For neurological residents, communication skill is a core competency of training due to the complexity and incurability of nervous system diseases1,9. Work in the neurology discipline frequently involves the delivery of complex and difficult information to patients and their families, and effective communication is vital to the care of patients with neurological disease. Despite the importance of communication skills for neurologists, specific training in this area at the residency level is often lacking, especially regarding difficult conversations. Therefore, we sought to perform a needs assessment of difficult conversation education within neurology residency programs in five Chinese neurology training programs. To our knowledge, this is the first study to comprehensively assess the current situation of difficult conversation training in China. Overall, the results of this survey indicate that there is an unmet need for difficult conversation training in the participated neurology residency programs. This is actually not an unexpected finding, but it provides evidence for the need for further efforts to design and implement specific curriculum on this topic.
Our study showed that less than one quarter of residents had received prior training in communication skills, and the majority did not have enough confidence to independently manage difficult conversations. These results demonstrate that communication skills training in Chinese medical schools and post-graduate education might be insufficient. Moreover, most respondent residents reported great interest in receiving training in holding such difficult conversations. Therefore, our results suggest that there is a need to further develop and implement educational activities to teach residents to lead difficult conversations.
Our results indicated that difficult conversations are quite regular and common in neurological clinical care and almost all residents would be exposed to different types of difficult conversations during their training periods. Various clinical scenarios were reported by respondent residents. These difficult conversations range from delivering a diagnosis to sensitive conversations about a new disability, palliative care, advanced care planning, or brain death, and many of these conversations occur within the context of substantial prognostic uncertainty. Our results demonstrated that the top three common scenarios in difficult conversations reported by Chinese residents were working with emotional or unsatisfied patients and their families, disclosing bad news, and disclosing medical errors, which might be different from findings from other countries. As is well known, the physician-patient relationship in China is highly strained11. Therefore, managing difficult patients and their families might be the most stressful aspect of work for our clinicians, especially for inexperienced residents. Our results identified specific target areas in difficult conversations for neurology residency programs in China and provide evidence for developing future targeted curriculum in difficult conversations.
Communication skills training curriculum has been introduced into China for more than ten years, and have been increasingly described in some other medical disciplines, including surgery and oncology recently12,13. These studies have demonstrated that communication skills training program can improve the communication competency of residents. Our study showed that residents who received prior communication skills training had more confidence and faced less stress when they encountered difficult conversations. Although such a comparison does not represent that the previous training can improve the communication skills of the residents, this positive emotion may make them more enthusiastic to participate in practice of difficult conversations, and also encourage them to participate in future training. A few studies in neurological communication skills training have offered some evidence-based templates for curriculum development14, 15. The next step is to develop and implement a formal target curriculum in difficult conversations for our neurology residency programs. At the end of training, residents should be prepared to effectively communicate complex and difficult information to patients and families.
Our results noted barriers in developing and implement difficult conversation training including emotions, fears, time constraints, and a lack of opportunity; these are similar to results have been described previously in other medical and surgical specialties 16. Another important barrier was the expertise of the teaching faculty. Our residents were often excluded when they encountered difficult conversations in clinical practice that were being held by faculty, which led them lose opportunities for observing and learning. Therefore, it is important to consider the development of communication curricula in residency with the goal of equipping the teaching faculty with skills to effectively teach and assess these skills. Efforts should be made to ensure that residents have opportunities to observe and be involved in complex communication encounters throughout their clinical training.
One major limitation in our study is the representativeness of the data. As we known, the scale of the training programs and the number of residencies is huge and the level of training quality is uneven in China. Therefore, it is quite difficult to conduct a survey including all training programs in China. Although the five programs were not randomly selected from all programs qualified to provide neurology residency training and cannot represent the overall situation in China, the main reason why we choose these five programs is that they are all from grade-A, class-3 teaching hospitals and the first batch of training programs to carry out standardized residency training in neurology in China. They represent the highest level of neurology residency training. Furthermore, the five hospitals are located in the North, West, East and Middle of China. Each hospital receives trainees from the surrounding hospitals at all levels, which is representative of the geographical distribution. Therefore, such survey can reflect the situation of residency training in neurology in China to a certain extent.
Another limitation is that our survey included only residents. Program directors, patients and their families were not included, which might result in reporting bias. Program directors have unique perspectives on their program’s successes and weaknesses. Future studies including program directors’ evaluation and patients and their family members’ evaluation will be necessary for curriculum development.