Original ReportsCommunication Skills Training in Surgical Residency: A Needs Assessment and Metacognition Analysis of a Difficult Conversation Objective Structured Clinical Examination
Introduction
Medical education is shifting toward outcomes-based assessment of residents and fellows as evidenced by the Next Accreditation System Milestone project developed by the Accreditation Council for Graduate Medical Education (ACGME). Residencies would be asked to evaluate trainees on developmentally based educational achievements in the ACGME core competencies through time.1 General surgery education, similar to general medical education, is adding emphasis on outcomes assessment.2 Obstacles such as resident duty hours and limited protected faculty time for observation and feedback create challenges for residencies in the evaluation of these outcomes. Two of the more challenging competencies to evaluate from an objective, outcomes perspective are Professionalism and Interpersonal and Communication Skills.3 Going forward, general surgery residency programs would need to develop assessment tools to demonstrate resident achievement of educational milestones.
In the past, several studies have evaluated the effect of dedicated curricula using standardized patients (SPs) in surgical training.4, 5, 6, 7 Some studies evaluate broad curricular topics like professionalism and communication.4, 5, 6 Other studies focus on the practice of specific skills such as disclosing operative complications and iatrogenic injury.7 Evidence shows that surgical residents can improve performance skills with SP-based curricula targeting the core competencies of Professionalism And Interpersonal And Communication Skills.4, 5, 6, 7, 8
The objective structured clinical examination (OSCE) is an assessment technique for professional and communication behaviors shown to be valid and reliable in the domains of Professionalism And Interpersonal And Communication Skills.9, 10, 11, 12, 13, 14 The OSCE allows trainees and SPs to evaluate trainee skills based on objective measures such as skill checklists. This is educationally efficient as the checklist serves as both the curricula and the evaluation method. Moreover, the use of SPs frees faculty time for other educational or clinical endeavors. The OSCE is also learner centered as each trainee receives individual feedback on his or her performance. As resident evaluation moves from time based to outcomes based, the OSCE may serve as a helpful evaluation tool for the General Surgery Milestone Project.15
At the University of Pittsburgh Medical Center, general surgery residents participate in a “difficult conversation” OSCE annually. Junior residents (postgraduate year 1-2) and senior residents (≥postgraduate year 3) participate in a 2-station OSCE. The first junior resident stations involve discussing operative risks and benefits (RAB) with a patient who has asymptomatic cholelithiasis and significant medical comorbidities. The second junior station involves breaking bad news (BBN) to a patient with recurrent pancreatic cancer. The first senior resident stations involve discussing goals of care (GOC) with a patient who has a perforated peptic ulcer in the setting of locally advanced pancreatic cancer. The second senior station involves discussing the transition to comfort measures only (CMO) status with two family members of a 91-year-old patient with a large intracranial hemorrhage.
The purpose of this study was to describe performance on the 2-station OSCE by junior residents and senior residents. Results would be used as a needs assessment for a dedicated communication-based skills curriculum to be used in the evaluation of general surgery residents with regard to Professionalism and Interpersonal and Communication Skills. We hypothesized that senior residents would outperform junior residents in the domain of communication.
Section snippets
Methods
This was a prospective study including categorical general surgery residents at the University of Pittsburgh Medical Center. Residents were included if they attended the OSCE and if they completed both level-appropriate cases. This OSCE occurred during scheduled time for weekly teaching conference. Each station of this OSCE was 15 minutes in length. Each resident was given 12 minutes per patient encounter. This was followed by 2 minutes of self-evaluation and 1 minute of tailored feedback by
Results
There were 27 junior residents (age 28.1 ± 1.9 years [30% female]) and 27 senior residents (age 32.1 ± 2.5 years [26% female]) who satisfied the inclusion criteria for this study. The male/female ratio between junior residents and senior residents was the same (p = 0.76).
SP assessment of junior resident performance on the 2-station OSCE is given in Table 1 for the RAB case (Table 1[A]) and the BBN case (Table 1[B]). SP assessment of senior resident performance on the 2-station OSCE is given in
Discussion
This study describes general surgery resident performance on a 2-station “difficult conversation” OSCE in the absence of a dedicated skills-based communication and professionalism curriculum. We found that junior residents and senior residents show a high degree of favorable body language and nonverbal communication skills. This is demonstrated by high percentages of encounters with effective use of eye contact, posture, facial expression, the use of silence, and sitting down when speaking to
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Source of financial support: This study was supported by the Geriatrics for Specialty Residents education grant from the American Geriatrics Society.