|Year : 2015 | Volume
| Issue : 6 | Page : 369-375
Introducing a teaching module to impart communication skills in the learning anaesthesiologists
Vaijayanti Nitin Gadre, Kalpana V Kelkar, Vidya S Kelkar, Maya A Jamkar
Department of Anaesthesiology, B. J. GMC, Pune, Maharashtra, India
|Date of Web Publication||15-Jun-2015|
Vaijayanti Nitin Gadre
303-C Aarav, Opposite Yashwantrao Chavan Natyagriha, Behind Mhatoba Mandir, Kothrud, Pune - 411 038, Maharashtra
Source of Support: None, Conflict of Interest: None
Background and Aims: Pre-operative negative valence communications adversely affect intra and post-operative pain experience. This study was conducted to evaluate the teaching of communication skills by teachers in anaesthesia department and whether the post-operative pain is effectively modified due to the skill of communication acquired by students. Methods: All students and teachers in the department participated in the study. Patients with uncomplicated pregnancy posted for elective lower segment caesarean section were involved. Students were taught to explain the anaesthesia plan pre-operatively to the patients in a positive manner. They were taught the practice of giving positive suggestions before any potentially painful stimulus. Pre-operatively all students informed the patients about the conduct of spinal anaesthesia. The teachers evaluated the students performing spinal block. The performance was rated for procedural and interpersonal skills (direct observation of procedural skills [DOPS] and Smith and Kendall Behavioural scale [SKBS] respectively). The extent of cooperation and the ease with which spinal block could be administered correctly by the student was judged by the teacher. Post-operatively students were randomly provided questionnaires to elicit answers from patients. Results: P value DOPS and SKBS (0.567, 0.867) show no significant statistical variation. P > 0.05 = not significant, indicates no significant variation in procedural and behavioural skills of students in two groups. Conclusion: Teaching of communication skills to students showed a demonstrable effect on their pre-operative dialogue with patients. Pain mechanism was effectively modulated by improving patients' psychology to undergo anaesthesia.
Keywords: Anesthesiologists, communication skills, pain
|How to cite this article:|
Gadre VN, Kelkar KV, Kelkar VS, Jamkar MA. Introducing a teaching module to impart communication skills in the learning anaesthesiologists. Indian J Anaesth 2015;59:369-75
|How to cite this URL:|
Gadre VN, Kelkar KV, Kelkar VS, Jamkar MA. Introducing a teaching module to impart communication skills in the learning anaesthesiologists. Indian J Anaesth [serial online] 2015 [cited 2020 Feb 21];59:369-75. Available from: http://www.ijaweb.org/text.asp?2015/59/6/369/158744
| Introduction|| |
Communication with the patients is a core clinical skill. It is necessary for taking a history, explaining the diagnosis, giving instructions regarding medicines or obtaining consent for diagnostic and therapeutic procedures. It helps to counsel to relieve symptoms and motivate to participate in the therapy.
A good doctor must have an empathetic attitude towards patients. Empathy indicates one person's appreciation, understanding and acceptance to someone else's emotions. Tavakol et al. have explored medical students' understanding of empathy, emphasising its importance in modern patient-centered care. Their report hints that negative influence student and doctor communication hinders empathetic engagement. 
Empathy has been described as the foundation of patient - physician relationship by Hojat et al. Lack of empathy is associated with suboptimal patient care behaviours and more recently as important clinical outcomes such as blood glucose and lipid control in diabetic patients. 
Smith and Mishra stated that in any doctor-patient encounter, fact - finding and information gathering is the agenda of a doctor, whereas exploring hopes and fears rather than precisely giving information about symptoms is seen on the part of the patient. Communication should not be a mere exchange of words; in anaesthesia teams, it should be directed towards co-ordinated and safe progress of the patient into anaesthesia. 
Communications by the anaesthetist can elicit subconscious patient responses in mood resulting in anxiolysis and analgesia. Cognitive reframing is a recognised, relevant pain reduction strategy. For example, calling the sensation of a local anaesthetic injection 'a numbing sensation' rather than 'a sting' may result in quite different perceptions. 
Pain being an unpleasant sensory and emotional experience associated with actual or potential tissue damage; therefore a nocebo or negative suggestion will elicit a subconscious change that might be expected to adversely affect the post-operative experience. 
| Methods|| |
This study was carried out in anaesthesia department, from January to May 2014. All residents and faculty members were involved. Totally 20 residents were evaluated by 10 lecturers while performing spinal anaesthesia. Senior faculty members were involved in training and teaching as follows: Lectures were taken to create a background that patients are fearful about anaesthesia. Students were informed about their involvement in patient interaction and the need for effective communication. Students were explained the pathophysiology of pain and the need to adopt the practice of sympathetic listening to alleviate patients' anxiety about anaesthesia and surgery. Need for attitudinal change to impart the understanding about behavioural modification in future practice was taught.
Students were informed about the questionnaires [Annexure 1] and [Annexure 2] that they will be required to ask to the patients. Department faculty was provided with checklists [Annexure 3 and [Annexure 4] with scores. They were also informed to rate the students in behaviourally anchored scale.
Students were randomly evaluated by teachers. Students were not aware as to which teacher is evaluating his/her performance at the time of giving spinal anaesthesia. The teachers were blinded about the type of questionnaire that the student will receive post-operatively.
Pre-operatively all students informed the patients about the proposed conduct of spinal anaesthesia in a sympathetic manner. Post-operatively they were randomly given the questionnaires to allocate them into group P or group C [Annexures 1 and 2]. The interview questions in group P (pain) mainly focused the attention of patients on the surgical pain and those of group C (comfort) mainly diverted their attention from the pain. The effect of students' communication skill of alleviating patients' anxiety about pain was to be tested.
Patients were also evaluated by the teachers at regular intervals. Analgesic doses required post-operatively were recorded. Students performed spinal anaesthesia under direct observation of procedural skills (DOPS) and their performance was assessed [Annexure 3]. The extent of patient cooperation and skill of communication acquired was judged using Smith and Kendall behaviourally anchored scale (SKBS). Student performance was measured using a 10-point scale [Annexure 4]. 
Data was analyzed using Chi-square test to find association between group P and group C with respect to Questions-1, 2, pain on movement, pain at rest and botheration due to wound. Mann -Whitney test was used to find significant differences between groups P and C with Median VAS and Median VNRS. Two independent sample t-test was used to find the significant difference between the study groups for Mean DOPS and SKBS scores.
| Results|| |
Totally 20 residents were evaluated by 10 teachers while performing spinal anaesthesia. Communication skills and professional attitudes, as well as procedural skills, were taught to these students before they were subjected to this evaluation. The responses to the questionnaires that were given to the students for a patient interview in the post-operative period were collected. The checklists that the teachers were given to judge the students' performance were also collected.
Patients undergoing elective lower segment caesarean section (LSCS) were included. Those with complications like pregnancy induced hypertension, coagulation disorders, placenta previa, heart disease and multiple pregnancies were excluded. Totally 100 patients were studied with the indications for LSCS being: Previous LSCS-24, previous 2 LSCS-11, oligohydramnios-10, post-dated pregnancy-7, cephalo-pelvic disproportion-18, intrauterine growth restriction-17, failure of induction-5 and breech presentation-8.
The questions that were asked to patients in each group were comparable as shown in [Table 1]. [Table 2] shows questions with results in both groups. Comparison of number of patients responding to Question 1 showed that, out of 50 patients in group P, 33 (66%) did not complain of pain while 17 (34%) had pain. In group C, 47 (94%) patients felt that they were recovering and 3 (6%) felt they were not. For comparison of Question 2 in group P 27 (54%) said yes, 23 (46%) said no; and in group C 40 out of 50 patients (80%) said yes, 10 (20%) said no. This shows that number of patients not having pain is more in C-group than in P-group.
Median visual analogue scale (VAS) in group P was 3, and in group C it was 8. Mann-Whitney test was used; (P < 0.01) significant difference in groups P and C was noted. Lower VAS score in group P means lesser pain scores in the group and higher VAS score in group C means more comfort.
Comparison of number of patients responding to Question 3, when pain on movement was asked showed that in group P, 29 (58%) had pain and 21 (42%) had no pain. In group C, 24 (48%) had pain, 26 (52%) had no pain. P =0.423 indicates, more patients complained of pain in group P; in group C, number of patients not having the pain was more but not statistically significantly higher.
Comparison of number of patients responding to Question 4, when pain at rest was asked showed that in group P, 11 out of 50 patients (22%) had pain and 39 (78%) did not have pain. In group C, 6 (12%) had pain, 44 (88%) did not have pain. Comparison of number of patients responding to Question 5 showed that in group P, 20 (40%) patients complained of wound pain and 30 (60%) did not complain of pain. In group C, 14 out of 50 patients (28%) complained of pain and 36 (72%) did not complain of pain. Verbal numerical rating scale (VNRS) median in group P was 2.5 and that in group C it was 7. A significant difference in groups P and C was noted. Lower VNRS score in group P means lesser pain scores in the group and higher VNRS score in group C means more comfort.
Students were evaluated using DOPS and SKBS [Table 3].
Mean value of DOPS score obtained by 11 students in P-group was 3.98 (standard deviation [SD] = ±0.62) out of total 5 points and that obtained by 9 students in C-group was 4.13 (SD = ±0.56). This indicates no significant variation in procedural skills of students allocated randomly into two groups. Thus, students allocated to P-group have performed spinal anaesthesia equally effectively as those allocated to C-group.
Mean value of SKBS obtained by 11 students in P-group was 7.23 (SD = ±1.27) out of 10 points and that obtained by 9 students in C-group was 7.31 (SD = ±0.95).This indicates no significant variation in behavioural skills of students allocated randomly into two groups.
Comparison of number of analgesic doses required in post-operative period in both groups' showed that, in group P, 10, 17, 13, 5 and 5 patients required 0, 1, 2, 3, and 4 analgesic doses respectively, post-operatively and in group C, 13, 13, 19, 5 and 0 patients required 0, 1, 2, 3 and 4 analgesic doses respectively post-operatively.
| Discussion|| |
Frenk et al. state that professional health education has not kept pace with the advances in the health systems worldwide in 21 st century. Largely fragmented and static curricula are likely to produce ill-equipped graduates if complete redesigning is not undertaken. The core of the system is the encounter between people who need services and those who have been entrusted to deliver them. Education of committed health workers empowers the health of citizens. The essence of empathetic work is service orientation steered by social accountability. 
The Charter of Medical Professionalism states that, to focus on 'primacy of patient welfare', doctor self-care is necessary for the doctors to meet the professional obligations expected of them. Empathy can be threatened by doctor's distress, which is seen at all levels of medical training. 
Clinical teaching brings together the learning triad of patient, student and clinician/teacher in a particular clinical environment. All three components are useful to provide effective student learning. Direct contact with patients is important for the development of clinical reasoning, communication skills, professional attitudes and empathy [Annexure Diagram 1]. 
It is generally observed that patients do not know about anaesthesia-related procedures and are anxious about surgery resulting in an overall excessively painful post-operative experience. Use of negative valence words like 'injection', 'prick', and 'pain', modulate the neurobiology towards more excruciating post-operative pain. Overall goal of our study was to teach the learning anaesthesiologists to communicate effectively with the patients. The aim was to teach them to build a rapport with patients, so as to assure them a smooth intra and less painful post-operative course.
The teaching was expected to be effective enough to obtain a calm and cooperative patient for spinal anaesthesia on table. The positive modulation of the neurobiology of patients was tested post-operatively by asking them both positively as well as negatively valenced questions. The questionnaires were either oriented towards pain (pain group) or towards comfort (comfort group). The questions in both groups were serially comparable, and the responses obtained were statistically correlated [Table 1] and [Table 2].
The professionalism and attitudinal skills of the students were tested by different teachers on different occasions. The tools applied to do so were: DOPS and SKBS. Mean value of DOPS score obtained by 11 students in P-group was found to be 3.98 (±0.62) on a 5-point scale; that of 9 students in C-group was 4.13 (±0.56). P value of two independent sample t-test was 0.567 (P > 0.05 = not significant). This indicated that students allocated to P-group performed spinal anaesthesia equally effectively as those allocated to C-group. Thus, the professional skills were comparable in two groups.
Comparing the attitudinal and behavioural skills using SKBS score, P - 0.867 (P > 0.05 = not significant). Mean value of SKBS score on a 10 point scale, of 11 students of P-group was 7.23 (±1.27) and that of 9 students of C-group was 7.31 (±0.95). This indicated that there was no significant difference between behavioural skills of students allocated to two groups [Table 3].
In a similar study, Chooi et al.  randomized 300 post-LSCS patients into pain and comfort groups. Patients were interviewed using standard questionnaires by two midwives before evaluation by doctors, post-anaesthesia. The midwives were aware about the group to which a patient was allocated, but the patients had no idea of any such intervention. Written informed patient consent to take part in the study was obtained after the questioning was completed. Post-operative pain management was given to all patients as per usual protocol. According to authors, though different questionnaires were employed both ultimately focused patients' attention towards pain. Ethical challenge was possible as consent was taken after being questioned.
They expressed a need of phrasing post-operative questions more accurately and improving internal validity in terms of randomisation and allocation concealment to minimise bias. They reported that 75.7% of patients in pain group had pain and 79.4% patients in comfort group were comfortable. In our study, 54% patients in group P had pain and 80% patients in group C were comfortable. 60% patients in group P had no botheration due to wound compared to 72% in group C. However, this number was not statistically significantly higher in group C compared to group P. Thus, in our study 28% patients in group C and 40% patients in group P were bothered because of wound, whereas Chooi et al. reported 15.1% in comfort and 55% in pain groups.
Thus, as a result of communication skill training given to students, they could improve the intra and post-operative patient satisfaction significantly. The pre-operative visit helped to improve patients' psychology to undergo anaesthesia procedures and surgery as has been judged by DOPS and SKBS tool by teachers while assessing the students.
Effective communication between doctor and patient has been stated the core of clinical requirement for the medical profession.  Multi-disciplinary assessment of students' clinical performance using Amsterdam Attitude and Communication scale (AACS) has been made precise by De Haes et al. The goal of their study was to enhance students' awareness about the relevance of learning behavioural skills in the earlier stages of their medical training.
Four hundred and forty-two 5 th year clinical students were judged 6 times in two settings by doctors and nurses and video-taped interviews judged by psychologists and doctors. Overall mean of the clinical performance was 3.96 ± 0.55; judgments of behaviour in the clinic were more precise standard error ranging from 0.11 to 0.16. In conclusion, the authors have recommended the use of AACS and the like instruments in other medical schools also for their summative assessments to be more feasible and useful. 
Comparison of the analgesic requirement in our study shows group C patients more comfortable than group P. Dauphinee described the outcome of current education policies in health professions. He referred to the need of a common framework to find out the impact of education programs at advance levels of training. He suggested studying patient outcomes like improved survival, fewer complications and fewer side-effects from the hospital records and patient feedbacks about the quality of life reported after the treatment from patient records. 
| Conclusion|| |
Students in both groups effectively communicated with patients pre-operatively. The pre-operative visit helped to improve patients' psychology to undergo anaesthesia procedures. Though post-operative questions were oriented towards either pain or comfort, number of patients without pain was found to be more in C-group than in P-group. Pain on movement was found to be more in P-group. Pain at rest and botheration due to wound was found to be comparable with less requirement of analgesics in C-group. We, therefore, conclude that the pain mechanism was effectively modulated pre-operatively with the soothing pre-operative dialogue.
| References|| |
Tavakol S, Dennick R, Tavakol M. Medical students' understanding of empathy: A phenomenological study. Med Educ 2012; 46:306-16.
Hojat M, Louis DZ, Markham FW, Wender R, Rabinowitz C, Gonnella JS. Physicians' empathy and clinical outcomes for diabetic patients. Acad Med 2011; 86:359-64.
Smith AF, Mishra K. Interaction between anaesthetists, their patients, and the anaesthesia team. Br J Anaesth 2010; 105:60-8.
Cyna AM, Andrew M. Words can help! Pain 2005; 117:239.
Chooi CS, White AM, Tan SG, Dowling K, Cyna AM. Pain vs comfort scores after Caesarean section: A randomized trial. Br J Anaesth 2013; 110:780-7.
Dent JA, Harden RM. Principles of assessment. A Practical Guide for Medical Teachers. 3 rd
ed., Ch. 40. Churchill Livingstone, Elsevier Health Sciences UK (London); 2009: p. 303-10.
Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, and Evans T, et al
. Health professionals for a new century: Transforming education to strengthen health systems in an interdependent world. (The Lancet Commissions-Education of Health Professionals for the 21 st
Century). Lancet 2010; 376:1923-58.
American Board of Internal Medicine; American College of Physicians-American Society of Internal Medicine; European Federation of Internal Medicine. Medical professionalism in the new millennium: A physician charter. Ann Intern Med 2002; 136:243-6.
Dent JA, Harden RM. Bedside teaching. A Practical Guide for Medical Teachers. 3 rd
ed., Ch. 13. Churchill Livingstone, Elsevier Health Sciences UK (London); 2009: p. 96-103.
Ong LM, de Haes JC, Hoos AM, Lammes FB. Doctor-patient communication: A review of the literature. Soc Sci Med 1995; 40:903-18.
De Haes JC, Oort FJ, Hulsman RL. Summative assessment of medical students' communication skills and professional attitudes through observation in clinical practice. Med Teach 2005; 27:583-9.
Dauphinee WD. Educators must consider patient outcomes when assessing the impact of clinical training. Med Educ 2012; 46:13-20.
[Table 1], [Table 2], [Table 3]