Use of Checklists Teaches Communication Skills Utilized by Specialties

Objectives: The purpose of the current study was to implement the use of communication checklists and determine whether medical students were able to attend to and distinguish differences in communication skills between various physician specialties. Methods: As part of a newly-revised medical education curriculum, all first-year medical students at a mid-Atlantic medical school were required to complete a communication skills checklist while observing 10 clinical encounters performed by attending physicians. The checklists were collected and analyzed for trends found within the reporting. Results: Even novice learners distinguished complex medical communication skills when structured observation checklists were used as a teaching tool. Significant differences were noted in demonstrations of targeted communication skills when analyzed by physician specialty and gender. Conclusions: Structured observation checklists can be used as an instructional tool for exposing medical students to advanced physician-patient communication skills, providing students with guidance on what skills to observe and identify, and highlighting the differences in implementation of these skills across specialties. Practice implications: This study provides implications for faculty development as well as medical communication curriculum. Communication checklists can assist in providing structured observations and normative feedback for learners and faculty desiring to improve their physician-patient communication skills.

This early instruction included in-class practice with the communication observation checklist to ensure familiarity with the skills and checklist use. First-year students were required to complete the structured observation checklist during each of 10 shadowing experiences with physicians across specialties. These shadowing experiences were discussed with their student peers and a faculty facilitator in small group meetings to review communication best practices. Observation checklists from these shadowing encounters were collected and analyzed based on both individual faculty and specialty scores on each communication domain. Appendix A contains the observation checklist used by students for each observation experience.
Medical students were randomly assigned to faculty physicians who had agreed to participate in shadowing experiences. For the purpose of data analysis, physician scores were grouped based on their departmental specialty. Table A2 lists those departments represented by this sample, the number of physicians in each department that were observed, and the number of students that observed physicians in each department. Specific departments were grouped into primary care or specialty care categories. Arguably, there were multiple ways in which the specialties could be divided. For example, groupings of physician specialties were designated as "people-oriented specialties" and "technology-oriented specialties" during the development of the Jefferson Scale of Physician Empathy (Hojat et al., 2001;Hojat et al., 2002]. The current groupings were based upon the results of consensus among the co-authors and were viewed as indicating those physician-patient relationships which tend to occur over a length of time and address more comprehensive aspects of care (i.e., primary care) versus more shortterm, acute, and focused visits (i.e., specialty). communication best practices for learners. Medical students have indicated improved satisfaction with required physician observation experiences using the checklists, noting the structure of the assignment provides guidance and objectivity to an otherwise subjective task (2013 personal communication; unreferenced). Repeated observations using the checklists provide opportunities for increased discernment of developing skills and exposure to assessment tools prior to being evaluated. Such checklists also provide a shared vocabulary for medical educators attempting to teach communication skills.
Similarly, use of structured observation checklists embedded throughout the curriculum provide a means of objective assessment of student progress. Such structure provides both specific goals to target and an objective measurement of skill attainment in patient-centered communication that, without such structure, can otherwise appear nebulous. Repeated assessment of communication skills throughout training and in a variety of patient situations also is important as skill level may decline from preclinical to clinical years, as suggested by studies of empathy (Chen et al., 2007). Additionally, these communication skills are essential to graduation requirements, as medical educators must indicate whether graduating medical students possess the requisite skills needed to provide the level of medical care entrusted to them as house staff (i.e., "Expected behavior for an entrustable learner"; AAMC, 2014). The Association of American Medical Colleges includes communication skills in the expected skills for students entering residency, including, "Obtaining a complete and accurate history in an organized fashion" and "Demonstrates patient-centered interview skills." Therefore, the communication checklist can provide an objective and standardized method of assessing these skills.
Beyond the medical student, the checklist may be utilized for faculty development by providing feedback to attending physicians on their communication skills without adding more demands on their time. Although faculty physicians in teaching hospitals often are observed, feedback on observed behaviors is rare. Establishing a sufficient pool of structured observations for each specialty could provide normative data on communication skills that are relevant to patient-centered care in general as well as specialty-specific skills. Providing feedback to faculty on their doctor-patient communication skills ratings relative to other faculty in their specialty could offer valuable insights for reflection and improvement. Moreover, faculty may be more receptive to observational data from students than from results of patient-satisfaction surveys. The latter may be more subject to sampling bias (i.e., patients who are very satisfied or very dissatisfied may be more likely to return surveys) than the former in a medical curriculum requiring that all students complete observation checklists during clinical observational experiences.
Additionally, peer observation and feedback by physician colleagues could help improve communication and relationship skills in not only the observed physician, but also the observer. As noted by Mauksch et al. (2013), even experienced clinical educators reported improvement in their own skills when teaching medical communication via observation and feedback. Faculty development using peer observation of communication behaviors and structured feedback for enhancing skills could contribute to a more constructive and effective culture of observation and feedback in these essential clinical skills; however, such peer observation by physicians is not only rare, but costly given the time demands in busy academic medical settings. Incorporating a means of providing feedback to faculty into a required assignment for students, as in the current medical communication curriculum, is efficient and costeffective.
Finally, if medical providers differ in their demonstration of communication skills by specialty and gender, it may be important to take these findings into consideration when assigning medical students to physician observation experiences when targeting specific communication skills. A sufficiently broad range of physician shadowing assignments may be necessary to provide a comprehensive picture of physician communication behaviors for medical student observers. Medical educators responsible for communication curriculum should consider both cueing student attention to best practices by structuring the observation experience, as well as varying the gender and

Study Limitations and Strengths
This study contains several limitations; as such the findings should be viewed as important pilot data in the implementation of a staged school-wide communication curriculum redesign. The study was conducted in one academic medical center using faculty physicians who have volunteered to be observed by first-year medical students, obviously limiting transferability of findings. It should be noted, however, that these physicians are faculty of a medical school, with resulting implications for regularly teaching medical trainees at various levels of training. It is unlikely that these physicians vary in reliable ways from other academic medicine physicians that were not observed, suggesting that they are likely representative of their practices. Second, the required observations by students have been part of the curriculum for several years, and many faculty physicians were unaware of communication-focused observation checklists in use. Thus, physicians being observed were unlikely to modify their behavior for the specific checklist items.
Likewise, individual student observation experiences could have varied widely in the half-day observation periods. Given a broad range of clinic and hospital settings, students could have observed one or several patients with each physician, inpatient or outpatient, scheduled or emergency, new patient or return patient. Participating physicians vary in years of practice, gender, and country of origin. The amount of time spent with patients would likely vary considerably. It is hoped that this very broad range of observation experiences provided breadth, in contrast to depth, of observed physician communication behavior to first-year medical students.
Student performance of observation checklists did not include multiple observers of the same physician encounter, leaving questions about reliability of the ratings. Observations and the subsequent ratings could be separated by several days, as students were required to hand in their checklists weekly, leading to possible memory degradation if checklists were not completed at the time of the observation. Also, it is unclear to what extent different types of patient presenting problems or clinic structure and organization affect the communication skills demonstrated by the physicians.

Future Directions
Future directions include determination of whether particular observational experiences during medical student preclinical years (e.g., higher proportion of primary care observations versus specialty care) affect communication performance in later clinical clerkships. Determining whether particular observational experiences during training impacts specialty preference may have policy implications given the looming shortage of primary care providers, as suggested by Chen and colleagues in their reflection on differences in average empathy ratings of various physician specialists (Chen et al., 2007). Another direction for future study is to establish norms for specific communication tasks at various levels of training and for various medical specialties to develop "benchmarks" for expected progress and need for potential remediation experiences. Development of normative data on communication skills that are specifically relevant to various medical specialties can be used to create competency milestones for resident physicians in task-specific skills. LeBlanc et al. (2009), incorporated checklists to assess surgical procedural skills simultaneously with patient-centered communication skills in simulated scenarios, with results indicating residents outperformed medical students in procedural skills, but only on one domain of the communication skills being assessed. Such findings are provocative in their indications for application of observation checklists to residency milestone attainment and finding and addressing gaps in training. Vargovich A, Sperry J, Spero R, Xiang J, Williams D MedEdPublish https://doi.org/10.15694/mep.2016.000064 Page | 12

Conclusions
All future physicians will require advanced communication skills for enhancing health-promoting behaviors and improving a patient's chronic illness self-care behaviors. In addition, medical educators can benefit from increased self-awareness of their role in teaching physician-patient relationship skills, and also may benefit from improved efforts focused on teaching and modeling effective physician communication behaviors. Medical schools may want to carefully consider the impact of role modeling by various physician specialists on student learning. Medical educators responsible for communication curriculum should consider both cueing student attention to best practices by structuring the observation experience, as well as varying the gender and specialty of the attending physician being observed. As studies accumulate indicating the health benefits for patients whose physicians display empathy (Kelley et al., 2014), structured measurement of well-defined skills in clinical settings may become increasingly important to patients seeking care, insurers seeking best practices for patients in their panels, and for employers seeking objective ways to quantify various levels of performance on patient-centered care indices. Structuring the observational learning process using communication checklists may facilitate future medical professionals in attaining these multidimensional goals.

Take Home Messages Practice Points
Shadowing experiences are a mainstay of medical education, but often have little structure or guidance related to what the student should attend to in the visit. Patient-centered relationship skills and high-quality communication skills are important in addressing the needs of the medically underserved and those with chronic health conditions. The use of communication skills checklists for teaching and structuring student observations provides a more standardized and streamlined process for assessment and feedback during the development of physicianpatient communication skills. Communication skills checklists may be utilized for faculty development by providing feedback to attending physicians on their communication skills without adding more demands on their time. By utilizing structured communication checklists, physician-patient communication skills can be tracked and improved over the course of the students' training. Improvement in communication skills, such as empathy, has been shown to result in behavior change and improved health benefits for patients, thus helping students to become more effective physicians.