Background

Interpersonal and communication skills are an integral element of quality patient care and are recognized as a core area of competency for medical students, residents, and practicing physicians [1,2,3,4,5]. Furthermore, effective communication and empathic relationships with healthcare practitioners are highly valued by patients and their families [6,7,8,9,10] with compromised clinical care and an overall lower satisfaction with care being associated with poor communication [11,12,13]. Hence formal training and assessment programs at the undergraduate, graduate and continuing education levels are needed [14,15,16,17]. Examples of these include Objective Structured Clinical Examination (OSCE) with a Standardized Patient (SP), that assesses clinical skills in a standardized setting. Although medical schools have a variety of methods to teach communication skills, there still remains a considerable gap. Not all communication curricula are based on a specific validated framework, nor incorporate a patient-centered communication approach, nor foster professional and personal growth. Additionally, the learners’ communication skills may not always be assessed directly and the quality of the program may not be evaluated [17].

In 1999, the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS) stated that “interpersonal and communication skills that result in effective information exchange and partnering with patients, their families, and professional associates” is a core area of competency for residents and practicing physicians [1, 4]. Additionally in 2004, the National Board of Medical Examiners (NBME), the Federation of State Medical Boards (FSMB), and the Educational Commission for Foreign Medical Graduates (ECFMG) implemented the Step 2 Clinical Skills (CS) Examination [18]. One of three subcomponents of the exam is Communication and Interpersonal Skills, which requires medical students or graduates to “establish rapport with the patients, gather and provide information, help the patient make decisions and provide counseling when appropriate and in a professional manner” [18].

Despite the importance of communication skills to the training of future healthcare practitioners and the requirement to demonstrate competence in those skills at all levels of the medical continuum, faculty and residency program directors often struggle with identifying effective remediation strategies for those who fail to meet expectations [19,20,21]. This has mainly been due to the fact that remediation is a time consuming process that can be daunting and cumbersome [22] and that remediation of non-cognitive problems is more challenging than remediation of cognitive problems [20, 23].

The literature has shown that policies and guidelines for best practice are needed to improve the quality of the remediation process and to increase the confidence of educators in applying specific remediation strategies according to the learner’s skill deficit in all areas of competencies [23, 24]. A variety of remediation strategies have been utilized with most consisting of three steps: identification/diagnosis, remediation intervention, and re-assessment [25,26,27]. Hauer et al. proposed a four-step model which included: (i) initial assessment to identify deficiencies using multiple assessment tools, (ii) diagnosis and development of an individualized learning plan, (iii) deliberate practice, feedback, and reflection, and (iv) reassessment [23]. A structured seven-step approach of relationship-centered care, coaching and effective feedback was also found to be an effective model to successfully remediate learners in communication and interpersonal skills [28]. Some of the key steps included establishing a supportive learning environment, listening to the learner, encouraging reflective practice, developing a learning plan and documenting progress.

The literature on challenges in identifying and remediating learners struggling with communication skills are wide and varied [28]. Therefore, the goal of this systematic review was to determine the appropriate assessment tools used to identify learners struggling in communication skills, the strategies used to remediate them and to discuss the best practice recommendations proposed by the authors. In this study we defined remediation as “additional teaching above and beyond the standard curriculum, individualized to the learner who without the additional teaching would not achieve the necessary skills for the profession” [29].

To achieve this, our research question was:

How do you diagnose a trainee struggling with communication skills and what are the effective remediation strategies?

Method

In this systematic review a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) flow diagram was utilized for reporting the study selection.

Data sources and search strategy

A comprehensive, search for literature was performed in the academic databases PubMed, MEDLINE (OVID), EMBASE (OVID), CINAHL (EBSCO), PsycInfo (OVID), Web of Science and Scopus and in sources of grey literature. Pre-searches to identify relevant search strategies, search terms and information sources were conducted in March–June, 2018, and the final search was carried out in June 2018. An update of the search in PubMed and Scopus were performed in May 2019 to ensure inclusion of the latest published studies on remediation in communication for healthcare practitioners before completing the manuscript.

PubMed was used to systematically develop a search string, which later was applied in the other databases. All selected keywords were searched both in the fields “Abstract” and “Article Title” (alternatively “Topic”) and in MeSH/Subject Headings/Thesaurus when available. No filters or limitations were applied to retrieve the largest number of result and to avoid excluding pre-indexed materials. Language, document type, and publication year restrictions were instead included in the exclusion criteria for the screening process. We defined trainees as healthcare practitioners in undergraduate, graduate and continuing education. For the purpose of this study we defined healthcare practitioners as individuals who may be involved in healthcare delivery (for example: physicians, nurses, dentists, physiotherapists and pharmacists). A full search log, including detailed search strings for all included information sources, results and notes is available in Appendix.

Searches for grey literature were conducted in ProQuest Dissertation and Thesis, Ethos, Open Grey and BASE, The New York Academy of Grey Literature Reports and in the library catalogues for British Library, Library of congress and WorldCat. Due to lack of advanced search features in many of the grey resources, broader search strings than the one used in the academic databases had to be applied. The grey search was updated in May 2019. A full search log can be found in Appendix.

All the references were uploaded into Covidence (Melbourne, Australia), systematic review software for blinded screening. Duplicate detection and removal were carried out using this software.

To complete the selection of relevant references for the review, a systematic hand screening of references lists in studies identified to be included in the systematic review was also carried out. Two additional studies were identified eligible for the systematic review.

Study selection and title and abstract review

Articles were included if they were original research on remediation in the area of interpersonal and communication skills. Articles that were not written in the English language, systematic reviews, conference abstracts, proceedings, book chapters, comments, editorials or letters and publications prior to 1998 were excluded. We wanted to limit the review to primary studies following the implementation of the Accreditation Council for Graduate Medical Education’s (ACGME) outcome project where competencies for training, including communication skills, were defined and implemented. The search in academic databases and in grey sources yielded 1636 articles (Fig. 1). Based on the title and abstract, the two reviewers (DA and TA) screened the articles using Covidence and excluded articles that were clearly irrelevant. The screening in Covidence was blinded. In situations where it was difficult to determine eligibility based on the title and abstract review the article was included for full article review. The authors met regularly and all uncertainties were resolved by consensus. Only articles that described an assessment tool to identify struggling learners as well as an intervention methodology or remediation strategy were included. Articles with an assessment and remediation strategy but no clear outcome were also included.

Fig. 1
figure 1

PRISMA flow diagram [30]

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Data extraction

Data were entered into a structured extraction framework that we created. The framework included information on the article (Year, participant level, participant number, country of study), assessment tool, remediation strategy and intervention outcome. One author (DA) extracted the data.

The Medical Education Research Study Quality Instrument (MERSQI) used to evaluate the methodological quality of experimental, quasi-experimental, and observational studies in medical education was used [31]. The tool includes 10 items, reflecting 6 domains of study quality [study design, sampling, type of data (subjective or objective), validity, data analysis, and outcomes]. The potential range of a MERSQI score is 5–18. Each study was scored at the highest possible level.

We used the Kirkpatrick’s four-level model for evaluation of educational interventions to classify the outcomes of the studies that met our selection criteria [32]:

  • Level 1: Participant reaction assessed (learner satisfaction).

  • Level 2: Participant learning assessed (changes in knowledge and skills).

  • Level 3: Participant behavioral change assessed (application in practice).

  • Level 4: Results (changes in institutional practice and patient outcome).

Data synthesis

Characteristics of studies, assessment and intervention strategies and outcomes were synthesized qualitatively and summarized in tables. Articles that described similar assessment tools or similar interventions were grouped to facilitate the analysis. We used the consensus mean MERSQI scores with standard deviations to describe the overall quality of included studies. Meta-analysis was not possible, given the heterogeneity of assessment tools, interventions and outcome measurements.

Results

Characteristics of eligible studies

From the 1636 records found, 1020 were identified through electronic database searching and 616 were identified through other resources such as databases for grey literature and by systematically reviewing citations in studies selected to be included in the review. After de-duplication, a total of 933 references were identified for a first review. The total number of articles that were eligible for inclusion through review of titles, abstracts and full texts was 16 (Fig. 1). Table 1 summarizes information on the country of the study, the level of struggling learner, number of remediated learners, assessment tools, interventions and outcomes. Struggling learners in the studies were predominantly students (n = 11, 69%), followed by residents (n = 4, 25%), and one study included family physicians and specialists (n = 1, 6%). Only one study included pharmacy students (6%), 14 included learners in medicine (88%) and one included both nursing and medical students (6%). Eight studies were conducted in the US, three in the UK, two in Canada, one in Belgium, one in Australia and one in Korea. Only seven studies focused solely on learners struggling with communication skills [33,34,35,36,37,38,39] while the remaining studies addressed multiple deficiencies.

Table 1 Summary of characteristics of eligible studies
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Quality of studies

The mean consensus MERSQI score was 10.5 (range 5.5–11), with a standard deviation of 1.67 and a median score of 8.5, indicating that the overall study quality was not high. Total consensus MERSQI scores for each paper are shown in Table 2. Mean domain scores were highest for type of data (2.63), data analysis (2.19) and sampling (2.06); they were lowest for validity evidence (1.17) and study design (1.13). Most of the studies (81.3%) were single group cross-sectional or single group post-test only. One study was a retrospective review of records [40], two studies were surveys of medical schools [24, 39] and one study was a survey of surgery residency programs [20].

Table 2 The MERSQIa domain and item scores for the 16 selected studies that meet the review criteria
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Assessment methods used to diagnose struggling trainees

Table 1 provides details of the assessment tools that were used in the studies to diagnose trainees struggling with communication skills and Table 3 provides a summary of the overall assessment methods used in the studies reviewed. Most studies (n = 10, 62.5%) used a format of a clinical OSCE, a tool to assess clinical skills in a controlled setting, to identify struggling learners [33,34,35, 37,38,39, 41,42,43,44], four (25%) used a 360-degree or peer evaluation tool [42, 45,46,47], one study did not address assessment methods used [21] and another identified struggling learners by their failure to meet criteria in one or more CanMed Roles but did not expand on what tools were used to achieve this [40].

Table 3 Summary of assessment methods and remediation strategies
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(Table 3: Summary of Assessment Methods and Remediation Strategies) – Insert near here.

Remediation interventions and outcomes

The studies included a wide range of intervention strategies such as one-on-one coaching/mentoring, tutorials, individual and group work, focus reading, SP exercises, role-play, videotape review, and counseling (Table 1). None of the studies had a single intervention strategy with the majority including an experiential component with feedback. Half of the studies (n = 8) developed a remediation course or program [33,34,35,36, 38, 41, 43, 47] with the duration of the intervention ranging from as short as a weeklong course [34] to a longitudinal one-year program [35].

Five studies (35.3%) had a program director or a committee to devise an individualized remediation plan that included input from learners [20, 37, 40, 45, 46] and one of those studies used the CanMed Roles as a framework for the development of the plan [40]. In one Canadian study on improving physicians in practice a variety of intervention strategies were used. However, the strategies that were used to remediate deficiencies in communication skills were not specified [42]. A study that surveyed how medical schools in the UK support students struggling with communication skills found that some schools had a structured remediation program that included coaching, one-on-one encounters and simulated patient intervention. However, most schools used an ad hoc approach [39]. Only one study on medical students in Australia developed a remediation program based on a learning theory [47].

Based on Kirkpatrick’s model of educational outcomes [32], three (18.8%) of the studies assessed reaction, which was based on learner satisfaction and appraisal of the program [20, 33, 41, 44]. Eleven (68.8%) assessed learning, which included changes in knowledge and skills [34, 35, 36, 37, 38, 40, 42, 43, 45,46,47].

Discussion

This systematic review on the remediation of deficiencies of interpersonal and communication skills of healthcare practitioners across the continuum yielded very few studies that described the diagnosis, remediation, intervention and the assessment of the outcomes of remediation. Furthermore, the studies that we identified were small scaled (range: n = 1 to n = 225) and of single-institutions. They utilized a variety of assessment methods to diagnose the specific problems the learners were struggling with including evaluations, clinical performance exams, OSCEs with SPs, direct observations, oral certifying exams and global rating scales. This is similar to the recommendations from the Kalamazoo II report that outlined specific assessment methods to evaluate communication skills [48]. Those included (i) direct observations with real patients, (ii) ratings of simulated encounters with real patients, (iii) ratings of video or audiotaped interactions, (iv) patient surveys and (v) examinations of knowledge, skills or attitude.

In our study, OSCE with SP was the most widely used method for assessing the learners with the majority utilizing a standardized or validated checklist. According to the literature OSCE with SPs is considered the “gold standard” tool for clinical assessment [49] as it can be designed to examine skills and ability at the “Show how” level of Miller’s triangle [50]. The checklist is thought to be the most frequently used assessment tool of communication behavior as it provides clearer behavioral definitions that may improve reliability [51]. In one of the studies, the students rated practicing with SPs, receiving feedback, from SPs and faculty, in real time and observing others in small groups to be the most beneficial components of the program that helped them improve in their communication skills [41]. This was also observed in other studies that included OSCEs with opportunities for video review and feedback as part of the remediation intervention [34, 43].

Deficiencies in non-cognitive skills are the most challenging to remediate [52]. Therefore, it was not surprising that our systematic review identified a lack of standardized remediation programs for learners struggling with communication skills. However, we identified common themes for remediation strategies, which included the use of clinical practice with an SP, a clinical faculty or another peer, reflective practice, role-play, video review and structured feedback. Having institutional policies and guidelines for remediation, a faculty development as well as a mentoring program, using learning contracts and documentation of every aspect of the remediation process are important components that support the success of the remediation plan. The challenge in the systematic review was that there were no clear outcomes specified in most of the remediation programs other than the learners progressing to the next year of their education program, passing a certifying exam or graduating.

Moreover the results from this systematic review confirm what was previously published in that there is a deficiency of outcomes-based research on strategies for remediation [23] and a lack of standardized remediation programs [53, 54]. Three steps that lead to successful remediation were identified in our study that are similar to those identified in previous studies: (i) early identification and diagnosis, (ii) developing an individualized remediation plan and (iii) re-assessment and feedback [22, 26, 53, 55, 56].

Our study further confirmed what was previously described in that remediation interventions lack theoretical foundation and clinical teachers struggle with using a structured process framed by appropriate theory to generate a specific educational diagnosis of learners’ difficulties [55]. The majority of the studies we reviewed did not utilize theory to develop their remediation plan. Only one study used theory (socio-cognitive self-efficacy beliefs) to develop the remediation program [47] and the authors noted that participants benefited from enhanced self-efficacy beliefs. Adult learning theory is thought to have a direct impact on remediation as the relevance of what is taught as well as self-direction are important since each learner has their own approach based on their life experiences [57]. Kolb’s experiential learning cycle [58] has been successfully used to develop remedial courses for surgical residents struggling with the surgery-qualifying exam [57] and for residents deficient in communication skills, namely clinical interviewing skills [59]. Kolb’s experiential cycle has multiple intercalations with many educational theories. Therefore designing an experiential remedial program using educational activities that mirror principles of educational theories would be beneficial [59]. Such activities would target various increasing levels of cognitive development [60], provide supportive corrective feedback [61] and reflective practice [62]. In both of the above studies, the strategies used included learning contracts, structured reflection, reviewing videos or reading material and role modeling. Although the majority of authors in the studies we reviewed do not mention the use of learning theories to develop their remediation plans they have unknowingly done so. Most of the remediation strategies used included a clinical experience (concrete experience), an observation and reflection on that experience for example reviewing the video recordings of encounters (reflective observation), conceptualizing and learning from that experience as well as learning new techniques for example through didactics and role-plays (abstract conceptualization) and finally deliberate practice to apply what was learned (active experimentation) and immediate feedback. These are the main components of Kolb’s experiential cycle [58].

In our study, several remediation plans included reflection by the learners following their OSCEs, role-plays or clinical encounters with patients. Reflection before, during and after an action is foundational to self-directed learning and is necessary to promote learning. Using Schon’s model [62] of the reflective practitioner provides those learners with a framework for choosing an effective action in a complex situation. It is important for the learners to be able to develop the capacity to derive lessons from a concrete clinical experience [58]. Such experiences help them refine their skills and apply their learning to subsequent encounters. By actively reflecting on what they do and do not understand, they can enhance their own learning from the concrete experience, which in turn may facilitate the potential transformative impact [63].

Strengths and limitations of the review

The major strengths of this study lie in the search process itself, which was very comprehensive and included a wide range of academic databases as well as grey literature. Additionally, we did not limit the study to one group of learners and included all healthcare practitioners across the continuum. The study however has several limitations. First, the data extraction was performed by a single author, and did not include conference abstracts, proceedings, book chapters or articles that only described an assessment tool to identify struggling learners or an intervention methodology or remediation strategy. Second based on the MERSQI score, the quality of the studies included were not high and that is a limitation of the work conducted in the area of study. Furthermore, the studies included in this systematic review were heterogeneous and hence we were not able to perform a meta-analysis. There was not enough data to indicate whether institutions that remediate trainees struggling with communication skills assess their own communication training programs to identify any deficits that could be addressed. Additionally, it was not possible to investigate the structural differences of the 16 studies identified due to the variation in the type of information provided.

Implications for practice and future work

Despite these limitations, we can make some recommendations based on our observations from the studies reviewed. Having regular evaluation and feedback methods in place may facilitate the identification of deficiencies early to avoid serious learning problems later on [64]. For a remediation strategy to be successful it is important to ensure early identification and diagnosis, the development of an individualized plan and reassessment with feedback. The most effective methods for teaching and evaluating interpersonal and communication skills involve multiple methods of assessment [3]. Therefore, we would recommend using multiple methods that would include direct observations (with patients, SPs or via video review] using a checklist or global rating scale, 360-degree evaluations, patient surveys, case discussions, role-plays or written examinations of knowledge, skills or attitude. Following the diagnosis of the problem the next steps would include discussions with the learner in order to develop an individualized remediation plan, having a learning contract, setting clear goals and objectives, a reasonable timeline, assigning a mentor, ongoing monitoring, deliberate practice, re-evaluation and feedback.

Conclusion

This study supports the need for more rigorous outcomes-based research, using control or comparison groups, for the diagnosis and remediation of healthcare practitioners struggling with interpersonal and communication skills across the continuum. It is important to consider the following practice points: (i) deficiencies in non-cognitive skills are challenging to remediate, (ii) a major challenge is whether faculty know how to identify the deficiency and what strategies to use to remediate, (iii) a variety of assessment tools need to be used to evaluate communication skills and (iv) early identification and diagnosis, creating an individualized plan and reassessment with feedback are key to successful remediation.