2006 APDS SPRING MEETING
Missed Opportunities: A Descriptive
Assessment of Teaching and Attitudes
Regarding Communication Skills in a Surgical
Residency
Olivia A Hutul, BS*, Robert O. Carpenter, MD*†, John L. Tarpley, MD*, and Kimberly D. Lomis, MD*
*Department of General Surgery and †Department of Preventive Medicine, Vanderbilt University Medical
Center, Nashville, Tennessee
BACKGROUND: The Accreditation Council for Graduate
Medical Education (ACGME) requires that “residents must be
able to demonstrate interpersonal and communication skills
that result in effective information exchange and teaming with
patients, their patients’ families, and professional associates.”
The authors sought to assess current methods of teaching and
attitudes regarding communication skills in their surgical
residency.
METHODS: After obtaining Institutional Review Board
(IRB) exemption, voluntary anonymous surveys were com-
pleted by a sample of convenience at the Vanderbilt University
Medical Center: surgical residents at Grand Rounds and at-
tending surgeons in a faculty meeting. Data were evaluated
from 49 respondents (33 of 75 total surgical residents, 16 rep-
resentative attending surgeons).
RESULTS: One hundred percent of respondents rated the im-
portance of communication to the successful care of patients as
“4” or “5” of 5. Direct attending observation of residents com-
municating with patients/families was confirmed by residents
and faculty.
Residents reported varying levels of comfort with different types
of conversations. Residents were “comfortable” or “very comfort-
able” as follows: obtaining informed consent, 91%; reporting op-
erative findings, 64%; delivering bad news, 61%; conducting a
family conference, 40%; discussing do not resuscitate (DNR) or-
ders, 36%; and discussing transition to comfort care, 24%.
Resident receptiveness to communication skills education
varied with proposed venues: 84% favored teaching in the
course of routine clinical care, 52% via online resources, and
46% in workshops.
Correspondence: Inquiries to Kimberly D. Lomis, MD, Assistant Professor of Surgery,
Vanderbilt University Medical Center, D-5203, Medical Center North, 1161 21st Avenue
South, Nashville, TN 37232-2577; fax: (615) 343-9485; e-mail: kim.lomis@
vanderbilt.edu
Presented March 22, 2006 at Surgical Education Week, Tucson, Arizona.
CURRENT SURGERY • © 2006 by the Association of Program Directors in Surgery
Published by Elsevier Inc.
Residents were asked how frequently they received feedback
specific to their communication skills during the past 6 months:
Most residents reported 0 (39%) or 1 (21%) feedback episode.
Only 30% of resident respondents reported receiving feedback
that they perceived helpful.
Attending surgeons reported that they did provide residents
feedback specific to their communication skills. When asked to
estimate the number of feedback episodes in the last 6 months,
16 faculty members reported a total of 67 feedback episodes,
whereas 33 residents reported a total of only 24 episodes.
Most faculty members rated their comfort with providing
feedback specific to communication skills as “very comfortable”
(56%) or “comfortable” (19%). “Time constraints” was the
most frequently cited barrier to teaching communication skills.
CONCLUSIONS: Communication skills are valued as inte-
gral to patient care by both residents and faculty in this study.
Residents are most receptive to teaching of communication
skills in the clinical setting. Faculty members report they are
providing feedback to residents. Although residents report di-
rect observation by faculty, currently only a minority (30%) are
receiving feedback regarding communication that they consider
helpful. A need exists to facilitate the feedback process to resolve
this discrepancy. The authors propose that an evaluation instru-
ment regarding communication skills may strengthen the feed-
back process. (Curr Surg 63:401-409. © 2006 by the
Association of Program Directors in Surgery.)
BACKGROUND
Program directors are well aware of the 6 core competencies
required by the Accreditation Council for Graduate Medical
Education (ACGME). These competencies include interper-
sonal and communication skills:
“Residents must be able to demonstrate interpersonal and
communication skills that result in effective information ex-
0149-7944/06/$30.00 401
doi:10.1016/j.cursur.2006.06.016
change and teaming with patients, their patients’ families, and
professional associates. Residents are expected to:
• create and sustain a therapeutic and ethically sound relation-
ship with patients;
• use effective listening skills and elicit and provide informa-
tion using effective nonverbal, explanatory, questioning, and
writing skills
• work effectively with others as a member or leader of a health
care team or other professional group.”1
In response to this requirement, the authors sought to assess
their own current methods of teaching and evaluating commu-
nication skills. Their program currently relies predominantly
on role modeling as a method of teaching communication tech-
niques. It remained unclear to what extent residents are exposed
to a formal discussion of these skills.
Regarding documentation of competence, scores for inter-
personal and communication skills are assigned by individual
faculty members on subjective clinical evaluation forms. The
authors’ program participates in the ACS/APDS evaluation
project. This evaluation provides limited behavioral anchors
upon which to base ratings of communication skills:
• Relations with patients and families: Competent—Consis-
tently shows a level of skill and sensitivity in patient/family
relations and creates and sustains sound relationships with
patients/families as expected at PGY-level.
• Relations with professional associates: Competent—Consis-
tently works effectively with others and documents and com-
municates patient-related information in a manner expected
at PGY-level.
• Communication and interpersonal skills during critical situa-
tions in the operating room: Competent—Consistently shows
appropriate and effective communicative behavior during
critical operating room situations expected at PGY-level.
• Communication and interpersonal skills during critical situa-
tions outside the operating room: Competent—Consistently
shows appropriate and effective communicative behavior
during critical situations outside the operating room ex-
pected at PGY-level.2
Baseline information was gathered as a needs assessment to
assist in the development of more formal teaching and evalua-
tive techniques.
METHODS
Survey instruments were designed to elicit from residents and
faculty their attitudes and concerns regarding communication
skills. Exemption from review was confirmed by the IRB. Vol-
untary, anonymous surveys were conducted of samples of con-
venience. Residents were surveyed at a single Grand Rounds.
Attending surgeons were surveyed at a single faculty depart-
mental meeting.
The content of the resident and attending surveys differed
slightly, although they addressed the same themes regarding
402 CURRENT SURGERY • Volume 63/Number 6 • November/December 2006
communication skills. These themes were value for communi-
cation in clinical care, frequency of communication tasks, com-
fort levels with various tasks, prior learning experiences, oppor-
tunities for observation, feedback (frequency and quality), and
future learning opportunities (Figs. 1 and 2).
Value
Residents and attendings were asked to rate the importance of
communication skills in the care of patients.
Frequency
Residents were asked to describe the frequency of primary re-
sponsibility for the communication process over the past 6
months.
Comfort
Residents and attendings were asked to rate their personal com-
fort with various types of conversations. Attendings were asked
to rate their comfort with evaluating resident communication
skills.
Prior Learning Experiences
Residents and attendings were asked whether they were familiar
with specific models of communication. Residents were asked
whether they had had exposure to workshops or other specific
forums to learn communication skills. Attendings were asked
whether they had had exposure to specific techniques to teach
communication.
Observation
Residents and attendings were asked whether interface oppor-
tunities exist for the attending to directly observe the resident
communicating with patients or families.
Feedback
Residents and attendings were asked to estimate the frequency
of feedback episodes. Residents were asked to rate the helpful-
ness of feedback. Attendings were asked to describe limitations
to providing feedback.
Future Learning Opportunities
Residents were asked to rate their openness to various learning
venues. Attendings were asked to rate their openness to faculty
development and to describe limitations to teaching communi-
cation skills.
RESULTS
Surveys were completed by 49 respondents: 33 surgical resi-
dents and 16 attending surgeons. The eligible resident pool was
65, which included categorical and noncategorical status. Res-
 Resident Survey
We are gathering data to evaluate teaching of the core competency of communication.
This survey is anonymous and voluntary. If you chose to participate, thank you in
advance for your input.
How important do you feel communication skills are to the successful care of patients?
not important somewhat important very important
1 2 3 4 5
comments:______________________________________________________________
______________________________________________________________________

Please estimate how often in the past 6 months you served as the PRIMARY source of
communication with the patient/family for these types of conversations:

Admission dx/plan 1 2 3 4 5 6 7 8 9 10 >10

Daily progress updates 1 2 3 4 5 6 7 8 9 10 >10
Informed consent 1 2 3 4 5 6 7 8 9 10 >10
Operative findings 1 2 3 4 5 6 7 8 9 10 >10
Delivery of bad news 1 2 3 4 5 6 7 8 9 10 >10
DNR orders 1 2 3 4 5 6 7 8 9 10 >10
Family conference 1 2 3 4 5 6 7 8 9 10 >10
Transition to comfort care 1 2 3 4 5 6 7 8 9 10 >10
Other (please specify) 1 2 3 4 5 6 7 8 9 10 >10
comments:____________________________________________________________________
_____________________________________________________________________________

Please rate your personal comfort level with each type of conversation:
uncertain adequate very comfortable

Admission dx/plan 1 2 3 4 5
Daily progress updates 1 2 3 4 5
Informed consent 1 2 3 4 5
Operative findings 1 2 3 4 5
Delivery of bad news 1 2 3 4 5
DNR orders 1 2 3 4 5
Family conference 1 2 3 4 5
Transition to comfort care 1 2 3 4 5
Other (please specify) ___________________________________________________________
comments:______________________________________________________________
______________________________________________________________________
FIGURE 1. Resident survey.

CURRENT SURGERY • Volume 63/Number 6 • November/December 2006 403

 Are you familiar with any specific models of the communication process (Macy model,
Bayer method, etc)? Yes No

Have you had learning experiences explicitly regarding communication skills (workshops,
role plays, etc; not routine clinical care)? Yes No
If yes, please describe:
______________________________________________________________________
______________________________________________________________________

How many times in the past 6 months has an attending directly observed you
communicate with a patient/family?

1 2 3 4 5 6 7 8 9 10 >10

If directly observed, how many times in the past 6 months did you receive feedback
specific to your communication skills?

1 2 3 4 5 6 7 8 9 10 >10

If you did receive feedback about your communication skills, was this helpful?
Yes No
Explain____________________________________________________________
_________________________________________________________________

Would you welcome specific feedback regarding communication skills in the course of
routine clinical care? Yes No

Would you welcome didactic sessions to teach communication skills? Yes No

Would you welcome online resources regarding communication skills? Yes No

PGY-level: _____________

Comments:
FIGURE 1. continued.

ident levels of training were as follows: PGY I: 13; II: 6; III: 7;
and IV: 6. One respondent did not indicate PGY-level. The
survey was administered at the end of the academic year during
transition; therefore, these groups are effectively PGY2-5 in
experience. The eligible faculty pool was 40, of which 16 were
present at the single faculty meeting during which the survey
was circulated and discussed. All faculty members present at the
meeting did respond to the survey. Attending surgeon experi-
ence was indicated by number of years on an academic faculty
rather than rank. The distribution was as follows: 0 to 5 years: 6;
6 to10 years: 4; and ⬎10 years: 6.
Value
All respondents (attendings and residents) rated the importance
of communication to the successful care of patients as “4” or “5”

404 CURRENT SURGERY • Volume 63/Number 6 • November/December 2006

 Attending Survey

We are gathering data to evaluate teaching of the core competency of communication.

This survey is anonymous and voluntary. If you chose to participate, thank you in
advance for your input.

How important do you feel communication skills are to the successful care of patients?
not important somewhat important very important
1 2 3 4 5

comments:______________________________________________________________
______________________________________________________________________

Please rate your personal comfort level with each type of conversation:
uncertain adequate very comfortable

Admission dx/plan 1 2 3 4 5
Daily progress updates 1 2 3 4 5
Informed consent 1 2 3 4 5
Operative findings 1 2 3 4 5
Delivery of bad news 1 2 3 4 5
DNR orders 1 2 3 4 5
Family conference 1 2 3 4 5
Transition to comfort care 1 2 3 4 5
Other (please specify) ____________________________________________________

comments:______________________________________________________________
_____________________________________________________________________

Are you familiar with any specific models of the communication process (Macy model,
Bayer method, etc)? Yes No

Have you had experience explicitly teaching communication skills (workshops, role plays,
etc; not routine clinical care)? Yes No
If yes, please describe: _______________________________________________
__________________________________________________________________
FIGURE 2. Attending survey.

CURRENT SURGERY • Volume 63/Number 6 • November/December 2006 405

 How many times in the past 6 months have you directly observed residents communicate
with patients and/or families?

1 2 3 4 5 6 7 8 9 10 >10

How many times in the past 6 months have you provided residents feedback specific to
their communication skills?

1 2 3 4 5 6 7 8 9 10 >10

Please rate your personal comfort with providing residents feedback specific to their
communication skills:
uncertain adequate very comfortable
1 2 3 4 5
comments:______________________________________________________________
______________________________________________________________________

Please check any factors that make teaching communication skills difficult for you:

____Time constraints
____Lack of vocabulary to discuss communication skills
____Not a priority
____Personal trait of the physician (not a teachable skill set)
____Viewed as a “soft” topic
____Other (please specify)

comments:______________________________________________________________
______________________________________________________________________
______________________________________________________________________

Would you welcome an evaluative tool (checklist) to help guide feedback regarding
communication skills? Yes No

Would you welcome a faculty development session regarding teaching communication

skills? Yes No

Would you welcome online resources regarding teaching communication skills?

Yes No

Number of years on (any) academic faculty: _________________

FIGURE 2. continued.

406 CURRENT SURGERY • Volume 63/Number 6 • November/December 2006

 FIGURE 3. Resident comfort levels with various communication tasks.
of 5. Comments from attendings included “Absolutely critical”
and “This is as important as operative technical skills.” Resident
comments included “Patients won’t let you [operate on] them
unless they fully trust you. A good communicator is less likely to
be sued for malpractice compared to poor communicator what-
ever the level of skill is” and “Communication among teams [is
important to patient care].”
Prior Learning Experiences
Few attendings (2/16) had knowledge of specific models of
communication or had prior training to teach communication.
Although few residents reported knowledge of specific models
of communication (2/33), the majority (21/33) had undergone
some formal teaching of communication skills. As per the com-
ments, most of this training occurred during medical school.
Frequency
Residents reported ample opportunity to serve as the primary
communicator with patients and families. The total resident
group estimated 1764 communication episodes in the preced-
ing 6 months.
Comfort
Residents reported varying levels of comfort with different
types of conversations. A high level of comfort was evident in
obtaining informed consent, reporting operative findings, and
delivering bad news. Residents were progressively less comfort-
CURRENT SURGERY • Volume 63/Number 6 • November/December 2006
able with discussing DNR status, conducting a family confer-
ence, and discussing transition to comfort care (Fig. 3).
Attendings reported comfort with providing feedback spe-
cific to communication skills, with 56% responding “very com-
fortable” and 19% responding “comfortable.”
Observation
Attendings and residents confirmed that attending surgeons do
directly observe residents communicating with patients and fami-
lies. Residents reported an average of 9 episodes of direct observa-
tion in the preceding 6 months, with only 2 residents reporting no
observed communication episodes. Similarly, faculty reported an
average of 8 direct observations in the preceding 6 months.
Feedback
Residents reported the following frequencies of feedback in the
preceding 6-month period: 0 feedback episodes, 13; 1 feedback
episode, 7; 2 feedback episodes, 3; 3 feedback episodes, 3; 4
feedback episodes, 3; 5 feedback episodes, 1; and 6 feedback
episodes, 1 (Fig. 4). Comments from residents regarding pro-
vision of feedback include “I have not received feedback from
any attendings, only nurses or the charge nurse.”
A discrepancy existed in estimates of feedback episodes pro-
vided by residents and attendings: 16 attendings reported a total
of 67 episodes, whereas the larger sample of 33 residents re-
ported total of only 24 episodes.
Residents were asked to rate the quality of the feedback they
did receive. Only 30% of resident respondents reported that
407
 NUMBER OF FEEDBACK EPISODES
5 6
4 (some conversations are challenging regardless of the provider’s
3 a “need to know,” creating a teachable moment.
0 The authors were uncertain whether direct observation of
2 meet demands for clinical productivity, the resident and attend-
1 does manage to convene in the operative suite. If communica-
FIGURE 4. Feedback.
they received feedback that was helpful. Resident comments
included “Some faculty have no business teaching communica-
tion skills. If feedback is to be given, pick instructors wisely.”
Future Learning Opportunities
Residents were asked to rate potential learning venues. Resi-
dents were open to various teaching techniques as follows: clin-
ical setting, 84%; online resources, 52%; and workshops, 46%.
Attendings were asked to rate potential resources for faculty
development. Faculty openness to various techniques was as
follows: structured evaluation form, 93%; online teaching re-
sources, 82%; and workshops, 63%.
Attendings were also asked to describe barriers to teaching
and evaluating communication skills. The following were con-
cerns (listed by frequency of citation): time constraints, 11; trait
of individual physician, 3; lack of vocabulary, 2; and not a
priority, 1.
Attending comments regarding barriers included “Should be
a priority but not given adequate time for emphasis it deserves”;
“[there is pressure to] maintain clinical volume with limited
support”; and “Clinics are so busy that students, residents, and
faculty often work in parallel, then faculty come behind the
trainees to confirm and verify.”
DISCUSSION
In summary, both attendings and resident respondents feel
communications skills are important to the successful care of
408 CURRENT SURGERY • Volume 63/Number 6 • November/December 2006
patients. Both groups indicated that these skills are worthy of
attention during the training process.
Residents demonstrated a continuum of comfort with vary-
ing types of conversations. As a result of the small sample size, it
is not possible to assess the effect of PGY-level on this finding.
The variation in comfort level could be explained by the in-
creasing complexity of the conversations that were assessed
experience level). This finding, however, also implies a role for
ongoing training. Residents prefer that training occur in the
course of the routine care of patients. A particular case can incite
communication occurred on a regular basis. As indicated by
comments, pressure exists to “divide and conquer.” In order to
ing may often work in parallel, with little interface of the full
team and patient/family. The authors argue that the whole team
tion skills are considered important to patient care, the team
could also be assembled for significant communication
episodes.
In discussion after the survey at the faculty meeting, it was
recognized that when both the attending and the resident are
present, the patient and family would look to the attending
surgeon to perform communication tasks. It was proposed that
certain services are more amenable to the resident taking a lead-
ing role in the communication process. Although direct obser-
vation may vary by the clinical service, responses to the survey
indicate that this interface is occurring. Residents reported that
153 of 1764 communication tasks in the preceding 6 months
were observed. Although infrequent, the opportunity does exist
for attendings to provide instruction and feedback to residents
regarding their skill in communication.
Despite such opportunities, relatively few of the residents
reported receiving feedback they perceived as helpful. Of the
153 observed encounters, residents reported only 24 episodes of
feedback, which implies that opportunities to teach and evalu-
ate these crucial skills are being missed.
The discrepancy in resident and attending reported estimates
of feedback episodes is intriguing. Feedback was not formally
defined in the surveys. Attendings and residents may interpret
feedback episodes differently. Perhaps attendings do not pro-
vide feedback specific to the actual communication process, but
they consider this a part of their global comments. Although
these attendings may be experts at communicating with pa-
tients and families, they may not be experts at discussing the
communication process. As medical schools have increased ef-
forts to formalize education in communication, residents are
more likely to have been exposed to structured teaching. They
may seek a more sophisticated evaluation than attendings
provide.
The small sample size of attendings limits interpretation.
The faculty members varied in experience level. Given that this
group of attendings surveyed was captured at a faculty meeting,
these individuals may be more actively committed to teaching
efforts. This group could account for the majority of feedback
provided by the faculty as a whole. In addition, social desirabil-
ity could promote a perception among this group that they
provide feedback more frequently than the resident responses
would support.
Another limitation of this study is that the surveys measured
respondents’ perceptions of experience. Comfort levels do not
necessarily equate with true levels of competence. Similarly,
actual episodes of feedback to determine quality were not ob-
served; instead, the authors relied on the interpretation of the
learner. Boehler et al3 demonstrated that students receiving
constructive criticism of their technical skills improved in per-
formance but reported less satisfaction with feedback compared
with peers receiving only praise. Perhaps the residents are just
not “hearing” the feedback.
Despite the statistical limitations, information exists here
that will guide efforts in improving the teaching and evaluation
of communication skills. The discrepancy in reported feedback
episodes indicates a “disconnect.” The current global assess-
ment “consistently shows a level of skill and sensitivity in pa-
tient/family relations and creates and sustains sound relation-
ships with patients/families, as expected at PGY-level” is
inadequate. We must be more intentional about teaching and
evaluating communication. A standardized approach to provid-
ing this type of feedback could facilitate the process. All parties
must be clear that feedback is indeed occurring.
Future Work
Boon and Stewart4 reviewed the literature regarding patient–
physician communication assessment instruments published
between 1986 and 1996. This review describes a “proliferation
of communication assessment instruments. However few are
widely used and many have never been demonstrated to be
reliable or valid.” Although the authors lament that this infor-
mation makes comparison of instruments difficult, it may be
expected that differing needs generate different instruments.
Effective feedback must be timely and specific. The results of
this study indicate that residents in the department desire im-
mediate feedback about a given communication episode with a
real patient/family. The faculty is concerned about time con-
straints. Thus, the authors favor a streamlined real-time assess-
ment by an observer over more resource-intensive standardized
patient or video-taped interactions. Based on the responses to
this survey and subsequent discussion, this surgical department
is at a novice level of discussion of this skill set. A tool is needed
that will introduce a common language regarding communica-
tion to the faculty and residents. Such an instrument will serve
to instruct as well as assess.
Vanderbilt University Medical Center has adopted the Macy
CURRENT SURGERY • Volume 63/Number 6 • November/December 2006
model for consistency in teaching communication skills. An
evaluation form has been developed based on this model. The
form provides appropriate language to discuss the structure and
specific skills involved in the communication process. Recog-
nizing that this model is likely to be used at a novice level, a
simplified Likert scale of only 4 points was selected. Services on
which the patient and family may have an immediate relation-
ship with the entire team (rather than primarily with the attend-
ing physician) were suggested as good venues for teaching and
evaluating communication skills. At Vanderbilt University
Medical Center, this teaching would include Emergency Gen-
eral Surgery, Trauma, and the Veterans Affairs services. Faculty
development will be carried out for the proposed services, and
completed forms will be required of the residents who rotate on
those services. The form will be readily available online to be
used at the point of care. Limitations in demonstrating reliabil-
ity and validity of such a tool are recognized. At this stage, the
authors see this as a bridge to the “disconnect” in the attending
and resident perceptions.
The plan is to repeat this survey process before and after use
of this form. The authors hope to be more inclusive with the
survey in order to generate sufficient data to address the ques-
tions posed by this needs assessment. It is unlikely that this form
will be a permanent solution. Different tools are envisioned that
may be more appropriate in the future as the level of sophisti-
cation in discussing communication increases. It is unclear
whether one tool could be generalized to other institutions. The
findings do indicate, however, that careful attention is needed
to assure that residents and attendings are communicating
clearly about communication.
REFERENCES
1. Accreditation Council for Graduate Medical Education.
Outcome Project. Available at: http://www.acgme.org/
outcome/.
2. American College of Surgeons/ Association of Program
Directors in Surgery (ACS/APDS) Evaluation Project.
Available at: http://residentassessment.facs.org/residency/
residency/AttendingHome.do.
3. Boehler ML, Rogers DA, Schwind CJ, et al. Feedback ver-
sus feeding. A randomized controlled trial. Presented to the
Association for Surgical Education/Association of Program
Directors in Surgery, Surgical Education Week, New York,
2005.
4. Boon H, Stewart M. Patient-physician communication as-
sessment instruments: 1986 to 1996 in review. Patient Educ
Counsel. 1998;35:161-176.
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