In “A Practicing Surgeon Dissects Issues in Physician-Hospital Relations,” I wrote that most physicians lack formal training in communication, negotiation, and conflict resolution.

I owe the inspiration for this post to two people:

1) Catherine Henderson, a Graduate Medical Education Consultant with Partners in Medical Education, Inc. reminded me that a decade ago, the Accreditation Council for Graduate Medical Education (ACGME – the organization that accredits all allopathic residency programs) mandated that residents demonstrate competence in the specific knowledge, skills, attitudes, and behaviors required in all six General Competencies:  medical knowledge, patient care, practice-based learning and improvement, systems-based practice, professionalism, and interpersonal and communication skills.  No longer will residency programs retain their accreditation by proving that they teach residents how to care for patients – they must also demonstrate that residents have learned the skills and behaviors in all six competency domains.

2) However, the ACGME did not point out how facilities can make sure that residents and faculty teaching the residents demonstrate the 6 competencies.  For insights into this journey, I am indebted to Ruben Azocar, Program Director, Department of Anesthesiology, Boston Medical Center, for his talk entitled, “Bringing the Six Core Competencies into the OR” at the 5th Annual Ellison Pierce Symposium: Positioning Your ORs for the Future, April 30-May 2, 2009, where we served on the faculty.

I will focus on the last competency, interpersonal and communication skills, not only because of my interest in the field but also because the Joint Commission on Hospital Accreditation has raised awareness of this issue by mandating zero tolerance for behavior that undermines a culture of safety.

Dr. Azocar’s presentation elucidated the skills that underlie the ACGME mandate that practitioners must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, families, and professional associates, including:

• Creating a relationship with patients
• Using effective listening skills
• Eliciting and providing information
• Working with others

Evaluation of these six competencies should be part of a rotation-by-rotation rating (such as “displays these behaviors: always, usually, sometimes, or rarely”) with a signed action plan for remedying deficiencies.  In addition to rule-based indicators, we may also see rate-based indicators that track practitioners’ clinical outcomes relative to their peers with appropriate thresholds (eg central line infections).

I was fascinated by the assessment tools to help physicians monitor and improve performance, extending beyond written and oral examinations to 360-degree feedback, direct observation (as with shadowing mentors or actors playing mystery patients), and after-action reviews of clinical simulations in which faculty assess resident performance not only for correct diagnosis and treatment but also for situational awareness and clarity of communication and follow-up measures.

He referenced a fascinating operational matrix developed by Bingham and Quinn from MD Anderson Cancer Center, in which interpersonal communication skills (“What should we say?”) could be tracked along the dimensions of the recommendations by the Institute of Medicine that care be safe, effective, patient-centered, timely, efficient, and equitable.  An important feature of the matrix is that it encourages users to close the loop; if a remedial action plan is not documented at the bottom of the matrix, problems have a high likelihood of recurring.

Dr. Azocar predicted that in the future, a physician’s portfolio will include not only a list of places worked, publications, and committee assignments, but also evaluation forms and action plans demonstrating improvement.

In “Collaborative Leadership at Academic Medical Centers” (Cohn KH. Collaborate for Success! Breakthrough Strategies for Engaging Physicians, Nurses, and Hospital Executives. Chicago: Health Administration Press. 2006, 149), I wrote that leadership derives not only from the people in charge but also from processes that foster transparency, trust, accountability, and collaboration.  The development of emotional intelligence that broadens residents’ skills beyond command-and-control is critical because, unlike practice management, interpersonal communication skills must be learned and not delegated. Furthermore, improved communication can decrease readmissions, as discussed in Collaborative Handoffs.

The questions that the competency-based approach to residency education raises include not only how do we measure competency but also who will assess competency, what remains confidential, and how do we train faculty assessors as well as residents.  Apparently, the competency evaluations are here to stay, we are on a journey of discovery, and the potential for improving communication and patient care is exciting. 

What do you think?

• Will 21st Century residents trained under the system of the general competencies and simulation change medical practice
• What collaboration is needed to make these changes possible
• Will competencies make a difference in the quality of medical care
• How will we know when we are “there”

As always, I welcome your input to improve healthcare collaboration.

Kenneth H. Cohn
© 2009, all rights reserved