Competency in Communication Skills: Curriculum Is Just the Beginning

Interpersonal and communication skills are considered core competencies in training programs according to the Accreditation Council for Graduate Medical Education common program requirements (1). These skills are vital in the field of medicine, in which crucial medical information needs to be solicited from patients, integrated with other findings, and effectively transmitted to different parties. This is none more evident than in pulmonary and critical care medicine (PCCM) fellowship programs, in which fellows consistently engage in end-of-life conversations in the intensive care unit. Therefore, formal education during fellowship is necessary to hone these skills.

The study in this issue of ATS Scholar by Van Scoy and colleagues focuses on the multiple goals theory (2). This communication framework highlights the importance of addressing multiple goals during these conversations rather than focusing on just one goal (3). In this framework, scholars argue that high-quality communication balances task, relational, and identity goals, whereby task goals center on making patient care–centered decisions, relational goals focus on building the relationship between the patient and family and the provider, and identity goals focus on accommodating patients’ beliefs and tailoring the conversation to the needs of the participants. Van Scoy and colleagues build on this theory in their communication curriculum. Specifically, the pulmonary and critical care fellows: 1) undergo didactic training in multiple goals theory and its application to patient–provider relationships in critical care contexts, 2) participate in multiple workshops in which they assess the quality of communication in family meetings based on how well different aspects of these three goals were addressed using a transcript-based coding method called communication quality analysis (CQA) (4), and 3) reflect on their own experience during family meetings in written communication logs. We note that, in these CQA workshops, participants sometimes, but not always, had the opportunity to review the family meetings in which they took part.

In this qualitative study, Van Scoy and colleagues performed semistructured interviews to better understand perceptions toward this three-pronged communication curriculum (2). In general, participants (including PCCM fellows and program leadership) appreciated the use of the multiple goals theory as a valuable framework for communication. Specifically, they noted that this curriculum highlighted the importance of other goals outside of a task-oriented goal and made them appreciate the need to address relational and identity goals in particular. Additionally, they noted that the CQA workshops were a practical educational tool that allowed participants the opportunity to analyze real-world conversations based on this theory. However, participants also noted that the written communication logs were difficult to complete as a result of time constraints related to other clinical responsibilities.

There are a few limitations to the study. First, many of the authors held leadership or supervisory roles in the fellowship. This power dynamic could impact the responses received. Additionally, the interpretation of the study results may be limited by nonresponse and/or attrition bias. Only 7 of the 13 participants elected to participate in the interview, and only 23 of the 52 possible communication logs were completed. The pulmonary and critical care fellows who elected not to participate in the interview may have had a different impression of the curriculum.

Additionally, the article raises important questions regarding the effectiveness of communication. Competency-based education, which has recently become popularized in medical education (5, 6), relies on valid assessment tools to provide initial feedback in regard to baseline proficiency, ensure progress, and ultimately determine mastery. Wass’s adaptation of the Miller Competence Pyramid illustrates different levels of assessment practices used to demonstrate clinical competence (7). Effectiveness of communication suggests some level of competency achieved by the fellow as a result of this training. Although these PCCM fellows did perceive benefit from this curriculum, the fellows did not consistently undergo individualized assessments to assess the quality of their own communication training, and it is unclear whether fellows demonstrated entry-to-practice competence in communication. Specifically, there were no consistent CQA-based assessments to provide direct feedback to the fellows after their family meetings to guide this learning process on a longitudinal basis. Actually, some may argue that the goal standard for an assessment of competence is the patient’s perception of the quality of communication provided by the healthcare provider. This study did not include patient perception surveys, similar to other communication-based studies (8–11).

Overall, Van Scoy and colleagues demonstrate that the multiple goals theory provides a deeper understanding of effective communication. It defines high-quality communication based on whether these three communication goals (task, relational, and identity) are achieved (12), rather than a checklist of communication behaviors, as often seen in communication guidelines (13). Therefore, it highlights the importance of the quality of the communication. In this study, Van Scoy and colleagues provide the community with this conceptual framework and describe a feasible and well-received curriculum that can be used in other training programs. A deeper understanding of the efficacy of this communication curriculum is needed. Future studies should evaluate whether this curriculum aids in this pursuit of competency in communication skills. Reliable and valid assessment methodologies are needed to assess for communication competency within this framework. This may require studying outcomes that focus on behavioral acquisition by the participant as well as perception by the patient and/or family. This addition would better inform training programs about the impact of this communication curriculum on clinical practice, and we hope to read about these discussions in future issues.