Learning in context: Identifying gaps in research on the transfer of medical communication skills to the clinical workplace
Introduction
There is compelling evidence that communication affects numerous important and meaningful health outcomes, such as adherence to drug regimens and diets, pain control, and improvements in physical, functional, and psychological well-being [1], [2], [3], [4], [5]. Despite the importance of communication, there are frequent reports of low satisfaction with the communication between practicing doctors and their patients [6], [7]. Medical education has recognized the importance of communication skills, as evident from the fact that dedicated training programs have become an integral component of the undergraduate medical curriculum. Paradoxically, however, systematic communication skills training is quite rare during postgraduate training where residents learn in the clinical workplace with day-to-day contacts with patients [8], [9], [10], [11]. This contrasts sharply with research reporting a strong need for communication training at postgraduate level [12]. Rider et al. [13] for instance showed that less than half of all residents were confident about their more advanced communication skills, such as breaking bad news, dealing with end-of-life issues and communicating with difficult patients and seriously ill children. O’Neill et al. [14] confirmed that residents feel unprepared for the required extent of emotional involvement with patients. There is an unfortunate discrepancy between this obvious need for training and the absence of communication training programs reaching out to high numbers of residents [10], [11]. General practice may be an exception to this situation, since its residency program does pay attention to communication skills on a more regular basis.
Studies on the effectiveness of postgraduate communication training have reported contradictory and variable findings [15], [16], [17], [18], [19], [20], [21]. This suggests that this research area might benefit from a new approach, moving beyond single effectiveness studies to a broader, non-reductionistic view on the issue at hand [18], [22]. This paper is an attempt to develop such a broader view.
The broader view on communication skills training we propose in this review is driven by a main problem in the field: absence of consensus on how to define and capture effectiveness. In fact, effectiveness has been defined in numerous ways by many different theorists and researchers. Well-known in this regard are the four levels of evaluation developed by Kirkpatrick (Fig. 1) [23].
In recent years however the suitability of Kirkpatrick's levels to evaluate the effectiveness of interventions has been questioned [24], [25], [26], [27]. The main critique is that it involves many implicit assumptions [26], masking underlying mechanisms and causal relationships between the intervention and its outcomes [25]. Besides, organizations prefer to measure the first two levels rather than the last two, which are harder to measure [24]. Levels three and four are however most interesting to know, since they measure whether real change has occurred due to the intervention. Looking at effectiveness of communication skills, what we are striving for is an observable change in the communication behavior of clinicians in their daily practice. Hawken [28] defines this as transfer of communication skills from training to daily practice, equaling level three of Kirkpatrick.
If we want to increase this transfer or transition in communication skills, much is to be gained by more clarity about the underlying assumptions of what makes learning and transfer effective.
The objective of this article therefore is to identify gaps in the literature on effectiveness of postgraduate communication skills training and discuss relevant theories and insights in the literature on transfer and learning, to gain more clarity about underlying principles and to guide future research. In order to do so, relevant literature will be reviewed.
More specifically, the following research questions will guide and structure this article:
- 1.
Which gaps can be identified in the research on effectiveness of postgraduate communication skills training?
- 2.
Which relevant insights can be identified in the research on transfer of training and theories on learning, to guide future research in the field of postgraduate communication skills training?
We present the results in a narrative review as this format seems particularly suited to comparing and interpreting complex, multi-faceted concepts and findings [29].
Section snippets
Literature search
In this narrative review we present and interpret general findings on medical communication skills training and transfer of training and learning, combining different perspectives. We searched for literature studies, systematic reviews, and empirical studies on the subjects “medical communication skills (training)” and “transfer of training and learning”. The following keywords were used to search Pubmed, GoogleScholar, Cochrane database, and Web of Science: “medical communication skills”,
Gaps in the research evidence on postgraduate medical communication skills training
Since the vast majority of the papers addressed more than one of the gaps described below, no precise number of papers in each of these categories can be provided. However, the gaps are presented in the order of ‘most often mentioned’ to ‘least often mentioned’, where ‘most often’ indicates that more than half of the papers addressed this gap, and ‘least often’ still means that about one third of the papers discussed the issue.
Discussion
Most studies on effectiveness and transfer of medical communication skills examine the extent to which communication skills – learned off the job – are transferred to the clinical workplace. This way of looking at learning and transfer fits more the traditional view of learning. This view may not be sufficient to understand the mechanisms underlying the learning and transition of communication skills for clinicians. A broader, more contemporary view on learning and transfer views effectiveness
Conflict of interest
The authors have no conflict of interest.
Role of funding
The authors did not receive any funding for conducting this narrative review or for the preparation of this manuscript.
References (83)
- et al.
Doctor-patient communication: a review of the literature
Soc Sci Med
(1995) - et al.
How does communication heal? Pathways linking clinician–patient communication to health outcomes
Patient Educ Couns
(2009) - et al.
The value of training in communication skills for continuing medical education
Patient Educ Couns
(2011) Clinical communication training in continuing medical education: possible, do-able and done?
Patient Educ Couns
(2011)- et al.
Effective training strategies for teaching communication skills to physicians: an overview of systematic reviews
Patient Educ Couns
(2011) - et al.
Helping cancer patients disclose their concerns
Eur J Cancer
(1996) - et al.
Effects of gynaecological education on interpersonal communication skills
Br J Obstet Gynaecol
(2001) Patient-centredness
Patient Educ Couns
(2003)- et al.
Communication in context: new directions in communication research
Patient Educ Couns
(2003) A critical analysis of evaluation practice: the Kirkpatrick model and the principle of beneficence
Eval Program Plann
(2004)
Transfer of communication skills training from workshop to workplace: the impact of clinical supervision
Patient Educ Couns
Vocational trainees’ views and experiences regarding the learning and teaching of communication skills in general practice
Patient Educ Couns
Endpoints in medical communication research, proposing a framework of functions and outcomes
Patient Educ Couns
Improving patient education by an in-service communication training for health care providers at a cancer ward: communication climate, patient satisfaction and the need of lasting implementation
Patient Educ Couns
From best evidence to best practice: effective implementation of change in patients’ care
Lancet
Shared decision-making in the Netherlands-current state and future perspectives
Ger J Qual Health Care
Studies of expansive learning: foundations, findings and future challenges
Educ Res Rev
From context to contextualizing
Learn Instr
Are physicians’ attitudes of respect accurately perceived by patients and associated with more positive communication behaviors?
Patient Educ Couns
Assessing the effects of physician–patient interactions on the outcomes of chronic disease
Med Care
Effective physician–patient communication and health outcomes: a review
Can Med Assoc J
Teaching and learning communication skills in medicine
Factors affecting patient and clinician satisfaction with the clinical consultation: can communication skills training for clinicians improve satisfaction?
Psycho-oncology
Enduring impact of communication skills training: results of a 12-month follow-up
Br J Cancer
Transfer of communication skills to the workplace during clinical rounds: impact of a program for residents
PLoS One
Faculty development to change the paradigm of communication skills teaching in oncology
J Clin Oncol
Pediatric residents’ perceptions of communication competencies: implications for teaching
Med Teach
Does a new undergraduate curriculum based on tomorrow's doctors prepare house officers better for their first post? A qualitative study of the views of pre-registration house officers using critical incidents
Med Educ
Teaching clinically experienced physicians communication skills. A review of evaluation studies
Med Educ
Creativity in clinical communication: from communication skills to skilled communication
Med Educ
Effects of continuing paediatric education in interpersonal communication skills
Eur J Pediatr
Evaluating training programs: the four levels
Transfer of training: a review and new insights
Int J Manage Rev
The flawed four-level evaluation model
Hum Resour Dev Quart
Kirkpatrick's levels and education evidence
Med Educ
Good communication skills: benefits for doctors and patients
N Z Fam Pract
Balancing the strengths of systematic and narrative reviews
Hum Reprod Update
The efficacy of the mind map’ study technique
Med Educ
Effects of continuing medical education on improving physician clinical care and patient health: a review of systematic reviews
Int J Technol Assess Health Care
De schoen wringt, maar waar? Discrepanties tussen het trainen, evalueren en praktiseren van consultvoeringsvaardigheden
Huisarts en Wetenschap
Cited by (71)
Translating knowledge into practice for communication skills training for health care professionals
2022, Patient Education and CounselingCitation Excerpt :The systematic and sustained implementation of evidence-based communication training in clinical practice as a part of the continuing professional development in health care is still quite rare [1–5].
Decision making at extreme prematurity: Innovation in clinician education
2022, Seminars in PerinatologyIdentifying residents’ educational needs to optimising postgraduate medical education about shared decision-making
2022, Patient Education and CounselingLarge-scale communication skills trainings – how clinical institutions manage change
2021, Patient Education and Counseling