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msJAMA
January 1, 2003

Communication Skills Education in Medical School and Beyond

JAMA. 2003;289(1):93. doi:10.1001/jama.289.1.93

While the idea that communication is an essential aspect of medicine is not new, communication skills teaching and assessment have recently become more visible in medical education. For instance, communication skills feature prominently in a new national initiative: The National Board of Medical Examiners, the Federation of State Medical Boards, and the Educational Commission for Foreign Medical Graduates are working together to implement a clinical skills examination using standardized patients, to be taken between the third and fourth years of medical school as part of the United States Medical Licensing Examination (USMLE).1,2 This examination will "require students to demonstrate they can gather information from patients, perform a physical examination, and communicate their findings to patients and colleagues."2

In 1995, the 2 bodies that accredit North American programs leading to the MD degree adopted a resolution stating that "there must be specific instruction and evaluation of [communication] skills as they relate to physician responsibilities, including communication with patients, families, colleagues and other health professionals."3 While past initiatives did not generate much curricular change in medical schools, this resolution is likely to have a significant effect, given its link to program accreditation. It is important to note, however, that the standard requires only the presence of instruction and evaluation; it says nothing about the specific timing, quality, or quantity of the education.

There is tremendous variation among medical schools in the way, and extent to which, communication skills are taught and assessed.4,5 The most recent and comprehensive survey on communication skills education in North American medical schools was conducted by the Association of American Medical Colleges (AAMC), and published in a 1999 report.4 Eighty-nine of the 144 medical schools responded to questions on the AAMC survey regarding communication skills teaching. Of these, 85% reported they use a combination of discussion, observation, and practice in teaching such skills. The primary teaching methods were small-group discussions and seminars (91%), lectures and presentations (82%), student interviews with simulated patients (79%), student observation of faculty with real patients (74%), and student interviews with real patients (72%). Nearly half of the schools (45%) reported using rounds to teach communication skills. All of these forms have value, but without a model to help structure and focus attention on communication, teaching is less likely to be consistent and effective.4,6

Ninety-two schools responded to the portion of the AAMC survey on communication skills assessment. Most of these schools (92%) reported that they assessed communication skills informally, through faculty feedback to students during teaching sessions. The next most frequently cited form of assessment was formal faculty feedback and observation (78%). More objective assessment methods, such as the use of standardized patients, were less widespread (70%). Again, the reliability and effectiveness of observation and feedback, regardless of the particular method, are likely to be compromised unless they are grounded in a coherent conceptual framework. While schools use a variety of teaching and assessment methods, many of these activities lack such a structure: At the time of the AAMC survey, less than one-third (32%) of medical schools were using a structured model to organize their communication skills teaching and assessment. Of the schools using a model, most used either the SEGUE Framework for Teaching and Assessing Communication Skills or the Calgary-Cambridge Observation Guide.7,8

The focus on communication skills extends into residency and clinical practice, and is now linked specifically to accreditation of residency programs and maintenance of certification for practicing physicians. In 1999, the Accreditation Council for Graduate Medical Education, which oversees US residency programs, and the American Board of Medical Specialties, the umbrella organization for specialty boards that certify physicians, stated that "interpersonal and communication skills that result in effective information exchange and teaming with patients, their families, and other health professionals" is a core area of competency.9,10 The idea of communication as bedside manner or history taking has given way to a reconceptualization of communication as a measurable clinical skill.4,6

References
1.
Klass D, DeChamplain A, Fletcher E, King A, Macmillan M. Development of a performance-based test of clinical skills for the United States Medical Licensing Examination.  Federation Bull.1998;85:177-185.
2.
 United States Medical Licensing Examination. Available at: http://www.usmle.org/news/cse.htm. Accessed December 6, 2002.
3.
Liaison Committee on Medical Education.  Functions and Structure of a Medical SchoolWashington, DC: Liaison Committee on Medical Education; 1998.
4.
Association of American Medical Colleges.  Contemporary Issues in Medicine: Communication in Medicine (Report III of the Medical School Objectives Project). Washington, DC: Association of American Medical Colleges; 1999.
5.
Hargie O, Dickson D, Boohan M, Hughes K. A survey of communication skills training in UK Schools of Medicine: present practices and prospective proposals.  Med Educ.1998;32:25-34.
6.
Bayer conference on physician-patient communication in medical education.  Essential elements of communication in medical encounters: the Kalamazoo consensus statement.  Acad Med.2001;76:390-393.
7.
Makoul G. The SEGUE Framework for teaching and assessing communication skills.  Patient Educ Couns.2001;45:23-34.
8.
Silverman J, Krutz S, Draper J. Skills for Communicating With PatientsAbingdon, Oxon, UK: Radcliffe Medical Press; 1998.
9.
Batalden P, Leach D, Swing S, Dreyfus H, Dreyfus S. General competencies and accreditation in graduate medical education.  Health Aff (Millwood).2002;21:103-111.
10.
Horowitz SD. Evaluation of clinical competencies: basic certification, subspecialty certification, and recertification.  Am J Phys Med Rehabil.2000;79:478-480.
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