Pediatric residents’ perceptions of communication competencies: Implications for teaching

Abstract

Background: Medical regulatory organizations worldwide require competency in communication skills. Pediatric communication competencies are unique, and little is known about pediatric residents’ perceptions regarding these skills.

Aim: The purpose of this study was to examine pediatric residents’ attitudes about communication skills, their perceptions of the importance of learning 15 specific communication skills relevant to pediatrics, confidence in these skills, and relevant program supports.

Methods: We developed a 47-item cross-sectional questionnaire to study pediatric residents’ attitudes and perceptions regarding communication competencies. 104 pediatric housestaff in a university-affiliated program in the US were asked to complete the questionnaire. Scale variables were created and evaluated for reliability. Data were analysed using descriptive and univariate statistics.

Results: Response rate was 86% (89/104). Cronbach's alpha reliabilities of the Importance Scale (r = 0.92) and Confidence Scale (r = 0.90) were excellent. Ninety nine percent of the participants agreed that learning to communicate effectively with patients was a priority. All agreed it is important to demonstrate empathy and caring, and to teach medical students to communicate effectively with patients. Pediatric residents agreed that the 15 communication competencies studied were important to learn. Most reported confidence in core communication competencies (interviewing, listening, building rapport, demonstrating caring and empathy), but only half or fewer were confident in 7 more advanced communication skills (ability to discuss end-of-life issues, speaking with children about serious illness, giving bad news, dealing with the ‘difficult’ patient/parent, cultural awareness/sensitivity, understanding psychosocial aspects, and understanding patients’ perspectives). Few reported the availability of relevant program supports for learning these skills.

Conclusions: Pediatric residents perceive communication competencies as important and a priority for learning, yet report a lack of confidence in advanced communication skills and insufficient program supports. Our measurement scales can add to the evaluation of residency programs, and may provide suggestions for pediatric curricular content in core and advanced communication skills.

Introduction

The delivery of quality health care requires effective physician-patient communication. Evidence-based studies show that good communication and focus on the relationship between patient and physician correlate directly with improved quality of care including symptom improvement (Mumford et al. 1982; Uhlmann et al. 1988; Brody et al. 1989; Stewart 1995; Stewart et al. 2000) increased patient adherence to treatment plans (DiMatteo 2004), better management of chronic conditions (Heisler et al. 2002; Gascon et al. 2004; Cabana et al. 2006), increased patient and physician satisfaction (Flocke et al. 2002; Daghio et al. 2003), and reduced risk of medical errors (Woolf et al. 2004) and malpractice claims (Shapiro et al. 1989; Lester & Smith 1993; Levinson et al. 1997). Physicians’ caring and openness to communication are significant factors in patients’ deciding to continue a relationship with their physician (DiMatteo et al. 1979; Safran et al. 2001). Communication problems in medical care are common (Tates et al. 2002) and may negatively affect patient management and outcomes. Public sector complaints about physicians usually concern communication problems rather than competency issues (Richards 1991), and the majority of malpractice claims arise from communication errors (Beckman et al. 1994).

Increasing emphasis on interpersonal and communication skills at all levels of training is reflected in international guidelines for medical schools [Liaison Committee on Medical Education 1998; Association of American Medical Colleges 1999; General Medical Council 2003; the Association of American Royal College of Physicians and Surgeons of Canada (Frank et al. 2005)], consensus statements (Simpson et al. 1991; Makoul & Schofield 1999; Bayer–Fetzer Conference on Physician–Patient Communication in Medical Education 2001), and certification standards [United States Medical Licensing Examination–USMLE (Klass et al. 1998), Accreditation Council for Graduate Medical Education (ACGME 2001, 2007; Rider et al. 2007), American Board of Medical Specialties and others (Tate et al. 1999)].

Table

Practice points

Medical organizations worldwide require competency in communication skills. Pediatric communication competencies are unique, and little is known about pediatric residents’ attitudes and perceptions regarding these skills. The pediatric residents we studied reported confidence in basic communication skills such as interviewing, listening, building rapport, and demonstrating caring and empathy, yet they lacked confidence in advanced communication competencies relevant to pediatrics including the ability to discuss end-of-life issues, speaking with children about serious illness, giving bad news, dealing with the ‘difficult’ patient or parent, cultural awareness/sensitivity, understanding psychosocial aspects of care, and understanding patients’ perspectives. Our measurement scales may be used to add to the evaluation of the residency program, and may provide suggestions for pediatric curricular content in core and advanced communication skills.

Communication competencies in pediatrics

Pediatric communication competencies are distinct in medicine. Communicating with children and their families is complex, routinely involves the physician-parent-child triad and other family members, and is influenced by the developmental and cognitive stage of the child, interaction dynamics within the family, and differing parent and child needs. Increasingly, children are seen for behavioral, developmental, and psychosocial problems (Kelleher et al. 2000), and the need for skilled communication about these issues is added to communication regarding medical issues, anticipatory guidance, and parent education. The varied needs and perspectives of both children and family members, and the complexity of issues, require physician flexibility and ability to adjust interview and physical examination techniques as needed.

In an early landmark study on physician-patient communication, pediatrician Korsch et al. (1968) described communication lapses in the care of children in an emergency department, and noted that communication is an essential factor in quality of care. Pediatric studies show that effective physician–parent communication is associated with parents'satisfaction with care, enhanced discussion of psychosocial issues (Nobile & Drotar 2003), and adherence to treatment recommendations (Francis et al. 1969; DiMatteo 2004). Parents highly value physicians who seek to understand their perspective, who pay adequate attention to their concerns regarding their child's illness (Korsch & Negrete 1972), and who attend to both their and their child's feelings and concerns (Street 1991). Greater parent satisfaction with care is also positively associated with more active communication between physician and child, and parents’ perceptions of the physicians’ interpersonal sensitivity, partnership building, and ability to provide information (Street 1991).

Teaching and assessing communication skills

The Accreditation Council for Graduate Medical Education (ACGME) in the United States, and similar organizations worldwide, require residency programs to teach and assess residents’ interpersonal and communication skills. An international expert consensus group of medical education leaders further defined and expanded the ACGME interpersonal and communication skills competencies, and developed a teaching toolbox for communication competencies at all levels of medical training (Rider & Keefer 2006). The Academic Pediatric Association (formerly the Ambulatory Pediatric Association), with help from numerous pediatric experts, developed adaptable guidelines for education in pediatric residencies (Kittredge et al. 2004) and included communication skills in these guidelines.

A variety of communication models have been developed and can be learned (Rider 2007). Examples of models used to teach and assess communication competencies include: the Kalamazoo Consensus Statement framework (Bayer-Fetzer Conference on Physician-Patient Communication in Medical Education 2001), The Four Habits Model (Stein et al. 2005), The Calgary-Cambridge Guides (Kurtz et al. 2005), the 5-Step Patient-Centered Interviewing Model (Smith 2002), the Patient-Centered Clinical Method (Stewart et al. 2003), and a number of others (Rider 2007, 2008). These evidence-based models are similar as they derive from the same literature, and include specific communication competencies associated with improved health outcomes.

The models and conceptual frameworks described above incorporate basic interpersonal and communication skills competencies and relational capacities that can be applied to all specialties and settings. The pediatric interview and communication between child, adolescent, parents/caretakers, and pediatrician remain unique. While we can identify general communication skills competencies to teach and how to teach them (Rider & Keefer 2006; Rider 2007), little evidence exists as to which skills are most important for pediatric residents to learn and what content areas should receive emphasis in the curriculum.

Little is known about pediatric residents' attitudes and perceptions about communication skills during their residency, which content areas deserve primary focus for teaching, or the system supports that are needed in pediatric residency programs for developing these skills. Scant literature exists on these topics in pediatrics. Werner et al. (1979) found that pediatric interns at a high-pressure tertiary care hospital felt more confident about their interpersonal than technical skills. By the end of their internship they perceived the physician-patient relationship and psychosocial factors as less important for effective patient care. Many of the interns studied found faculty and hospital support insufficient.

Residents’ self-efficacy or confidence in successfully using communication skills is important, because high self-efficacy is related to successful use of skills (Smith et al. 1995). Studies show that confidence to perform successfully predicts the use of new skills (Bandura 1983) and actual performance, and that self-efficacy is relevant to medical education (Tresolini & Stritter 1994). Our objective was to examine pediatric residents’ (a) attitudes concerning communication skills, (b) perceptions of the importance of developing communication skills, (c) confidence in their own communication skills, and (d) system supports in the pediatric residency program that are relevant to learning and maintaining these skills.

Methods

Study design

This cross-sectional study incorporated a 47-item written questionnaire about pediatric residents’ perceptions, attitudes, and confidence regarding communication skills, and program supports relevant to learning and maintaining these skills.

Sample

The sample included all 104 pediatric housestaff who were in postgraduate years (PGY) 1, 2 and 3 in a large, university-affiliated pediatric residency program situated in a children's hospital in the Eastern United States. Medicine-pediatric residents were excluded.

Questionnaire

We developed a written questionnaire to examine residents’ attitudes and perceptions about interpersonal and communication skills. The 47-item questionnaire was designed based on a literature review and previous surveys (Merkel et al. 1990; Rosenzweig 1991; Novack et al. 1993), and survey items were reviewed by a group of experts for face validity. Representative questionnaire items and characteristics of the questionnaire are presented in Table 1. Additional question topics are listed later in this paper in Figure 1 and Tables 3 and 4.

Figure 1. Percent of housestaff reporting the development of communication skills as important and percent reporting confidence in their skills (N = 89).

Table 1.  Representative items and characteristics of questionnaire

Scale and selected questionnaire items	Likert scale definitions	Scale Alpha Coefficient (N = 89)	Number of Items
Importance scale*	1 Very low importance	0.92	15
How important is it for housestaff to develop skills in the following areas:	2 Low importance
a. Ability to communicate effectively with patients.	3 Moderate importance
b. Understanding patients’ perspectives on their illness	4 High importance
c. Giving bad news about a patient's illness to the patient and family.	5 Very high importance
d. Dealing with the ‘difficult’ patient or parent.
Confidence scale*	1 Not at all confident	0.90	15
How confident do you feel about your skills in each of these areas:	2 A little confident
a. Ability to demonstrate empathy and caring with patients.	3 Somewhat confident
b. Ability to discuss end-of-life issues with patients and/or family.	4 Rather confident
c. Understanding psychosocial aspects of patient care	5 Very confident
d. Cultural awareness/sensitivity

*Questionnaire items for the Importance and Confidence Scales are identical while the Likert anchors are different.

We asked pediatric residents to rate how important it is for housestaff to develop 15 specific communication skills (Importance Scale) during their residency training, and how confident they felt about their communication skills (Confidence Scale) in each area, using five-point Likert scales. The Importance Scale contained 15 items, with responses scaled 1 to 5 ranging from ‘very low’ to ‘very high’. The Confidence Scale contained 15 items on a scale 1 to 5 ranging from ‘not at all confident’ to ‘very confident.’ The Importance and Confidence Scales had the same question stems consisting of 15 communication skills/competencies–i.e., core communication skills including the ability to communicate effectively, ability to demonstrate empathy and caring with patients, interviewing parents, building rapport, listening skills, interviewing children and adolescents, and developing awareness of personal reactions to patients, and more advanced skills including the ability to discuss end-of-life issues with patient and/or family, speaking to children about serious illness, giving bad news about a patient's illness to the patient and family, dealing with the ‘difficult’ patient or parent, cultural awareness/sensitivity, understanding psychosocial aspects of patient care, and understanding patients’ perspectives on their illness.

Participants were also asked about their attitudes regarding communication skills and system supports in the residency program relevant to learning and sustaining these skills (using 12 items with responses on a Likert scale of 1 to 5 ranging from ‘strongly disagree’ to ‘strongly agree’). The survey included demographic information about program year, gender, and age, and an item asking whether residents had previously participated in a program to improve their communication skills with patients. Housestaff completed the survey during their fall retreat in 2000. Those absent (N = 6 out of 104) received a mailed survey. The Harvard Medical School Institutional Review Board approved the study.

Analysis

Descriptive data were generated and analysed for all survey and demographic questions. Scale variables were created to measure pediatric residents’ perceptions of the importance of developing communication skills and their confidence in these skills. These scales were evaluated for reliability using Cronbach's alpha coefficient (Carmines & Zeller 1979). Univariate Analysis of Variance (ANOVA) was used to compare the Importance, and Confidence Scales by post–graduate year. All analyses were carried out using version 10 of the SPSS program. Significance levels were set at <0.05.

Results

Sample

The sample included 104 pediatric residents in PGY years 1, 2, and 3. The response rate was 86% (89/104). Respondents were a mean age of 28.4 years and a majority was female (67%). Thirty-nine percent were in their PGY1 year, 33% in PGY2, and 28% in PGY3. Forty percent indicated they had previously participated in a program to improve their communication skills with patients.

Scale reliabilities

Scales representing Importance and Confidence were constructed using 5 point Likert-Type items. Cronbach's alpha reliability coefficient was calculated for each Scale. The reliabilities of the Importance (r = 0.92) and Confidence Scales (r = 0.90) were excellent.

Attitudes about communication skills

All of the pediatric residents in our study agreed or strongly agreed that it was important to demonstrate empathy and caring with patients and to teach medical students to communicate effectively with patients. Almost all (99%) agreed that learning to communicate effectively with patients was a priority for them, and that it is important to teach medical students to show empathy and caring with patients (98%). Most agreed that it is important to teach medical students to show respect for patients (89%) and that housestaff communication skills with patients can be improved (84%). Almost three-fourths agreed that housestaff communication skills with the team could be improved.

Importance of developing communication skills

Overall, pediatric residents rated all of the communication skills studied as high or very high in importance for housestaff to develop during their residency training (Figure 1). All rated the following four skills as high or very high in importance: ability to demonstrate empathy and caring with patients, ability to communicate effectively with patients, giving bad news about a patient's illness to the patient and family, and interviewing parents. The remainder of the skills were also rated highly in importance, from interviewing adolescents (99%), listening skills (98%) and building rapport with patients (98%) to the lowest, cultural awareness and sensitivity (86%) (Figure 1).

Univariate ANOVA examining differences in scale mean scores showed that the communication skills Importance Scale had significant differences. Participants who had reported previous communication skills training experiences rated the skills as more important to learn than those without previous communication skills training (F = 4.035; p < 0.05). There were no significant differences by age or gender (Table 2).

Table 2.  Communication skills survey scale comparisons

Scale	By post graduate year		By previous communication skill training		By gender		By age (Pearson correlation)
Variables	F	Sig.	F	Sig.	F	Sig.	r	Sig.
Communication skills importance	1.897	0.157	4.035	0.048*	0.245	0.622	0.041	0.715
Communication skills confidence	7.622	0.001*	0.093	0.762	0.248	0.620	0.201	0.077

*Significant.

Residents’ confidence in their communication skills

Of the 15 communication skills studied, 60% or more of the residents rated their confidence for eight of the skills as rather or very confident (Figure 1). Approximately half or fewer residents indicated they felt rather or very confident about 7 more advanced skills: understanding the patient's perspective, understanding psychosocial aspects of care, cultural awareness/sensitivity, dealing with the ‘difficult’ patient or parent, giving bad news to patient and family, speaking to children about serious illness, and ability to discuss end-of-life issues with patients and families (Table 3).

Table 3.  Percent of housestaff reporting feeling rather or very confident in each communication skill (N = 89)

Communication competency or skill	Percent reporting feeling rather or very confident
Ability to discuss end-of-life issues with patients and/or family	19
Speaking to children about serious illness	23
Giving bad news about a patient's illness to the patient and family	27
Dealing with the ‘difficult’ patient or parent	39
Cultural awareness/sensitivity	45
Understanding psychosocial aspects of patient care	52
Understanding patients’ perspectives on their illness	53
Developing awareness of personal reactions to patients	60
Interviewing adolescents	65
Interviewing children	75
Listening skills	78
Building rapport with patients	81
Interviewing parents	83
Ability to communicate effectively with patients	84
Ability to demonstrate empathy and caring with patients	87

Univariate ANOVA examining differences in scale mean scores by postgraduate year indicated that only the Confidence Scale had significant differences. Residents’ confidence in their communication skills increased significantly over postgraduate training years (F = 7.622, p = 0. 001). There were no significant differences in Confidence Scale mean scores by gender, age, or previous communication skills training experience. There were no significant differences in Importance by postgraduate year of training (Table 2).

System supports

In the program we studied, half or fewer of the residents agreed or strongly agreed that various system supports related to communication skills existed in their training program (Table 4). Half agreed or strongly agreed that they receive feedback on relationships with the team while almost half (49%) indicated they received feedback on their relationships with patients. Only one-fourth think they have adequate time to interact with their patients. One quarter indicated that their department rewards good physician-patient communication skills, while only 10% agreed that training in communication skills is available to them.

Table 4.  Percent of housestaff indicating presence of program supports (N = 89)

Program supports	Percent* agreeing or strongly agreeing	Percent neutral	Percent disagreeing or strongly disagreeing
I receive constructive feedback about my relationships with other team members	50	32	18
I receive constructive feedback about my relationships with patients	49	30	22
I have adequate time to interact with my patients	27	32	41
My department rewards good patient-doctor communication skills by housestaff	25	38	38
Formal training in effective communication with patients is available to me	10	39	51

*Percents may not add to 100 due to rounding.

Discussion

The ACGME in the United States, and accreditation organizations worldwide, require residency programs to teach and assess interpersonal and communication competencies (Rider 2007). These competencies are relevant to pediatrics, yet pediatrics is distinct, and the development of additional advanced pediatric communication competencies remains important. Little is known about pediatric residents’ perceptions regarding both basic and advanced communication competencies.

Strong agreement exists among the pediatric residents in our study about the importance of learning to communicate effectively with patients, demonstrating empathy and caring with patients, and teaching medical students to communicate effectively with patients. Residents perceive a need for education in more complex communication issues relevant to pediatrics. While pediatric residents rated highly the importance of learning these skills, half or fewer felt confident of their skills in the more advanced communication competencies including: ability to discuss end-of-life issues with patient and/or family, speaking to children about serious illness, giving bad news about a patient's illness to the patient and family, dealing with the ‘difficult’ patient or parent, cultural awareness/sensitivity, understanding psychosocial aspects of patient care, and understanding patients’ perspectives on their illness.

Hesketh et al. (2003) found that pre-registration house officers near the end of their first postgraduate year rated communication skills high in ‘importance given.’ Our residents also perceived developing communication skills as uniformly important. Studying medical students, Wright et al. (2006) found that the perceived importance of communication skills was positively associated with perceived confidence about communicating with patients. In contrast, Kaufman et al. (2000) noted that, while medical students’ experience communicating with patients increased their confidence in performing basic communication skills, it did not increase their confidence regarding more advanced communication competencies (such as giving bad news). Similarly, while the residents in our study rated all communication skills studied high in importance, they were notably less confident with advanced communication skills.

Our findings also are consistent with a study by Dube et al. (2003) that found 12% of incoming residents in various specialties in two residency programs reported no formal training in pediatric skills, and more than half had never observed a pediatric or adolescent ‘giving bad news’ interaction. During medical school, they reported less formal communication skills training and fewer opportunities for observation with feedback with younger patients than with adults. Residents in their study reported greatest discomfort discussing serious illness in younger patients, and least discomfort with adult and elderly patients.

Werner et al. (1979) recommended additional training for pediatric interns in communicating with patients and incorporating psychosocial factors into care. More recent research shows that psychosocial issues motivate 65% of primary care pediatric visits, and that 85% of mothers with young children indicate they would ‘welcome’ or ‘not mind being asked’ about emotional and psychosocial stressors (Kahn et al. 1999). While 91% of the pediatric residents in our study agreed that understanding the psychosocial aspects of care was of high or very high importance, only half (53%) felt rather or very confident about their skills in this area. Providing learning opportunities for pediatric residents to increase their confidence and skill in understanding the psychosocial aspects of care is important. Parents are more likely to disclose psychosocial issues when the pediatrician directly questions and shows interest in managing parenting and behavioral concerns (Hickson et al. 1983), and shows interest and attention while listening (Wissow 1994).

Developing competency in giving bad news is essential for quality care. Only 27% of our pediatric residents felt rather or very confident in their skills in giving bad news about a patient's illness to the patient and family. Although we did not study the association between resident confidence in communication skills and residents’ actual experience or performance, Dosanjh et al. (2001) found that medical and surgical residents expressed a need for increased focus and frequent feedback on communication skills with specific emphasis on giving bad news. These residents also emphasized the importance of the opportunity to process their own feelings regarding the delivery of bad news. The value of developing these skills is echoed in Fallowfield & Jenkins’ (2004) findings that an insensitive approach to giving bad news increases patients’ distress, may exert a lasting influence on their ability to adjust, and increases malpractice risk.

Perhaps some of the most difficult situations for pediatric residents, and some of the most important competencies to develop, include the ability to discuss end-of-life issues with patients and families and the ability to talk with children about serious illness. Only 19% of the residents in our study felt confident in their ability to discuss end-of-life issues with patients and families, and only 23% felt confident about speaking with children about serious illness. Our results are in concordance with Kolarik et al.'s (2006) who found that pediatric residents view palliative care as important for primary care physicians, perceive they are inadequately trained in palliative care, and desire more education in this area. They concluded that there is a clear need for increased training in pediatric palliative care during residency.

Our study also suggests that pediatric residents in the program studied perceived few program supports at the time of the study. Less than half reported receiving constructive feedback about relationships with patients, and only 10% reported receiving formal training in the residency program in communication skills with patients. A mismatch exists between the residents’ nearly unanimous agreement on the importance of learning communication skills, and the reported lack of program supports relevant to learning these skills. At the time our study was conducted, the residency program did not have formal training in communication skills.

Moss (1997) noted that, due to the overwhelming involvement of the postgraduate trainee in delivering service, learning communication skills could be haphazard. Another factor in learning these competencies, and one that may be relevant to the lack of confidence in more advanced communication competencies found in the pediatric residents in our study, is noted by Williams et al. (2001) who reported that first year postgraduate house officers experienced an inability to use their learned communication skills for several reasons, including job demands and the attitudes of their senior colleagues.

Our study has several limitations. We designed our questionnaire to enable us to study residents’ perceptions with the intention of providing information for curriculum development for our pediatric residents. Although the reliabilities for the Importance and Confidence Scales were excellent and we can assume some validity from this analysis, we were not able to assess the unidimensionality of the scales using factor analysis due to the small sample size. Further studies should be done to validate these scales. Additionally, small sub-group sizes could lead to a ceiling effect and type II error (insufficient power to find significant differences between groups). Further studies with larger sample sizes would be useful to confirm the findings of this study.

Actual communication performance ratings for the residents in our study were unavailable; hence, we do not know how performance is associated with pediatric residents’ attitudes and perceptions about communication skills. We studied residents in one large residency program. Pediatric residents in other programs may have different experiences and perceptions. Additional studies would illuminate the current status of system supports in residency programs for learning and sustaining communication skills, and whether these supports are increasing as programs work to meet the ACGME requirements. Although we had an excellent response rate (86%), the few residents who did not respond might have had different attitudes and perceptions than respondents.

Suggestions for further research include intervention studies to determine which training methods promote effective communication between residents, patients and families. Studies of the relationship between residents’ perceptions, attitudes and confidence in their communication skills and actual performance on measures of communication competency over a range of pediatric residency programs would prove useful. Examination of residency program supports and which supports are most effective in promoting acquisition and maintenance of communication skills competencies would be beneficial. Designing and evaluating effective faculty development programs is essential for the development and teaching of enduring communication skills curricula (Rider 2007).

Implications for pediatric residency curriculum development

While modern medicine has made extraordinary scientific and technological advances, the core skills essential for the delivery of quality pediatric healthcare remain those of skillful communication, and building and sustaining therapeutic and caring relationships with children, adolescents, and their families (Rider 2008). The present study provides suggestions for curricular content areas for pediatric residencies.

Morgan & Winter (1996), described a curriculum on communication skills for pediatric residents. Topics included: giving bad news, dealing with ‘hostile’ parents, talking with children about serious illness, and psychosocial aspects of death and dying. Residents perceived the program as valuable and effective, though the impact of the program on residents’ interactions with patients and families was not assessed. The curricular topics of the program are notably similar to some of the skills the residents in our study felt least confident about.

Although we found only one article (Morgan and Winter 1996) describing a curricular program for pediatric residents for the competency of interpersonal and communication skills, Bernstein & The Bright Futures Health Promotion Workgroup (2007), Smith (2002), Stewart et al. (2003), Kittredge et al. (2004), Rosenbaum et al. (2004), Kurtz et al. (2005), Kolarik et al. (2006), Rider (2006, 2007, 2008), Rider & Keefer (2006), and Browning et al. (2007) articulate components of such a curriculum. Dube et al. (2003) recommend additional formalized training during medical school in communication skills and techniques for giving bad news with pediatric and adolescent patients. Should further research show our study results generalizable to other pediatric training programs, we suggest consideration of formal teaching and assessment in the content areas listed in Table 3.

An important caveat is the fact that, while learning skills in these content areas is essential, acquisition of such skills or competencies alone is not enough. The physician's relational and humanistic capacities, including the ability to reflect, self-awareness, engagement, compassion, being ‘present’ for self and others, respect for the patient and family, trustworthiness, and attention to one's own behavior are essential capacities and significantly associated with patients’ perceptions of the quality of care (Novack et al. 1997; Miller & Schmidt 1999; Stewart et al. 2000; Zoppi & Epstein 2002; Browning 2003; Rosenbaum et al. 2005; Beach et al. 2006; Epstein 2006; Browning et al. 2007; Rider et al. 2007; Rider 2008).

Our study suggests that communication skills competencies are highly valued by almost all pediatric residents in the program we studied, yet these residents reported insufficient program supports to learn or sustain these skills. Implementation of ongoing program and curricular components such as formal communication skills training, faculty-observed patient and family interviews followed by feedback and evaluation (Rider & Keefer 2006; Rider et al. 2004), opportunities for reflection and the development of self-awareness, feedback on relationships with team members, rewards for good physician-patient communication skills and others, would provide support for residents’ development of communication competencies. The program we studied is currently implementing program supports for enhancing communication skills. Faculty development remains essential.

Conclusions

A physician's ability to communicate with patients, other physicians, members of the health care team, as well as those they teach and mentor, is vital to the health care process. The quality of the relationship and communication with pediatric patients and their families affects all aspects of patient care–the diagnostic process, treatment decisions, adherence with recommendations, and patient, parent, and physician satisfaction. In addition, pediatrics is distinct and requires not only skillful communication between patient and physician, but also expert communication with parents and other family members, and an understanding of family dynamics and the child's cognitive and developmental stage.

The pediatric residents in this study report confidence in their skills in the more basic communication competencies such as interviewing, listening, building rapport, and demonstrating caring and empathy, and a lack of confidence in more advanced communication skills–i.e., giving bad news, discussing end-of life issues, speaking to children about serious illness, dealing with the difficult patient or parent, understanding psychosocial aspects of care and understanding patients’ perspectives. Although we did not study the relationship between residents’ confidence and actual performance, our results may provide suggestions for advanced curricular content areas for pediatric residency programs, in addition to teaching general communication skills competencies required by the ACGME and similar organizations worldwide.

Based on the results of this study and what we know from the literature, we suggest that pediatric residency programs provide longitudinal training in both core and advanced communication competencies, and consider additional focus on the more advanced skills described in this study. Residency programs might consider using the measurement scales in this study to add to the evaluation of the residency program. For residency program directors, the challenge is to devote careful attention to developing curricula in communication skills for pediatric residents across all years of their training, and to train faculty to teach and role model these skills.

Acknowledgements

This research was supported in part by the Priscilla and Richard Hunt Scholars in Medicine Award (Dr. Rider), the Morgan-Zinsser Teaching Fellows Award (Dr. Rider), and the Arnold P. Gold Foundation. We thank the pediatric residents for their participation in the study.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

Notes

Additional information

Notes on contributors

Elizabeth A. Rider

ELIZABETH A. RIDER, MSW, MD is Director of Academic Programs, Institute for Professionalism and Ethical Practice, Children's Hospital; Director of Programs for Communication Skills, Stoeckle Center for Primary Care Innovation, Massachusetts General Hospital; and Assistant Professor of Pediatrics, Harvard Medical School, Boston, MA USA. She teaches and consults nationally and internationally on teaching and assessing communication competencies, reflective practice, relationship-centered care, and medical education program development.

Kevin Volkan

KEVIN VOLKAN, EdD, PhD, MPH is Professor of Psychology at California State University Channel Islands, Camarillo, CA and formerly Director of Assessment at Harvard Medical School where has taught extensively on leadership and assessment in medical education. His research interests include the creation and validation of objective structured clinical examinations and assessment of attitudes, skills, and knowledge among medical students and residents.

Janet P. Hafler

JANET P. HAFLER, EdD is Professor, Tufts University School of Medicine, Boston, MA. She has extensive experience teaching faculty, residents, and students about curriculum, teaching, and evaluation. Her current interests are in the area of developing resident-as-teacher programs, developing faculty members as educators and the scholarship of education.

Notes

A copy of the questionnaire is available upon request from Elizabeth A. Rider, MSW, MD; E-mail: [email protected].