Didactic and Experiential Training to Teach Communication Skills: The University of Wisconsin-Madison School of Veterinary Medicine Collaborative Experience

Abstract

Teaching communication skills to veterinary students is recognized as important; however, incorporation of this into an already crowded curriculum is difficult. At the University of Wisconsin-Madison School of Veterinary Medicine we provide mandatory communication lectures to freshmen and sophomores, and offer elective experiential courses to juniors and seniors. Providing both didactic and experiential training allows students to learn and practice communication techniques in a ‘‘safe’’ setting. Our approach to experiential training is unique in that graduate students in counseling psychology (masters and doctoral level) act as ‘‘clients’’ for the juniors, and professional simulated pet owners are hired for digitally captured role-plays with the seniors. A unique inter-professional partnership has been formed between the Schools of Veterinary Medicine, Education (Department of Counseling Psychology), and (Human) Medicine and Public Health to provide this experiential training for our students. The purpose of this article is to describe the communication training program at the University of Wisconsin-Madison School of Veterinary Medicine and to encourage other programs to reach across campus and partner with other colleges with the goal of improving training for all of the individuals involved.

INTRODUCTION

It is well recognized that communication training is an important component of human medical education, and teaching communication skills is now a mandatory part of the curriculum in human medical education.^1,2 The process of clinician-patient communication has been thoroughly described in the widely used Calgary-Cambridge guide.¹ At the heart of this issue is the fact that the information exchanged between doctor and patient (or client) can be significantly enhanced through the process by which the exchange occurs. The mechanics of teaching communication skills has been covered elsewhere,^3,4 and a full review is beyond the scope of this paper. Briefly, in the past five years there has been a concerted effort within the veterinary field to teach communication skills to veterinary students.^3–21 Studies in human medicine have shown that strong communication skills are associated with improved diagnostic accuracy, patient satisfaction, and adherence, decreased malpractice suits, and improved physician job satisfaction.^22–24 This is likely to be the case with veterinary medicine as well.¹⁵ One survey of veterinary students and post-graduate veterinarians concluded that a professional skills curriculum addressing underlying self-awareness, communication, and interpersonal skills would probably increase the proportion of fourth-year veterinary students who felt competent and comfortable in their professional skills by the end of their training.²⁴

Obstacles that impede communication training in veterinary medicine are the already overflowing required curriculum, the need for instructors trained to teach these skills, and costs (both monetary and logistic). Regardless, veterinary schools in the United Kingdom and Canada have been successful in incorporating communication training into their curricula.^4,6–13 While programmatic support is crucial, it is equally important to have faculty that know how to teach these skills. In 2003, the United Kingdom formed the National Unit for the Advancement of Veterinary Communication Skills to encourage and support teaching veterinary students communication skills by creating a lectureship in veterinary communication skills. This lecturer travels to veterinary schools in the United Kingdom to aid communication training and train faculty facilitators as needed.¹¹ Since 2002, the Bayer Animal Health Communication Project (BAHCP) has provided an even more structured framework, training North American veterinary educators to teach communication skills as well as providing lecture slides, DVDs, and exercises on a variety of communication topics.¹⁴ The project described here is the result of a collaboration between faculty and staff at the University of Wisconsin (UW)-Madison School of Veterinary Medicine (SVM) (R.C. and S.S.), the School of Medicine and Public Health (S.E.S. and J.B.), and the Department of Counseling Psychology in the School of Education (C.C.L.). All of the authors are actively involved in communication skills training to veterinary students and/or other health professionals.

DESCRIPTION OF COURSES

At the UW Madison SVM, we provide mandatory didactic communication training to freshmen and sophomores (80 students per class) and offer elective basic and advanced communication training to juniors and seniors. The mandatory training has been taught since 2007, the junior course has been taught since 2001, and the senior course has been active since 2006.

Freshman Year

In the freshman year, training is part of the pre-existing ‘‘History, Physical Examination, and Restraint’’ course, which (although implied in the name) had no ‘‘history-taking’’ component. The goal of training in this first year is to impart a recognition of the importance of the professional relationship between veterinarian and client, and how communication technique affects the quality and quantity of information gathered from the client. Inherent in the discussion is how all parties involved in communications make assumptions about each other, and how those assumptions can impact the relationship and communication process. Training consists of a one-hour lecture on how one is perceived by the client and how to structure an interview, and 1.5 hours of interactive discussion (10 students in each group, with one or two facilitators), ‘‘batting practice,’’ and de-briefing. Batting practice is a communication training tool that involves a ‘‘pitch’’ to the student (e.g., ‘‘she’s just not herself anymore’’) to which the student must respond in a manner that is likely to build a relationship with the client (e.g., empathy, reflective listening, questioning skills). After each ‘‘bat,’’ the small group de-briefs on the response and the client’s potential reaction. Thus, batting practice also allows for recognition of assumptions and their role in communication.

Sophomore Year

The four one-hour sophomore lectures are incorporated into a two-semester course titled ‘‘Introduction to the Veterinary Medical Teaching Hospital’’; a course intended to increase students’ clinical experiences in the teaching hospital. The lectures again focus on recognizing the human tendency to make assumptions during any interpersonal interaction, and use components of the BAHCP modules to provide didactic training on the four core communication skills: questioning, empathy, reflective listening, and nonverbals.¹ The specific goal of the lectures is to show that communication skills can be learned and used with intent to improve information gathering, diagnosis, client adherence to recommendations, and job satisfaction.

Junior Year

The junior elective is divided into six 2.5-hour classes, with attendance limited to 20 students per semester. The class is offered in both semesters of the junior year. Each class includes an approximately one-hour didactic lecture on topics such as principles of helping relationships, responding to client emotion, dealing with resistance and confrontation, euthanasia, and enhancing compliance and commitment. In addition, guidelines for providing and receiving feedback are taught during the first class period. The next hour is spent doing exercises that complement the lecture, followed by a 30-minute de-briefing session. Initially, experiential training (e.g., role-playing) is through veterinary students interacting with each other. In the last four sessions of the elective we utilize UW-Madison Counseling Psychology (CP) graduate students as simulated clients. Examples of exercises are in Table 1.

Table 1:

Examples of exercises during the junior course

Lecture Topic	Learning Objectives	Example Exercises
Core communication skills (nonverbals, questioning, reflective listening, empathy)	Recognizing the impact that nonverbals play in communication. Gaining awareness of one’s own nonverbal behaviors. Understanding the purposes of both open- and closed-ended questions in gathering a client’s story. Developing intentional use of open and closed questioning skills. Understanding the purposes and use of verbal encouragers, paraphrasing, and summarizing skills.	Back-to-back conversation, mimicking a telephone conversation of breaking bad news with no nonverbal cues. Role-play of a physical examination with just open-ended questions, then with just close-ended questions. Processing observations of differing outcomes of using open- versus closed-ended questions. Scenario is the discussion with a client who accidentally left his cat out overnight. The cat came home limping and on evaluation is found to have a broken leg. The goal is to gather information, and demonstrate to the client an understanding and clarification of his story.
Responding to client grief	Understanding the importance of recognizing and responding to client emotion. Understanding the use of empathic listening and reflection of feeling. Gaining self-awareness of how one’s own reactions might impact interactions with grieving clients. Raising comfort levels and confidence in dealing with client emotions (e.g., guilt, sadness).	Role-play with CP student involves breaking bad news (e.g., a show horse with permanent lameness, a pet with a terminal illness) and discussing euthanasia (helping the client to make a decision and to cope during and afterwards). Throughout the scenario, responding to client emotions. Feedback and processing afterwards.
Responding to resistant and angry clients	Understanding potential sources of client resistance and anger responses. Gaining self-awareness of one’s own responses to conflict and how these potentially impact interactions with clients. Understanding how use of attending skills and empathic listening can facilitate communication with resistant and angry clients.	Role-play with CP student involves dealing with client anger (e.g., a show cat inadvertently spayed, a hospital bill much higher than the estimate). Throughout the scenario, maintaining a focus on the relationship and intentional use of attending skills and empathic listening. Feedback and processing afterwards.

Role-plays with the CP students involve scripts written by the communications course faculty with the goal of practicing specific communication skills. Role-plays are based on actual cases and are designed to encourage the development of a veterinarian-client relationship through the use of empathy, reflective listening, and questioning. The situations are meant to be challenging and to take students out of their ‘‘comfort zone’’ so that they must consciously use the communication skills they are being taught to get through the interaction. The medical/treatment aspect of the case is minimized (e.g., by having the pet afflicted by a made-up disease) so the students must focus on their communication skills rather than their veterinary knowledge. Two or three veterinary students are typically paired with one or two CP students, with one veterinary student and one CP student engaging in the role-play and the other students observing or, if needed, acting as ‘‘doubles’’ to help get through a difficult point in the role-play. During each class, each veterinary student has a chance to act as both ‘‘veterinarian’’ and ‘‘observer.’’ Role-plays typically last for five to 10 minutes, after which students self-evaluate and receive feedback in their small groups, with instructors circulating between the groups for observation, facilitation, and de-briefing. The CP students are coached by course instructors on how to accurately portray clients’ situations and points of view, and they also provide conscientious and informed feedback to the veterinary students. The discussion is then continued at the level of the entire class, focusing on generalized learning points. As has been reported by others, veterinary students are initially uncomfortable with role-plays.^8,9,12 However, with practice and the use of CP students, veterinary students are able to fully engage in role-playing in a completely ‘‘safe’’ setting.

Senior Year

The junior course is prerequisite for the senior didactic. This course is divided into six three-hour sessions, and attendance is limited to 10 students. It is comprised of student-driven discussions on specific communication skills and situations, digitally captured role-plays with simulated pet owners (SPOs), and group viewing and discussion of the interactions. It is offered once a year as a two-week elective during the second semester of the senior year. In this elective, we partner with the UW School of Medicine and Public Health Clinical Assessment and Training Center (CTAC). CTAC is a self-contained center, the mission of which is to provide health sciences students and faculty with opportunities to practice and demonstrate clinical communication. CTAC hires and trains the SPOs and all role-plays are captured digitally to allow for extensive review and de-briefing. More information about CTAC is available at http://www.med.wisc.edu/ctac/index.php.

Role-plays with SPOs are written by the communication faculty (R.C., S.S., C.C.L.) with input from CTAC (J.B.). Again, the intention of the role-plays in this course is to take students far out of their comfort zone with challenging scenarios. All of the role-plays are based on actual veterinarian-client interactions experienced by the instructors. After each role-play the student receives feedback from the SPO and a faculty member, if the faculty member was directly observing the interaction. In the first week of the course, the role-plays are 10- to 15-minute scenarios dealing with conflict and emotion (e.g., a husband and wife who differ in their decision for their pet’s therapy or diagnostics, or a technician in the practice who is not respectful to a new veterinarian they are working with). In the second week, the role-plays are set up to be very brief (five- to 10-minute) ‘‘trigger’’ encounters that allow the students to focus closely on managing the relationship, rather than lapsing into client education or medical treatment issues (see Table 2). The students then return to the SPOs for a second ‘‘appointment,’’ during which they must work to maintain or repair their relationship with the same client.

Table 2:

Examples of brief (five- to 10-minute) role-plays used in the senior elective

	Example 1	Example 2	Example 3
Primary scenario	A cat in for a routine spay died at 1:30 pm due to an idiosyncratic anesthesia reaction. The client comes in at 4 pm to pick the cat up. The client has not been informed of the death.	A dog with severe immune-mediated hemolytic anemia is not responding to aggressive medical therapy. The owner’s religious beliefs do not allow for blood transfusion.	A client brings his pet in weekly for small issues (e.g., nail trim, anal gland evacuation, ear cleaning). The client asks the veterinarian out on a date.
Second appointment	The client brings another cat in on an emergency because of a urinary obstruction.	The client brings the dog back in because of concerns that the dog is suffering and wants to do something, but declines euthanasia.	The client brings the dog in again for a minor cut on the paw.
Skills to practice	Empathy, dealing with strong client emotion, professionalism, setting personal boundaries.	Empathy, respect of others’ beliefs, setting personal boundaries.	Setting personal boundaries, professionalism.

OBSERVATIONS AND DISCUSSION

Providing communication training at the UW-Madison SVM is a work in progress. Fitting lectures and experiential exercises into previously existing courses such as History and Physical Examination Skills, or potentially into a professional skills course, allows for pertinent material to be incorporated relatively easily into the curriculum. Currently, the courses with the largest experiential components are elective, which presents both opportunities and disadvantages. The positive aspects include the presence of students who truly want to be there and are therefore more readily engaged in the process. The smaller class size of 20 students per semester, rather than 40 students, is a more manageable size for division into role-play groups as well as for deeper reflection and discussion. The disadvantages include that not all students take the elective and, indeed, it may well be the students most in need of communication training that opt not to take the junior and senior courses. In addition, the electives are taught on top of an already full course load. While there are no examinations in the communication courses, participation does result in decreased study time and this may be a detracting factor when students are deciding whether to sign up for the electives.

The mandatory lectures on the importance of the veterinary-client relationship and core communication skills in the freshman and sophomore years allows the junior elective to delve more deeply into practicing communication skills. Course evaluations and feedback from students for the elective courses are consistently positive. Of 65 course evaluations for the junior class, the response to the question ‘‘Would you recommend this class to other students’’ was answered ‘‘yes’’ by 56 students, ‘‘unsure’’ by five students, and left blank by four students. Because enrollment in the junior course has been at maximum capacity for the past two years, it is now taught each semester. The most powerful aspect of this course is the role-plays with the CP students; of the 65 course evaluations, role-plays with the CP students were cited as the most helpful aspect of the course by 56 students. The role-plays with CP students are beneficial in that (1) the veterinary students role-play with someone unfamiliar to themselves and veterinary jargon, and (2) the CP students are trained in the same communication skills and in how to provide critical feedback. Thus, the veterinary students practice communication skills with people unfamiliar to them, but in a safe setting. Of even perhaps more benefit is the opportunity to de-brief with their role-play ‘‘client,’’ receiving specific feedback and a deeper understanding of the client perspective. CP students are encouraged to share their honest reactions and to help veterinary students explore alternative uses of communication skills.

An unanticipated advantage of the junior course is the positive benefit the CP students gain from observing and coaching specific communication practices. The CP students are recruited to act as clients with the incentive of earning extra credit in one of their graduate courses, with no cost to the SVM. A consistent comment from the CP students is how much they gain from interacting with professional students outside of their own specialty. For example, CP students report that the opportunity to be in the role of the client in a veterinary scenario gives them a greater appreciation and empathy for how vulnerable clients may feel in counseling situations. They describe improved awareness and sensitivity to the power differential in the room and how this can impact communication and the ‘‘telling’’ of the client’s story. Furthermore, CP students gain valuable experience in providing consultation to another helping professional, including enhancing their comfort and confidence in providing critical feedback. Although participating in the veterinary communication course is not required for the CP students, it does provide them with an excellent learning and professional development opportunity. In addition, the course instructors have gained valuable insights into ways of fostering cross-campus learning.

The costs of using the CTAC facility for the senior didactic are covered by a donation from the Wisconsin Veterinary Medical Association. The resources of the CTAC facility provide important contributions through the use of a discrete digital capture system, a ‘‘clinical’’ setting, and SPOs trained not only in portraying certain client characteristics or emotions, but also in giving feedback. While this is still a safe setting, course evaluation comments specify that the role-plays at CTAC feel ‘‘real,’’ and students appreciate the opportunity to practice their responses to challenging situations.

CONCLUSION

Teaching communication skills to veterinary students is a mandate supported by literature and experience. However, it is difficult to find time in an already crowded curriculum and to provide the experiential methods needed to effectively integrate this content. Currently at the UW-Madison SVM, a small but significant portion of mandatory communication skills training is incorporated into two previously existing courses, with an additional two elective courses providing experiential training. The goals of the training are to: (1) build an understanding of the importance of the veterinarian-client relationship in the freshman year; (2) teach the skills necessary to build the relationship in the sophomore year; (3) build confidence in using these skills through role-plays in the junior year; and (4) refine communication skills and build professional identity in the senior year. Providing experience and ‘‘real-life’’ practice to veterinary students through the use of role-plays has helped our veterinary students to gain confidence in, and improve, their professional communication skills.

A continuous question within this team-taught curriculum is whether (and, if so, how) to provide mandatory experiential training. While our experience and that of others suggests that practicing communication skills through role-plays is an excellent way to learn, many students have a strong aversion to the idea of role-playing and those who might benefit the most from this experience elect not to take the course.⁷ To date, there is no resolution to this issue. The administration and faculty continue to look for opportunities to implement aspects of communication training into pre-existing courses through curricular revision and refinement.

The strong collaboration of the SVM with the School of Medicine and Public Health and the School of Education has significantly enhanced our ability to provide this unique opportunity for experiential training through the use of shared expertise and resources among the three schools. Students receive an added benefit from working inter professionally across the health care disciplines.

Biography

Ruthanne Chun, DVM, Dipl. ACVIM (Oncology), is a Clinical Associate Professor of Oncology and the Section Head of Oncology at the University of Wisconsin-Madison School of Veterinary Medicine, 2,015 Linden Dr., Madison, WI 53706 USA. E-mail: chunr@svm.vetmed.wisc.edu. Her area of research is clinical oncology.

Susan Schaefer, DVM, MS, Dipl. ACVS, is a Clinical Assistant Professor of Surgery and the Section Head of Surgery at the University of Wisconsin-Madison School of Veterinary Medicine, 2,015 Linden Dr, Madison, WI 53706 USA. Her area of research is magnetic resonance imaging of the axial skeleton.

Corissa C. Lotta, PhD, is a faculty member in the Department of Counseling Psychology and Co-Director of the Personal and Wellness Support Services Office in the School of Veterinary Medicine at the University of Wisconsin-Madison, 2,015 Linden Dr, Madison, WI 53706 USA.

Jane A. Banning, MSSW, is the Director of the Clinical Teaching and Assessment Center of the University of Wisconsin School of Medicine and Public Health, 1,180 Health Sciences Learning Center, 750 Highland Ave, Madison, WI 53705 USA.

Susan E. Skochelak, MD, MPH, is the Senior Associate Dean for Academic Affairs at the University of Wisconsin School of Medicine and Public Health and a Professor of Family Medicine, 4,121 Health Sciences Learning Center, 750 Highland Ave, Madison, WI 53705 USA.