improving anaesthetists' communication skills

SPECIAL ARTICLE

Improving anaesthetists’ communication skills

C. Harms,1 J. R. Young,5 F. Amsler,2 C. Zettler,3 D. Scheidegger4 and C. H. Kindler1

1 Staff Anaesthetist, 2 Consultant Psychologist, 3 Resident, 4 Professor and Chairman, Department of Anaesthesia,

University Clinics Basel, 5 Biostatistician, Basel Institute of Clinical Epidemiology, University Clinics Basel,

Kantonsspital, CH-4031 Basel, Switzerland

Summary

The attitude, behaviour and communication skills of specialised doctors are increasingly recognised

as important and they have been identified as training requirements. We designed a programme to

teach communication skills to doctors in a University Department of Anaesthesia and evaluated its

effect on patient outcomes such as satisfaction and anxiety. The 20 h programme was based on

videotaped reviews of actual pre-operative visits and role-playing. Effects on patient satisfaction and

pre-operative anxiety were assessed using a patient questionnaire. In addition, all participating

anaesthetists assessed the training. We provide evidence that the training increased patient satis-

faction with the pre-operative anaesthetic visit. Training also decreased anxiety associated with

specific aspects of anaesthesia and surgery, but the effect was rather small given the intense pro-

gramme. The anaesthetists agreed that their interpersonal skills increased and they felt better

prepared to understand patients’ anxieties. Communication skills training can increase patient

satisfaction and decrease specific anxieties. The authors conclude that in order to better demon-

strate the efficacy of such a training programme, the particular communication skills of anaesthetists

rather than indirect patient outcome parameters should be measured.

Keywords Patient satisfaction. Anxiety. Pre-operative care. Physician-patient relations. Communication.

Clinical competence. Education.

........................................................................................................

Correspondence to: C. H. Kindler

E-mail: [email protected]

Accepted: 31 August 2003

Effective communication between doctor and patient

improves patient satisfaction, patient recall of information

and medical outcome, and can even protect doctors

against malpractice litigation [1]. Although interest in

teaching communication skills in medical schools has

increased over the years, most postgraduate medical

education still focusses on the technical and biomedical

aspects of medicine [2]. However, the importance of

non-technical skills in the daily work of doctors is now

increasingly recognised, even in subspecialties such as

anaesthesia [3]. Anaesthesia residency review committees

in different countries now demand documentation of

training in communication skills. For example, the Royal

College of Anaesthetists requires an assessment of com-

munication skills, attitudes to patients and behaviour for

its Certificate of Completion of Specialist Training [4].

The American Accreditation Council for Graduate

Medical Education (ACGME) has endorsed six general

competencies including interpersonal and communica-

tion skills for residents in all specialties [5]. The ACGME

and the American Board of Medical Specialties are now

collaborating to implement and evaluate these general

competencies. The impact of doctors’ personal skills has

therefore become an area of clinical interest and research.

Most medical training programmes that teach communi-

cation skills are designed for general practitioners, but a

few have been designed for surgeons [1] or for Accident

and Emergency Department doctors [6].

Apart from personal observations, there are no data

available on how anaesthetists communicate with their

patients [7, 8]. We designed a programme to teach

communication skills to anaesthetists using videotaped

reviews of their pre-operative visits and role-play. Com-

munication skills that are effective for general practitioners

are not necessarily effective for other specialists [1]. Our

programme was therefore tailored to the particular

Anaesthesia, 2004, 59, pages 166–172.....................................................................................................................................................................................................................

166 � 2004 Blackwell Publishing Ltd

situation of the anaesthetist and patient in the pre-

operative setting. The objectives of the training pro-

gramme were to improve the receptive and affective

behaviour and interpersonal skills of anaesthetists and to

increase patient participation in informed or shared

decision-making with respect to the planned anaesthetic

technique. Despite the resources invested in communica-

tion skills training, few programmes seem to have been

assessed in terms of patient outcome [2, 9]. Using a patient

questionnaire, we assessed whether our training pro-

gramme increased patient satisfaction and decreased

patient anxiety before surgery. In addition, the training

programme was assessed by a questionnaire distributed to

all participating anaesthetists.

Methods

The Local Research Ethics Committee of the University

of Basel approved the communication skills training

programme and its assessment by questionnaires. A

clinical psychologist (F.A.) led the training. Anaesthetists

in a University Department of Anaesthesia were trained in

small groups of 7–10 with a similar mixture of residents

and faculty within each group. Each group received 10

training sessions, one each month, and each session lasted

about 2 h. Participation in the training was mandatory for

all 59 anaesthetists involved in patient care during the

study period, although not all received the full 20 h of

training.

Training started with a short theoretical introduction to

interpersonal communication and its effect on patient

outcomes such as patient satisfaction. After this, training

consisted firstly of reviewing videotaped pre-operative

visits. Each trainee had to record two of his ⁄ her pre-

operative visits and these videos were discussed and

analysed within each group. Trainees were asked to

observe themselves, recognise their own emotions, rec-

ognise their patients’ expressions and listen actively to

what their patients were saying. Second, role-playing was

used to prepare for difficult situations. Trainees were

asked to apply four behaviours of effective clinicians,

adapted to the pre-operative situation:

1 establish a welcoming atmosphere for the pre-operative

visit and agree with the patient on an agenda;

2 elicit the patient’s concerns about anaesthesia and

surgery;

3 demonstrate empathy both verbally and non-verbally;

4 actively involve the patient in making decisions about

the planned anaesthetic technique whenever possible, and

appropriately conclude the visit by reassuring the patient

of ongoing care.

The training programme was assessed using a pre- and

postintervention design. Patient satisfaction and patient

pre-operative anxiety were defined as appropriate meas-

ures of improvement in communication skills. We

constructed a questionnaire using a modified Delphi

procedure [10] to measure patient satisfaction with the

pre-operative visit, patient pre-operative anxiety [11] and

patient perception of the anaesthetist [12]. The final

version of the questionnaire contained 86 items. Inclusion

criteria for patients were: age over 18 years; fluency and

literacy in the German language; written informed

consent. Patients with a seriously impaired mental status

were excluded. Anaesthetists were informed verbally and

in writing about the purpose of the study and asked

to participate. They were told that they did not have to

distribute questionnaires to patients if they did not wish to

do this and they also signed a physician questionnaire

containing patient and physician demographic data. Pre-

intervention data were collected for a period of 3 months

from all patients undergoing elective surgery, the inter-

vention consisted of training in communication skills for a

period of 10 months using videotape reviews and role-

playing, and postintervention data were collected for a

3-month period after the training finished. At the end

of the programme, all participating anaesthetists also

assessed it.

Summary response variables

Six response variables were used to summarise patients’

satisfaction with the pre-operative anaesthetic visit and

pre-operative anxiety. Satisfaction with the pre-operative

anaesthetic visit was summarised by ‘overall satisfaction’ in

the form of each patient’s response to a general question

on overall satisfaction, and by ‘median satisfaction’ in the

form of each patient’s median response to 10 specific

questions on satisfaction with different aspects of the pre-

operative anaesthetic visit. All 11 questions used the same

five ordered categories (insufficient, fair, appropriate, very

good, excellent). Pre-operative anxiety was summarised

by using the German version of the Spielberger-State-

Anxiety-Score (STAI-G Form X1) [13], by ‘overall

anxiety about anaesthesia’ and ‘overall anxiety about

surgery’ in the form of each patient’s response to two

general questions on overall anxiety, and by ‘median

anxiety’ in the form of each patient’s median response to

10 specific questions on different aspects of anxiety about

anaesthesia and surgery [11]. These 12 questions on

anxiety all used a 10-cm visual analogue scale (VAS).

Predictor variables

The predictor variables used to model each summary

response variable were: age, gender, level of education,

prior experience of anaesthesia, whether or not pati-

ents felt they were involved in choosing the type of

anaesthesia they would receive, planned duration of

Anaesthesia, 2004, 59, pages 166–172 C. Harms et al. Æ Improving anaesthetist communication skills......................................................................................................................................................................................................................

� 2004 Blackwell Publishing Ltd 167

surgery, the anaesthetist and the number of hours of

training the anaesthetist had received before the anaes-

thetic visit. Age, planned duration of surgery and the

number of hours of training were continuous variables; all

other variables were categorical. The patients’ level of

education was coded as one of three categories: at most

primary or secondary school, apprenticeship or high

school, college or university. Prior experience of anaes-

thesia was also coded as one of three categories: none,

prior experience, prior bad experience.

Models and model fitting

The six summary response variables were modelled using

analysis of covariance. ‘Mixed’ models were fitted with

the anaesthetist as a random effect and all other predictors

as fixed effects. As a fixed effect, each predictor variable or

category of a predictor variable is represented by a single

parameter. As a random effect, each anaesthetist is said to

form a cluster; responses from patients with the same

anaesthetist are correlated but responses from patients

with different anaesthetists are independent. A single

parameter, the between-cluster variance, describes the

differences between clusters; cluster effects are assumed to

be normally distributed with a mean of zero. In this way,

variability between anaesthetists is modelled without

needing additional predictor variables to describe the

differences between them.

Different distributions were assumed for the six sum-

mary response variables. For both overall and median

satisfaction, < 1% of responses were ‘fair’ and none was

‘insufficient’. The lower three categories were therefore

combined and renamed ‘standard’. Overall and median

satisfaction were assumed to follow underlying normal

distributions, although each was measured on an ordinal

scale [14]; the Spielberger score was assumed to follow a

normal distribution; and the other anxiety responses were

assumed to follow exponential distributions (Fig. 1).

Models were fitted using the NLMIXED, MIXED and

GENMOD procedures in SAS version 8.2. (SAS Institute

Inc., Cary, NC). The NLMIXED procedure fits non-

linear models with both fixed and random effects; the

MIXED procedure fits linear models with both fixed and

random effects; the GENMOD procedure fits non-linear

models with only fixed effects. Where possible, therefore,

parameter estimates from NLMIXED were checked

against estimates from other procedures: the MIXED

procedure reproduced estimates for the Spielberger score

with the random effect, the GENMOD procedure

reproduced estimates for the other anxiety responses

without the random effect.

When using NLMIXED, models were first fitted

without the random effect to provide suitable starting

values for fitting with the random effect. Optimisation in

NLMIXED was by the trust region method or, if this

failed to converge, by quasi-Newton methods. The trust

region method uses both first and second order partial

derivatives and often provides stable estimates when a

model has a small number of predictor variables. When

a model has more variables, the trust region method

may fail to converge, but quasi-Newton methods may

converge as these use only the first order partial derivatives

[15]. All confidence intervals were approximate 95%

%

0

10

20

30

40

Anxiety - anaesthesia

0 -<1

1 -<2

2 -<3

3 -<4

4 -<5

5 -<6

6 -<7

7 -<8

8 -<9

9 -10

%

0

5

10

15

20

Spielberger score

20 -<25

25 -<30

30 -<35

35 -<40

40 -<45

45 -<50

50 -<55

55 -<60

60 -<65

65 -<70

70 -<75

75 -80

%

0

10

20

30

40

50

Satisfaction - overallStandard Very good Excellent

%

0

10

20

30

40

Anxiety - median

0 -<1

1 -<2

2 -<3

3 -<4

4 -<5

5 -<6

6 -<7

7 -<8

8 -<9

9 -10

%

0

10

20

30

40

Anxiety - surgery

0 -<1

1 -<2

2 -<3

3 -<4

4 -<5

5 -<6

6 -<7

7 -<8

8 -<9

9 -10

%

0

10

20

30

40

50

Satisfaction - medianStandard Very good Excellent

Figure 1 The six summary responsevariables for patient satisfaction withthe pre-operative anaesthetic visit andpre-operative anxiety expressed as apercentage of patients in each category.Anxiety-surgery, anxiety-anaesthesia,and anxiety-median are represented on a10 cm visual analogue scale.

C. Harms et al. Æ Improving anaesthetist communication skills Anaesthesia, 2004, 59, pages 166–172......................................................................................................................................................................................................................


confidence intervals based on the Wald statistic. All

significance tests were based on the likelihood ratio

statistic.

Results

A total of 1338 patients completed the survey. Of these,

1228 patients were included in the statistical analysis: 905

were patients of anaesthetists without training in com-

munication skills and 323 were patients of anaesthetists

who received at least some training. Patients were

included in the analysis if their data were available for

all predictor variables and if their anaesthetist saw at least

10 surveyed patients. Missing values for response variables

further reduced the sample size for specific models; the

lowest sample size was 902 for the Spielberger score.

Patients seen by anaesthetists with or without training

were similar in age, education and prior experience of

anaesthesia (Table 1). However, patients seen by anaes-

thetists without training were more likely to be male;

those seen by anaesthetists with training were more likely

to be female. Both the expected duration of surgery and

the length of the pre-operative visit were similar for

patients seen by anaesthetists with or without training.

Overall satisfaction with the pre-operative visit was

high. With and without training, 79% and 78% of

patients, respectively, felt that their anaesthetic visit had

been ‘very good’ or ‘excellent’. Overall pre-operative

anxiety was low. On a 10-cm VAS, overall anxiety about

anaesthesia scored a median [IQR] of 2.0 [0.5–4.8] both

with and without training, while overall anxiety about

surgery was 2.3 [0.8–5.1] with training and 2.4 [0.4–2.6]

without (Table 1).

After adjusting for other predictor variables, there was

some evidence that training increased patient satisfaction.

The estimated effect of training on both overall and

median satisfaction was an increase of 0.02 of a response

category per training session (Table 2); an increase

equivalent to a fifth of a response category if an

anaesthetist attended all 10 sessions. To put this in

context, overall and median satisfaction increased by

0.06 and 0.05 of a response category, respectively, for

each 10-year increase in patient age. Both overall and

median satisfaction were lower amongst those with little

education ()0.11 and )0.24 of a response category,

respectively) and amongst those with higher education

()0.23 and )0.07 of a response category, respectively)

compared to those with an intermediate level of

education.

There was no evidence that training had any effect on

overall anxiety when measured by the Spielberger score or

by general questions about anxiety. However, having

adjusted for other predictor variables, there was strong

evidence that communication skills training decreased

median anxiety about specific aspects of anaesthesia and

surgery. On a 10-cm VAS, the estimated effect of training

was )0.05 cm per training session, a decrease equivalent to

)0.5 cm if an anaesthetist attended all 10 sessions

(Table 2). To put this in context, median anxiety was

significantly higher for females than males (0.7 cm) [11].

We then estimated the effect of training on each of the

10 specific aspects of pre-operative anxiety. The low

within-cluster correlation (Table 2) and similar parameter

estimates with and without the random effect suggest that

the effect of different anaesthetists can be safely ignored.

Models were fitted using the GENMOD procedure with

the same eight fixed effects but without the random effect

of different anaesthetists. Training seemed to decrease

the anxiety associated with all 10 specific aspects of

Table 1 Patient characteristics, satisfaction with the pre-opera-tive anaesthetic visit and pre-operative anxiety. Values arepercentage or median [IQR].

Without training(n = 905)

With training(n = 323)

Gender (male ⁄ female) 53% ⁄ 47% 44% ⁄ 56%Age; years 53 [39–66] 55 [40–68]

EducationLow 15% 14%Medium 66% 67%High 19% 19%

Prior experience of anaesthesiaNone 33% 33%Good 55% 55%Bad 12% 12%

Felt included in choice of anaestheticYes 50% 49%No 50% 51%

Expected duration ofsurgery; min

90 [60–120] 90 [60–150]

Length of pre-operativevisit; min

20 [15–30] 20 [15–30]

Training received byphysician; sessions

0 [0–0] 5 [5–7]

Overall satisfactionStandard 22% 21%Very good 43% 39%Excellent 35% 40%

Median satisfactionStandard 22% 20%Very good 46% 41%Excellent 32% 39%

Spielberger anxiety score 37 [30–45] 37 [31–45]Overall VAS anxiety scorefor anaesthesia; cm

2.0 [0.5–4.8] 2.0 [0.6–4.7]

Overall VAS anxiety scorefor surgery; cm

2.4 [0.8–5.1] 2.3 [0.7–4.7]

Median VAS anxiety score; cm 1.1 [0.4–2.6] 0.9 [0.3–2.1]

VAS = Visual analogue scale.



anaesthesia and surgery except anxiety about being aware

during surgery (Table 3).

The participating anaesthetists rated the training pro-

gramme on a four-point Likert scale as helpful and useful

for their daily clinical practice (mean (SD) = 3.1 (0.7)),

and they appreciated the video as a learning tool. The

majority agreed that the value of the pre-operative

anaesthetic visit is much underestimated both during

medical school and postgraduate education and that the

training programme increased their interpersonal skills.

Discussion

Our results show some evidence that training anaesthetists

in communication skills can increase patient satisfaction

with the pre-operative anaesthetic visit, although this

increase was not statistically significant. Programmes that

teach communication skills to doctors often have a limited

effect. A review of studies evaluating such training

programmes showed that most studies used poor method-

ology and that in studies with the best methodology,

training had the least effect [2]. A recent evaluation of an

8-h programme of workshops and audio-taped office visits

designed to teach communication skills to primary care

physicians and surgeons, found no increase in patient visit

satisfaction [16]. Factors that may explain why training does

not always lead to improved patient outcomes include:

• environmental constraints such as changing practice

volume;

• appropriateness of outcome measures;

• time point of outcome measurement;

• high pre-intervention scores of the outcome measure;

• differences in study groups;

• bias of participants (i.e. volunteer participants may be

more motivated and therefore already more skilled at

communication than control subjects);

• a genuine difficulty in or resistance to changing a

fundamental behaviour such as a personal communication

style [2, 17].

Randomised controlled studies often use sample sizes

that are too small to give definitive results, although mean

differences between study groups consistently suggest

improved patient satisfaction and well-being [18]. Never-

theless, a few studies also have shown significant increases

in patient satisfaction after such programmes [19, 20].

Of the six summary response variables used in the

present study, those measuring satisfaction were the least

sensitive to differences. Overall and median satisfaction

Table 2 Mixed (fixed andrandom effects) models for the sixsummary response variables.Probability values were calculatedwith the Likelihood Ratio Test.Response

Samplesize

Within-clustercorrelation

Training effect

OthersignificanteffectsEstimate

95%

ConfidenceInterval p-value

Overallsatisfaction

1019 0.02 0.02 [)0.01–0.05] 0.13 Age, p = 0.01Education,p = 0.03

Mediansatisfaction

1029 0.01 0.02 [0.00–0.05] 0.08 Age, p = 0.03Education,p = 0.05

Spielbergeranxiety score

902 0.00 0.04 [)0.24–0.31] 0.75 Age, p < 0.01Gender, p < 0.01Duration surgery,p = 0.02

Overall anxiety –anaesthesia

1013 0.01 0.00 [)0.07–0.07] 1.00 Gender, p < 0.01Prior experience,p < 0.01

Overall anxiety –surgery

1011 0.00 )0.02 [)0.09–0.05] 0.75 Age, p = 0.01Gender, p < 0.01Duration surgery, p = 0.01

Median anxiety 1015 0.01 )0.05 [)0.09–)0.01] 0.01 Gender, p < 0.01

Table 3 Fixed effects models for the 10 specific aspects ofanxiety about anaesthesia and surgery. Probability values werecalculated with the Likelihood Ratio Test.

ResponseSamplesize

Training effect

Estimate

95%ConfidenceInterval p-value

Waiting 1002 )0.03 [)0.08–0.02] 0.29At the mercy of staff 984 )0.04 [)0.09–0.01] 0.12Awareness 969 )0.01 [)0.04–0.02] 0.56Losing control 971 )0.04 [)0.07–0.00] 0.06Emerging from anaesthesia 951 )0.04 [)0.08–0.00] 0.06Harm from anaesthesia 958 )0.05 [)0.09–)0.01] 0.04Not waking up 948 )0.04 [)0.08–0.00] 0.05Postoperative pain 979 )0.05 [)0.09–0.00] 0.06Postoperative nausea 972 )0.03 [)0.07–0.01] 0.15Results of surgery 971 )0.06 [)0.11–0.01] 0.04



were measured on an ordinal scale and only three of the

five categories were commonly chosen. A VAS scale

would have had more power to detect the effect of

training on satisfaction. Patient satisfaction with the pre-

operative anaesthetic visit was already high before the

training programme. In a previous analysis of 10 811

patients, the overall level of satisfaction with anaesthetic

care was also very high (96.8%) and only 0.9% of patients

were ‘dissatisfied’ [21]. Patient satisfaction questionnaires

may therefore have a limited value as an evaluation tool in

the doctor–patient relationship because patient satisfaction

is usually very high before an intervention [22]. In such a

situation, the modest improvements we have seen may be

all we can reasonably expect.

In addition to a modest increase in patient satisfaction,

our results show good evidence that teaching communi-

cation skills to anaesthetists significantly decreased patient

anxiety associated with specific aspects of anaesthesia and

surgery. However, the training had no effect on overall

pre-operative anxiety. These two results are not neces-

sarily inconsistent. General questions about overall anxi-

ety may be more of a measure of ‘irrational anxiety’,

whereas specific questions may be more of a measure of

‘rational anxiety’. The former is probably more difficult

to influence and may reflect the ‘trait’ of the personality.

Consistent with this idea is the finding that training had

no effect on overall anxiety about surgery but decreased

anxiety about the results of surgery. The general questions

on overall anxiety about anaesthesia and surgery were

asked before the 10 specific questions on anxiety; the

specific question on the results of surgery was the last

question asked. Therefore, general questions were asked

before patients thought about specific issues; having

thought about such issues, patients may have been more

‘rational’ about their anxiety.

The within-cluster correlation gives the ratio of

random effect variation to total variation. Hence, the

variability associated with different anaesthetists is at most

2% of the total variability in a response. This low

percentage suggests that patient-dependent predictor

variables are more important than anaesthetist-dependent

predictor variables in modelling patient satisfaction with

the anaesthetic visit and pre-operative anxiety. As a

consequence, changing the anaesthetist’s behaviour may

have little impact on a patient’s perceptions.

In the present study, essential environmental factors

such as the anaesthetist’s workload remained constant pre-

and postintervention. The length of the pre-operative visit

was also constant (median = 20 min). The training ses-

sions were always held in the afternoon during regular

working hours and the participants were relieved of their

clinical responsibilities in the operating theatres by nurse

anaesthetists and by those anaesthetists not in training on

that day. While this format increased the cost of training, it

maintained the mandatory aspect of the programme so as

to minimise participant bias. It was also a change from

clinical routine work and it was not surprising that most

participants enjoyed these training sessions, although some

faculty members complained about disruption to their

non-clinical responsibilities and schedules. Anaesthetists

found their empathy developed so that they could

perceive the needs and anxieties of their patients better,

although the transfer of the newly acquired techniques to

the actual patient encounter seems for many to be difficult.

As a teaching hospital, we have a considerable turnover

of residents and faculty. This makes a longitudinal study

over a 16-month period difficult, and only 10 out of

59 physicians were present for the full 16 months. A

randomised design with intervention and control groups

might have been easier to organise and more successful in

detecting significant differences. However, given the costs

and effort involved, we wanted to offer communication

training to all anaesthetists in the department. It also

might have been easier to detect significant differences by

measuring anaesthetists’ behaviour directly, but we felt it

was more relevant to measure behaviour indirectly in

terms of patient outcome. Finally, while our anxiety

measures have been validated [11], our measures of

satisfaction with the pre-operative visit have unknown

reliability and validity.

Despite efforts by the American Board of Internal

Medicine to understand patient expectations of doctors’

behaviour [23], it is still not clear which communication

skills should be taught to the different medical specialties.

Recently, a group of experts identified seven essential

tasks of medical communication: building a relationship,

opening the discussion, gathering information, under-

standing the patient’s perspective, sharing information,

reaching agreement on problems and plans, and providing

closure. Our communication training programme inclu-

ded, at least in part, all seven of these elements, which are

published as ‘The Kalamazoo Consensus Statement’ [24].

Such effective communication between doctors and

patients is an important factor in the quality of clinical

care as well as a determinant of patient satisfaction, and

both of these are important markers for health plans in a

competitive health care environment [16]. Therefore, we

encourage Departments of Anaesthesia to continue to

teach communication skills to their anaesthetists and to

investigate the effects of such programmes further.

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improving anaesthetists' communication skills

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