-based training on communication skills during internship will help the interns to communicate effectively with patients and their relatives.

Aim: To develop, introduce and evaluate a structured, validated module on communication skills for interns in a Tertiary Care Teaching Hospital of Kolkata, India.

Materials and Methods: A quasi-experimental, prospective, non randomised educational intervention study was conducted in the Department of Community Medicine at Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India, from January to December 2020. A structured and validated module for teaching communication skills to interns was used to train one batch of interns posted (n=40) in the department, over two days. To establish the content validity of the module, the items on content validation were rated on a scale of 1-4 by 10 experts. The validators were asked about their responses favouring face validity of the module and the average of their responses were calculated. Post-training their knowledge, skills and self-reported efficacy were assessed. Feedback from the faculty (n=6), and the interns (n=40) were collected using structured survey forms with likert scale ratings and open-ended questions. The trained cohort of interns was also assessed on communication using the SEGUE (Set the stage, Elicit information, Give information, Understand the patient’s perspective, and End the encounter) Framework during patient encounter.

Results: Post-training knowledge score (16.68±2.5) was significantly higher than the pretraining score (15.45±2.9). Also, there was significant increase in self-assessed knowledge (11.08±3.7 and 17.23±3.3) and skills (9.60±4.6 and 16±2.9) before and after the training. All the interns had positive attitude towards communication skill on the Communication Skills Assessment Scale (CSAS). The mean score of interns on assessment using the SEGUE framework was 16.6±3.59. The satisfaction index of the items on the feedback survey obtained from interns ranged from 82.5% to 93%. There was 100% agreement by the faculty on the relevance, usefulness and use of the module by other departments for communication skill training. More faculty involvement and more such sessions were suggested by both groups as evident from thematic analysis of open-ended responses to the feedback questsions.

Conclusion: The development and delivery of a structured training module on communication skills for interns improved the knowledge and skills of the interns. Both the faculty and the interns were satisfied with the module.

Attitude, Doctor, Faculty, Feedback, Internship, Patient, Satisfaction, Self-reported efficacy

Communication is a two way process of exchanging ideas, feelings and information. It is necessary to pave way for desired change in human behaviour (1). Many problems in Indian healthcare settings occur due to lack of effective communication between doctors and patients or their relatives. This often results in mistrust, violence and allegations, and litigations against doctors. Patients expect politeness, empathy and human touch from doctors. Some of the barriers to good communication include use of medical terminology, communicating in a language that is difficult for the patient to follow, cultural insensitivity, arrogance, telephone calls, inadequate time given to the doctor-patient encounter, and interrupting the patient frequently while the patient is narrating his/her problems (2),(3),(4).

Traditionally, medical students have been learning some basic communication skills consciously or subconsciously by merely observing their teachers; however, these are unstructured, not uniform across all batches of Indian Medical Graduates (IMG) and largely inadequate to exhibit good communication skills in their professional careers (5). Another problem encountered in teaching interpersonal interactions in clinical settings is that teachers may display both positive and negative role model behaviours. These unspoken messages form part of the “hidden curriculum” and influence the behaviour of the learners (6),(7). Physicians, apart from being clinicians, must be good communicators as the very basis of doctor-patient relationship is formed on communication skill of the doctor. The acquisition of communication and interpersonal skills is recognised and documented as a core competency for physician training in many countries (8),(9),(10).

The revised regulations on Graduate Medical Education (GME)-2019 envision the IMG as a doctor of first contact of the community who possesses requisite knowledge, skills, attitudes, values and responsiveness. This requires development of competencies in the domain of knowledge, skill, attitude and communication and their reflection in daily practice for the benefit of the individual and community being served. The vision 2015 document of the MCI mentions the need to schedule dedicated time for training in communication skills for IMG (11).

In India, while this is included as a requirement in the 1997 GME regulations of the Medical Council of India (MCI), undergraduates are not being taught or assessed in most medical colleges (12). Due to this, Indian medical students often have less than adequate communication skills. In the present study institution too, there is currently lack of any structured communication skills training program for the interns. A medical student is exposed to patient care after completing all the professional examinations during internship for the first time. The communication skills of the nascent IMG are put to maximum testing during this period as he/she is exposed to patients and patients’ relatives in the hospital. So, this education innovation project was undertaken to develop and implement a structured module on communication skill training for interns.

The study hypothesised that a structured module-based training on communication skills during internship will train the interns to communicate effectively with patients and their relatives. The primary aim of the study was to develop, introduce and evaluate a structured, validated module on communication skills for interns.

Material and Methods

A quasi-experimental, prospective, non randomised educational intervention study was conducted in the Department of Community Medicine, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India, from January to December 2020. The batch of interns posted in the department during July to September 2020 were included in the study. Permission to conduct the study was obtained from Ethics Committee of Institute of Post Graduate Medical Education and Research, Kolkata. Informed consent form was prepared according to the requirement of the Ethics Committee and submitted. Informed written consent was obtained from the participants prior to the study. Complete enumeration was done. Total 40 interns and six faculty of the Department participated in the study.

Inclusion and Exclusion criteria: All interns who gave written consent to participate were included and those who were absent on either day of the training were excluded from the study.

Study Procedure

A module for training interns on communication skill for a total duration of six hours (two training sessions of three hours each spread over two days) was developed and validated by the faculty of the department. A core committee comprising of three faculties from the Department of Community Medicine was formed to develop the training module for interns on communication skills. This was followed by internal validation of the module by the core committee members as well as by the other faculties of the department and compilation was done by the main researcher. The final module was sent to ten experts outside the institution for external validation. The basic goal of this module was to develop the communication skills of interns so that they would be able to communicate effectively with patients and their relatives. The module was suitable for training interns on communication skills before they start their internship in batches. The competencies addressed by the module included ability to communicate adequately, sensitively, effectively and respectfully with patients in a language that the patient understands and in a manner that will improve patient satisfaction and healthcare outcomes; ability to establish professional relationships with patients and families that are positive, understanding, humane, ethical, empathetic, and trustworthy; ability to communicate with patients in a manner respectful of patient’s preferences, values, prior experience, beliefs, confidentiality and privacy and ability to communicate with patients, colleagues and families in a manner that encourages participation and shared decision making.

Data collection tools: The data collection tools included module validation forms, pre/post-training knowledge assessment questionnaire, self-efficacy questionnaire for interns and feedback questionnaires for faculty and interns as well as Communication Skill Assessment scale (CSAS) (13). The CSAS is a validated tool consisting of two subscales:

• The Positive Attitude Scale (PAS) and
• Negative Attitude Scale (NAS).

Each of these has 13 items, accompanied by a 5-point Likert scale ranging from ‘strongly agree’ to ‘strongly disagree’. The score for each scale ranges from 13-65, with higher scores indicating stronger positive or negative attitudes towards communication skills learning. The items in the scale have got good internal consistency (Cronbach’s alpha: 0.80) and satisfactory test-retest reliability.

Conducting the training workshop: The batch of interns were informed regarding the time, venue and duration of the training sessions when they reported for joining the department at the beginning of their posting, through WhatsApp. On the first day of the training workshop, pretesting of knowledge of interns regarding communication was done using the pre/post-training knowledge assessment questionnaire before beginning the training. The attitude towards communication was assessed using CSAS. Subsequently the interns were trained using the training module and appropriate TL method for two days.

Assessment of the interns: On completion of the training, knowledge of the trained interns regarding communication skills was assessed using the same pre/post-training knowledge assessment questionnaire. Feedback was obtained from the interns as well as the faculty using predesigned and pretested survey questionnaire. The trained cohort of interns was observed at the time of community medicine posting by the faculty members using the SEGUE framework during patient encounter in Outpatient Department (OPD) (14). Self-perceived improvement in knowledge and skills was recorded using predesigned and pretested questionnaire four weeks after the training.

SEGUE framework: The SEGUE framework contains 25 items divided into five content areas (set the stage; elicit information; give information; understand the patient’s perspective; and end the encounter). Total 17 of the items focus on the content. These tasks include topics to be covered or behaviours to be enacted at least once during the encounter. Each of these items is coded “YES” if the topic is covered/behaviour enacted at least once during the encounter. It is coded “NO” if it does not happen at all. The other 8 items focus on process. These are communication behaviours that should be maintained throughout the encounter. Thus each of the process oriented items is coded “NO” if the behaviour is not enacted once during the encounter.

Feedback: Feedback from interns and faculty of the Department of Community Medicine (n=6) regarding the training program was collected using validated questionnaire.

Outcome measures of the intervention:

1. A structured module for training of interns on communication skills was developed.
2. Face and content validity of the module was established.
3. Attitude of interns towards communication skills was assessed.
4. Knowledge of interns regarding communication improved after training using the module.
5. Self-perceived knowledge and skills regarding communication improved after delivery of the module.
6. Faculties were satisfied with the delivery of module based communication skills training.
7. Interns were satisfied with the training on communication skills.

Statistical Analysis

Data collected was entered in MS Excel and analysed using Statistical Package for the Social Sciences (SPSS) version 25.0. Median of pre and post-training knowledge and self-assessment scores was determined and compared using Wilcoxon-signed rank test. Agreement on CSAS was determined. The summary scores for assessment using the SEGUE Framework were generated by assigning a value of “1” to “YES” and “0” to “NO” for each item. Mean±SD scores were calculated. Descriptive statistics was used to present the data. A p-value of <0.05 was considered to be significant.

Results

A. Analysis of Quantitative Data

Mean pretraining and post-training knowledge scores were calculated (Table/Fig 1). Post-training knowledge score (16.68±2.5) was significantly higher than pretraining knowledge score (15.45±2.9, p-value <0.002). Also, there was significant difference in self-assessed knowledge and skills regarding communication before and after the training workshop (p<0.05).

On the PAS of CSAS all the interns agreed to the fact that “learning communication skills has helped or will help facilitate team-working skills” and “learning communication skills is important because ability to communicate is a lifelong skill” while least number (70%) of interns agreed upon the fact “learning communication skills is fun. Majority of the interns (95%) disagreed on the statement “I can not see the point in learning communication skills” while over 30% agreed to the fact that “learning communication skills was too easy” and “ability to pass exams will get me through medical school rather than my ability to communicate” on NAS of CSAS. There was 100% agreement on PAS (62.5% strongly agreed while 37.5% agreed to PAS). A 65% interns had disagreement towards negative attitude (Table/Fig 2). The (Table/Fig 3) shows the mean score (16.6±3.59) of interns on post-training assessment using the SEGUE framework was.

There was 100% agreements (agree or strongly agree) on the relevance of the topics covered in the module by the interns, while 95% felt that the module achieved the learning objectives. 95% of the interns agreed on the fact that the TL methods used as well as delivery of the module by the faculty made the sessions effective. Majority (95%) of the interns felt that the training led to the improvement of their knowledge, rapport building and information eliciting capacity. However, a little above 30% were neutral on their ability to communicate effectively with patients after the training. An 80% of the interns felt adequate time was allotted for the training, while 77.5% demanded more such training sessions. The satisfaction index of the items ranged from 82.5% to 93% (Table/Fig 4).

There was 100% agreement by the faculty on the relevance, usefulness and use of the module by other departments for communication skill training. However, two out of six faculties disagreed to the adequacy of time for training. One faculty disagreed to the fact that interns will be able to use the SEGUE framework while communicating with patients, while two others remained neutral. Faculty satisfaction index (96.7) was maximum for the item “The training module will be useful for interns to communicate effectively with patients/patients’ relatives” (Table/Fig 5). A 92.5% of the interns and 100% of the faculty were overall satisfied with the training program.

B. Analysis of Qualitative Data

The themes generated from the feedback of interns and faculty were topics covered during the training which were found useful, aspects of the Training which were liked and what else could have been included in the training or suggestions for improvement (Table/Fig 6), (Table/Fig 7). The topics considered useful by both faculty and the interns included “breaking bad news, doctor-patient relationship and basic counseling”. Aspects of the program liked by both the groups were coverage of relevant topics, use of role plays and skills training. More faculty involvement and more such sessions were suggested by both groups (Table/Fig 8).

Discussion

Better patient compliance, better health outcomes, decreased litigation, and higher satisfaction both for doctors and patients are the rewards of good communication practice. Communication skill training during the formative years is challenging and can be achieved more readily during internship allowing students and faculty to see their relevance (15). More recently, the Attitude, Ethics and Communication (AETCOM) module has also identified the competencies like doctor-patients communication including counseling, breaking bad news, health education to be delivered during final years and internship (16). Realising the need for teaching communication skills to the interns, a structured module was developed and validated by the faculty of the Department of Community Medicine, Institute of Post Graduate Medical Education and Research, Kolkata, India. The module was delivered over a period of two days. The findings of the current study are similar to a study by Brahmbhatt K and Lodhiya K, (2019) in the Department of Community Medicine of a medical college of Junagadh, India, who reported a significant improvement in self-assessment of communication competence by third MBBS students after training (17). A study by Hausberg MC et al., also reported significant improvement in pre and post-training communication skills through self-assessments by psychosocial medicine students, which is similar to the present study (18). Results of a study by Tanwani R et al., among second year MBBS students reported that 96.43% of the students agreed that a course on special basic communication skills training had improved their communication skills with the patients (19). Similar findings were observed by Jagzape TB et al., in their observational study which reported a 78.46% improvement in communication skills experienced by the students (20). The current study found that 95% of the interns felt the training led to the improvement of their knowledge, rapport building and information eliciting capacity. A study by Wagner PJ et al., stated that students have reported increased confidence in their interviewing skills and clinical preceptors have reported increased levels of preparedness among students who have participated in the structured skill-based training on communication (21).

Attitude towards communication skill was assessed using CSAS. There was 100% agreement on PAS (62.5% strongly agreed while 37.5% agreed to PAS). On NAS 30% of the interns reported negative attitude, while 5% were neutral. A study by Choudhary A and Gupta V, among final year MBBS students using CSAS found that a total of 78.1% had a positive attitude toward learning communications skills, 11.3% students displayed negative attitude, and 10.6% were neutral (22). A study by Alofisan T et al., using a self-administered questionnaire developed by Harvard University for assessing attitude towards communication reported that 85% of senior level residents and 65% of junior level residents believed that learning communication skill was important, whereas in the current study 70% of the interns reported that “learning communication skills is important because ability to communicate is a lifelong skill” (23). The present study found that 92.5% of the interns and 100% of the faculty were overall satisfied with the training program, which was similar to a study by Choudhary A and Gupta V, where 90% of the students were satisfied with a teaching program on communication (22). In response to open-ended questions on feedback form, both the interns as well as the faculty liked the use of role plays for teaching communication skills. For communication skills training, instructional methods such as lectures and seminars are less effective than experiential methods supplemented with feedback (15),(24). Methods like role plays, or interaction with simulated and real patients are preferred by students as they help in reinforcing strengths and identifying weaknesses in the component skills of communication (25),(26). In the present study, the interns also requested more training time, follow-up sessions and more such programs emphasising the fact that communication skills are best learnt when taught as part of a longitudinal teaching plan rather than single occasion training (27),(28),(29). A study by Tanwani R et al., also echoed similar findings (19).

A study by Towle A and Hoffman J, found that students rated an advanced course on communication skill training highly (30). The relevance of the weekly themes was rated 4.21 on a five-point scale. The effectiveness of the SP interviews was rated 4.10 while the effectiveness of the group discussion and feedback was rated 4.18. The overall course effectiveness in enhancing communication skills was rated as 3.91.

The interns were assessed post-training using the SEGUE framework. The mean post-training score of interns was 16.6±3.59, which was similar to the findings reported by Brahmbhatt K and Lodhiya K (17). The later found the mean post-training communication skills assessment score of 16.1±2.87.

Thus, this curriculum innovation project led the researchers to develop, validate and deliver a structured module for training of interns on communication with improvement in knowledge and skills of the interns after the training.

Limitation(s)

This study was not a randomised control study. Only one batch of interns could be trained and assessed during the study period. The pretraining communication skills of the interns could not be assessed due to time and faculty constraints.

Conclusion

A structured module for communication skills training for interns was developed and validated. There was significant improvement in knowledge and skills of the interns regarding communication after delivery of the module. Both the interns as well as the faculty were satisfied with the implementation of the module.

Structured module based training on communication will lead to improvement of the communication skills of the interns. The module can be used to teach communication skills as a part of training in AETCOM. This will help the IMG to be competent in communication skills and thus lead to better doctor-patient relationship, lesser incidents of conflicts and violence and better utilisation of health services.

DOI and Others

DOI: 10.7860/JCDR/2022/52388.16110

Date of Submission: Sep 14, 2021
Date of Peer Review: Nov 17, 2021
Date of Acceptance: Dec 21, 2021
Date of Publishing: Mar 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS: [Jain H et al.]
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