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A Standardized Patient Model to Teach and Assess Professionalism and Communication Skills: The Effect of Personality Type on Performance

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A Standardized Patient Model to Teach and Assess Professionalism and Communication Skills: The Effect of Personality Type on Performance
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  ORIGINAL REPORTS   A Standardized Patient Model to Teach and Assess Professionalism and CommunicationSkills: The Effect of Personality Typeon Performance Scott D. Lifchez, MD, and Richard J. Redett III, MD  Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore,Maryland INTRODUCTION:  Teaching and assessing professionalismand interpersonal communication skills can be more dif  󿬁 -cult for surgical residency programs than teaching medicalknowledge or patient care, for which many structured educational curricula and assessment tools exist. Residentsoften learn these skills indirectly, by observing the behavior of their attendings when communicating with patients and colleagues. The purpose of this study was to assess theresults of an educational curriculum we created to teach and assess our residents in professionalism and communication. METHODS:  We assessed resident and faculty prior educa-tion in delivering bad news to patients. Residents thenparticipated in a standardized patient (SP) encounter todeliver bad news to a patient ’ s family regarding a severeburn injury. Residents received feedback from the encoun-ter and participated in an education curriculum on com-munication skills and professionalism. As a part of thiscurriculum, residents underwent assessment of communi-cation style using the Myers-Briggs type inventory. Theresidents then participated in a second SP encounter discussing a severe pulmonary embolus with a patient ’ sfamily. RESULTS:  Resident performance on the SP evaluationcorrelated with an increased comfort in delivering bad news.Comfort in delivering bad news did not correlate with theamount of prior education on the topic for either residentsor attendings. Most of our residents demonstrated anintuitive thinking style (NT) on the Myers-Briggs typeinventory, very different from population norms. DISCUSSION:  The lack of correlation between comfort indelivering bad news and prior education on the subject may indicate the dif  󿬁 culty in imparting communication and professionalism skills to residents effectively. Understanding communication style differences between our residents and the general population can help us teach professionalismand communication skills more effectively. With the nextaccreditation system, residency programs would need todemonstrate that residents are acquiring these skills in their training. SP encounters are effective in teaching and assessing these skills. (J Surg 71:297-301. J C  2014 Associa-tion of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.) KEY WORDS:  standardized patient, Myers-Briggs, com-municating bad outcomes, surgical complications COMPETENCIES:  Professionalism, Interpersonal and Com-munication Skills, Practice-Based Learning and Improvement INTRODUCTION Professionalism and interpersonal communication are 2 of the 6 core competencies as required by the AccreditationCouncil for Graduate Medical Education for all specialties. 1 Unlike medical knowledge and patient care, which can bereliably measured with in-training ex aminations and objec-tive standard clinical examinations, 2 education and assess-ment of professionalism and communication skills is moredif  󿬁 cult to do. 3 Professionalism is often taught in a nonformal manner,commonly referred to as the  “ hidden curriculum, ”  whereresidents learn professionalism by observing how their attendings behave in the clinical setting. 4 More structured techniques for education in professionalism have beenshown to be more effective than the passive  “ hiddencurriculum. ” 5 To address this need for education inprofessionalism and interpersonal communication skills,residency programs have developed more formal curricula  Correspondence  : Inquiries to Scott D. Lifchez, MD, FACS, 4940 Eastern Ave, A Building Room 520, Baltimore, MD 21224; fax:  þ 1-410-550-1808; e-mail:slifche1@jhmi.edu  Journal of Surgical Education    &   2014 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.1931-7204/$30.00 http://dx.doi.org/10.1016/j.jsurg.2013.09.010  297   to teach their trainees these skills, including some that usestandardized patients (SPs) for this purpose.The principle situation in which surgeons demonstrateprofessionalism is in communication. The importance of effective communication can have a direct effect on patientcare and outcomes. Better patient communication canimprove not only comfort and satisfaction, 6 but it can alsodecrease the frequency of legal action even in the setting of a poor outcome. 7,8 Many authors have designed curricula toteach these critical skills, and the results have beenencouraging. 9,10 In the present study, the authors developed a SP moduleto teach and assess our residents ’  skills in professionalismand interpersonal communication competencies. The pur-pose of this study was to assess the skills of plastic surgery residents in professionalism in a SP encounter of delivering bad news to the patient ’ s family members. METHODS Residents were surveyed for their prior education incommunicating ba d  news to patients. We adapted theOrgel questionnaire 11 to assess residents ’  comfort in deliv-ering bad news and self-rated ability to do so. Faculty alsocompleted this questionnaire. All postgraduate-2 and higher residents in our training program participated in a SP encounter at the start of thismodule. In this scenario, residents were speaking to thefamily of a child who sustained burns on 80% of total body surface area, including discussing that the child may die of his injuries. After conclusion of the encounter, residentsreceived direct feedback from the SP. The SP discussed areas where the resident communicated effectively and demonstrated professionalism as well as areas whereimprovement was needed.Residents and faculty participated in a seminar onprofessionalism and communication skills. As part of thissession, resid ents completed the Myers-Briggs type inven-tory (MBTI) 12 to assess personality differences, as theseaffect perception, decision making, and communication.Based on answers to this standardized questionnaire,respondents were grouped into extroverted (E) vs. intro-verted (I); sensing (S) vs. intuitive (N); thinking (T) vs.feeling (F); and perceiving (P) vs. judging (J). In theseminar, we discussed how preferences identi 󿬁 ed in thistest can affect how the resident communicates in thehospital setting.The residents participated in a second SP encounter approximately 1 year after the  󿬁 rst one. In this scenario,residents were speaking to the spouse of a patient whosuffered a massive pulmonary embolus after postbariatricbody-contouring surgery. After the encounter, residents were asked to rate their own performance using theKalamazoo Consensus statement 13 modi 󿬁 ed for a surgicalencounter. The SPs also rated the resident on this samescale. After these assessments were completed, the SP againprovided qualitative feedback to the resident regarding his/her performance. Speci 󿬁 cally, the SP identi 󿬁 ed and dis-cussed instances within the encounter in which the residentcommunicated well or poorly in response to the SP ’ sdemonstrated emotional needs. SPs also emphasized moments in the encounter in which the resident used language that was too technical, particularly when itappeared to the SP that the resident was doing so to mask his/her discomfort with discussing this information. All statistical analyses were performed using the MicrosoftExcel 2007 internal statistics package (Redmond, WA) withthe exception of interrater reliability. Krippendorff alpha  was used to assess interrater reliability for ratio data and wasperformed using ReCal (http://dfreelon.org/utils/recalfront/recal-oir/). RESULTS Overall, 17 residents completed the questionnaire on prior education in delivering bad news and participated in the SPsessions (Table); while 23 faculty members completed thequestionnaire.Self-reported comfort in delivering bad news did notcorrelate with the number of previous education sessions ondelivering bad news that they had received. This was truefor both residents and faculty. The mean comfort level of residents who received up to 10 sessions (including 2 resi-dents who reported receiving 0 sessions) was not signi 󿬁 -cantly different from that of residents who reported receiving 11 or more sessions (8.1 vs. 9.2 of 10, p  ¼ 0.24). Most of the prior education sessions had beenreceived in medical school or previous residency training (e.g., independent track residents who had completed general surgery training at another institution before begin-ning plastic surgery training at our institution). Prior sessions ranged from discussions with faculty members toformal seminars. None of the faculty members had received more than 10 education sessions in delivering bad news, and only 3 reported receiving more than 2 education sessionsduring their medical school and residency training. Despitethis, all but 3 of the faculty rated their comfort and ability to deliver bad news at 8 of 10 or higher.Resident self-reported comfort in delivering bad news did correlate with performance on the SP encounter. Thoseresidents who rated their comfort as 10 of 10 ( n  ¼  9) rated their performance on the patient encounter as better thanthose who rated their comfort as less than 10 of 10 (4.17 vs.3.52 of 5, p  ¼  0.035, Student  t   test). The SPs also tended to score the residents who rated themselves as morecomfortable delivering bad news higher than the residents who rated themselves as not as comfortable, but this 298 Journal of Surgical Education    Volume 71/Number 3    May/June 2014  difference did not reach statistical signi 󿬁 cance (4.65 vs. 4.07of 5, p  ¼  0.12, Student  t   test).Resident performance in the SP encounter also correlated  with the level of training. Residents with 6 or more years of training after medical school ( n  ¼  8) performed better onthe SP encounter. Self-assessed performance was better for the group with more years of training (4.04 vs. 3.67 of 5, p ¼  0.037, Student  t   test). The SPs also rated the senior resident group higher than the junior group (4.57 vs. 4.17of 5, p  ¼  0.003, Student  t   test). Interobserver reliability wasbetter between faculty and SP (0.837) than resident and SP(0.449) or resident and faculty (0.741).The MBTI demonstrated several trends in our residents.Of the 17 residents, 12 (71%) fell in the intuitive (N) ascompared with 5 in the sensing (S) type; 13 (76%) were inthe thinking (T) group vs. 4 in the feeling (F) group. Of the17 residents (59%) who completed the MBTI, 10 had thecombination of intuitive (N), thinking (T), and judging (J).Only 7 residents (41%) did not have the NT combination(3 ST, 2 SF, and 2 NF). DISCUSSION  With the next accreditation system scheduled to go live for some surgical specialties (neurosurgery, orthopedics, and urology) in 2013 and the remainder in 2014, programs would need to demonstrate that they are educating their residents in professionalism and interpersonal communica-tion and demonstrate their residents ’  pro 󿬁 ciency in thesecompetencies more concretely than they have in the past. Inplastic surgery, 36 milestones have been developed  to track the progress of a resident through his/her training. 14 Four of these milestones speci 󿬁 cally assess pro 󿬁 ciency in interper-sonal communication or professionalism or both.Previous studies have demonstrated the effectiveness of SPs in assessing  resident ’ s skills in communication. Posner and Nakajima  15 demonstrated improved performance by obstetrics (OB)/gyn residents evaluated by SPs after formalteaching sessions on disclosing adverse events to a patient.Davis and Lee 16 used a SP encounter to assess all 6 corecompetencies using delivery of a melanoma diagnosis as a model. The 6 residents in their study were assessed by SPsand faculty. Resident performance scores correlated withtheir level of training. In both these studies, the SPexamination was used for both assessment and as a meansto educate the resident via structured feedback, as was donein our study.Communication style has a very direct effect on how patients and their families would perceive the q uality of communication they have received. Cousin et al. 17 found a correlation between  “ high-caring  ”  and   “ high-sharing  ”  physiciancommunication and increased patient satisfaction. However, intheir study, a computer model was used to demonstrate thesebehaviors rather  than actual human communication.Clack et al. 18 assessed differences in MBTI betweenmedical school graduates and a large population sample inthe United Kingdom. In general terms, preferred commu-nication styles for each group are as follows: ST prefersdetails and structure/rules, SF prefers details and humanity/compassion, NF prefers concepts and humanity/compas-sion, NT prefers concepts and structure/rules. 19 In theClack study, nearly 80% of the population preferred sensing (S) to intuition (N), whereas the medical school graduates were split relatively equally between the 2 groups. Nearly allthe variables tested and combinations thereof were signi 󿬁 -cantly different for the doctors compared with the popula-tion. The authors caution that these differences can have a major in 󿬂 uence on how patients perceive communication TABLE.  All Data for Residents ’  Prior Experience and Comfort in Delivering Bad News, MBTI Score, and Performance on theStandardized Patient Encounter. PG Year is Calculated as Years Since Completion of Medical School. Number of Residents per PGYear is Unequal Because Some Residents had Prior Residency Training (in General Surgery) and Some Spent a Year in the Laboratory PGY Number of PriorTeaching sessions MBTI Type Comfort Self-Score SP Score Faculty Score 2 3 ESTJ 10 3.89 4.44 4.222 0 INTJ 10 4.44 5 4.892 0 ESFP 10 4.11 3.78 43 3 INTJ 9 3.00 4.22 3.443 3 ENFP 8 3.56 5 54 3 INTJ 5 4.00 5 4.784 2 ENTJ 4 2.78 2.56 2.675  4 10 INTJ 9 3.56 3.33 3.445 3 ESTP 10 3.00 4.67 3.786  4 10 ENTJ 10 4.33 4.44 46  4 10 INTJ 10 4.22 4.89 56 3 ESTJ 10 5.00 5 56  4 10 INTJ 6 3.78 3.67 46 3 ENTJ 7 4.56 5 47 2 ENTJ 8 2.89 3.78 48 3 ISFJ 10 4.44 4.89 4.788 3 ENFJ 10 4.11 4.78 5  Journal of Surgical Education    Volume 71/Number 3    May/June 2014  299   with physicians, particularly in the setting of receiving bad news.In our residents, intuitive thinking (NT) was the mostcommon combination of scores (59%, 10 of 17 residents)for how the residents perceive the world and makedecisions. This differs markedly from the study by Katzet al. 20  who found this combination in only 35% of medicalschool graduates beginning residency in surgery, 9% of those going into OB/gyn, and 27% of those going intointernal medicine. In our residents, only 18% (3 of 17residents) demonstrated the ST preference as compared with38% of residents going into surgery, 23% going into OB/gyn, and 33% going into internal medicine in the Katzstudy. This difference may represent disparity in residentsseeking training in plastic surgery as compared with generalsurgery, or it may be because of those preferring anacademic residency program to a community-based program.In the Clack study, the NT combination occurred in10% of the population as compared with most of our residents who demonstrated this preference. This preferencemay pose a challenge when speaking to an SF (43% of thepopulation in the Clack study) patient who might prefer details with emotional support to the big picture, moreabstract message that an NT speaker might tend to deliver.Recognizing and adapting to the patient/family  ’ s preferred communication style can have a large protective effect for the physician fr om a medicolegal standpoint when bad outcomes occur. 7,8 Conversely, failure to do so can havedisastrous consequences.Faculty in our program uniformly reported minimal formaltraining in communicating bad news to patients. Despite this,they uniformly reported high comfort in performing this task.This high comfort in the absence of formal training in thedelivery of bad news may indicate our own limitations inteaching our residents these skills or the con 󿬁 dence that NTsnaturally feel in their decision-making ability. It may alsohighlight the NT ’ s lack of understanding of the emotionalneeds of patients during dif  󿬁 cult times. This  󿬁 nding empha-sizes the need for formal programs such as the one we havecreated to help surgeons better understand the naturalcommunication preferences of people who are not like them.There are several limitations to our study. As only 1 program at 1 institution was assessed, these  󿬁 ndingscannot be interpreted to represent all surgical trainees or even all plastic surgery trainees. Even using a standardized rating system such as the modi 󿬁 ed Kalamazoo Consensusstatement, there is still some risk of subjectivity when the SPor faculty member rates the resident or the resident rateshimself/herself. Finally, the MBTI may not fully representall factors or preferences of the resident in communicating  with patients and their families.Despite these limitations, the authors feel that this SPeducation module is a simple and effective method for teaching residents professionalism and interpersonalcommunication as well as assessing their skills in thesecompetencies. We also recommend use of the MBTI as a means to better understand the resident ’ s preferred method of communication and to guide his/her education incommunication skills for these dif  󿬁 cult conversations. Wehave incorporated these modules into our annual residenteducation curriculum.  ACKNOWLEDGMENT The authors would like to thank Linda Dillon Jones, PhD,for her assistance with administration and interpretation of the MBTI. REFERENCES 1.  Antiel RM, Thompson SM, Hafferty FW, et al. Duty hour recommendations and implications for meeting the ACGME core competencies: views of residency directors.  Mayo Clin Proc  . 2011;86:185-191. 2.  Son J, Zeidler KR, Echo A, Otake L, Ahdoot M, LeeGK. Teaching core competencies of reconstructivemicrosurgery with the use of standardized patients.  Ann Plast Surg  . 2013:11 ([Epub ahead of print]). 3.  Symons AB, Swanson A, McGuigan D, Orrange S, Akl EA. A tool for self-assessment of communicationskills and professionalism in residents.  BMC Med Educ  . 2009;9:1-7. 4.  Gofton W, Regehr G. What we don ’ t know we areteaching: unveiling the hidden curriculum.  ClinOrthop Relat Res  . 2006;449:20-27. 5.  Iramaneerat C. Instruction and assessment of profes-sionalism for surgery residents.  J Surg Educ  . 2009;66:158-162. 6.  Stewart MA. Effective physician-patient communica-tion and health outcomes: a review.  CMAJ  . 1995;152:1423-1433. 7.  Huntington B, Kuhn N. Communication gaffes: a root cause of malpractice claims.  Proc (Bayl Univ Med Cent) . 2003;16:157-161. 8.  Robbennolt JK. Apologies and medical error.  ClinOrthop Relat Res  . 2009;467:376-382. 9.  Hochberg MS, Kalet A, Zabar S, Kachur E, GillespieC, Berman RS. Can professionalism be taught?Encouraging evidence  Am J Surg  . 2010;199:86-93. 10.  Deptula P, Chun MB. A literature review of profes-sionalism in surgical education: suggested componentsfor development of a curriculum.  J Surg Educ  .2013;70:408-422. 300 Journal of Surgical Education    Volume 71/Number 3    May/June 2014  11.  Orgel E, McCarter R, Jacobs S. A failing medicaleducational model: a self-assessment by physicians atall levels of training of ability and comfort to deliver bad news.  J Palliat Med  . 2010;13:677-683. 12.  Available at:  〈 http://www.humanmetrics.com/cgi-win/ jtypes2.asp 〉  Accessed January 21, 2013 – February 02,2013. 13.  Makoul G. Essential elements of communication inmedical encounters: the Kalamazoo consensus state-ment.  Acad Med  . 2001;76:390-393. 14.  Available at: http://www.acgme-nas.org/assets/pdf/Milestones/PlasticSurgeryMilestones.pdf  Accessed June 29,2013. 15.  Posner G, Nakajima A. Assessing residents ’  communica-tion skills: disclosure of an adverse event to a standardized patient.  J Obstet Gynaecol Can . 2011;33:262-268. 16.  Davis D, Lee G. The use of standardized patients inthe plastic surgery residency curriculum: teaching corecompetencies with objective structured clinical exami-nations.  Plast Reconstr Surg  . 2011;128:291-298. 17.  Cousin G, Schmid Mast M, Roter DL, Hall JA.Concordance between physician communication styleand patient attitudes predicts patient satisfaction. Patient Educ Couns  . 2012;87:193-197. 18.  Clack GB, Allen J, Cooper D, Head JO. 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