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Medical Teacher, Vol. 28, No. 5, 2006, pp. e127–e134
WEB PAPER
A model for communication skills assessment across
the undergraduate curriculum
ELIZABETH A. RIDER, MARGARET M. HINRICHS & BETH A. LOWN
Harvard Medical School, USA
ABSTRACT Physicians’ interpersonal and communication skills
have a significant impact on patient care and correlate with
improved healthcare outcomes. Some studies suggest, however,
that communication skills decline during the four years of medical
school. Regulatory and other medical organizations, recognizing
the importance of interpersonal and communication skills in the
practice of medicine, now require competence in communication
skills. Two challenges exist: to select a framework of interpersonal
and communication skills to teach across undergraduate medical
education, and to develop and implement a uniform model for the
assessment of these skills. The authors describe a process and
model for developing and institutionalizing the assessment of
communication skills across the undergraduate curr iculum.
Consensus was built regarding communication skill competencies
by working with course leaders and examination directors,
a uniform framework of competencies was selected to both teach
and assess communication skills, and the framework was
implemented across the Harvard Medical School undergraduate
curr iculum. The authors adapted an assessment framework based
on the Bayer–Fetzer Kalamazoo Consensus Statement adapted a
patient and added and satisfaction tool to bring patients’
perspectives into the assessment of the learners. The core
communication competencies and evaluation instruments were
implemented in school-wide courses and assessment exercises
including the first-year Patient–Doctor I Clinical Assessment,
second-year Objective Structured Clinical Exam (OSCE),
third-year Patient–Doctor III Clinical Assessment, fourth-year
Comprehensive Clinical Practice Examination and the Core
Medicine Clerkships. Faculty were offered workshops and
interactive web-based teaching to become familiar with the
framework, and students used the framework with repeated
opportunities for faculty feedback on these skills. A model is
offered for educational leaders and others who are involved
in designing assessment in communication skills. By presenting
an approach for implementation, the authors hope to provide
guidance for the successful integration of communication skills
assessment in undergraduate medical education.
Introduction
Communication is a core clinical skill that can be taught and
learned. A physician performs 160,000 to 300,000 interviews
during a lifetime career making the medical interview the
most commonly performed procedure in clinical medicine
(Lipkin, 1996).
Evidence-based studies show that effective interpersonal
and communication skills are associated with improved
health outcomes (Stewart, 1995; Stewart et al., 1999).
Ineffective communication skills are associated with mal-
practice claims and suits (Levinson et al., 1997) and
medication errors (Kohn et al., 1999).
Regulatory and other medical organizations, recognizing
the importance of interpersonal and communication skills
in the practice of medicine, now require competence in
communication skills. Medical school guidelines (Institute
for International Medical Education [IIME]—Institute
for International Medical Education, 2002; General
Medical Council [GMC]—General Medical Council, 2003;
Liaison Committee on Medical Education [LCME]—
Liaison Committee on Medical Education, 1998;
Committee on Accreditation of Canadian Medical Schools
[CACMS]; Association of American Medical Colleges
[AAMC]—Association of American Medical Colleges,
1999; Association of Canadian Medical Colleges [ACMC]
Practice points
. Studies suggest communication skills decline during
medical school.
. Regulatory and other medical organizations recognize
the importance of teaching and assessing communica-
tion skills and require assessment of competence in
these skills.
. The authors describe a uniform, longitudinal approach
for assessing communication competencies.
. Instituting a uniform assessment framework of com-
munication competencies provides repeated opportu-
nities for student assessment and feedback, and
consistently reinforces basic and more complex com-
munication skills.
. Ongoing faculty development in teaching and assessing
communication skills, and training for standardized
patient assessors are important.
Correspondence: Elizabeth A. Rider, MSW MD, Harvard Medical School –
Pediatrics, 1153 Centre Street, Suite 31, Boston, MA 02130, USA. Tel: 617-
795-0385; fax: 617-522-6366; email: elizabeth_rider@hms.harvard.edu
ISSN 0142–159X print/ISSN 1466–187X online/06/050127–8 ! 2006 Informa UK Ltd.
e127
DOI: 10.1080/01421590600726540
reflect international recognition of the importance of teaching
and assessing communication skills during undergraduate
medical training. As of 2005, US medical students are
required to demonstrate competence in clinical, interper-
sonal, and communication skills on the United States
Medical Licensing Examination (USMLE) Clinical Skills
Examination (Klass et al., 1998).
Competence in communication skills is also required
via certification standards including the Canadian Medical
Education Directions for Specialists 2000 Project (CanMeds)
(Royal College of Physicians and Surgeons of Canada, 1996),
Accreditation Council for Graduate Medical Education
(ACGME) (Accreditation Council for Graduate Medical
Education, 2001), Educational Commission for Foreign
Medical Graduates (ECFMG) (Whelan, 1999), and others
(Tate et al., 1999).
Several consensus statements have proposed essential
skills to teach and assess across the spectrum of medical
education, including Kalamazoo (Bayer–Fetzer Conference
on Physician–Patient Communication in Medical Education,
2001), Toronto (Simpson et al., 1991), and International
(Makoul & Schofield, 1999). The recent Kalamazoo II
Report (Duffy et al., 2004) and other reports (Whelan, 1999)
summarize the state of the art in assessing communication.
The report outlines how the Kalamazoo Consensus
Statement (Bayer–Fetzer Conference on Physician–Patient
Communication in Medical Education, 2001) and the
ACGME interpersonal and communication skills competen-
cies (Accreditation Council for Graduate Medical
Education, 2001) are associated, and how these may be
applied developmentally as trainees progress through
training. Rider & Keefer (2005), with an international
group of medical education leaders, further defined and
expanded the ACGME interpersonal and communication
skills competencies, added 20 sub-competencies and created
a teaching toolbox. Their teaching toolbox connects these
competencies to teaching strategies at each level of medical
education.
Faculty, however, use a variety of models to teach and
assess these skills (Cohen-Cole, 1991; Kurtz & Silverman,
1996; Stewart et al., 1995; Makoul, 1998). Faculty are better
able to teach and assess communication skills when they use
the same framework of competencies to accomplish both
tasks across the undergraduate curriculum. A framework
grounds the reliability and effectiveness of observation and
feedback (Makoul, 1998). A report from the AAMC
published in 1999 found that, while medical schools use a
variety of teaching and assessment methods, the majority
(70%) did not use uniform frameworks for assessment
throughout the curriculum (Association of American
Medical Colleges, 1999). Additional data on the impact of
using a uniform framework on individual performance and
program efficacy is needed.
Some studies suggest that communication skills decline
during the four years of medical school (Pfeiffer et al., 1998;
Prislin et al., 2000; Pfeiffer et al., 2001). This may reflect
a lack of reinforcement combined with assessment and
feedback on skills, or other factors. The majority of North
American medical schools report fewer courses in commu-
nication skills training in the clinical (third and fourth) years
than in the preclinical years (Association of American
Medical Colleges, 1999).
Our goal was to implement a uniform communication
skills assessment plan to reinforce basic skills introduced
in years 1 and 2 and to elaborate on these skills
during years 3 and 4, identifying appropriate skills for
assessment at the different levels of training. We implemen-
ted a uniform communication skills framework for assess-
ment across all four years of undergraduate medical
education.
Developing a uniform framework for
assessing communication skills
A Communication Skills Task Force, consisting of Patient–
Doctor course leaders, Harvard Medical School experts
involved nationally in the area of communication skills, and
several clinical site faculty, held a series of meetings over
several years to discuss core competencies and a framework
for teaching and assessing communication skills during
undergraduate medical education. A core group adopted
a set of seven communication competencies based on the
Bayer–Fetzer Kalamazoo Consensus Statement (Bayer–
Fetzer Conference on Physician–Patient Communication in
Medical Education, 2001).
The Kalamazoo Consensus Statement represents the
collaboration and agreement of a group of experts, including
the architects of five existing models of physician–patient
communication. The Bayer–Fetzer Kalamazoo group identi-
fied seven broadly supported essential communication
competencies, with sub-competencies for each, applicable
to most medical encounters and adaptable across specialties,
settings and health issues. The competencies include:
building the patient–doctor relationship; opening the discus-
sion; gathering information; understanding the patient’s
perspective; sharing information; reaching agreement on
problems and plans; and providing closure (Bayer–Fetzer
Conference on Physician–Patient Communication in
Medical Education, 2001). Members of the Bayer–Fetzer
Kalamazoo consensus group also drafted an assessment tool
correlated with these competencies.
The original Kalamazoo assessment tool included 23
communication sub-competencies with possible ratings:
done well, needs improvement, not done, not applicable.
Global ratings on the seven core communication competen-
cies were not included. We adapted the Kalamazoo assess-
ment tool, choosing to use global ratings of the seven core
competencies using a Likert scale: 1 ¼ poor, 2 ¼ fair,
3 ¼ good, 4 ¼ very good, and 5 ¼ excellent (Table 1). In
years 1 and 2, we use global ratings on six core competencies,
excluding reaching agreement. In year 3, we rate all seven
core competencies as well as each sub-competency (a total
of 30 ratings). In year 4, we again use global ratings on the
seven core competencies. Assessment methods for each year
are described below.
We also adapted the American Board of Internal
Medicine (ABIM) patient satisfaction assessment tool
(American Board of Internal Medicine, n.d.). We chose six
items (five items in the first year) for our adapted tool
including patient ratings of the interviewer’s greeting,
respect, listening, showing interest, encouraging questions,
and using simple language. Faculty examiners and/or
standardized patients complete our adapted Kalamazoo
assessment tool (i.e., the Harvard Medical School [HMS]
E. A. Rider et al.
e128
Communication Skills Tool) and standardized patients
complete our adapted ABIM patient satisfaction tool
(Table 2) in assessment exercises at different stages over
the four years of medical school.
Table 3 shows our framework for uniform assessment of
communication skills across the curriculum. We use
the HMS Communication Skills Tool, adapted from the
Kalamazoo assessment tool, and the adapted ABIM Patient
Table 1. Competencies and sub-competencies in communication skills
adapted from the Bayer–Fetzer Kalamazoo consensus framework: the HMS
Communication Skills Tool.
1. Builds a relationship:
. Greets and shows interest in the patient as a person
. Uses words that show care and concern throughout the interview
. Uses tone, pace, eye contact, and posture that show care and concern
. Responds explicitly to patient statements about ideas, feelings, and values
2. Opens the discussion:
. Allows patient to complete opening statement without interruption
. Asks ‘is there anything else’ to elicit full set of concerns
. Explains and/or negotiates an agenda for the visit
3. Gathers information:
. Begins with patient narrative using open-ended questions (‘tell me about . . .’)
. Clarifies details as necessary with more specific or ‘yes/no’ questions
. Summarizes and gives patient opportunity to correct or add information
. Transitions effectively to additional questions
4. Understands the patient’s perspective:
. Asks about life events, circumstances, other people that might affect health
. Elicits patient’s beliefs, concerns and expectations about illness and treatment
5. Shares information:
. Assesses patient’s understanding of problem and desire for more information
. Explains using words that are easy for patient to understand
. Asks if patient has any questions
6. Reaches agreement (if new/changed plan):
. Includes patient in choices and decisions to the extent she/he desires
. Checks for mutual understanding of diagnostic and/or treatment plans
. Asks about patient’s ability to follow diagnostic and/or treatment plans
. Identifies additional resources as appropriate
7. Provides closure:
. Asks if the patient has questions, concerns, or other issues
. Summarizes
. Clarifies follow-up or contact arrangements
. Acknowledges patient and closes interview
Notes: Ratings used: 1 ¼ poor; 2 ¼ fair; 3 ¼ good; 4 ¼ very good; 5 ¼ excellent.
Source: Adapted from Essential Elements: The Communication Checklist, !Bayer-Fetzer
Group on Physician–Patient Communication in Medical Education, May 2001.
Used with permission.
Table 2. Adapted ABIM Patient Satisfaction Tool.
Items:
1. Greeting you warmly; calling you by the name you prefer; being friendly; never crabby or rude
2. Treating you like you’re on the same level; never ‘talking down’ to you or treating you like a child
3. Letting you tell your story; listening carefully; asking thoughtful questions; not interrupting you while you’re talking
4. Showing interest in you as a person; not acting bored or ignoring what you have to say
5. Encouraging you to ask questions; answering them clearly; never avoiding your question or lecturing you
6. Using words you can understand when explaining your problems and treatment; explaining any technical medical terms in plain
language
Notes: Ratings: 1 ¼ poor; 2 ¼ fair; 3 ¼ good; 4 ¼ very good; 5 ¼ excellent; 6 ¼ unable to evaluate. Source: Adapted from
American Board of Internal Medicine. Patient and peer assessment forms. Available at: http://www.acgme.org/outcome/
downloads/IandC_1.pdf
A model for communication skills assessment
e129
Table 3. Uniform communication skills assessment across the medical school curriculum.
Year 1 Year 2 Year 3 Year 4
Assessment Patient–Doctor I Clinical
Assessment
Patient–Doctor II OSCE Patient–Doctor III Clinical
Assessment
Core Medicine Clerkships
Communication Skills
Assessment
Comprehensive Clinical Practice
Examination (CPX)
Description of
examination
Two videotaped interviews
with standardized patients
(SP), mid-year and end
of year, with SP and
faculty feedback
Seven 20-minute OSCE stations
including history-taking, physical
examination, communication
skills, differential diagnosis, with
SP and faculty feedback
Videotaped oral case presenta-
tion to faculty followed by
giving bad news to a standar-
dized patient; SP and faculty
feedback
1. Two faculty-observed real-
patient interviews followed
by faculty feedback
2. Single case standardized
patient exercise at end of
clerkship with student self-
assessment and SP and
faculty feedback**
Nine station CPX: 7 stations
with SPs; history, physical
examination, communication
skills, differential diagnosis
& some management with
SP and faculty feedback
HMS assessment
tool*
HMS Communication Skills
Tool* completed by faculty
during clinical assessment
and all observed interviews
throughout the course
HMS Communication Skills Tool
completed by SP and faculty
during seven-station OSCE
HMS Communication Skills
Tool completed by
faculty – with additional
content-specific items
HMS Communication Skills
Tool completed by faculty
and used as self-assessment
tool by students
HMS Communication Skills
Tool completed by SP and
faculty in 7 of 9 OSCE
stations
Patient Satisfaction
Tool
Adapted ABIM Patient
Satisfaction Tool completed
by SPs at year end clinical
assessment
Adapted ABIM Patient Satisfaction
Tool completed by SPs at seven
OSCE stations
Adapted ABIM Patient
Satisfaction Tool
completed by SPs
Adapted ABIM Patient
Satisfaction Tool
completed by SPs
Adapted ABIM Patient
Satisfaction Tool completed
by SPs at seven of nine
OSCE stations
Notes: *Adapted from Essential Elements: The Communication Checklist, !Bayer-Fetzer Group on Physician–Patient Communication in Medical Education, May 2001. Used with
permission. **This SP exercise occurred in 2004 only.
E. A. Rider et al.
e130
Satisfaction Tool in school-wide assessment exercises across
four years and in the core medicine clerkship required of
all third-year students.
Description of the curriculum and the
implementation of assessment tools
Year 1
The communication skills curriculum begins with the
Patient–Doctor I course. Students work closely with faculty
preceptors and a small group of peers one afternoon each
week for nine months to learn the fundamentals of patient
interviewing and the impact of illness on patients’ lives.
Faculty teach interviewing content and skills in small-group
tutorials and in clinical settings with real, and occasionally
simulated, hospitalized or ambulatory patients. The goals of
this first-year course include exploring the patient–doctor
relationship and the contextual forces that affect it, and
learning interviewing skills that demonstrate establishing
rapport, collecting accurate data and understanding the
patient’s perspective. Students also learn the standard
medical write-up, and are introduced to the oral presenta-
tion. Students review videotapes of their patient interviews
with peers and faculty at least twice during the year, mid-year
and during the final clinical assessments. In the clinical
assessment exercises, standardized patients portray cases that
contain common biomedical and psychosocial problems.
Students are assessed on their ability to elicit a complete
history, including inquiring about the patient’s explanatory
model and sensitive areas such as screening for smoking,
substance abuse and domestic violence, and taking a sexual
history. The HMS Communication Skills Tool is used for
assessment and feedback. The year-long small-group format
allows students to develop supportive, mentoring relation-
ships with faculty. The multiple opportunities for one-on-one
observation and assessment with immediate feedback help
students set personal goals, receive and use feedback and
practice self-reflection, all of which are central to professional
development and improved communication skills.
Core faculty and Patient–Doctor I and II course leaders
selected six of the seven Kalamazoo competencies (excluding
reaching agreement) to be used for assessments in the first
two years. Course leaders grouped a detailed list of skills
already used in the curriculum into the competency
headings in the Kalamazoo format. The detailed list of sub-
competencies under each Kalamazoo heading is included
on the interview observation–feedback forms for faculty and
students in the course guides. Faculty use these feedback
forms for teaching and assessment during observed student
interviews with real and standardized patients throughout the
year. Standardized patients interviewed by students in clinical
assessment exercises complete the adapted ABIM patient
satisfaction assessment tool.
Year II
Patient–Doctor II students concentrate on physical exam-
inations and continue to learn and practice interviewing,
interpersonal and communication skills. Students are
assigned to a clinical site for the year, and the goals of
the course are met using site-specific experiences and
resources. Toward the end of the second year, students
participate in an Objective Structured Clinical Examination
(OSCE) consisting of seven stations, each with a 15-minute
encounter with a standardized patient (SP) and five minutes
of SP and faculty feedback. Standardized patients assess
students’ communication skills in the seven stations using the
HMS Communication Skills Tool (see Table 1) and
complete the adapted ABIM Patient Satisfaction Tool (see
Table 2).
Year III
Concurrently with clinical clerkships, third-year students
participate in weekly small-group tutorials over six months in
the Patient–Doctor III course. The Patient–Doctor III course
includes an in-depth clinical assessment with a standardized
patient encounter centered on giving bad news. Students
read an excerpted hospital chart of a patient who has
metastatic breast or prostate cancer and present the case to
a faculty examiner. The presentation begins with a discussion
of the student’s planned approach to the patient, including
psychosocial as well as medical issues. The student then
meets with a standardized patient (SP) and gives the patient
the bad news that the cancer has metastasized. Faculty
observe and assess the students’ interviews. Student inter-
views and faculty feedback are videotaped, and students
receive a copy of the videotape for review.
Faculty examiners assess and provide immediate feedback
to each student, using an expanded HMS Communication
Skills Tool, adapted from the Kalamazoo assessment tool.
Using this expanded assessment tool, faculty assess students
on the seven core communication competencies and 23 sub-
competencies using a five-point Likert scale. Faculty also rate
additional items related to this particular patient’s situation
and case history. The standardized patients complete the
HMS Communication Skills Tool and our adapted ABIM
patient satisfaction assessment tool.
Faculty development workshops and a web-based faculty
development learning module (Rider & Hinrichs, 2003)
prepare faculty to assess students’ communication skills and
give feedback. The workshops and web module provide the
opportunity to practice using the assessment tool and to hone
observation and feedback skills.
Core medicine clerkship
We implemented a communication skills curriculum and
assessment in the 12-week core medicine clerkships (Rider
et al., 2004). We created interactive, web-based modules
with embedded videoclips on each of the essential elements
of communication defined in the Kalamazoo Consensus
Statement and assessed by our HMS Communication Skills
Tool (Lown, 2003; Rider, 2003) [1].
The purpose of this resource was to provide both faculty
and students with a common vocabulary, descriptions of the
skills and videotaped demonstrations to help create a more
consistent basis for skills performance and evaluation.
At the end of the clerkship, all students completed a
standardized patient interview, again with faculty assessment
and feedback, and student self-assessment using the
HMS Communication Skills Tool. Standardized patients
also rated students’ communication skills using the HMS
A model for communication skills assessment
e131
Communication Skills Tool and the adapted ABIM patient
satisfaction assessment tool. In 2004, one-half of the third-
year students on their core medicine clerkship completed
two faculty-observed interviews with real patients followed by
faculty assessment ratings and feedback, and the student’s
self-assessment, both using the HMS Communication
Skills Tool. In 2005, all third-year students completed
observed interviews followed by faculty assessment and
feedback.
In addition to a faculty development workshop, faculty
assessing and teaching students during their core medicine
clerkships and in the standardized patient exercise at the
end of the medicine clerkship were provided with a self-
instructional, web-based faculty development learning
module. This module provided training for faculty in
assessing communication skills and giving reflective feedback
(Rider & Hinrichs, 2003).
Year IV
Students must pass a school-wide Comprehensive Clinical
Practice Examination at the beginning of their fourth year.
Students are assessed at nine clinical skill stations. Many of
the stations are integrated across disciplines. For example,
one station may integrate skills in medicine and neurology;
another content and skills from surgery, obstetrics/gynecol-
ogy and medicine. Standardized patients assess students’
communication skills in seven of nine clinical skill stations
using the same HMS Communication Skills and ABIM
assessment tools. Faculty assess students’ skills in interview
content, physical diagnosis, differential diagnosis and
management, and provide feedback on communication skills.
Discussion
While public interest and professional accreditation and
licensure requirements are driving curricular change, barriers
to enhancing interpersonal and communication skills
teaching in medical education persist (Board of Medical
Education, 2004; Institute of Medicine, 2004). Decreasing
length of stay in hospitals, emphasis on the technological
aspects of care and increasing demands on faculty time pose
significant barriers to developing attitudes in trainees that
value interpersonal and relational aspects of care (Ludmerer,
1999). The paucity of resources to support clinical teaching
and the cost of school-wide clinical assessments using
standardized patients present additional obstacles.
Infrequent or absent faculty development in teaching
and assessing communication skills also poses a barrier to
implementation of new curricula. Clinical preceptors who
assess communication skills often have varying experience
and approaches (Lang et al., 2000; Novack et al., 1993).
A survey of medical school deans showed that faculty
development in interpersonal skills teaching was favored by
62% of 114 (Novack et al., 1993). Challenges include
providing continuous orientation and faculty development
for new and ongoing faculty each year, increasing the number
of trained faculty invested in teaching and assessing students’
communication skills, and providing ongoing training
for faculty and standardized patient assessors.
Continuous reinforcement and longitudinal development
of skills is critical for their retention and expansion.
Providing repeated opportunities for students to receive
feedback on directly observed interviews using a uniform
framework for teaching and for both formative and summa-
tive assessment over the four undergraduate years enables
them to reinforce basic skills, and to learn more complex
communication skills. To reinforce the skills, we assess
the same seven core communication competencies, with 23
sub-competencies evaluated either separately or as part
of global ratings of the seven core competencies, in each
assessment exercise throughout the undergraduate years.
We adopted the principle that multiple perspectives and
methods enhance skills-based assessment (Epstein &
Hundert, 2002). The HMS Communication Skills Tool
is completed by faculty, by standardized patients and/or
by students for self-assessment, and standardized patients
complete the adapted ABIM Patient Satisfaction Tool.
Resources, time available for the assessment exercise,
and standardized patient and faculty training determine the
tools used in any given assessment exercise.
We also sought to bring patients’ perspectives into our
assessment strategies. An assessor personally involved in
the interaction––e.g. an actual patient, simulated patient
or standardized patient––may be able most accurately to
measure the experience of the therapeutic relationship (Zoppi
& Epstein, 2002). Various authors note that the patient’s
experience may be a more relevant measure of the patient–
physician relationship than observations by impartial coders
(Street, 1992; Janisse & Vuckovic, 2002). To bring patients’
perspectives into our assessment system, we asked standard-
ized patients to complete the adapted ABIM Patient
Satisfaction Tool and, for some examinations, also the
HMS Communication Skills Tool.
Finally, the goals of any curriculum should include
the promotion of self-reflection and continuous self-directed
learning not only in technical skills but also in relational
skills and self-awareness. Using our assessment tools
with students for formative evaluation and feedback, and
for self-assessment, promotes these goals.
Implications
We implemented an integrated framework and resources
for teaching and assessment to begin to address the
increasing public and professional need for enhanced
interpersonal and communication skills training, particularly
in the latter years of the undergraduate medical curriculum.
Until recently, medical training has not emphasized or
consistently assessed communication and interpersonal
skills and the physician–patient relationship. The new
licensing and accreditation requirements for competence in
clinical skills, including communication skills, provide an
impetus for medical schools in the US to teach and assess
communication skills in a more consistent and comprehen-
sive manner throughout the curriculum than in the past.
The last available national report on the teaching and
assessment of communication skills in US medical schools
noted that the majority of schools did not use uniform
frameworks for teaching and assessment (Association
of American Medical Colleges, 1999). Our framework
formalizes and institutionalizes the assessment of commu-
nication skills across the curriculum. Its use will enable us to
collect data regarding the retention of these skills, and
E. A. Rider et al.
e132
whether uniform teaching and assessment over four years
improves students’ performance. Students use, practice and
are assessed on these competencies numerous times over
the course of their undergraduate training, in order to
promote retention and further development of competence
in communication skills. Implementation of our approach
has raised the profile of communication skills teaching
and assessment in our medical school curriculum, and has
enabled us to expand and maintain this focus across all
four years.
We hope to lay the groundwork for a focus on commu-
nication skills as a required competence throughout medical
school. Multiple licensing and accreditation agencies join
us in this important goal. Our experience provides one model
for successfully integrating uniform communication skills
assessment across the years of undergraduate medical
education.
Notes on contributors
ELIZABETH A. RIDER, MSW, MD, FAAP is Director, Communication
Skills Teaching Program and Assistant Professor of Pediatrics, Harvard
Medical School; Director of Programs for Communication Skills, John D.
Stoeckle Center for Primary Care Innovation, Massachusetts General
Hospital; and Course Director, Program to Enhance Relational
and Communication Skills (PERCS), Children’s Hospital, Boston,
Massachusetts USA. She is a member of the Bayer–Fetzer Kalamazoo
Consensus Group on Physician-Patient Communication.
M
ARGARET M. HINRICHS, MEd an Educational Consultant for the
Integrated Clerkship Professional Boundaries Project, Cambridge
Hospital, Cambridge, MA, USA, was formerly Program Coordinator
and Medical Educator, Patient-Doctor Courses, Program in Medical
Education, Harvard Medical School, Boston, MA, USA.
B
ETH LOWN, MD is Director, Communication Skills Teaching Program
and Assistant Professor of Medicine, Harvard Medical School; Director
of Faculty Development, Mt. Auburn Hospital; Associate Director of the
Fellowships in Medical Education at Beth Israel Deaconess Medical
Center, Mt. Auburn Hospital and the Academy at Harvard Medical
School, Boston, Massachusetts, USA.
Acknowledgments
The authors’ work was funded in part by a generous grant
from the Arthur Vining Davis Foundations. We appreciate
the input and perspective of Ronald Arky, MD, Daniel
Federman, MD, Gordon Harper, MD, David Hirsh, MD,
Edward Krupat, PhD, Beverly Woo, MD, and the
Communication Skills Task Force at Harvard Medical
School as we developed a uniform, longitudinal assessment
program across the curriculum. We also acknowledge the
important work of the Bayer–Fetzer Kalamazoo Consensus
Group on Physician-Patient Communication in Medical
Education.
Notes: Our assessment tools are available upon request
from elizabeth_rider@hms.harvard.edu.
1. Expanded web-based modules are available in Novack
et al. (2005).
References
ACCREDITATION COUNCIL FOR GRADUATE MEDICAL EDUCATION (2001)
General Competencies: ACGME Outcome Project 2001. (Chicago, IL,
ACGME) Available at: http://www.acgme.org/outcome/comp/
compMin.asp (accessed 4 March 2005).
A
MERICAN BOARD OF INTERNAL MEDICINE (n.d.) Patient and peer assessment
forms. Available at: http://www.acgme.org/outcome/downloads/
IandC_1.pdf (accessed 25 May 2006).
A
SSOCIATION OF A MERICAN MEDICAL COLLEGES (1999) Medical School
Objectives Project, Report III. Contemporary Issues in Medicine:
Communication in Medicine (Washington, DC, Association of
American Medical Colleges).
B
AYER–FETZER CONFERENCE ON PHYSICIAN–PATIENT COMMUNICATION IN
MEDICAL EDUCATION (2001) Essential elements of communication in
medical encounters: the Kalamazoo consensus statement, Academic
Medicine, 76, pp. 390–393.
B
OARD OF MEDICAL EDUCATION, BRITISH MEDICAL ASSOCIATION (2004)
Communication Skills Education for Doctors: An Update (London, BMA).
C
OHEN-COLE, S.A. (1991) The Medical Interview: The Three-Function
Approach (St Louis, Mosby Year Book).
D
EPARTMENT OF HEALTH (2003) Guiding Pr inciples Relating to the
Commissioning and Provision of Communication Skills Training in
Pre-Registration and Undergraduate Education for Healthcare
Professionals (London, Department of Health).
D
UFFY, F.D., GORDON, G.H., WHELAN, G., COLE-KELLY, K., FRANKEL, R.
& All Participants in the American Academy on Physician and Patient’s
Conference on Education and Evaluation of Competence in
Communication and Interpersonal Skills (2004) Assessing competence
in communication and interpersonal skills: The Kalamazoo II Report,
Academic Medicine, 79, pp. 495–507.
E
PSTEIN, R.M. & HUNDERT, E.M. (2002) Defining and assessing
professional competence, Journal of the American Medical Association,
287, pp. 226–235.
G
ENERAL MEDICAL COUNCIL (2003, February) Tomorrow’s Doctors:
Recommendations On Undergraduate Medical Education (London and
Edinburgh, GMC). Available at: http://www.gmc-uk.org/med_ed/
tomdoc.htm (accessed 4 March 2005).
I
NSTITUTE FOR INTERNATIONAL MEDICAL EDUCATION (2002) Global
minimum essential requirements in medical education, Medical
Teacher, 24, pp. 130–135.
I
NSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES (2004) Cuff, P.A., &
Vanselow, N.A. (Eds) Improving Medical Education: Enhancing the
Behavioral and Social Science Content of Medical School Curricula,
Committee on Behavioral and Social Sciences in Medical School
Curricula, and Board on Neuroscience and Behavioral Health
(Washington, DC, National Academies Press). Available at: http://
www.nap.edu/books/030909142X/html/R1.html (accessed 25
September 2005).
J
ANISSE, T. & VUCKOVIC, N. (2002) Can some clinicians read their
patients’ minds? Or do they just really like people? A communication
and relationship study, Permanente Journal, 6, pp. 35–40.
K
LASS, D., DE CHAMPLIAN, A., FLETCHER, E., KING, A. & MACMILLAN, M.
(1998) Development of a performance-based test of clinical skills for the
United States Licensing Examination, Federal Bulletin, 85, pp. 177–185.
K
OHN, L.T., CORRIGAN, J.M. & DONALDSON, M.S. (1999) To Err is
Human: Building a Safer Health System (Washington, DC, National
Academy Press).
K
URTZ, S.M. & SILVERMAN, J.D. (1996) The Calgary–Cambridge
observation guides: an aid to defining the curriculum and organizing
the teaching in communication training programs, Medical Education,
30, pp. 83–89.
L
ANG, F., EVERETT, K., MCGOWEN, R. & BENNARD, B. (2000) Faculty
development in communication skills instruction: insights from a
longitudinal program with ‘real-time feedback’, Academic Medicine,
75, pp. 1222–1228.
L
EVINSON, W., ROTER, D.L., MULLOLY, J.P., DULL, V.T. & FRANKEL,
R.M. (1997) Physician–patient communication: the relationship
with malpractice claims among primary care physicians and
surgeons, Journal of the American Medical Association, 277,
pp. 553–559.
L
IAISON COMMITTEE ON MEDICAL EDUCATION (1998) Functions and
Structure of a Medical School (Washington DC, Liaison Committee on
Medical Education).
L
IPKIN, M. Jr. (1996) Sisyphus or Pegasus? The physician interviewer in
the era of corporatization of care, Annals of Internal Medicine, 124,
pp. 511–513.
A model for communication skills assessment
e133
LOWN, B.A. (2003) Seven Modules: An Introduction to Communication in
Clinical Encounters; Opens the Discussion; Gathers Information;
Understands the Patient’s Perspective; Shares Information; Reaches
Agreement; Provides Closure. MyCourses web-based teaching modules,
Harvard Medical School, Boston, MA USA. Available at: http://
mycourses.med.harvard.edu (accessed 15 October 2005).
L
UDMERER, K.M. (1999) Time to Heal: American Medical Education from
the Turn of the Century to the Era of Managed Care (Oxford, Oxford
University Press).
M
AKOUL, G. (1998) Communication research in medical education,
in: L. Jackson & B.K. Duffy (Eds) Health Communication Research: A
Guide to Developments and Directions, pp. 17–35 (Westport, CT,
Greenwood Press).
M
AKOUL, G. & SCHOFIELD, T. (1999) Communication teaching and
assessment in medical education: an international consensus statement,
Patient Education and Counseling, 137, pp. 191–195.
N
OVACK, D.H., VOLK, G., DROSSMAN, D.A. & LIPKIN, M. Jr. (1993)
Medical interviewing and interpersonal skills teaching in US medical
schools, Journal of the American Medical Association, 269,
pp. 2101–2105.
N
OVACK, D., CLARK, W., SAIZOW, R. & DAETWYLER, C. (Eds) (2005)
doc.com: an interactive learning resource for healthcare communication.
Available at: http://www.aachonline.org/doccom (accessed 25 May
2006).
P
FEIFFER, C.A., ARDOLINO, A.J. & MADRAY, H. (2001) The impact of a
curriculum renewal project on students’ performances on a fourth-year
clinical skills assessment, Academic Medicine, 76, pp. 173–175.
P
FEIFFER, C., MADRAY, H., ARDOLINO, A. & WILLMS, J. (1998) The rise
and fall of students’ skill in obtaining a medical history, Medical
Education, 32, pp. 283–288.
P
RISLIN, M.D., GIGLIO, M., LEWIS, E., AHEARN, S. & RADECKI, S. (2000)
Assessing the acquisition of core clinical skills through the use of serial
standardized patient assessments, Academic Medicine, 75, pp. 480–483.
R
IDER, E.A. (2003) Builds the Relationship. MyCourses web-based
teaching module, Harvard Medical School, Boston, MA USA.
Available at: http://mycourses.med.harvard.edu. (accessed 15 October
2005).
R
IDER, E.A. & HINRICHS, M.M. (2003) Teaching Communication Skills:
Assessment and Reflective Feedback. MyCourses web-based faculty
development teaching module, Harvard Medical School, Boston, MA
USA. Available at: http://mycourses.med.harvard.edu and http://
ecommons.med.harvard.edu (accessed 15 October 2005).
R
IDER, E.A. & KEEFER, C.H. (2006) Communication skills competencies:
definitions and a teaching toolbox, Medical Education, 40, pp. 624–629.
doi: 10.1111/j.1365-2929.2006.02500.x (in press).
R
IDER, E.A., LOWN, B.A. & HINRICHS, M.M. (2004) Teaching commu-
nication skills, Medical Education, 38, pp. 558–559.
R
OYAL COLLEGE OF PHYSICIANS AND SURGEONS OF C ANADA (1996)
CanMeds 2000 Project: Skills for The New Millennium: Report of the
Societal Needs Working Group (Ottawa, Canada, RCPSC).
S
IMPSON, M., BUCKMAN, R., STEWART, M., MAGUIRE, C.P., LIPKIN, M.,
N
OVACK, D. & TILL, J. (1991) Doctor–patient communication:
the Toronto consensus statement, British Medical Journal, 202,
pp. 1384–1387.
S
TEWART, M.A. (1995) Effective physician–patient communication and
health outcomes: a review, Canadian Medical Association Journal, 152,
pp. 1423–1433.
S
TEWART, M., BELLE BROWN, J., WESTON, W.W., MCWHINNEY, I.R.,
M
CWILLIAM, C.L. & FREEMAN, T.R. (1995) Patient-centered Medicine:
Transforming the Clinical Method (Thousand Oaks, CA, Sage
Publications).
S
TEWART, M., BROWN, J.B., BOON, H., GALADJA, J., MEREDITH, L. &
S
ANGSTER, M. (1999) Evidence on patient-doctor communication,
Cancer Prevention and Control, 2, pp. 25–30.
S
TREET, R.L. (1992) Analyzing communication in medical consultations:
do behavioral measures correspond to patients’ perceptions? Medical
Care, 30, pp. 976–988.
T
ATE, P., FOULKES, J., NEIGHBOUR, R., CAMPION, P. & FIELD, S. (1999)
Assessing physicians’ interpersonal skills via videotaped encounters: a
new approach for the Royal College of General Practitioners
Membership Examination, Journal of Health Communication, 4,
pp. 143–152.
W
HELAN, G.P. (1999) Educational Commission for Foreign Medical
Graduates: clinical skills assessment prototype, Medical Teacher, 21,
pp. 156–160.
Z
OPPI, K. & EPSTEIN, R.M. (2002) Is communication a skill?
Communication behaviors and being in relation, Family Medicine, 34,
pp. 319–324.
e134
E. A. Rider et al.
