Conceptual
Framework
Interpersonal Skills Training
“Though affiliation and control have been operationalized in varying ways in past research, many studies have found a positive relationship between physicians who adopt a warm interpersonal style and patient satisfaction, compliance, and salubrious medical outcomes” (Jordan & Foster, 2016, p. 1011).
Being in a role: A teaching innovation to enhance empathic communication skills in medical students
A quasi-experimental design study that uses interpersonal skills training and a common measurement tool, the Jefferson Scale of Physician Empathy was reviewed as the authors felt that participants achieved empathy, “during motivational interviewing and the overall performance of consultation skills” (Lim et al., 2011, p. e664). The main focus of the study is on drama training and learning through role-play that may give students a new perspective and has the possibility to increase empathy. The study included 72 students in a control group and 77 students in an intervention group. All students in the study participated in a Psychological Medicine module in their fifth year at the University of Otago, Wellington School of Medicine and Health Sciences in New Zealand.
The study used the Jefferson Scale of Physician Empathy as well as the Objective Structured Clinical Examination (OSCE). The OSCE was used to measure clinical competency skills. It is a required examination that is controlled with variables and complexities outlined. It is also a very common exam and used in many medical schools. The intervention was conducted by, “a theatre skills tutor and is a brief introduction to some acting skills and methods that focused on enhancing the participants’ capacity to connect with their patients, listen to what they are saying, observe their body language, pick up interpersonal cues, and improve their interpersonal and interactive skills” (Lim et al., 2011, p. e665). “The student is given a brief introductory note outlining the clinical scenario and the task expected of them” (Lim et al., 2011, p. e665) then an examiner uses a structured marking sheet. Usually the examiners consist of physicians and residents, but for this study, the students also completed a self-assessment by viewing video recordings of their approach to the clinical scenario.
In addition to the Jefferson Scale of Physician Empathy, the students medical competence in their behaviour change during a consultation was surveyed. “All students were asked to self-mark their OSCE clinical performance and use the Behaviour Change Counselling Index tool, self-grading attitudinal attributes empathy and consultation skills” (Lim et al., 2011, p. e665). The results were significantly higher for the students in the intervention group for the Jefferson Scale of Physician Empathy and the Behaviour Change Counseling Index. Additionally, “tutor-rated OSCE performance was significantly associated with students’ self-OSCE ratings” (Lim et al., 2011, p. e666) and students in the intervention group had better performance rates than those in the control groups. The, “findings suggest that just 1 hour of the actor-facilitated teaching innovation ‘How to act-in-role’ was effective not only in increasing medical students’ empathy, but also their competence in consultations about behaviour change, indexed in the Behaviour Change Counseling Index scores, as well as the students’ OSCE performance” (Lim et al., 2011, p. e667). I agree that including all three components of the study led to better results.
The discussion of this study was very informative and made several suggestions on additional empathy training. It included some discussion of interprofessional studies including the plan, “to repeat this research with nursing students, clinical psychology trainees, and community based pharmacists” (Lim et al., 2011, p. e667). This study is a good representation of moving towards designing and implementation of enhancing medical students’ learning of empathy. Additionally, Lim et al. (2008) suggest that, “teaching and learning of empathy skills hold great promise for both patient care and health practitioners’ wellbeing” (p. e667). The authors also indicate that physicians must be mindful of interactions with patients and be willing to be flexible, as well as adjust their communication with patients as needed.
Empathy training for resident physicians:
A randomized controlled trial of a neuroscience-informed curriculum.
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A unique approach involving neuroscience as a theoretical framework for interpersonal training of medical trainees was also examined in the literature review. Riess et al., 2012, suggested that, “a decline in empathy may buffer medical residents from the psychological distress from learning to perform painful procedures on patients. However, studies suggest physicians may not rebound from their decline in empathy once they have completed their training” (p. 1280). In order to eliminate the decline of empathy, Riess et al. (2012) indicated that neuroscience may challenge these perspectives and look at the correlation between brain circuits and empathetic behaviours. “The training was designed to improve physician skills in detecting subtle non-verbal signs of emotions, in themselves and in their patients, and to respond in ways that provided support and resolution of communication challenges” (Riess et al., 2012, p. 1281). The goals of the training work to improve awareness of patient communication, respond in an empathetic way, increase awareness and emotion, and use the skills in difficult situations with patients.
The residents and fellows that participated in the study came from a variety of specialities from Massachusetts General Hospital as well as Massachusetts Eye and Ear Infirmary. Patients were asked to rate their interactions with the resident using 10 statements as a measurement. The study included randomization and masking. Physicians were blind on which patients participated in the survey and patients were blind in the physician randomization, except they could identify physicians by photos. The researchers, “used an empathy and relational skills training protocol developed by the Riess and previously tested in a pilot study. The training was comprised of three 60-minute modules spaced over 4 weeks, delivered to groups of 6-15 residents in the same speciality in both inpatient and outpatient settings” (Riess et al., 2012, p. 1281).
One month prior to the training, the patients rated physicians on the Consultation and Relational Empathy (CARE) Measure tool. “The CARE is a 10-item instrument assessing physician empathy and relational skill (sample item: ‘At today’s appointment, how was the doctor at showing care and compassion?’)” (Riess et al., 2012, p. 1282). There was also a variety of other measurement tools including a neurobiology and physiology of empathy test, the Ekman Facial Decoding Test, the Jefferson Scale of Physician Empathy, the Balanced Emotional Empathy Scale and a self-report of questions on attitudes, skills and program evaluation. There was a total of 99 residents and fellows that participated in the training. The results indicated that, “physicians randomly assigned to the training group showed greater improvement on patient ratings of physician empathy (CARE measure) than the control group,” (Riess et al., 2012, p. 1284) who did not participate in the training. The training group also proved to be more knowledgeable in neurobiology and physiology of empathy.
This is the first study to use neurobiology of emotions as an educational intervention for empathy. It also proved to be useful for awareness of emotional states and decoding facial expressions. However, “improvement in self-reported empathy on the Jefferson Empathy Scale was not statistically significantly greater for the training group as compared to control” (Riess et al., 2012, p. 1284), which shows similar results to other studies involving the Jefferson Empathy Scale. The most important take-away message from this study, however, is the suggestion that, “long-lasting improvements in empathic clinical care cannot be sustained without organizational changes at all levels of healthcare” (Reiss et al., 2012, p. 1284).
Benefits of Interpersonal Skills Training
Challenges of Interpersonal Skills Training
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Improvement of communication skills (both verbal and non-verbal)
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Many studies have indicated there is a positive physician/patient relationship when physicians adopt a warm interpersonal style
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In some studies, there was an increase of physician empathy after workshops on interpersonal skills took place
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Can be a unique educational intervention when incorporating both the arts and science
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Time-consuming
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"There has only been one empirical paper using interpersonal theory and its structural component, the Interpersonal Circumplex, to examine interpersonal distinctions and correlates of empathy" (Jordan & Foster, 2016, p. 1010).
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Limited longitudinal studies on interpersonal skills training
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Physicians/medical students must be mindful and flexible as they adjust how they communicate to patients