CHAPTER 16

Teaching the Skill Sets

Ponder, for a moment, the last time you had to learn a new skill as an adult. What circumstances made learning effective? What circumstances made learning more challenging?

Now imagine that you are 30 years into practice and are told that you have to change the way you conduct your initial interview of a patient. How do you feel? How easy or hard will it be to change? What would make it easier?

Every time I (Ellen Pearlman) start a train-the-trainer workshop, I find myself in a room with 12 experienced physicians who are faced with this challenge. There are days when I think to myself, “Who do I think I am, that I can teach under these impossible circumstances?” and wonder if it is going to be worth it. Yet workshop after workshop, I emerge with the satisfaction of witnessing physicians have new light bulbs go off in their heads for the first time in many years of practicing medicine.

In this chapter, I will describe the best methods to teach communication skills and make them stick. A published review article named these the best strategies: role-play, feedback, and small group discussion.¹

The Power of Role-Play

I was recently running a train-the-trainer session and had just finished giving a brief presentation on Skill Set Three, the use of ART (Ask, Respond, Tell) in educating and counseling (see Chapter 5). The trainers I was working with were highly engaged and clearly perceptive, and they prided themselves on their communication skills. As we broke up into small groups, one remarked, “This seems pretty straightforward!” After a couple rounds of practicing with patient-clinician scenarios, the group wanted to exercise their muscles at a scenario involving colleagues. One of the nurse managers exclaimed, “Oh, I have one! I recently had to bring in one of our night nurses for falling asleep on the job.” “Great!” I replied. “Would you be willing to play her or him?”

What followed was anything but ART. The physician assigned to play the nurse manager, after starting with “Do you know why you are here?” ripped into the unsuspecting night nurse for her unacceptable behavior of falling asleep on the job.

During the debrief of the role-play, everyone nodded in agreement that this approach is exactly what would happen on the job. When I asked if ART was used, they tentatively nodded their heads. Then one participant offered, “Well, the opening question wasn’t exactly open-ended.” And the physician playing the nurse manager added, “I guess I didn’t really respond with empathy.” When I asked if this was a dialogue or a monologue, they clearly recognized that the manager had “downloaded” on the nurse.

“Let’s try it again, this time starting with an open-ended question, responding with empathy, and using more than one ART cycle,” I suggested. What followed was a magical “aha” moment.

Nurse Manager: Can you tell me all about what happened the other night? (Ask)

Nurse: I am so sorry—I fell asleep on the job. I promise it will never happen again!

Nurse Manager: I can see that you are upset about it. (Respond)

Nurse: My mother was hospitalized two days ago and both of my kids were home sick with a stomach virus. I didn’t get my usual sleep during the day. I knew we were short-staffed and didn’t want to call in sick, but I guess maybe I should have.

Nurse Manager: It sounds like you had your hands full! I appreciate your desire to help. (Respond) I also agree with you that if you don’t feel like you can give 100 percent, it is safer for patients if you call in sick. Sounds like you know it is unacceptable to fall asleep on the job—important things can be missed. (Tell)

Nurse: Oh, definitely! I was horrified when I woke up. I felt really lucky that nothing serious had gone wrong.

The group was profoundly affected by this version. Some of the group members were concerned that “the message,” i.e., falling asleep was unacceptable, wasn’t made clear enough. Yet the participant playing the nurse reassured them, “It was all the more powerful because he took the time to hear me out, and I was already feeling ashamed.” “But what if you hadn’t been feeling bad? What if you were an employee who didn’t care?” the others exclaimed. Once again, she rebuffed them, “Then that would have been part of your Tell. Not only does this approach prevent you from making assumptions, it helps you diagnose the problem by assessing the nurse’s perception of the problem!” The entire group walked away from the experience convinced that ART could be a powerful tool.

This example demonstrates the power of role-play. Role-play allows adult learners to:

•   Practice new skills—skills that may seem easy on paper but harder in practice

•   Experience what it is like to be a difficult patient or colleague, and thus gain insight into and empathy for that person

•   Compare and contrast new and old approaches with patients or colleagues.

It is for these reasons that we strongly endorse the use of role-play when learning new communication skills. Like learning to master a tennis or golf stroke, communication skills require deliberate practice.

Making Role-Play Successful

When I first ran workshops on running role-play, I said, “Whatever you do, don’t call it a role-play.” I initially advocated this approach because of the typical moans and eye-rolling I’d get after announcing that we would do a role-play. Others have similarly tried to diminish this effect by calling it “real play.” Over time, I have come to accept the response and to use it to elicit group members’ experiences about role-play—to address the elephant in the room. It can help in three ways: (1) to acknowledge its artificial nature, (2) to explain its purpose (“We wouldn’t be doing this if everyone could do it right the first time”) and (3) to advocate for the opportunity to try something new and potentially make mistakes without any adverse consequences. In my experience, it is a tiny minority of people who truly can’t participate in a role-play and get something out of it. And as luck would have it, often participants will volunteer positive prior experiences with role-play, so that you won’t need to do all of the convincing.

Facilitating role-play is a skill in itself that also requires practice. Let’s start by reviewing a scenario where the role-play unfolds poorly. In this scenario, Dr. Thompson is a cardiologist who has graciously volunteered to practice Skill Set One (see Chapter 3). She proceeds to elicit the patient’s chief complaint and dives immediately into the history of the present illness when one of the observers calls a “time-out”:

Observer: You didn’t elicit all of the concerns.

Another Observer (jumping in): But she is just the consultant. It isn’t really her job to elicit concerns that aren’t connected to the visit.

Facilitator (redirecting): Maybe the patient can tell us how she felt. (Turning to the person playing the patient)

Patient: Well, I was really most concerned that I had a heart attack, but she didn’t even get to that.

At this point, Dr. Thompson’s eyes begin to well up with tears. She had been nervous conducting an interview in front of her peers to begin with and clearly had failed at the task given to her. She feels ashamed.

Unfortunately, I have seen many examples like this one where role-plays are poorly managed, resulting in either undermined learning or unintentional humiliation of a participant who has been brave enough to practice in front of others. I have even seen facilitators curse when someone doesn’t follow a communication skills process exactly as prescribed.

For these reasons, I recommend always adhering to two guiding principles. All other basic rules will follow.

GUIDING PRINCIPLE #1

It is your job as the facilitator to prevent the participant practicing the new skill from being humiliated in public.

Always remember that the participant practicing the new skill is in a vulnerable position, no matter how senior the participant is or how confident he or she seems. The participant is practicing something new in front of other people for the first time and is prone to being easily shamed. A few simple steps can ensure the role-play is not humiliating.

Rule #1

Move your chair to sit next to the participant practicing the new skill and let him or her know you will be nearby as a “coach,” as shown in Figure 16.1.

FIGURE 16.1 Supportive Seating Arrangement

That way, if the learner in the “hot seat” has any trouble, you are right there to offer support. You may even coach him or her by giving suggestions under your breath.

Note: The benefit of this setup is that you are nicely arranged to debrief in order: participant practicing the new skill, then participant playing the patient, then the observers, and then you have the final say.

Rule #2

Review the skills that the participant is going to practice, ideally with the help of a “cheat sheet” such as a handheld card, poster, flip chart, or blackboard with the skills written down.

This review helps the participant focus on the task at hand and the cheat sheet helps the participant figure out where he or she is in the process at any given point.

Rule #3

Only you or the participant can call a “time-out.”

Let him or her know that if you call a time-out, it doesn’t mean he or she has done something wrong. This rule gives the power to the participant and to you, the skilled facilitator. Now the role-play cannot be derailed by an observer.

Rule #4

Once a time-out has been called, check in with the participant practicing the new skill first.

This rule gives you the opportunity to assess the participant’s vulnerability. A simple “How is it going?” can let you know how critical the person is being of him or herself or how nervous he or she is feeling.

Rule #5

Reinforce effectiveness before giving corrective feedback.

As we saw in Chapter 10, studies have shown that people are more likely to incorporate constructive criticism if it is given in a ratio of four reinforcing observations to one corrective observation. The idea is that if you shore up someone’s confidence, he or she will be more receptive to criticism. I also believe that when practicing a new skill, it is just as important for “muscle memory” to highlight the effective aspects as it is to critique what was less effective.

Note that it is human nature—especially in medical culture—to go directly to criticism. As a facilitator, you will need to redirect both the participant practicing the new skill and the observers to start with reinforcing feedback. It can help to set this as a ground rule and to remind people that you will “get to that, but let’s first start with what was effective.”

When you do get to corrective feedback, remember to have the participant practicing the new skill self-reflect first. If he or she offers self-criticism, ask the participant playing the patient to respond from his or her perspective before moving to the observers for comment. Keeping in mind the ratio of four reinforcing to one corrective observation, try to focus on only one piece of criticism and get feedback from the others on that one piece, rather than soliciting additional corrective observations.

Rule #6

Give the participant the opportunity to re-practice.

As with all new skills, it takes time to learn. After he or she has been given both reinforcing and corrective feedback, it can be helpful to have the participant give it one more try to experience success. Finally, soliciting “takeaways” from the participant is an ideal way to conclude the role-play, e.g., “What are you taking away from this experience that you can use in your practice?” This, by the way, illustrates the ART technique (Chapter 5) yet again.

GUIDING PRINCIPLE #2

For learning to occur, the scenario must be relevant.

In revisiting the role-play involving Dr. Thompson, let’s imagine a second version of the same scenario:

Dr. Thompson is a cardiologist who has graciously volunteered to practice Skill Set One (eliciting all concerns and negotiating the agenda). She proceeds to elicit the patient’s chief complaint and dives immediately into the history of the present illness and then times herself out. The facilitator asks her, “How is it going?” She responds that even though she is feeling a little nervous, it went OK. When asked what she felt she did effectively, she responds that she felt she elicited the chief complaint and listened attentively. The participant playing the patient confirms.

When asked what she could have done more effectively, she responds, “Well, I didn’t really elicit ALL the concerns. I guess I don’t really think that is appropriate in my role as a consultant. I can see a primary care doc doing that, but I don’t want to give her the false impression that I can help her with things I can’t really do anything about.”

It is clear from this scenario that, first and foremost, Dr. Thompson doesn’t buy into this skill set—it doesn’t seem relevant to her day-to-day practice. As a consequence, she has not practiced the actual skill set, and is thus unlikely to employ it in real life. When the facilitator checks in with Dr. Thompson first, a key barrier to her learning experience is revealed, setting up a teaching opportunity.

Making the skills and scenarios relevant to the participants is critical for buy-in, practice, and retention. There are a number of ways to accomplish buy-in. Rather than telling the participants how you think the skills are relevant, it can be more powerful for them to discover relevance themselves. For example, it can be helpful to simply query, “What is your version of a doorknob question?,” “Can you imagine a time when eliciting all concerns would be helpful?,” or, “Is there a way to frame the ‘what else’ that makes it clear you are asking for concerns related to the heart?”

Other Forums for Practice

In addition to role-playing in small groups, three other forums are especially helpful for practicing communication skills: (1) standardized patient encounters, (2) videotape review, and (3) coaching by an observer.

Standardized patient encounters are essentially role-plays but with actors playing patients. They can be done in a clinical skills lab with feedback given by the standardized patients. Alternatively, the actors can participate in small group role-play as just described. If actors are not readily available or affordable, I have had success training staff and faculty members to play patients. One notable disadvantage of this model is that the participants themselves don’t get the experience of being a patient and feeling the direct impact of the skills being practiced.

Videotape review of role-plays, standardized patient encounters, or real patients is particularly helpful for self-reflection. Participants are able to watch by themselves, just with a facilitator, or with a small group. They are able to reflect on their effectiveness in real time. If equipment or logistics are a barrier, a simple audio recording using “Voice Memo” on a smartphone is a handy alternative.

Finally, direct observation by a coach is a great option for continued practice that allows feedback on real patient interactions, tailored to the individual (see Chapter 11). Observation can be time limited and focused on a single skill or expanded to longer time periods and encompassing more skill sets. Feedback can be based on predetermined skills checklists or notes taken by the observer.

Table 16.1 summarizes the relative advantages and disadvantages of these three practice methods.

TABLE 16.1 Comparing Other Forums of Practice

Conclusion

Teaching communication skills is both challenging and gratifying. It requires providing opportunities for learners to practice skills in situations that are relevant and realistic. Role-play is perhaps the cheapest and logistically easiest form of practice, yet requires a skilled facilitator to (1) ensure the participant practicing new skills is not humiliated in public, and (2) ensure the scenario in which the skill is being practiced is relevant and realistic. The use of standardized patients, videotape review, and direct observation by a coach are useful adjuncts for practicing communication skills. While this overview can get you started with facilitating teaching through role-play, Chapter 17 explains how useful a train-the-trainer model can be for developing and deepening facilitation skills.