Since the Institute of Medicine’s (now the National Academy of Medicine’s) 2001 emphasis on communication skills to promote patient-centeredness and satisfaction (Institute of Medicine, 2001), a robust literature on communication and patient satisfaction has emerged (Allenbaugh et al., 2019; Anderson et al., 2007; Beach et al., 2006; Boissy et al., 2016; Mauksch et al., 2008). While communication is formally taught in medical school education (Makoul, 2003), communication remains challenging for residents and other physicians. Psychologists, especially those at academic health centers, often have the competency and skill for teaching communication (Kaslow et al., 2008).
Many factors affect communication with patients, families, and teams, including competing demands of residency training: time pressures, clinical volume, patient complexity and acuity, and resultant physical and emotional fatigue. In response to these challenges, we extended an innovative, clinical communication coaching program for physician faculty to assess feasibility and acceptability with University of Rochester Medical Center (URMC) residents. This program uses trained psychologist coaches to assess and improve residents’ communication skills. Senior coaches provide communication coaching for attendings across the Medical Center. Junior faculty and postdoctoral psychologist coaches are embedded in residency programs also to address important health system goals including patient satisfaction, healthcare quality, and resident work-life satisfaction (Bodenheimer & Sinksy, 2014; Spinelli, 2013). As such, the coaching program contributes to a culture of feedback and self-improvement.
The University of Rochester Physician Communication Coaching Program
Dr. McDaniel developed the UR Physician Communication Coaching program in 2011 to enhance physician faculty skills in patient- and family-centered communication and improve the patient care experience. A pilot study focused on three skills associated with patient satisfaction and quality measures: Introduce yourself; elicit patient/family Concerns; and check for patient/family Understanding (or “ICU”). Results revealed differences in how high and low Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHP) scorers communicated with their patients on “ICU” behaviors (McDaniel et al., 2020). The program grew rapidly. In 2016, the URMC GME Senior Associate Dean and multiple Residency Program Directors requested the program be adapted for residents. Subsequently, the senior and second authors (SM and LD-R) began training communication coaches who are now embedded in multiple clinical departments throughout the medical center.
Psychologists as Communication Coaches
Psychologists are particularly well-suited to function as communication coaches. We are trained in clinical observation, behavior change, and understand the foundations of effective communication. Psychologists think systemically, use relational frames to conceptualize behavior, and understand factors that influence behavior change (motivation, confidence, skills, and modeling) (McDaniel et al., 2014). These skills allow psychologists to construct and deliver feedback in an individualized, developmental, and constructive manner. Kaslow et al. (2008) describe several competencies for psychologists in academic health centers that align with the communication coaching role. First, psychologists as teachers are in positions to train other healthcare professionals about communication, power hierarchies, group dynamics, and conflict management as essential to team functioning. Communication coaches maintain professional identities as medical educators and regularly incorporate these principles into conceptualizing communication behaviors with patients, families, and/or teams.
Consultation is another functional competency domain for psychologists in academic health centers (Kaslow et al., 2008). As of 2021, our communication coaches are embedded in 11 clinical departments of our medical center. Residency programs that have not historically hired behavioral scientists or psychologists have partnered with our program, demonstrating of the acceptability of the communication coaching role. These partnerships have resulted secondary faculty appointments and fellowship training opportunities within our institution. Coaches embedded in residency programs include psychologists, some faculty physicians, and psychology fellows, all of whom have completed or are currently completing a 2-year part-time coaching training program. Currently our psychology fellows have communication coaching built into their fellowship training experience to promote several of these core competencies for psychologists in academic health centers. This role requires experience as a psychotherapist and a medical educator such that postdoctoral fellows are the most junior trainees we believe are appropriate. Coaches must also have a solid professional identity to manage medical/system hierarchy, know how to navigate resistance, and have appropriate boundaries, all of which require more training than practicum. Communication coaching is a manifestation of many psychologists’ aims in academic healthcare settings to competently take on new roles using interpersonal skills and psychological expertise, and becoming visible, relevant, and integral in academic medical centers (Hong & Robiner, 2016).
Communication Coaching and the “Hidden Curriculum”
Medical school typically emphasizes communication skill development early in students’ education but less so as training progresses, possibly contributing to decreasing empathy through medical school (Hojat et al., 2004). Additionally, the “hidden curriculum” influences physician identity development as students absorb the commonly held “understandings” driven by institutional, systemic, and cultural guidelines (Hafferty, 1998). Trainees may enter residency with well-developed knowledge about pathophysiology and differential diagnosis, but less prepared for the self-reflection, professionalism, and interpersonal communication skills important for residency success (Lyss-Lerman et al., 2009).
Communication training tools address some, but not all, of these broader medical education challenges. Some tools use behaviorally-anchored checklists, record qualitative data (Keen et al., 2015) and offer coaching on specific communication skills (Brock et al., 2011) or a broader patient encounter framework (Kurtz et al., 2003). These approaches emphasize repeated observation of skills in real-time, to identify strengths, habits, and professional blind spots (Gawande, 2011; Mauksch et al., 2008). The URMC communication coaching program builds on these tools, providing a “deep dive” into patient, family, and team communication with individualized feedback for the resident. Coaching can be useful in various contexts: outpatient, inpatient, the operating room, intensive care units, and the emergency department.
Professionalism can be difficult to teach (Huffmyer & Kirk, 2017; Phillips & Dalgarno, 2017) as it focuses on behaviors and communication that determine the quality of patient, family, and collegial relationships. Professionalism behaviors include responsiveness and compassion to patient and family needs (Irby & Hamstra, 2016) while communicating clearly and respectfully with colleagues. Communication and professionalism issues can reflect skill deficits and underlying wellness concerns. Resident burnout is common (60%) (Dyrbye et al., 2014) and can manifest as diminished empathy (Wallace et al., 2009) and increased irritability, abruptness, and objectification (Passalacqua & Segrin, 2012). Recognizing this, ACGME proposed adjusting the professionalism milestones to include self-awareness and help-seeking subcompetencies (Edgar et al., 2018). Communication coaching can identify wellness concerns early, connect residents to resources to prevent and address burnout, and support positive patient and physician outcomes (Boissy et al., 2016; Gazelle et al., 2015). Our embedded coaches in residency programs are positioned optimally to promote the ACGME educational commitment to professionalism (Chervenak et al., 2018) and address conflicts that can emerge between the “hidden” and explicit curriculum.
The following vignette illustrates how communication can suffer when a fatigued, stressed resident without strong communication skills works with a patient and family. In this example, the residents’ physician-centered approach resulted in unprofessional, disrespectful interactions with others. He did not partner effectively and ultimately hurt his relationship with his team. Finally, his limited self-awareness prevented recognition of his own deteriorated well-being, precluding him from seeking help from team members. The story is a composite of actual experience in resident communication coaching, using factitious names:
Inpatient nurses paged 3 rd year Medicine resident, Dr. Resident, several times regarding Mr. Jackson’s care. Busy with other patients, he forgot to respond. At 10 pm, he remembered the Jackson family was waiting. Though tired, he went to the unit. A nurse said, “Good, you finally made it! I hope they stuck around.” Frustrated, he snapped, “What do you mean, you hope they’re here? Didn’t you tell them I was busy?”
Dr. Resident entered Mr. Jackson’s room; he was asleep with his wife sitting nearby. Dr. Resident said, “Mr. Jackson, wake up! You wanted to speak to me? Did you want me to talk to … it’s your wife, right?” Mr. Jackson barely nodded before dozing off again. Dr. Resident (Dr. R) sighed and turned to Mrs. Jackson (Mrs. J): “Is there something I can help with?” Exhausted and worried about her husband, she replied, “You are….?”
Dr. R: I’m the resident overseeing your husband’s care.
Mrs. J: Your team said conversations about my husband’s treatment need to go through you. My daughter has a lot of questions.
Mrs. J: You’ll have to ask her.
Dr. R: I’ll be back tomorrow.
Mrs. J: She can’t be here then. Can we call her now? I don’t understand what’s happening.
Dr. R: I’ve had a long day. My team knows the plan regarding your husband’s care… I don’t have time to look at his chart now.
Dr. R interrupted: See you tomorrow. If you need anything, tell the nurse.
Mrs. Jackson called the nurse and shared what happened. The nurse contacted the attending who quickly developed a care plan and called the daughter to answer her questions. The attending emailed Dr. Resident, providing feedback about her understanding of the day’s events and the poor communication observed by multiple parties; she copied in the Residency Program Director. This was the 2nd complaint about Dr. Resident. Dr. Director met with Dr. Resident the next day. She inquired about what happened, and asked more generally about how he was doing. Dr. Resident felt he had done nothing wrong: “I was tired. You say I can’t work past 80 hours, so I set some boundaries.” Dr. Director expressed concern about the event and suggested that the resident meet with the program’s communication coach. Dr. Director spoke with Dr. Coach about the resident and then emailed both, asking them to work together.
Dr. Resident’s interactions with the patient, family, team, and program leadership suggest growth opportunities in several ACGME milestones universal to residency programs, including Interpersonal and Communication Skills (ICS) and Professionalism (PROF) (Edgar et al., 2018). Residency leaders regularly face similar situations in which skill development may reduce risk of communication problems, work hour violations, exhaustion, or mood disorders (Passalacqua & Segrin, 2012). Communication coaching provides direct assessment and functional evaluation of these milestones and skills.