Defining competency-based evaluation objectives in family medicine: Communication skills

Tom Laughlin; Stephen Wetmore; Tim Allen; Carlos Brailovsky; Tom Crichton; Cheri Bethune; Michel Donoff; Kathrine Lawrence

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Table 1

Themes and observable behaviours in communication with patients

THEMES	OBSERVABLE BEHAVIOURS WITH PATIENTS
THEMES	APPROPRIATE	INAPPROPRIATE
Listening skills
Uses both general and active listening skills to facilitate communication	Appropriately looks at the patient while the patient is talking Allows time for appropriate silences Feeds back to the patient what he or she understood from the patient Provides appropriate nonverbal responses to the patient’s statements Responds to important cues at all times (eg, it is not appropriate to go on with regular questioning when the patient reveals important life or situation changes such as “I just lost my mother”) Clarifies jargon when used by the patient Comprehends what the patient says Lets the patient tell his or her story (does not interrupt the patient inappropriately)	Does other things while the patient is talking (eg, looks at computer chart, takes telephone calls)
Language skills
Verbal Can be understood by the patient Is able to converse at an appropriate level for the patient’s age and educational level Uses appropriate tone for the situation to ensure good communication and patient comfort	Asks open- and closed-ended questions appropriately Checks back with the patient to ensure understanding (eg, “If I say this, am I understanding you correctly?”) Facilitates the patient’s story (eg, “Can you clarify that for me?”) Provides clear and organized information in a way the patient understands (eg, test results, pathophysiology, side effects) and checks back to ensure the patient understands Provides explanations to accompany examinations or procedures When first meeting a patient, clarifies how the patient would like to be addressed	Fails to greet the patient Interrupts the patient inappropriately Uses inappropriate word choices for the patient’s level of understanding (eg, use of scientific language that the patient cannot understand, overuse of jargon) Displays inappropriate anger Uses inappropriate humour Uses paternalistic language (eg, calls the patient “dear”) Uses offensive language (eg, swearing) Shouts or uses excessively loud speech Asks multiple questions without awaiting the answers Has language skills that are insufficient to be easily understood by most patients (eg, patient cannot understand what the physician is saying)
Written Clearly articulates and communicates thoughts in a written fashion (eg, letters, educational materials, instructions)	Writes legibly Written material is organized so that the patient can understand (spelling, grammar and punctuation must be sufficient to permit understanding) When providing written information, chooses materials that are appropriate to the patient’s level of understanding	Uses abbreviations that are not understood by the patient
Nonverbal skills
Expressive Is conscious of the effect of body language on communication with the patient and adjusts it appropriately when it inhibits communication	Sits while interviewing the patient (to convey the feeling of providing the patient more time and attention) Ensures eye contact is appropriate for the culture and comfort of the patient Is focused on the conversation Adjusts demeanour to be appropriate to the patient’s context (eg, is pleasant, appropriately smiles, is appropriately serious, is attentive, is patient and empathetic) Communicates at eye level (eg, children, patients who are bedridden) Ensures physical contact is appropriate to the patient’s comfort	Fidgets Hygiene or dress inhibits communication Gets too close (eg, does not respect others’ personal space)
Receptive Is aware of and responsive to body language, particularly feelings not well expressed in a verbal manner (eg, dissatisfaction, anger, guilt)	Responds appropriately to the patients discomfort (eg, gets a tissue for a patient who is crying, shows appropriate empathy to the patient’s difficulties) Verbally checks the meaning of body language (eg, “You seem nervous/upset/uncertain/in pain; is that right?”) Comments on behaviour or nonverbal actions of the patient when appropriate (eg, “You seem quiet/unhappy/angry/worried/in pain”) Modifies actions during examination or history taking in response to patient’s discomfort (eg, adjusts angle of table when a patient is short of breath during an abdominal examination)	Misses signs that the patient does not understand what is being said (eg, blank look, look of astonishment, look of puzzlement)
Cultural and age appropriateness
Adapts communication to the individual patient for reasons such as culture, age, and disability (eg, young child or teenager, speech deficit, hearing deficit, language difficulty)	Adapts communication to the adolescent (eg, offers to see the patient independently, respects capacity to make decisions, acknowledges issues of confidentiality, specifically directs questions to the adolescent, is not judgmental) Adapts communication style to patient’s disability (eg, writes for deaf patients) Asks about need for and arranges for interpreter Speaks at a volume appropriate for the patient’s hearing Adapts communication style based on the patient’s cultural expectations or norms (eg, other family members in the room) Identifies and adapts manner to the patient’s cultural needs Uses appropriate words for children and adolescents (eg, pee vs void)	Ignores the patient while exclusively engaging the caregiver, especially with children, the elderly, and patients with cognitive impairment (eg, no questions to the patient, patient not involved in management plan) Makes assumptions based on patient’s appearance or dress (ie, stereotyping) Uses colloquialisms that the patient does not understand
Additudinal skills
This permeates all levels of communication. This includes the ability to hear, understand, and discuss an opinion, idea, or value that might be different from the physician’s own, while maintaining respect for the patient’s right to decide for himself or herself. Communication conveys respect for the patient	Expresses interest in the patient’s opinion Is empathetic Maintains an appropriate attitude in response to inappropriate or offensive language or comments made by the patient	Appears rude Appears impatient Displays irritation or anger Belittles the patient Trivializes or dismisses the patient’s ideas or concerns Is sarcastic Appears intimidating Appears arrogant (eg, ignores the patient’s concerns or opinions about the management plan)

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Table 2

Themes and observable behaviours in communication with colleagues

THEMES^*	OBSERVABLE BEHAVIOURS WITH COLLEAGUES
THEMES^*	APPROPRIATE	INAPPROPRIATE
Listening skills
Uses both general and active listening skills to facilitate communication	Is attentive Stops and takes time to listen respectfully to colleagues Appropriately maintains eye contact while discussing issues with all members of the health care team Allows sufficient time for colleagues to articulate their concerns	Does other tasks that interfere with listening
Language skills
Verbal Can be understood in face-to-face communication, and with all other commonly used methods (eg, telephone, video conference, etc) Can understand complex profession-specific conversation Uses appropriate language for colleagues with different backgrounds, professions, and education Uses an appropriate tone for the situation to ensure good communication and colleague comfort	Introduces self when meeting for the first time When asking colleagues to do something, makes sure the request is clear and checks that it is understood Offers rationale for the plan or approach to improve understanding Is able to adjust tone to be appropriate to circumstances Asks rather than demands Uses non-blaming, appropriate, and specific observations when dealing with difficult circumstances	Case presentations are poorly organized or incomplete Is not specific with requests Interrupts colleagues Asks multiple questions without awaiting the answers Does not target the language to the individual’s professional background and level of understanding Expresses inappropriate anger Uses inappropriate humour Uses condescending language Shouts or uses excessively loud speech Swears or uses offensive language
Written (eg, hospital and office charts, consultant letters, lawyer letters) Clearly articulates and communicates thoughts in writing Writes legibly and uses spelling, grammar, and punctuation that facilitate understanding	Writes legibly Written material is organized When writing to request consultation, is specific about questions and reasons, and provides relevant information Writes patient care plans (eg, test requests, follow-up orders) clearly and ensures they are securely transmitted to the appropriate recipient	Uses abbreviations that are not universally known or are prone to misinterpretation
Nonverbal skills
Expressive Uses appropriate eye contact, is respectful of personal space, uses an appropriate demeanour (eg, pleasant, smiles appropriately, is appropriately serious, attentive, patient, and empathetic), is conscious of the effect of body language on the colleague	Is focused on the conversation Ensures eye contact is appropriate for the culture and comfort of the colleague Adjusts demeanour to the colleague’s context Ensures physical contact is appropriate to the colleague’s comfort
Receptive Is aware of and responsive to body language, especially that expresses dissatisfaction Correctly interprets signs of feelings not expressed, such as anger and frustration	When a colleague shows signs of distress, demonstrates awareness by doing things such as modifying demands, exploring concerns, and seeking resolution
Attitudinal skills
Able to respectfully hear, understand, and discuss opinions, ideas, or values that might be different from their own; this permeates all levels of communication	Seeks to understand rather than to judge Returns the focus to effective patient care when interprofessional conflicts occur Attempts to resolve difficulties before ending the discussion or walking away Apologizes when appropriate	Is rude Is impatient Belittles colleagues or their field of work Trivializes or dismisses ideas or concerns of colleagues Is arrogant Displays anger or irritation Uses derogatory language when describing a patient’s circumstances or case Is threatening

↵* Assessment of cultural and age appropriateness is best dealt with in the assessment of other communication skills with the patient and of professionalism.