Development and introduction of a communication skills module for postgraduate students of ophthalmology.

Purpose: Effective communication lies at the heart of a patient--doctor relationship. Communication skills (CS) teaching and assessment is not a part of the postgraduate (PG) curriculum. Lack of effective CS in current PG students' results in patient distrust and dissatisfaction, conflicts, and compromised healthcare. The regulatory authorities of medical education have recognized the need to inculcate soft skills among medical graduates, one of which is CS. The purpose of this study was to assess the need for teaching CS to ophthalmology PG students and develop and introduce a module for the same.
Methods: In this prospective, interventional study done at the ophthalmology department of a tertiary hospital, a validated 8 day CS workshop was conducted for 60 PG students through interactive lectures, observations, video sessions, and role plays. Feedbacks were obtained through narratives, validated Google survey, reflections and verbal method and analyzed.
Results: In the needs assessment done on 27 departmental faculties, 20 faculties found poor communication to be a major reason for patient complaints. All faculties agreed that CS should be taught to medical students. Statistically significant improvement in CS awareness was noted among students after the workshop. Lack of CS training, work burden, and language were identified as main barriers to effective communication. All the students were satisfied with the workshop and wanted it to be conducted regularly.
Conclusion: This study establishes that CS training is essential to improve patient satisfaction and patient-doctor relationships. Barriers to effective CS could be identified, for which possible solutions could be found.

If knowledge of medicine, clinical acumen, and surgical expertise are the crafts of medical practice, soft skills are the necessary art. Unfortunately, traditional medical teaching imparts the students with theoretical and practical knowledge of diseases and their management but soft skills like ethics, professionalism, and communication are not taught formally. They are learnt by students only by willful and passive observation. Communications skills (CS) are a backbone over which lot of areas of patient care rest such as history taking, explaining treatment options and complications, taking consent, counseling and advising follow-up. Studies have shown that 60--80% diagnoses and treatment decisions can be made only by careful history taking.[1]

Better communication between a doctor and patient builds confidence, improves patient compliance, and reduces medical errors, thereby reducing conflicts and litigations and ultimately culminating into improved healthcare outcomes.[2]

A review of the courses of different degrees of medicine shows that soft skills are not included in the formal curriculum of medical education.[3] CS training also requires specific content and teaching techniques that quite differ from those used to teach traditional medical subjects.[4] In spite of these limitations, it has been found that effective communication can be easily taught and practiced.[5]

Keeping these points in mind, a module was designed, as a pioneering project in our college, to sensitize the postgraduate (PG) students of ophthalmology and increase their awareness towards CS in an attempt to improve their overall clinical competence. The objectives of the study were to assess the need for teaching CS to PG students of ophthalmology, develop and introduce a validated module for teaching CS and which could possibly be implemented in all disciplines of medical education, increase the awareness of the PG students about CS, determine their perception regarding the module, and identify barriers to effective communication among them.

Methods

This was a prospective, interventional study done in the ophthalmology department of a tertiary hospital and medical college from February to December 2018. The study participants (60) were all the PG students studying in the ophthalmology department during June 2018. Their enrollment and obtaining informed consent was done from 17 to 19 June 2018 through an online form [Annexure I].

After permission from the Dean of the College and Head of the Ophthalmology Department to conduct the project, a Gantt's chart was prepared. A core faculty team comprising of four assistant professors and one senior resident of the ophthalmology department was formed to assist in module designing and implementation. Literature was extensively reviewed, a CS module was designed and questionnaires and feedback forms were prepared and validated. The project was submitted to and approved by the Institutional Ethics Committee.

The link for online (Google) needs assessment questionnaire was sent to all departmental faculty (27) by mail and WhatsApp [Annexure II]. The responses were analyzed. The module design was found to be in synchrony with the faculty responses.

Scenarios for video sessions and role plays were discussed and finalized. The scenarios focused on history taking, patient counseling, breaking bad news, and managing aggressive patient and relatives. The video clips were taken from YouTube and from various Bollywood Hindi movies. Appropriate editing of the video clips was done. The role plays were performed by the core team with frequent rehearsals.

The detailed schedule of module implementation is shown in Table 1. The duration of the entire workshop was 8 days, with the duration of each session being about 1.5 h. All responses were entered in Microsoft Excel sheet. Calculation of numbers, percentages, means, medians, significance calculation using Wilcoxon Signed-Rank Test, “Chi-square” test and paired “t” test where applicable was done. Transcripts were prepared for all qualitative data. These were then analyzed and segregated according to content, codes, and themes.

Table 1

Workshop schedule for communication skills training of postgraduate students of Ophthalmology

Date and Day	Time	Teaching Learning method	Remarks
21st June 2018, Thursday	5-6.30 pm	Observations	The pre-workshop activity was explained to the participants
			Observation was done by all students for one randomly selected departmental colleague whose identity was kept confidential, from CS perspective, for subsequent 2 days during working hours
23rd June 2018, Saturday	1-2.30 pm	Narratives	The students were briefed about writing of narratives. Submission of the observations was done as narratives
25th June 2018, Monday	5-6.30 pm	Interactive Lectures	Introduction and sensitization to the workshop
			An overview, Need to learn CS, Types of CS
26th June 2018, Tuesday	5-6.30 pm	Video session	Students were divided into six random groups
			Video clips displaying different types of CS were displayed followed by intragroup discussions, group presentations, and subsequently large group discussions
27th June 2018, Wednesday	5-6.30 pm	Video session	Same as above
28th June 2018, Thursday	5-6.30 pm	Role plays	Predesigned role plays were performed by the core team, depicting improper/poor communication followed by intra group discussions, group presentations, and large group discussions
29th June 2018, Friday	5-6.30 pm	Role plays Observations	Role plays were done by the students on same scenarios depicting improved/better communication
			Repeat observation (of same previous colleague) was done during working hours for one day
30th June 2018, Saturday	1-2.30 pm	Narratives, Google feedback survey [Annexure III], Reflections, Verbal Feedback.	Submissions of post workshop observations were done in form of Narratives
			The students were briefed about reflections and then instructed to write the same for the workshop.
			Feedback was taken through an online Google feedback survey [Annexure III]
			Verbal feedback was also taken and was video recorded with prior consent of the students [Annexure I]

Results

Needs assessment of faculty

All 27 faculty of the ophthalmology department responded to the survey (100% response rate). Among them four (14.8%) were professors, seven (25.9%) were associate professors, 15 (55.6%) were assistant professors, and one (3.7%) was a tutor. Their teaching experience ranged from less than 5 years to more than 15 years, with 11 (40.7%) faculty having more than 15 years’ experience [Annexure II].

Ninety-three percent faculty (25) agreed that learning CS can be helpful in professional as well as personal life. Two were unsure of the same. Regarding the importance of body language, dressing, tone of conversation, and use of personal space when interacting with patients, the faculty ranked them on a scale of 1--4, where 1 depicts least important and 4 the most, as shown in Fig. 1. Twenty-six (96.3%) faculty opined that students quite often make matters worse while trying to resolve a conflict with a patient. Twenty faculty (74.1%) found an increase in the incidence of complaints arising due to patient dissatisfaction because of poor communication with them. Four (14.8%) were unsure of the same.

Figure 1

Faculty ranking of body language, dressing, tone of conversation, and use of personal space during communication in order of their importance (n = 27)

The responses obtained regarding the importance of CS in medical practice and their current status in medical education are shown in Fig. 2. Responses obtained regarding their perception of skills of communication among the current ophthalmology PG students are shown in Fig. 3. Barriers of communication among ophthalmology PG students were identified among which workload (18 responses), lack of training (13 responses), and language (9 responses) were found to be the most common ones [Table 2]. Following suggestions for improving CS among the students were shared among which the most common was to provide training for the same (19 responses) [Table 3].

Figure 2

Faculty perception about importance of communication skills in medical practice and its current status in medical education (n = 27)

Figure 3

Faculty perception about communication skills in current ophthalmology postgraduate students (n = 27)

Table 2

Faculty responses for barriers of communication among Ophthalmology postgraduate students

Student related	Teacher related	Curriculum related	Administration related	Patients related	Others Others
• Workload	• Lack of training	• Lack of training	• Workload	• Differences in perception	• Individual upbringing
• Language		• Absence of soft skills assessment	• Environment
• Lack of empathy			• Discipline
• Lack of interest		• Exam oriented education
• Differences in perception
• Stress
• Lack of

Table 3

Faculty suggestions to improve communication skills among Ophthalmology postgraduate students

Student related	Teacher related	Curriculum related	Administration related	Others
• Work management	• Provide proper training	• Inclusion of communication skills teaching in curriculum	• Availability of social workers for crisis management	• Spiritual Workshops
• Command over local language	• Role modelling by teachers	• Early exposure to communication skills	• Work management
• Faith in self and system	• Constant supervision

Student feedback after completion of the workshop

Fifty-seven students responded to the Google survey [Annexure III], among whom 22 (38.6%) belonged to year I, 23 (40.4%) to year II, and 12 (21.1) to year III of ophthalmology PG and 36 (63.2%) were girls and 21 (36.8%) were boys. Eleven students agreed to have problems in communicating in local language with the patients. All the students agreed to the fact that CS is important in medical practice. Rating of awareness regarding CS, on a scale of 0-10, showed an improvement after the workshop as seen in Fig. 4. Following the workshop, the median increased from 7 to 9, on a scale of 0-10. According to Wilcoxon Signed-Rank Test, the value of z was −6.3586 with a P value < 0.00001. The result is significant at P < 0.05.

Figure 4

Students’ rating of their awareness about communication skills before and after the workshop, on a scale of 0--10. (n = 57)

Perception of improvement of CS before and after the workshop was noted while eliciting history from patients, discussing treatment with them, confidently interacting with them and communicating with them in a way that they easily understood. Using the Chi-square test, a statistically significant improvement was noted, with P < 0.0001 in all four situations.

Gender wise, there was a statistically significant improvement noted in awareness regarding CS after the workshop among girls (P = 4.2 × 10-14) as well as boys (P = 1.1 × 10-5). The average ratings in girls changed from 5.4 to 8.4 after the workshop and in boys from 6.04 to 8.60 (on a scale of 0--10).

In similar analysis according to year of PG, year I, II, and III all showed improvement in awareness after the workshop (P = 7.2 × 10-9 for I years, 2.7 × 10-7 for year II and P = 0.000155859 for III year). The average ratings provided by year I, II, and III were 5.68, 6, and 4.63 before the workshop which increased to 8.63, 8.56, and 8.09 after the workshop, respectively.

All the students were satisfied with the objectives, duration, execution, and relevance of the workshop. Their median rating was 5,4,5,5, respectively where 5 related to strong agreement, 4 to agreement, 3 to neutral, 2 to disagreement, and 1 to strong disagreement. The satisfaction index for each was 92.63%, 83.85%, 91.57%, and 91.22%, respectively. The workshop was rated an average of 8.59 by the students, on a scale of 0-10, 0 being the least and 10 being the highest rating. The satisfaction index was 84.48%. The students ranked the workshop sessions on a scale of 0--5, where 0 meant not useful and 5 meant maximally useful, as shown in Fig. 5. Role plays were rated to be the most useful and effective followed by video sessions. Although 11 students were unsure whether they wanted such a CS module to be a part of their curriculum, 44 definitely wanted it. The probability that the students would recommend these sessions to other students was an average of 8.73, on a scale of 0 to 10.

Figure 5

Students’ rating of the usefulness of sessions, on a scale of 0-5. (n = 57)

The barriers to communication were found to be similar to those identified by faculty, with over work being the chief barrier among students also (12 responses).

Qualitative data analysis

All the above responses matched with qualitative analysis of the verbal feedbacks of students. Reflections were analyzed from the perspective of appropriateness of reflective writing[6] [Fig. 6] as well as qualitatively through coding, categorizing, and thematic analysis [Fig. 7].[7] Analysis of narratives showed that there was improvement in awareness regarding various components of CS. Aspects of communication which were completely unobserved or considered unimportant prior to the workshop were carefully noted during the post-workshop observation period [Fig. 8].

Figure 6

Analysis of reflective writing of students[6] (n = 57)

Figure 7

Content analysis of Reflective writing of students[7] (n = 57)

Figure 8

Components of communication skills which were observed only after the workshop, as mentioned in student narratives

The students have been very receptive to the module. They expressed their concern that such one time workshops may not lead to long-term behavioral changes and have requested for repeat sessions to be conducted at regular intervals. During observations, not only had the students observed their colleague closely for their CS but also the narratives showed that it also made many of them reflect on their own behavior and communication. This helped them to identify their own strengths and weaknesses which further helped them to develop corrective measures. Few students accepted that reflection was an interesting and effective way to enhance and reiterate the learning. Students enthusiastically enacted the role plays and found it to be the most effective and realistic way of teaching [Figs. 9 and 10]. They discussed their concerns and obstacles to effective communication and freely asked for advices and solutions. Two students also considered this as an important opportunity for large group peer interaction.

Figure 9

Role Play by faculty

Figure 10

Role play by students

Discussion

Good physician communication can itself have therapeutic value.[8] Beyond improving diagnostic accuracy, patient satisfaction, and adherence to treatment, it has been shown to influence patient psychology and day-to-day functioning.[8]

Based on an extensive review of the literature, we realized to the best of our knowledge that not much has been done for teaching CS to PG students. The objective of the present study was therefore the development, validation, implementation, and evaluation of a module on CS for ophthalmology PG students.

Effective communication has been accepted as a core competency for medical practitioners.[5] Inculcating habits of good CS during formative years will help the medical students and future practitioners. Regular courses on effective communication should be included in the medical education curriculum. Student's positive attitude toward learning CS indicated that there is a necessity of CS training during undergraduate years. These essential soft skills can be learned during the formative years and practiced to perfection over the years.[5] A similar positive attitude was also demonstrated during our workshop. Furthermore, in our study, maximally increased awareness among first year students places emphasis on early exposure to soft skills training.

Our study showed that students’ skills and confidence in communicating with patients increased after training. This was also observed in various other studies.[59] A study done by Mishraet al. showed that there is an opportunity to improve CS training in ophthalmology residency through formalized curriculum.[10] Another study done by Zakrzewskiet al. also supports that formal CS training in breaking bad news should be included during ophthalmology residency.[11] Aspegren in his guide on CS stated that CS can be taught at courses, are learnt, but are also easily forgotten if not maintained by practice.[12] This concern was also shared by our students.

Needs assessment by faculty showed that these soft skills can be imparted to medical students by the faculty, practiced to increase competency, used to build doctor--patient relationships and enhance health outcomes. This was also stated in a study published by Modi et al.[13]

Gathering all the students at the same time for 8 days beyond the working hours was a tough task. Constant reminders and motivation to the students from the core team helped to tackle this challenge effectively. Due to other departmental responsibilities and emergency duties, complete punctuality for the entire duration of workshop was not possible for all students though this did not seem to have any effect on the learning process or responses.

Conclusion

To conclude, CS have been stated by all the faculty to be a core clinical skill. Lack of effective CS was identified as an important reason for patient dissatisfaction and conflicts. All the faculty agreed that CS should be taught to the PG ophthalmology students. Significant improvement in awareness regarding CS was noted among the students after the workshop. Desire to include such a module in the curriculum was expressed by majority of the students. Barriers to effective CS could be identified, chief ones being lack of training in CS, workload and language, for which possible solutions could be found. This module may open the path to development of modules for other soft skills which can further help to establish the platform for competency-based medical education and maybe a stepping stone in the direction towards better patient communication and improved patient--doctor relationships.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

SR. NO.	Name	Gender	Year of study	Mobile no.	Email id