Clinical and communication skills

Physician communication skills training: a review of theoretical backgrounds, objectives and skills
Donald J Cegala1 & Stefne Lenzmeier Broz2

Context Signicant shortcomings have been noted in the literature in communication skills training for practising doctors. Given the importance of competent communication to the doctorpatient relationship and health care in general, these shortcomings should be addressed in future research. Objective Research into physician communication skills training is examined with respect to the communication objectives and behaviours that are addressed. Methods A Medline search of literature from 1990 to the present was conducted. Results A total of 26 studies of doctor communication skills training were found. The majority of studies included insufcient information about the communication behaviours taught to participants. In several studies, there was a mismatch between stated behav-

iours and instruments or procedures used to assess them. Conclusion Three recommendations are suggested. Firstly, future researchers should take greater care in matching assessment instruments with stated communication skills. Secondly, researchers should provide and use a theoretical framework for selecting communication skills to address in interventions, and thirdly, the timing of communication skills within the interview context should be part of the instruction in interventions. Keywords *physician patient relations; *communication; education, medical, continuing *standards; family practice education; quality of health care; review literature. Medical Education 2002;36:10041016

Introduction
The majority of studies assessing physician communication skills interventions do not include sufcient information about the behaviours taught to participants. Over the last 30 years there has been considerable research into doctorpatient communication.14 This work has affected several aspects of health care and has increased the attention given to instructing medical students and doctors in communication skills. Most medical schools now include some form of communication instruction in their curriculum,5 although it has been noted that the actual time devoted to it may be minimal.6 Despite self-reported inadequacies in communication,7 practising doctors have even
1

School of Journalism & Communication and Department of Family Medicine, Ohio State University, USA, 2 School of Journalism & Communication, Ohio State University, USA Correspondence: Donald J Cegala PhD, School of Journalism & Communication and Department of Family Medicine, Ohio State University, 3016 Derby Hall, 154 N Oval Mall, Columbus, Ohio 43210, USA. Tel.: 00 1 614 292 3675; Fax: 00 1 614 292 2055; E-mail: cegala.1@osu.edu

less exposure to communication skills training, as most continuing medical education (CME) creditearning programmes focus on technical and biomedical aspects of health care.8 Even so, the literature on doctorpatient communication underscores the value of competent communication in enhancing patient satisfaction, adherence, functional status and clinical outcomes.912 Thus, it is important to track the development and implementation of communication skills training programmes. The purpose of this paper is to extend the critique of the doctor communication skills training literature reported by Hulsman et al.6 Hulsman et al.6 report signicant shortcomings in the literature on communication skills training for practising doctors. They note that most studies use inadequate research designs and that positive behavioural effects are reported for only half or less of the target communication behaviours. We extend the Hulsman et al. critique by focusing on issues relevant to the communication skills addressed in the literature. Although Hulsman et al. do not ignore the communication aims and objectives of training studies, they focus more on other aspects of the research. While they

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Results Key learning points

The majority of studies assessing doctor communication skills interventions do not include sufficient information about the behaviours taught to participants. In several studies of doctor communication skills interventions there is a mismatch between stated behaviours and the instruments or procedures used to assess them. Addressing these problems in future research will enhance the utility of results. Selected aspects of the 26 studies in our data base are reported in Table 1. As indicated above, we focused on the communication objectives addressed in these studies. Readers interested in other aspects of this research should consult reports of individual studies or Hulsman et al. Contrary to the observations put forward by Hulsman et al., we see little consistency across the 26 training studies in what is considered to be a communication skill. Moreover, little effort has been made to provide an over-arching framework for organizing provider communication skills, although some scholars have suggested a classication following a distinction between information exchange and relational development,13 while others have organised skills according to the stage, or component, of the medical interview.14 However, scholars who conduct research into provider communication skills typically do not frame their work along either of these lines, or offer an explicit, alternative structuring principle. To make matters worse, very little information is typically reported about specically what communication skills were taught,15 26 and often when skills are reported there is incongruity between the stated objectives of the intervention and the instrument used to assess communication effects.16,17,19,22,2528 In Table 1, we identify communication skills on 2 levels: stated focus of the intervention and specic skills. All the studies, with varying degrees of explicitness, make reference to some kind of conceptual framework for the intervention that is examined. We identify this level of framing as the studys focus in Table 1. While the focus of a study helps to understand the basic intent and direction of training, it is not explicit enough to convey specically which communication skills were taught. For example, several authors indicate that the intervention was designed to promote patient-centred interviewing skills.8,22,2932 However, there are several models of patient-centred interviewing, and the concept of patient-centred communication is applied to various parts of the medical interview, each emphasising different objectives and skills. Thus, stating that the focus of the intervention is patient-centred interviewing does not clearly convey which specic communication skills were taught. The same ambiguity arises for other foci (e.g. psychosocial interviewing skills, psychiatric interviewing skills, breaking bad news). Regarding specic skills, in nearly one half of the studies so little information, if any, is provided about communication skills that it is impossible to determine

offer valuable and, in our estimation, correct assessment of weaknesses in the existing doctor communication skills training literature, the lack of attention to detail about the communication skills that are addressed in this literature omits important basic information for guiding future research into this essential domain. Our aim is to build upon the Hulsman et al. review and provide additional direction to researchers investigating the effects of doctor communication skills training. As such, we will not comment on the research designs, methods or results of the studies included in this review. The reader is recommended to Hulsman et al. for commentary on those matters. Our attention is directed to issues about the objectives and skills that are included in the literature on communication skills training for practising doctors.

Methods and procedures

We conducted a Medline search of literature published from 1990 to the present, using the keywords communication, skills, training, medical education, instruction, physician, doctor and patient relations. Additionally, we examined relevant studies from the reference lists of the literature identied by the Medline search, including the Hulsman et al. report. Only complete studies on provider communication skills training are included here; review pieces, position papers, commentaries, letters and method development pieces were consulted but are not included. We focused on training studies involving practising doctors, residents or other postgraduate providers. The results of our search produced the post-1989 data base critiqued by Hulsman et al. plus studies published since their publication. Hulsman et al. critiqued 14 separate studies published between 1985 and 1998. Our data base includes 26 studies published since 1990.

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Table 1 Descriptive summary of health care provider communication skills training studies Intervention Assessment Analysis of video with SP, SP report of physician, patient self-reports, physician chart notes Focus: psychosocial, data gathering and interview organisation Specic skills: ? Skills Com-specic results Es had more open Qs, fewer leading Qs, SPs rated as having better communication skills

Source

Design and sample*

Roter et al.26

RC; En 24; Cn 24; primary care residents.

Lewis et al.37

RC; En 20; Cn 14; paediatric residents

Readings; group discussion; role play; videotaped practice with feedback with SPs; live interviews with feedback with RPs; 1 month psychosocial rotation Instructional videotape; readings; post-interview self-assessments; 1 hour and 15 min Analysis of video with RP; self-reported satisfaction

E physicians addressed more recommendations to child or child and parent

Physician communication skills training: theoretical backgrounds, objectives and skills

Smith et al.24

NRC; P-P; En 28; Cn 20; primary care residents

Focus: promote childrens participation in the medical interview Specic skills: building rapport with children; checking on childrens understanding of medical information; handling incorrect or inadequate information provision from children; agenda setting with parent and child; facilitating expression of concerns Focus: psychosocial skills Specic skills: ?

Es improved in knowledge attitudes and skills

Participants self-assessment of knowledge, attitudes and skills associated with psychosocial medicine

D J Cegala & S Lenzmeier Broz

Blackwell Science Ltd ME D I C A L E D UC A T I O N 2002;36:10041016 4-week rotation in psychosocial medicine; partially learnerdetermined objectives; lecture; discussion; demonstrations modelling; role play with feedback; supervised interviews with RPs 18 weekly, 2-hour sessions; small group, role play with feedback Focus: psychiatric interviewing skills Specic skills:? facilitation; checking and clarifying comments, empathic statements, open Qs, establish eye contact, seek patients views, establish realistic goals

Bowman et al.16

P-P; single group; 9 GPs

Analysis of video with RP immediately after intervention and after 2 years

Immediate: more open Qs; less closed Qs; more social Qs; less psychological Qs; more checking out Long-term: maintained more open Qs, less closed Qs; increased social over psychological Qs and checking out

Kaaya et al.27 8-week rotation in psychiatry; instructional video; role play; group discussion; videotaped interviews with RPs and feedback Analysis of videotaped role plays with another trainee Increase in Qs about pain site; more exploration of health beliefs; more acknowledging of patient symptoms

P-P; single group; 18 GP residents

Blackwell Science Ltd ME D I C A L ED U C A T I ON 2002;36:10041016 Short: 4 hours; lecture and discussion; Long: 25 days, learner-determined objectives; practice interviews with RPs and feedback Analysis of recorded visits with 10 RPs (5 pre, 5 post); global affect ratings on anger, anxiety, dominance, friendliness, responsiveness, interest No effects from short intervention; Long: Es used more open Qs; asked for opinion more; lower negative affect ratings Focus: psychological component of primary care Specic skills: take full history of pain; explore health beliefs; explore family and social factors; acknowledge patients symptoms; summarise physical ndings; reframe by connecting psychological to life events Focus: patient-centred interviewing Specic skills: eliciting patients concerns; use more open Qs and less closed Qs; give information about illness and therapy; engage in psychosocial discussion; ask patients opinion; more listening, less talking; summarise what patient says; allow patient to tell story without interruption Focus: giving distressing information Specic skills: ? Analysis of recorded role play with SP Focus: psychosocial skills Specic skills: ? Residents self-reports of condence in and knowledge of psychosocial matters E residents scored higher on all measures 2-day programme; recorded role play with SP; group discussion; learner-determined objectives 4-week rotation in psychosocial; partially learner-determined objectives; lecture discussion; live demonstration modelling; role play; supervised interviewing with RPs RPs assessment of residents skills; patient satisfaction Es self-rated higher psychosocial skills, non-directive facilitation

Levinson & Roter8

RC; P-P; Short: En 15; Cn 15; Long: En 20; no C; primary care physicians

Physician communication skills training: theoretical backgrounds, objectives and skills

Faulkner et al.21

Training effects on 3 6 skills

Post-test only, single group; 78 senior registrars, senior house ofcers, nurses and others

Smith et al.25

RC; P-P En 15; Cn 11 primary care residents

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Smith et al.43**

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Table 1 Continued Intervention Assessment Analysis of interviews with RPs and 1 SP; physicians recognition of psychosocial problems and emotional distress; clinical prociency; patients reported reduction in emotional stress Two interventions (see focus); 8 hours, in two 4-hour sessions, 1 week apart; lecture, roundtable discussion; practice with SP; role play based on segments of interviews with RPs Skills Com-specic results EHs used more EH utterances; PDs used PD utterances; PDs recognised more psychosocial and emotional behaviours in patients; PDs procient; PDs patients had more reduction in stress

Source

Design and sample*

Physician communication skills training: theoretical backgrounds, objectives and skills

Roter et al.35

RC; P-P; EHn 22; PDn 23; Cn 24; primary care physicians

Joos et al.38 45 hours over three 90-minute sessions; videotaped role play with SP

RC; P-P; En 22; Cn 20; primary care physicians and residents

Analysis of interviews with SPs; patients assessment of desired concerns services; patients perceptions of information received; patient satisfaction; patient compliance Analysis of interviews with SPs, immediately after intervention and 6 months later

Es had greater proportion of visits in which all concerns were met; Es patients perceived greater information giving

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Blackwell Science Ltd ME D I C A L E D UC A T I O N 2002;36:10041016 3 or 5-day workshop; learner-determined objectives; instructional videos; role play with feedback

Maguire et al.33

P-P; single group; 169 physicians, nurses, social workers and others in cancer care

Focus: emotion handling skills (EH); problemdening skills (PD) Specic skills: EH: asking about feelings; listening more, talking less; follow up on signs of emotional stress; complimenting effort; legitimising patients views feelings; expressing empathy; expressing partnership or support; providing reassurance PD: resisting immediate follow up of rst concern; asking anything else?; negotiating time; starting with open Qs; facilitating utterances; assessing psychosocial aspects; probing for patients understanding; expressing concern; clarifying patients expectations Focus: doctors awareness of patients concerns Specic skills: identifying and eliciting patients agenda; negotiating a realistic interview agenda; identifying patients attributions expectations; relationship-building skills Focus: skills promoting and inhibiting patient disclosure of information Specic skills: promoting skills: open Qs; Qs with psychological focus; clarifying psychological focus; educated guesses; empathy

Increase in 3 6 promoting skills immediately and 6 months later; decrease in inhibiting behaviours in 3 6 immediately and 6 months later

Maguire et al.34 Focus: disclosure of psychological problems Specic skills: open Qs; Qs with psychological focus; clarifying psychological focus, screening Qs; educated guesses Focus: delivering bad news Specic skills: ? Analysis of interviews with SPs Increase in use of Qs with psychological focus; clarication of psychological concerns; open Qs

P-P; single group; 3 or 5-day workshop; 206 physicians, nurses, learner- determined social workers, objectives; instructional psychologists and others videos; role play in cancer care

Morgan & Winter23 P-P; single group; 24 paediatric residents

Baile et al.15

P-P; single group; 9 oncologists, 1 psychiatrist, 3 fellows

45 hours in 3 sessions; lecture; panel discussion; live demonstration, role play; group discussion 3-day workshop; lecture; instructional videotape; readings; practice interviews with SP and feedback; personal awareness exercise; learner-determined objectives

Analysis of interviews with Residents evaluated SP; residents evaluation programme highly; of training programme 2 5 residents showed subtle improvement Participants self-appraisal Improvement on 6 10 skills

Blackwell Science Ltd ME D I C A L ED U C A T I ON 2002;36:10041016 Focus: skills for stressful interactions Specic skills: ? initiate discussion of patients concerns; access patients knowledge of illness; ask Qs to elicit illness concerns; encourage elaboration of illness concerns; summarise illness concerns; move patient to discuss other concerns; manage own feelings Focus: breaking bad news Specic skills: ?

Falloweld et al.20

P-P; 178 oncologists

Physician communication skills training: theoretical backgrounds, objectives and skills

Greco et al.22

Langewitz et al.29

NRC; P-P; En 35; Cn 33 primary care physicians RC; P-P; En 19; Cn 23; internal medicine residents

15 or 3-day workshop; Analysis of interviews with Improvement on readings; instructional SPs; participants self-condence ratings video; learner-determined self-rated condence objectives; role play with SPs and feedback 05 day per week over 13 weeks Focus: patient-centred RP assessment of Improvement on 7 12 items or 5-hour workshop; discussion interviewing physicians in triads Specic skills: ? communication Es better on 10 14 skills Focus: patient-centred interviewing Analysis of interview 15-day seminar; lecture; with SP; global ratings Specic skills: empathy in demonstration interviews greeting; acknowledge initial with SPs; role play; complaints; take up emotions; progress assessment clarify consultation reasons; meetings; one-on-one summarise patients statement sessions during clinical of concern; announce history work with RPs taking phase; structure consultation; share evaluation; convey detailed information as desired by patient

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Table 1 Continued Intervention Assessment Analysis of interviews with RPs; patient satisfaction; global affective tone ratings 8 hours over 2 days; lecture; role play Skills Com-specic results Es used more open Qs and facilitators; rated as expressing more interest and friendliness

Source

Design and sample*

Roter et al.30

NRC; P-P; En 10; Cn 8; primary care physicians

Physician communication skills training: theoretical backgrounds, objectives and skills

Smith et al.31

RC; P-P; En 31; Cn 30; primary care residents

Same as Smith et al. 199525

Residents knowledge; attitudes, and commitment to psychosocial medicine; patient satisfaction and self-reported physical functioning; analysis of interviews with SP and RPs

Es greater on knowledge, attitudes; greater on 2 10 data- gathering skills with RPs; 10 10 data-gathering skills with SPs; 10 14 informing and motivating skills; 8 14 managing somatisation skills

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Blackwell Science Ltd ME D I C A L E D UC A T I O N 2002;36:10041016 2 5-hour workshops, 6 weeks apart; learnerdetermined objectives; lecture; readings; instructional video; role play with feedback

Baile et al.19

P-P; single group; 15 oncologists, 2 fellows

Focus: patient-centred interviewing Specic skills: information giving in both biomedical and psychosocial domains; open Qs; expression of concern, empathy, reassurance; positive exchanges; use of facilitators, interpretations and signals of interest Focus: patient-centred interviewing Specic skills: encouraging patient responses; allowing the patient to talk; responding to emotions; not completely pursuing biomedical data initially; including psychosocial data initially; not dominating the interview; building rapport; following up on patient-initiated topics, effectively managing the interview Additional skills with SPs: provide information; motivate behavioural change; support patients achievement in attaining health goals; manage somatising patients Focus: breaking bad news (BBN) and managing difcult patients (MDP) Specic skills: BBN: create an appropriate setting; elicit patients perception of the problem; assess patients desire for information; give information in small chunks; check patients understanding frequently; avoid medical jargon; empathise and explore patients emotions; provide a summary; negotiate a treatment strategy MDP: ? Participants self-rated self efcacy

Improvement on 18 21 BBN skills; improvement on 4 15 MDP skills

Brown et al.17 2 4-hour workshops; readings; lecture; role play; taped ofce visits with RPs Patients judgements of physicians skills; 1 item patient satisfaction measure; physicians self-assessments Es improvement on selfassessments (no C group comparison)

RC; P-P; En 32; Cn 29; primary care physicians, nurse practitioners, others

Costanza et al.18 5 hours; seminar; lecture; instructional video; live demonstration; readings; role play with SP 1 day workshop; lecture discussion; instructional video; role play Self-assessments of interviewing skills, immediately after and 3 months post intervention SP assessment of physicians skills

P-P; single group; 85 primary care physicians

No improvement in communication skills; improvement in 1 3 stage counselling skills Improvement on all 18 selfassessment skills

Blackwell Science Ltd ME D I C A L ED U C A T I ON 2002;36:10041016 Focus: skills for building effective relationships with patients (ER); negotiation skills, especially for disagreement situations (NS) Specic skills: ER: listening actively; communicating concern; understanding, respect; responding to patients feelings NS: ? Focus: counselling intervention (mammography screening) Specic skills: ? Focus: skills for enhancing effectiveness and efciency of interviews (EE); and managing difcult patients (MDP) Specic skills: EE: using open Qs; asking if there is anything else; asking about psychosocial issues; explore barriers to adherence; use own feelings as diagnostic information; negotiate and set agendas; guide effective information ow MDP: determine which behaviours are difcult and why; state impasse or dilemma; express common goals; use empathy to diffuse strong emotions

Physician communication skills training: theoretical backgrounds, objectives and skills

Stein & Kwan36

P-P; single group; 911 physicians over 5 years

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Table 1 Continued Intervention Assessment Skills Com-specic results

Source

Design and sample*

Vaidya et al.28

P-P, single group; 7 paediatric intensive care fellows

Physician communication skills training: theoretical backgrounds, objectives and skills

van Dulman & Holl32

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Hardoff & Schonmann42

Post interview evaluation Improvement in 1 5 skill 1-day workshop in 2 Focus: breaking bad news by SP categories; improvement sessions; role play with Specic skills: ? allows parents in overall score across all SPs and feedback from SP to talk ask Qs; expresses sympathy 5 categories and compassion; avoids medical jargon; uses appropriate body language; asks about parents understanding; discusses assessment and prognosis; discusses rationale and approach to therapy; leaves room for hope; asks psychosocial Qs; relieves parents of blame guilt; prepares parents; greets parents warmly; lets parents tell their story; shows interest; encourages parents to ask Qs Analysis of videotapes with Es asked more psychosocial P-P, NRC; En 10; 5 days; role play with Focus: patient-centred RPs, pre-intervention Qs, looked at patients Cn 11; paediatricians feedback; discussion of interviewing; handling compared to 4 months parents more, gave videotapes with RPs patients and parents post-intervention; postpatients parents more instrumental and affective intervention self-report of room to talk needs Specic skills: training evaluation providing information and advice, showing support and understanding communicating affect, attending to psychosocial issues, giving patients and parents room to talk Self-report 1 month Self-reported afrmation P-only, single group; 3045 minute session; role Focus: improving skills in after intervention of using learned principles paediatricians, family play with SPs and communicating with physicians, feedback adolescents gynaecologists ? Specic skills: careful groups of 2030 listening, a non-judgemental approach, assuring condentiality, others?

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*RC randomized control; NRC non-randomized control; P-P pre post test; P-only post test only; E experimental (intervention) group; C control group. SP simulated (or standardized) patient; RP real patient; role play alone other participant or instructor assumed a role, as opposed to an SP or RP. Qs questions; ? alone insufcient information about skills or no report of skills; ? followed by skills uncertainty about skills listed, derived from assessment instrument rather than a description of skills. Improvements, etc. reect statistically signicant results involving E C or pre post comparisons; assessments not mentioned were non-signicant or not specically communication-related. ** This is the same study as Smith et al.,39 except for a different assessment.

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what was actually taught.1526 In other studies, little or no information is provided about specic skills, but reasonably good detail is reported about criteria used to assess participants communication. However, in light of the rather signicant misalignment problem mentioned above (also discussed in more detail below), we cannot be condent that assessment items necessarily reect the communication skills actually taught. Thus, because of the lack of reported information or uncertainty due to misalignment, it is unclear in the majority of studies which specic communication skills were addressed by the intervention. What, then, can be said about the communication skills addressed in the remaining studies? An examination of Table 1 reveals varying degrees of specicity both across and within studies. For example, listening more, talking less, and using open Qs8,30,3336 appear comparatively more specic in terms of conveying which skills were taught than handling incorrect or inadequate information provision from children,37 relationship building skills,38 or encouraging patient responses.31 Similar variance can also be observed within studies. For example, Maguire and associates33,34 indicate the somewhat specic skill of asking Qs with a psychological focus, but they also list as a skill using educated guesses. Similarly, Langewitz et al.29 report the rather specic skill of summarising the patients statement of concern, but they also list take up emotions and empathy in greeting. Overall, we see very little specicity of communication skills even among the studies that report skills and do not have apparent problems of misalignment. In making this assessment, we asked ourselves whether, given the stated communication skill, we could teach it just based on the stated information. We realise this is perhaps an overly rigorous test for a variety of reasons. However, we believe the application of this criterion revealed some interesting and potentially useful insights into the current literature on provider communication skills training. These ideas are discussed in the following section.

suggest an alternative with more direct implications for improving the quality of training research, as well as the clarity with which it is reported. In particular, we recommend that future researchers take care in using and reporting assessment instruments that are closely matched with the communication skills taught to study participants. This not only enhances clarity, but, more importantly, it signicantly enhances the interpretability of results. For example, in our judgement Smith et al.,31 have arguably done one of the best jobs of matching assessment items with intervention objectives. Although their reporting of communication skills generally lacks the degree of specicity we would like to see, they make clear in the report that care was taken to match assessment items with communication skills. Thus, examination of the results of each assessment item provides a clear sense of the impact of the training intervention and a reasonable sense of what was taught. However, the clarity of the latter could be improved even in the Smith et al. report. For example, they indicate that one of the skills addressed in the intervention was encouraging patient responses. They also report that an item on the assessment instrument was encourages responses, for which they provide means and statistical results. So far, so good. However, in the methods section where they discuss the alignment of items and skills, they state the following: Rating scales were anchored at the upper and lower ends with examples of criterial [sic] behaviours. For example, the upper end of encouraging patient responses had examples such as uses exploratory questions, uses echoing, or uses paraphrasing. Criteria for the lower end of the scale included such examples as uses directive questions and dismisses patients responses. We nd this statement even more explicit with respect to the specic communication skills actually taught to participants. Accordingly, we recommend that researchers either use assessment items as specic as the criterial [sic] behaviours listed above, or indicate the range of specic behaviours associated with upper and lower level criteria appearing on the assessment instrument. We believe that following this recommendation will signicantly improve the specicity of reporting communication skills as well as enhancing the meaningfulness and utility of results. Our second recommendation is concerned with both conceptual and methodological issues. On the conceptual side, we recommend that more effort be made to provide a theoretical framework for the communication skills addressed in interventions. This should involve more than merely reporting such a framework. In light

Discussion
Clearly, one reason for the lack of detailed information about communication skills is that journal editors, pressured by numerous submissions and page limitations, cannot provide the needed space for researchers to specify exactly what was addressed in an intervention, especially those that spanned more than a few hours. While a variety of practical solutions might be suggested to rectify this (e.g. indicate to readers where more detailed information may be obtained), we

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of much of the current research, we recommend that researchers develop or use an existing theoretical framework to drive decisions about inclusion of communication skills. Too often researchers rely on vague references to the literature on providerpatient communication or broad philosophical principles, such as patient-centred interviewing, to frame their selection of communication skills. While such frames are helpful, they do not provide the solid theoretical structures needed to advance research in communication skills training. Ideally, theoretical frameworks might incorporate literature from research into providerpatient communication, communication theory and educational psychology. The providerpatient communication literature offers a wealth of information about specic communication behaviours that can guide identication of topic areas and skills that meet objectives important to medical interviews. Communication theory literature is essential to developing specic communication skills and projecting to associated effects. Moreover, this literature reects a level of sophistication about the communication process that is often lacking in current research. Educational psychology provides valuable information about instructional design and strategies that promote learning of various kinds of cognitive, affective and behavioural objectives. Our nal recommendation represents an extension of some points already mentioned. In examining the specic skills listed by some researchers, we noted instances that seemed especially informative: for example, resisting immediate follow-up of rst concern, starting with open Qs,35 identifying and eliciting the patients agenda and negotiating a realistic interview agenda.38 What struck us about these skills is that they implied when, during the interview, they might be most effectively used. We think that indicating the timing of communication skills is important for at least two reasons. Firstly, indicating where in the interview communication skills may be most useful provides an additional over-arching structure for skills beyond whatever other conceptual framework might be offered. Providers are typically trained with respect to stages of the interview and the communicative functions associated with those stages (e.g. history taking and information gathering). Thus, structuring communication skills along the lines of interview stages and communicative functions would reect a natural way of viewing the interview and would be especially helpful to providers. The Silverman et al.14 approach is structured entirely by interview stages and functions, and is in our judgement one of the most comprehensive, useful frameworks available for instruction in provider communication skills. We

believe giving attention to interview stages and communicative functions might improve the identication, coherence and specication of communication skills and the interventions designed to address them. A second advantage of specifying the timing of communication skills is linked to implications for how the communication process is viewed and ultimately reected in interventions. The concept of time is essential for assuming an interactive, transactional perspective on interpersonal communication. Research into discourse and conversation analysis39 clearly shows that the exchange of information and meaning unfolds sequentially as participants produce, interpret and respond to communicative acts. An approach to communication skills and training interventions that reects this perspective could have signicant impact on both conceptual and methodological aspects of research. For example, assuming such an approach would make it likely that skills would be taught from an interactive perspective, rather than from the linear view currently prevalent. In terms of methodology, researchers would be more likely to assess training interventions by examining the sequence and timing of skills (i.e. communicative acts) than by their frequency of occurrence only. Assessing skills in this way could have a signicant impact on results, as well as inuencing training procedures themselves. For example, Joos et al.38 report that their intervention enhanced the frequency of trained doctors elicitation of patients concerns. However, only 22% of doctors elicitations occurred at the beginning of the interview; most occurred at the end (we suspect in the form of open questions like Is there anything else?). The issue here is that the use of open questions (a frequent communication skill in training research) in and of itself may not necessarily be more patient-centred or more communicatively competent. The timing and placement of such questions appears far more important than their frequency.40,41 It is unclear, however, to what extent, if any, sequential placement of specic communication skills is emphasised, or even discussed, in training interventions. Our recommendation to include the timing of communication skills would address several of the issues identied here. We cannot claim to have included all the research into practising doctor communication skills training since 1990, but we are condent that the 26 studies examined here are representative of the literature. It is now widely accepted that effective communication is central to quality of health care. Given the importance of communication, it is essential for research into communication skills training interventions to provide meaningful results that can be implemented

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by participants and trainers. A signicant component in producing and reporting such results is the selection, denition, placement and assessment of communication skills. We believe the recommendations offered here will help to advance research into communication skills training for doctors along these lines.24,42,43

12

13

Contributors
Both authors conducted library searches, although the majority of this work was carried out by SLB. Both authors independently read and evaluated the studies. DC drafted the manuscript. SLB provided editing suggestions.

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15

16

Funding
There was no external funding for this project.

17

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References
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