In the late seventies communication skills training also became part of general practice vocational training [Van Zalinge 1991, Pieters 1994, Ram 1999b, Evans 2001]. At first, the main educational approach consisted of reflection on real patient encounters. Since the nineties, in several western countries patient-physician communication issues are addressed in primary care and general practice vocational training by assessment of and feedback on videoed consultation with real patients [Tate 1999, Ram 1999b, Campion 2004, Edwards 1996, Evans 2001, Hobma 2006, Kramer 2004]. Also starting in the nineties, communication workshops and courses were offered to medical specialist residents and consultants especially in oncology. These optional courses mainly concerned exploring patients' concerns and breaking bad news [Maguire 1996, Fellowfield 1998] using didactics, demonstrations and role-play with feedback and reflection as teaching methods. Some workshops for consultants even focused on the teaching of communication skills to students and residents [Bird 1993, Bylund 2008, Falvo 1988]. Other workshops paid attention to the use of learned skills in clinical practice [Razavi 2003]. However, assessment of performance in clinical practice was lacking [Butler 2005]. In The Netherlands, optional courses and workshops for consultants were offered [Dugardyn 1997]. Several initiatives used videoed outpatient consultations for assessment and feedback [Gaasbeek 1995, Wouda 1991]. In some western countries optional communication courses were offered in residency training [Morgan 1996, Langewitz 1998] and in the late nineties compulsory courses were incorporated in the training of Dutch residents of Obstetrics & Gynecology and Surgery [Van de Wiel 1993, Wouda 2000]. These courses addressed challenging patient education issues such as breaking bad news and dealing with conflict, non-adherence and complaints. However, the effects of these courses on residents' communication behavior in clinical practice was not investigated further.

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