Educ. changes

Training in communication skills is nowadays a regular part of undergraduate medical curricula and most undergraduate communication skills programs also teach patient education skills. However, the effects of communication skills training is not impressive. Small to moderate improvements have been found in the communication competence of students after one or more communication courses [Aspegren 1999, Henwood 1996, Humphris 2001, Shapiro 2009, Smith 2007, Yedidia 2003], but a deterioration in the communication competence of students over time has also been reported [Bombeke 2011, Hook 2007, Pfeiffer 1998]. Furthermore, although communication skills training appear to be effective in improving targeted communication skills, the effects of CST on performance and outcomes in clinical practice remain obscure [Henwood 1996]. Postgraduate communication courses also appear to have positive effects on the communication competency of practising physicians [Aspegren 1999, Butow 2007, Bylund 2010, Fallowfield 2001, Fellowes 2004, Girgis 2008, Gysels 2004, Hobma 2006, Maguire 1996], but these effects are limited [Butler 2005, Cegala 2002, Hulsman 1998].  Only interventions for residents and consultants which specifically address communication behavior in clinical practice, seem to have some positive effects on behavior and outcomes [Tulsky 2011, Barth 2011, Girgis 2009]. Even the ample attention to communication skills in general practice training has hardly any effect on clinical communication behavior [Hobma 2006, Kramer 2004]. Furthermore, the effects of patient-physician communication education on consultation outcomes such as patient satisfaction, understanding, adherence, self-management and health status, are almost absent [Dwammena 2013, Claramita 2006, Fossli Jensen 2011, Uiterhoeve 2009, Zimmerman 2007]. Veldhuijzen therefore concluded that:

"These findings points to the sobering conclusion that the vast effort to shape or change how doctors communicate with their patients has in fact been rather ineffective in practice" [Veldhuijzen 2011, p. 15].

Apparently, an expert level of communication competence in clinical practice is difficult to attain. Especially, the transfer of communication competence acquired in formal learning conditions, into clinical practice appears to be problematic [Rethans 2002, Wallenstein 2010, Essers 2011, Eertwegh 2013] and contextual learning as provided by workplace based learning, is nowadays considered essential for clinical communication competence development [Van Dalen 2013, Van Eertwegh 2013]. The lack of transfer of communication competence acquired in educational settings, into clinical practice is often attributed to the inhibiting influence of clinical culture and supervisors' rejective behavior [Hodges 2012, Brown 2010, Dosanjh 2001, Essers 2012, Hutul 2006, Sandhu 2010, Silverman 2009, Williams 2001, Van Dalen 2012, Rosenbaum 2013]. Continuing positive reinforcement of favourable communication behavior in clinical practice probably diminishes these negative effects [Heaven 2006]. However, even if the clinical culture supports the performance of learned communication behavior, the transfer of this behavior into clinical practice will not be obvious due to case-specificity. Case-specificity means that physicians' individual communication performance quality varies dependent of the content, type and context of the consultation. Until recently, case-specificity was mainly regarded as an assessment problem since the case-specific variation in performance jeopardizes the assessment reliability and validity. By assessing communication competence in more than one consultation, such as in an Objective Structured Clinical Examination (OSCE), a reliable estimate of a trainee'saverage communication competence could be obtained. However, in a functional, outcomes based approach of communication assessment physicians' performance variability should be restricted, since a physician should demonstrate superior communication performance in all consultations regardless of the type and complexity of the consultations. Otherwise, performance quality could drop below standard in some consultations, and patients might suffer from physicians' inferior communication performance. Case-specificity could mean that a set of generic or transferable communication skills that show a high level of stability and have applicability to a wide range of encounters, does not exist. This would have far-reaching implications for both the teaching and assessment of communication skills, because it would imply that each type of consultation that a physician might encounter, would have to be taught and assessed separately [Hodges 1996]. However, the causes of case-specificity and its effects on physicians' communication behavior and on consultation outcomes are hardly investigated until now.