Views of new internal medicine faculty of their preparedness and competence in physician-patient communication

Medical interviewing is one of the most important skills in medicine and effective physician-patient communication is essential for optimal medical care. Effective physician-patient communication is associated with improved patient satisfaction [1–6], increased patient adherence with medications and recommendations [1, 6–8], improved medical outcomes [6, 7, 9], and less malpractice risk [10]. Indeed, consensus statements [11, 12] have concluded that effective physician-patient communication is an integral part of medical practice. The Association of American Medical Colleges (AAMC) [13] and the American College of Physicians [14] regard effective communication as a key attribute of professionalism, and the Accreditation Council for Graduate Medical Education (ACGME) [15] describes effective interpersonal and communication skills as a general competency common to all specialties.

Although previous surveys [16–20] assessed preparedness and competence in communication among internists, they did so only partially (eg, one or two questions). In addition, these surveys did not assess the preparedness for specific physician-patient communication scenarios. Herein, we describe the results of a survey that assessed self-rated preparedness, competence, and perceived benefit of additional training in physician-patient communication among new internal medicine faculty, regardless of their age or previous experience, at an academic medical center.

On a 10-point scale, the average ± standard deviation of self-rated competence (1 = not competent, 10 = highly competent) in medical interviewing by the new faculty was 7.7 ± 1.2. General internists rated themselves more competent in medical interviewing than subspecialists did (8.1 ± 1.1 vs 7.5 ± 1.1, P = .042), as did faculty who had completed their residency or fellowship training more than one year before beginning the physician-patient communication curriculum compared with recent graduates (7.9 ± 1.0 vs 7.3 ± 1.4, P = .032). There were no differences in self-rated competence in medical interviewing according to sex, age, or perception of benefiting from the curriculum (Table 2). On the basis of these results and the limited sample size, we performed ANOVA using the variables sex, specialty, and years since training. After accounting for sex and years since training, a statistically significant association was not found between specialty (general internist vs subspecialist) and self-rated competence in medical interviewing (P = .162), and a marginally significant association was found between years since training (ie, more than one year) and self-rated competence (P = .055).

The average self-rated importance of the medical interview in the practices of the new faculty was 9.4 ± 1.0. Faculty who had completed their residency or fellowship training more than one year before beginning the curriculum rated the importance of the medical interview higher than did recent graduates (9.6 ± 0.6 vs 9.0 ± 1.3, P = .039). There were no statistically significant differences in self-rated importance of the medical interview according to sex, age, specialty, or perception of benefiting from the curriculum (Table 2). ANOVA was then performed using the variables sex, specialty, and years since training. After accounting for sex and specialty, a statistically significant association between years since training (ie, more than one year) and self-rated importance of the medical interview was present (P = .012).

New faculty rated their overall competence in interviewing lower than the importance of the medical interview to practice. Matched-pairs testing revealed a significant difference when comparing how faculty rated their overall competence in medical interviewing and how they rated the importance of the medical interview in practice (difference 1.7 [95% CI, 1.4–2.0], P < .001). Similar results were obtained by sex, age, generalist versus specialist, years since training, and perceived benefit of training (Table 2).

Several previous surveys have partially assessed preparedness and competence in physician-patient communication. For example, a survey of 210 graduates of an internal medicine training program rated the adequacy of their communication training significantly lower than the importance of those skills to clinical practice [16]. Several other surveys of graduates of internal medicine training programs had similar results [17–19]. Finally, in a telephone survey of 300 physicians, 92% rated effective communication as important; yet, 28% rated the adequacy of their training in physician-patient communication as fair or poor [20].

The results of our survey add to those of previous surveys in several important ways. First, whereas the previous surveys partially assessed physician-patient communication (eg, only one or two questions), our survey was focused entirely on this topic. Second, unlike previous surveys, ours focused on new internal medicine faculty at an academic medical center regardless of their age or previous experience. Third, we not only assessed self-rated importance of the medical interview to clinical practice and competence in medical interviewing among the new faculty, we also assessed self-rated confidence and perceived adequacy of previous training in 8 challenging physician-patient communication scenarios. Fourth, we specifically asked the new faculty whether they would benefit from additional training in physician-patient communication. Finally, unlike previous surveys, we analyzed our results according to sex, age, years in practice, and generalist versus subspecialty focus.

Our new internal medicine faculty rated the importance of medical interviewing relatively high. This high regard for medical interviewing is consistent with consensus statements [11, 12] that concluded effective physician-patient communication is an integral part of medical practice and the position of the ACGME that effective communication is a general competency important to all specialties [15]. However, our faculty also rated the importance of medical interviewing to clinical practice significantly higher than their competence in medical interviewing. There are several possible reasons for this difference. On the one hand, the difference may be true. The statistical analysis (matched pairs) compared the means of 2 related medical interviewing topics – self-rated importance of and competence in medical interviewing – from the same group of physicians. A higher rating for importance than for competence suggests a perceived educational gap. On the other hand, the difference may not be true, but rather reflect different scales of judgment. Although a 10-point scale was used for all the survey questions, directly comparing self-rated importance of with self-rated competence in medical interviewing assumes the scales themselves are comparable (ie, each particular value on the importance scale means the same on the competence scale). In other words, physicians may naturally rate the importance of medical interviewing higher than their competence in interviewing not because of a true difference but because the items being rated are different (ie, akin to comparing an apple to an orange).

Older (age >40 years) and more experienced new faculty (completed residency or fellowship training more than one year before beginning the communication curriculum) rated the importance of medical interviewing higher than younger new faculty and those who were recent graduates. One reason for these differences may be the relative lack of clinical experience (compared with that of more experienced physicians) among younger faculty and recent graduates for whom the value and centrality of the medical interview to clinical practice has not been fully realized. Another reason may be that physician-patient communication is not part of the formal curriculum, and trainees may graduate from their program with the conception that effective physician-patient communication is not as important as other skills. Indeed, training in communication skills is underemphasized during internal medicine residency training [16, 17, 19]. Finally, we found that more experienced new faculty rated their competence in medical interviewing higher than less experienced faculty. Over time, it is likely that physicians expand their repertoires of communication skills and competencies in using them. Indeed, communication skills may improve with time and experience alone [21].

Our new faculty rated the adequacy of their previous training in handling 8 challenging physician-patient communication scenarios relatively low. For each scenario, a significant percentage of variability of confidence in handling the scenario was associated with self-rated adequacy of previous training (Table 3). Although it is plausible that confidence in handling the scenarios is influenced by previous training, our study does not establish a causal relationship. An alternative explanation may be that confidence in handling the scenarios is influenced by learning and that the less confident faculty attributed their confidence to their previous training programs rather than their own learning.

Importantly, a majority (57%) of our new faculty specifically said they would benefit from additional training in physician-patient communication. These faculty also rated the adequacy of their training in handling six of the challenging physician-patient communication scenarios significantly lower than those who said they might or would not benefit from additional training (Table 4). These findings are important because many internal medicine faculty at academic medical centers not only care for patients, but also teach clinical skills, including communication skills, to medical students, residents, and other trainees [22]. Teaching these skills, however, requires qualified and willing faculty members [23].

Our results also suggest that many new internal medicine faculty may perceive a need for additional communication training. Such training may enhance clinical practice and teaching and role-modeling communication skills to trainees. In fact, evidence suggests that effective physician-patient communication skills can be taught and learned [24]. Furthermore, training may improve medical outcomes (eg, improving patient satisfaction and reducing patient emotional distress) [25–27]. A review of specific curricula that might be used to teach such skills is beyond the scope of this paper.

Our survey has a number of limitations. First, the results may not apply to institutions unlike ours and to physicians who are not general internists or internal medicine specialists. Second, the survey used data derived from self-reported ratings of physician competence, confidence, and adequacy of previous training in communication (not measures of actual competency such as assessments of actual interactions between physicians and patients). Also, they may be influenced by recall bias [16] and experiences during the time since training [18]. However, a previous study of physicians found that performance correlated with self-reported preparedness for clinical practice [28]. Third, the size of our cohort was relatively small. However, this size was similar to that of some of the studies discussed above.

Although new internal medicine faculty regard medical interviewing as important to clinical practice, they also rate the adequacy of their training in handling challenging communication scenarios relatively low. In fact, many faculty specifically stated they would benefit from additional training in physician-patient communication. These results should encourage academic medical centers to make curricula (ie, faculty development) in physician-patient communication available to their faculty because many of them not only care for patients, but also teach clinical skills, including communication skills, to trainees.