Rationale and Objectives
Effective communication is essential for high quality care, yet little is known about radiologists’ communication with patients, what constitutes “best communication practices,” and how best to teach and evaluate it. We piloted educational strategies and an assessment instrument to teach and evaluate radiologists’ communication skills. We focused on communication in the diagnostic mammography suite, where patient–radiologist interactions are often intense and stressful.
Materials and Methods
We adapted existing instruments to create a Radiology Communication Skills Assessment Tool (RCSAT). We piloted an educational program that included patients as teachers and raters of interpersonal and communication skills, and implemented a radiology objective structured clinical examination (OSCE). We measured radiology residents’ self-assessed skills, confidence and stress, as well as patient-rated communication skills using the RCSAT.
Results
Residents’ baseline self-assessed communication skills regarding abnormal mammograms were fair, confidence in their communication was minimal, and they found this communication stressful. Overall baseline communication skills, rated by patient–teachers using the RCSAT, were 3.62 on a 5-point scale (1 = poor to 5 = excellent). Analysis of post-OSCE debriefing comments yielded nine themes regarding effective radiology communication, as well as residents’ reflections on the communication challenges they experience. The themes were integrated into subsequent RCSAT revisions. Residents’ reflections were used to inform teaching workshops.
Conclusion
Educational curricula on communication about difficult information can be implemented in radiology training programs. Radiology residents’ performance can be assessed using a communication skills assessment tool during standardized patient–teacher encounters. Further research is necessary in this important domain.
Effective communication is an essential component of high-quality, safe patient care. The importance of communication is recognized by the public and by new standards for professional licensure and postgraduate program accreditation ( ). Effective communication in the primary care disciplines has been shown to improve clinical outcomes and patient and physician satisfaction and reduce malpractice suits ( ). Educational interventions in primary care have significantly altered the process of interpersonal interactions with positive effects on objective (e.g., blood pressure, hemoglobin A1c [Hb A1c ]) and subjective (e.g., illness experience, patient satisfaction) health outcomes ( ).
Radiologists must communicate abnormal or uncertain mammographic findings to women, shepherd patients through complex interventions, and communicate with technologists and other health care providers to ensure coordinated care. Little is known, however, about the nature and impact of the process of communication among radiologists, other health professionals, and patients. Radiologist−patient communication challenges are heightened by the absence of previous or ongoing relationships and the short amount of time available to develop rapport. Despite the importance and challenges inherent in radiologist communication with patients, more radiologists than other specialists in one survey (80% vs. 47%, P < .001) reported feeling insufficiently trained in communication skills ( ). Radiology residents and faculty have expressed interest in enhancing their communication and interpersonal interactions ( ).
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Materials and methods
Radiology Communication Skills Assessment Tool Development
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Patient-Teacher Development
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Radiology Simulation: The Objective Structured Clinical Examination
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Educational Strategies
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Participants
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Evaluation
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Results
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Table 1
Average OSCE Scores (n = 9)
Overall Case A Case B STS 3.83 3.67 4.00 UPP 3.22 3.00 3.44 SI 3.61 3.44 3.78 RA 3.67 3.78 3.56 PC 3.25 2.75 4.00 MF 3.89 3.44 4.33 BR 3.69 3.38 3.89
BR = builds the relationship; MF = manages the flow; PC = provides closure; RA = reaches agreement; SI = shares information; STS = sets the stage; UPP= understands the patient’s perspective.
Likert ratings: 1 (poor); 2 (fair); 3 (good); 4 (very good); 5 (excellent).
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Table 2
Participant Suggestions for Effective Communication: Post-OSCE Debriefing Session
Preparation: • Be prepared with factual data. • Try to imagine yourself in that person’s shoes. • Be aware of your own reactions.Set-up: • Introduce yourself and your role. • Apologize if there’s been a wait. • Professional hand shake.Nonverbal behaviors: • Eye contact. • Maintain appropriate personal space. • Respond to nonverbal clues. • Open, receptive body language. • Calm demeanor.Elicit information about patient’s understanding and emotional state: • Use open-ended questions. • Active listening. • Ask questions to elicit patient’s understanding of procedures or what’s been said. • Give patient space to deal with the information, respond and question. • Determine what patient wants and needs. • Ongoing gauge of patient’s emotions as you’re sharing information.Understand the patient’s context: • Pay attention to contextual circumstances, e.g., family history. • Ask about why they feel the way they do.Respond to patient’s emotional state: • Acknowledge feelings and concerns. • Respectful, nonjudgmental attitude. • Ask about or offer support.Provide information: • Give correct information in language patient can understand. • Avoid euphemisms. • “Realistic optimism.”Decision-making: • Explain options, their advantages and disadvantages. • Make recommendations. • Ask for patient’s input in decision-making process. • Talk about time-frame patient has for making decisions. • If several step process, encourage taking one step at a time.Planning: • Be explicit about next steps. • Be explicit about the follow-up communication plan. • If patient plans to seek second opinion, ask to be informed about who will follow the patient.
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Discussion
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Acknowledgments
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Appendix I
Case Information for Patient-Teachers
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Rachel G. is sitting in the office waiting for the radiologist after having a mammogram. She knows something is wrong because the technician asked her to wait while she got the radiologist. She is visibly upset and tearful with tissues in hand.
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Clair M. is a single, 58-year-old physics professor. Clair undergoes screening mammography every 4 years because she does not believe there is solid evidence to support current screening recommendations and prefers to avoid the radiation exposure. The day after this year’s screening mammogram, Clair received a call from the mammography center asking her to return for extra mammographic views. The screening mammogram revealed a questionable developing density in the outer aspect of the right breast seen only in one view.
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Appendix II
Mount Auburn Hospital Radiology Communication Skills Assessment Tool (MAH RCSAT)
MAH RADIOLOGY COMMUNICATION SKILLS ASSESSMENT TOOLSets the stage: Introduces oneself and one’s role Arranges physical setting to maximize patient’s comfort and privacy Tells patient what to expect before and during interview, exams, proceduresOverall rating 1 (poor) 2 (fair) 3 (good) 4 (very good) 5 (excellent)Comments:Understands the patient’s perspective: Acknowledges patient’s personal or family history as related to current issue Elicits patient’s thoughts and concerns about recommendationsOverall rating 1 (poor) 2 (fair) 3 (good) 4 (very good) 5 (excellent)Comments:Shares Information: Asks about patient’s current understanding of her situation Asks if patient wants detailed statistical information or an overview Provides brief description of test/image interpretation Explains using patient’s preferred approach Uses words patient can understand Explains thought process and findings Offers patient opportunity to see films Describes and explains recommended options/next steps Asks what questions the patient has Avoids premature advice or reassuranceOverall rating 1 (poor) 2 (fair) 3 (good) 4 (very good) 5 (excellent)Comments:Reaches agreement: Reaches agreement about patient’s and physician’s follow-up tasks Asks about barriers to follow-up Identifies additional resources as appropriateOverall rating 1 (poor) 2 (fair) 3 (good) 4 (very good) 5 (excellent)Comments:Provides closure: Summarizes and clarifies follow-up Asks what remaining questions/concerns the patient has Acknowledges the patient and closes the interactionOverall rating 1 (poor) 2 (fair) 3 (good) 4 (very good) 5 (excellent)Comments:Manages the flow: Provides salient information in time allotted Allows patient time to speak, avoids rushing the patientOverall rating 1 (poor) 2 (fair) 3 (good) 4 (very good) 5 (excellent)Comments:Builds the relationship: Greets and shows interest in patient as a person Listens carefully, doesn’t interrupt Uses words and nonverbal behaviors that show care, concern, and respect Avoids words that convey judgment of patient or other healthcare professionals Responds explicitly to patient’s statements & nonverbal clues about ideas & feelingsOverall rating 1 (poor) 2 (fair) 3 (good) 4 (very good) 5 (excellent)Comments:
Descriptors below each heading were derived in part from our work with faculty, residents, and patient focus groups.
The elements “Understands the Patent’s Perspective,” “Shares Information,” “Reaches Agreement,” “Provides Closure, ”Builds the Relationship” are adapted from Essential Elements: The Communication Checklist, ©Bayer–Fetzer Group on Physician–Patient Communication in Medical Education. Essential Elements of Communication in Medical Encounters: The Kalamazoo Consensus Statement. Acad Med 2001; 76:390–393.
The heading “Manage flow” was coined and used with different descriptors by Kalet A, et al. Teaching Communication in Clinical Clerkships: Models from the Macy Initiative in Health Communications. Acad Med 2004; 79:511–520.
The heading “Set the stage” was coined and used with different descriptors by Makoul G. The SEGUE Framework for Teaching and Assessing Communication Skills. Patient Educ Couns 2001; 45:23–34.
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