Needs assessment for a curriculum for difficult conversations in a neurology residency training program in China

Background Communication skill is a core competency in neurology residency training. Specific training in this area at the residency level is often lacking, especially regarding difficult conversations. The aim of this study is to evaluate the current state in which neurology programs in China teach residents about difficult conversations and determine whether there is a perceived need for a formalized educational curriculum in this field. Method An anonymous, 27-question, cross-sectional online survey addressing difficult conversations for neurological residents were distributed to five grade-A, class-3 hospitals selected from the affiliated teaching hospitals of medical schools qualified to provide neurology residency training in China. Results A total of 182 residents responded to the survey, and the response rate was 67.16% (182/271). Of the participants, 84.6% were female and the average age was 26.8 years. The majority of respondent residents (n=168; 92.31%) reported being exposed to at least one difficult conversation in their medical careers. Only 43 (23.63%) participants reported having previously received formal communication skills training. In comparison with residents without previous training, those with previous training indicated significantly more confidence(P=0.003)and were under lower pressure(P=0.037) in managing difficult conversations. Only 97 (53.3%) residents indicated interest in receiving formal training. Time, lack of enthusiasm, lack of educational materials and faculty expertise were commonly cited barriers to formalized training. Conclusion This survey provides a contemporary assessment of the current status of education on the topic of difficult conversations in neurology residency training. Our results suggest that there is an unmet need to further develop and implement educational activities by teaching residents to lead difficult conversations. Targeted communication curriculum in difficult conversation should be further developed and implemented for the neurological residents in China.

and difficult communication with patients, families, and colleagues. Evidence has shown that effective communication could reduce adverse events and improve patients' satisfaction and adherence to treatment 2, 3 . Thus, practicable and effective training on this topic is important.
The Chinese Medical Association, under the commission of the Ministry of Health, released mandatory residency training standards in 2012, and the government implemented a plan for the nationwide initiation of 3-year standardized residency training programs beginning in 2015 4 .The aim of the training programs for residents is to develop competency-based curricula to improve the quality of training 5 . However, most of the curricula focus on delivering medical knowledge related to specific diseases 6 . Communication skills training is primarily informal, leaving the majority of residents poorly equipped to manage difficult conversations. There has not yet been a formal evaluation of the state of training in difficult conversations in neurology residency programs in China. Therefore, the objective of this study is to evaluate the current state in which neurology programs in China teach residents about difficult conversations and determine whether there is a perceived need for a formalized educational curriculum in this field.

Methods
We developed an anonymous, cross-sectional online survey addressing difficult conversations for neurological residents. These questions overlapped across multiple resources, including the Accreditation Council for Graduate Medical Education (ACGME) guidelines for communication skills training in neurology residency, educational milestones for neurology residencies, and topics from a review of the literature 7,8,9 . The survey included Likert-style questions, multiple choice questions, and free-text boxes for qualitative responses. All questions were optional, and completion was not required to end the survey. The residents' survey consisted of 27 questions (the full survey is available in Supplement 1). The questionnaire included the following areas: 1) basic demographic data, 2) resident's knowledge, experience, and confidence regarding the management of difficult conversations, 3) previous formal training in communication skills during neurology residency, and 4) interest in receiving training on difficult conversations and barriers to implementation. The surveys were distributed and collected using the electronic online survey tool Wenjuanxing (www.wjx.cn, China).
Surveys were distributed to five accredited neurology residency programs in China. The five hospitals were all grade-A, class-3 hospitals selected from the affiliated teaching hospitals of medical schools qualified to provide neurology residency training in China. An introductory letter that described the rationale and objective of the study was emailed to program directors for participation. Program directors were asked to distribute the survey to their residents to avoid direct contact between the authors and the residents. Informed consent was assumed if the respondent chose to complete the questionnaire.

Statistical analysis
Statistical analyses were performed using SPSS version 19.0 for Windows (SPSS Inc.). All p values were two-tailed and criteria for significance were p<0.05. Standard descriptive statistics were used.
Comparison between residents with and without previous training were performed using analysis of variance followed by Fisher LSD post hoc tests.

Results
From the number of residents in the five programs, it is assumed that the surveys were distributed to 271 residents. A total of 182 residents responded to the survey; therefore, the response rate was

Residents' demographic characteristics
The demographic features of the 182 resident respondents are listed in Table 1. Of the participants, 84.6% were female, which is likely representative of the current gender ratio in neurology training programs in China. The average age was 26.8 years. Residents from all postgraduate year (PGY) levels, from PGY1 to PGY5, completed the survey.    or unsatisfied patients and their families, disclosing bad news, and disclosing medical errors, which might be different from findings from other countries. As is well known, the physician-patient relationship in China is highly strained 10 . Therefore, managing difficult patients and their families might be the most stressful aspect of work for our clinicians, especially for inexperienced residents.

Previous formal training in communication skills during neurology residency and the correlation with confidence in managing difficult conversations
Our results identified specific target areas in difficult conversations for neurology residency programs in China and provide evidence for developing future targeted curriculum in difficult conversations.
Communication skills curricula and training have been increasingly described in a number of other medical fields, including internal medicine and oncology. Curricula in these fields and others have shown that communication skills can be taught and measured 11,12 . Our study showed that residents who received prior formal communication skills training had more confidence and faced less stress when they encountered difficult conversations, which was consistent with previous findings. A few studies in neurological communication skills training have offered some evidence-based templates for curriculum development 13,14 . The next step is to develop and implement a formal target curriculum in difficult conversations for Chinese neurology residency programs. At the end of training, residents should be prepared to effectively communicate complex and difficult information to patients and families.
Our results noted barriers in developing and implement difficult conversation training including emotions, fears, time constraints, and a lack of opportunity; these are similar to results have been described previously in other medical and surgical specialties 15    Confidence of the residents in dealing with a difficult conversation independently  Can communication skills in difficult conversations be improved by formal training? Figure 6 Frequency of feedback form the faculty after dealing with a difficult conversation Supplementary Files