Longitudinal Effects of Medical Students' Communication Skills on Future Performance

MILITARY MEDICINE, 180, 4:24, 2015

Longitudinal Effects of Medical Students’ Communication Skillson Future Performance

Ting Dong, PhD*; Lt Col (Sel) Jeffrey S. LaRochelle, USAF MC*; Steven J. Durning, MD, PhD*;LTC Aaron Saguil, MC USA†; Kimberly Swygert, PhD‡; CDR Anthony R. Artino Jr., MSC USN*

ABSTRACT Background: The Essential Elements of Communication (EEC) were developed from the Kalamazooconsensus statement on physician–patient communication. The Uniformed Services University of the Health Sciences(USU) has adopted a longitudinal curriculum to use the EEC both as a learning tool during standardized patientencounters and as an evaluation tool culminating with the end of preclerkship objective-structured clinical examinations(OSCE). Medical educators have recently emphasized the importance of teaching communication skills, as evidencedby the United States Medical Licensing Examination testing both the integrated clinical encounter (ICE) and commu-nication and interpersonal skills (CIS) within the Step 2 Clinical Skills exam (CS). Purpose: To determine the associa-tions between students’ EEC OSCE performance at the end of the preclerkship period with later communication skillsassessment and evaluation outcomes in the context of a longitudinal curriculum spanning both undergraduate medicaleducation and graduate medical education. Methods: Retrospective data from preclerkship (overall OSCE scores andEEC OSCE scores) and clerkship outcomes (internal medicine [IM] clinical points and average clerkship NationalBoard of Medical Examiners [NBME] scores) were collected from 167 USU medical students from the class of 2011and compared to individual scores on the CIS and ICE components of Step 2 CS, as well as to the communicationskills component of the program directors’ evaluation of trainees during their postgraduate year 1 (PGY-1) residency.In addition to bivariate Pearson correlation analysis, we conducted multiple linear regression analysis to examine thepredictive power of the EEC score beyond the IM clerkship clinical points and the average NBME Subject Exams scoreon the outcome measures. Results: The EEC score was a significant predictor of the CIS score and the PGY-1communication skills score. Beyond the average NBME Subject Exams score and the IM clerkship clinical points, theEEC score explained an additional 13% of the variance in the Step 2 CIS score and an additional 6% of the variance inthe PGY-1 communication skills score. In addition, the EEC score was more closely associated with the CIS score thanthe ICE score. Conclusion: The use of a standardized approach with a communication tool like the EEC can help explainfuture performance in communication skills independent of other education outcomes. In the context of a longitudinalcurriculum, this information may better inform medical educators on learners’ communication capabilities and moreaccurately direct future remediation efforts.

INTRODUCTIONThe importance of teaching, assessing, and improving the

communication skills of physicians-in-training cannot be over-

emphasized—physicians must be competent communicators

to effectively practice medicine.1 The Accreditation Council

for Graduate Medical Education (ACGME) and the American

Board of Medical Specialties (ABMS) have jointly identified

communication and interpersonal skills (CIS) as one of the six

general competencies for physicians.2,3 The Institute of Medi-

cine also specifies communication skills as one of the six

essential curricular domains for effective patient care.4 Post-

graduate accredited training programs are required to demon-

strate that they teach and evaluate trainees’ communication

skills. The importance of communication skills is also demon-

strated in licensing examinations. The U.S. Medical Licensing

Examination requires students to take a clinical skills exami-

nation with standardized patients as part of Step 2,5 the Step 2

Clinical Skills (CS) assessment; this has a separate subcom-

ponent and passing standard for the evaluation of CIS.

The development and administration of CIS assessment

tools is challenging and resource intensive. It is difficult to

assess communication skills through inauthentic means (such

as a written test), as it requires in vivo demonstration.1 Com-

petence in communication skills is not only about the presence

of specific behaviors but also about the timing of effective

verbal and nonverbal behaviors in the context of interactions

with patients.6 In 1999, leaders and representatives from

medical schools, residency programs, continuing medical edu-

cation providers, and prominent medical educational organiza-

tions in North America gathered in Kalamazoo for the purpose

of identifying and specifically articulating ways to facilitate

the teaching and evaluation of physician–patient communica-

tion.7 After examining 5 models of physician–patient commu-

nication that had been used by the conference attendees, the

group reached a consensus on a set of Essential Elements of

Communication (EEC).

*Department of Medicine, Uniformed Services University of the Health

Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814.

†Department of Family Medicine, Uniformed Services University of the

Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814.

‡National Board of Medical Examiners, 3750 Market Street, Philadelphia,

PA 19104.

The views expressed in this article are those of the authors and do not

necessarily reflect the official policy or position of the Department of

Defense or the U.S. Government.

doi: 10.7205/MILMED-D-14-00565

MILITARY MEDICINE, Vol. 180, April Supplement 201524

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From the standpoint of learning communication skills, many

research studies have shown that these skills can be taught.8,9

Yedidia et al9 found that communications curricula signifi-

cantly improved third-year medical students’ “overall commu-

nications competence as well as their skills in relationship

building, organization and time management, patient assess-

ment, and negotiation and shared decision-making.” Aspegren8

also pointed out that those students with the lowest pre-

training scores benefit the most from communication skills

curriculum and that the best time to learn these skills in

medical school is most likely during clinical clerkships.

At the Uniformed Services University of the Health

Sciences (USU), we have adopted a longitudinal curricu-

lum using the EEC (see the Appendix) as both a learning

tool during standardized patient encounters and as an eval-

uation tool culminating with the end of preclerkship objective-

structured clinical examination (OSCE). Students are provided

with a copy of the EEC on their second day of medical school

and immediately begin developing skills related to the first

two domains (opening the discussion and building the rela-

tionship). Students build upon their communication skills

through standardized patient interactions, real patient inter-

views, and small-group discussions, using the domains of

the EEC as a guide. The EEC then becomes the primary

assessment tool for communication skills during standardized

and real patient encounters over the course of the preclerkship

training period.

The purpose of this study was to determine the associa-

tions between students’ EEC OSCE performance during the

preclerkship period with later communication skills assess-

ment and evaluation outcomes in the context of a longitudinal

curriculum spanning both undergraduate medical education

(UME) and graduate medical education (GME). The out-

comes were the CIS and integrated clinical encounter (ICE)

scores of Step 2 CS, as well as the communication skills

component of the program directors (PDs) evaluation of

trainees’ during their postgraduate year 1 (PGY-1) residency.

If poor performance can be diagnosed as early as the end of

the preclerkship period by EEC assessment, this would better

inform medical educators on learner ability, and more accu-

rately direct remediation efforts. The research hypotheses

were (1) students’ EEC score would explain a significant

amount of variance in the Step 2 CS CIS score and the PGY-1

communication skills score, beyond the variance explained by

other established clerkship performance measures, and (2) the

associations between EEC score and Step 2 CS ICE score

would be weaker compared with those between EEC score

and CIS score since both EEC and CIS scores are measures

of students’ communication skills.

METHODS

Study Context and Participants

This investigation was part of the larger Long-Term Career

Outcome Study conducted at the F. Edward Hebert School of

Medicine, USU. As the United States’ only federal medical

school, USU matriculates approximately 170 medical students

annually and, at the time of this study, offered a traditional

4-year curriculum: 2 years of basic science courses followed

by 2 years of clinical rotations (clerkships). The participants

of the present study were students graduating in 2011 (N =167; 58 were female [34.7%] and 109 were male [65.3%]).

Measures

EEC Score

The EEC score on the OSCE consists of seven domains (open

the discussion, build the relationship, gather information,

understand the patient perspective, share information, reach

agreement, and provide closure), in addition to an overall

global rating. Each domain has a 5-point Likert-type scale

associated with behavioral anchors. Standardized patients are

trained on how to use the EEC assessment tool and complete

their evaluations after each encounter with a student. The

overall score on each OSCE station is converted into a per-

centage of available points, and the average across all OSCE

stations is recorded as the final EEC score on the OSCE.

According to a previously conducted but unpublished

generalizability study at the USU, the second-year OSCE

stations demonstrated a moderate generalizability coefficient

(r = 0.52), with 18.1% and 3.7% of the overall variance

explained by the OSCE station and rater, respectively. Over-

all, 40.8% of the total variance was explained by student

ability. These generalizability values are slightly lower than

the published reliabilities for the Step 2 CS components of

CIS, data gathering, and patient note, but are in line with

other school-level OSCE reliabilities.10 The EEC reliability

estimate is higher, as a study by Joyce et al found the internal

reliability coefficient (Cronbach’s a) of standardized patient

EEC scores to be 0.90.11

Average NBME Subject Exams Score

The third-year curriculum consisted of the school’s core clerk-

ship rotations: family medicine, internal medicine (IM), general

surgery, psychiatry, pediatrics, and obstetrics and gynecology.

All core clerkship rotations use the relevant NBME Subject

Exam, which is given near the end of the core rotation. The

average NBME Subject Exam score was the un-weighted mean

of the scores across the clerkships. Nationally, the mean scores

(2009–2010) ranged from 73.1 (SD = 8.9) in general surgery

through 78.2 (SD = 8.8) in psychiatry.

IM Clerkship Clinical Points

During the student’s IM clerkship, teachers recommended

grades for each student, and reported the number of clinics

spent with each student. Teacher-recommended grades were

weighted according to the number of clinics the teacher spent

with the students and summarized into a measure called

clinical points.

MILITARY MEDICINE, Vol. 180, April Supplement 2015 25

Effects of Medical Students’ Communication Skills on Future Performance



CIS and ICE Scores of Step 2 CS

We accessed the students’ CIS and ICE scores of Step 2

through a collaboration with the NBME. The ICE subcompo-

nent is a composite score of data gathering and data interpre-

tation skills via both spoken and written communication.

Performance on the ICE subcomponent is rated by the stan-

dardized patients for the history taking and physical exami-

nation portion (via checklist), and by trained physician raters

for the patient note (via a 1–9 scale). The final ICE score is on

the standardized score scale, scaled to have a mean of zero

and SD of 1. The CIS subcomponent includes assessment of

the patient-centered communication skills of fostering the

relationship, gathering information, providing information,

helping the patient make a decision, and supporting emo-

tions. Examinees’ performance of the CIS subcomponent is

evaluated by the standardized patients. This component is

scored as a combination of three 1 to 9 scales, with final CIS

scores ranging from 3 to 27.12

PGY-1 Communication Skills Score

We collect PGY-1 data annually from PDs. The items in our

most recent survey were designed to parallel the six ACGME

competencies. Each spring we identify the programs where

our interns and residents are trained, and we mail the evalua-

tion forms for each trainee to the respective GME PDs. The

psychometric properties of this evaluation form were recently

investigated, and the results indicated reasonable validity and

reliability.13 The structure of the form suggested five factors

or subscales—Medical Expertise, Military-unique Practice,

Professionalism, System-based Practice, and Communication

and Interpersonal Skills. We used the CIS subscale score,

which was calculated as the average of the four items in this

subscale, as an outcome in the present study (hereafter

referred to as the “PGY-1 communication skills score”).

Statistical Analyses

First, we examined the descriptive statistics and the bivariate

correlations of all the measures included. Next, we conducted

multiple linear regression analyses to examine the predictive

power of the EEC score beyond the IM clerkship clinical

points and the average NBME Subject Exams score on the

outcome measures. The USU’s Institutional Review Board

provided ethical approval for the present study.

RESULTSTable I shows the descriptive statistics of the measures

and Table II presents the bivariate Pearson correlations

among the measures. The EEC score had small but statisti-

cally significant correlations with the IM clerkship clinical

points (r = 0.24, p < 0.01) and the ICE scores (r = 0.17,

p < 0.05), and it had moderate correlations with the CIS score

(r = 0.42, p < 0.01) and the PGY-1 communication skills

score (r = 0.31, p < 0.01). Both the average Subject Exams

score and the IM clerkship clinical points were more strongly

correlated with the ICE score (r = 0.29, p < 0.01; r = 0.37,

p < 0.01) than the CIS score (r = 0.12, p = 0.16; r = 0.28,

p < 0.01). The correlation between the ICE score and the CIS

score approached a medium effect size (r = 0.30, p < 0.01).

The multiple linear regression modeling results for the 3

outcome measures are shown in Table III. The EEC score

was a significant predictor of the CIS score and the PGY-1

communication skills score. Beyond the average NBME

Subject Exams score and the IM clerkship clinical points,

the EEC score explained 13% of the additional variance in

TABLE I. Descriptive Statistics of the Measures

Measure Mean SD Min Max

EEC Score 0.66 0.09 0.38 0.84

Average NBME Subject Exams Score Across Clerkships 74.24 6.18 62.33 97.75

IM Clerkship Clinical Points 42.63 14.17 −5.30 69.50

CIS Score of Step 2 CS 20.09 1.01 17.00 22.44

ICE Score of Step 2 CS 0.34 0.74 −2.02 2.76

Communication Skills Component of PGY-1 Residency 3.70 0.74 2.00 5.00

TABLE II. Bivariate Pearson Correlations Between the Measures

Measure EEC Average NBME Clinical Points CIS ICE PGY-1 Communication

EEC Scorea 0.02 0.24** 0.42** 0.17* 0.31**

Average NBME Subject Exams Score Across Clerkships 0.50** 0.12 0.29** 0.004

IM Clerkship Clinical Points 0.28** 0.37** 0.25**

CIS Score of Step 2 CS 0.30** 0.22*

ICE Score of Step 2 CS 0.21*

Communication Skills Component of PGY-1 Residency

aAccording to a previously conducted but unpublished generalizability study at USU, the second-year OSCE stations demonstrated a moderate generalizabil-

ity coefficient (r = 0.52). The EEC reliability estimate is higher, as a study by Joyce et al found the internal reliability coefficient (Cronbach’s a) ofstandardized patient EEC scores to be 0.90.11 *p < 0.05; **p < 0.01.





the CIS score and 6% additional variance in the PGY-1 com-

munication skills score. For the ICE score, 16% of the vari-

ance was accounted for by the average NBME Subject Exams

score and the IM clerkship clinical points, while the EEC

score explained only a modicum of additional variance (R2

change = 0.01). However, if we remove the EEC component

score from the overall OSCE score, the remainder of the

OSCE accounts for an additional 7% of the variance in the

ICE score.

DISCUSSIONThe aim of this study was to investigate the strength of the

association between students’ EEC OSCE performance at the

end of the preclerkship period and later communication skills

assessment and evaluation outcomes at both the UME and

GME level. The results demonstrate that the EEC score is a

strong predictor of the CIS score on Step 2 CS and a good

predictor of the PGY-1 communication skills score. These

findings provide fairly robust validity evidence for USU’s

EEC evaluation method. The use of a standardized approach

with a communication tool such as the EEC can help inform

future performance in communication skills independent of

other education outcomes. In the context of a longitudinal

curriculum, this information may better inform medical edu-

cators on learners’ communication capabilities and more

accurately direct future remediation efforts (there was approxi-

mately one year between EEC assessment and Step 2 CS

Exam and another 18 months to PGY-1 PDs evaluation).

As our results suggest, for the ICE score, the EEC was a

poor predictor. However, the average NBME Subject Exams

score, the IM clerkship clinical points, and the overall OSCE

score without the EEC component score were significantly

associated with this component. This finding indicates that

clinical knowledge as measured by the Subject Exams and

preceptor observations are better predictors of the ICE per-

formance. To some extent, what EEC tested was different

from the rest of the OSCE and this provides another piece of

construct validity evidence for our EEC assessment.

There are several important limitations of the present, single-

institution study. In particular, since the reliabilities of the EEC,

OSCE, IM clinical points, and PGY-1 factors do not reach the

levels adequate for high-stakes decisions, the correlations

between measures may have been weakened, thereby impacting

our ability to accurately calculate the adjusted correlation coef-

ficients. A larger sample size consisting of multiple classes of

students would also increase the generalizability of the findings.

In conclusion, our EEC assessment appears to be a good

predictor of students’ later performance on communication

skills evaluation of Step 2 CS and the first year of residency.

As such, this tool could be used as a sign of poor performance

of communication skills as early as the start of the third-year

clerkship where specific interventions can be effectively

applied and tested before graduation from medical school.

Future studies should focus on the longitudinal development

within individual domains on the EEC, and the impact this

may have future performance.

TABLE III. Multiple Linear Regression Models of the Outcomes

Explanatory Variables

Unstandardized Regression Coefficient Standardized Regression Coefficient R2 Change

CIS ICE PGY-1 CIS ICE PGY-1 CIS ICE PGY-1

Average NBME Subject Exams Score 0.004 0.02 −0.02 0.02 0.16 −0.14 0.08 0.16 0.08

IM Clerkship Clinical Points 0.01* 0.01** 0.01* 0.18 0.27 0.25

EEC score 3.87** 0.65 1.85** 0.37 0.09 0.25 0.13 0.01 0.06

*p < 0.05; **p < 0.01.

APPENDIX

Essential Elements of Communication Checklist—Adaption From the University of New Mexico Medical School,Communication Skills Competency Committee, November 2005

Evaluator ________________ Room ______ Time _________ Student Code ____________

Patient Name _____________________ Date _______

Essential Elements of Communication – Global Rating Scale 2005 (EEC – GRS)

1. Open the Discussion ○ 1 ○ 2 ○ 3 ○ 4 ○ 5

1 2 3 4 5

Introduction

○ No greeting

○ Does not call you by name

○ Initiates use of inappropriate variation

of your name

○ Inappropriate familiarity or informality

○ Does not identify self by name or title

○ Polite greeting

○ Calls you by or establishes your

appropriate name

○ Appropriate formality

○ Accurately introduces self with

full name and title

○ Personal greeting shows genuine interest

○ Displays welcoming nonverbal behavior





1 2 3 4 5

Patient

Opening ○ Begins with closed-ended question

○ Interrupts your initial response

○ Begins with open-ended question

○ Does not interrupt your initial response

○ Asks if there is anything else you want to

add after you finish your initial statement

○ Summarizes your opening concerns and

verifies with you

Agenda

Setting

○ Offers no organizational overview

regarding what to expect during

the encounter

○ Offers an early, brief outline

of what to expect

○ Does not verify the agenda

with you

○ Offers timely, detailed outline of what to

expect during the encounter

○ Verifies the agenda with you

○ Includes an agenda for subsequent visits

2. Build a Relationship ○ 1 ○ 2 ○ 3 ○ 4 ○ 5

1 2 3 4 5

Listening

○ Misunderstands what you say

○ Does not acknowledge or allow

attempts to add or correct information

○ Frequently repeats questions

○ Interrupts your responses

○ Seems to understand what

you say

○ Accepts correction

○ Uses previous information as

basis for subsequent questions

○ Rarely interrupts

○ Summarizes at least once

○ Acquires and accurately assimilates the facts and

subtleties of your situation

○ Does not interrupt important silences

○ Uses restatements, summaries, or explicit checks

to verify information

Empathyand

Attitude

○ Gives false reassurance

○ Does not acknowledge your situation

○ Demonstrates or expresses

appropriate concern for you

○ Responds appropriately to each of your concerns

or issues

○ Provides nonjudgmental support

○ Helps you clarify your own feelings and thoughts

○ Expresses genuine concern throughout

the encounter

Nonverbal

Behavior

○ Inappropriate or distracting behaviors

○ Inappropriately groomed,

disheveled, malodorous

○ Unprofessional clothing

or adornment

○ Distracted manner

○ Tone of voice, facial expression,

posture, nodding, touch, and

distance are appropriate

○ Makes appropriate eye contact

○ Professional and appropriate

clothing or adornment

○ Tone of voice and facial expressions

consistently indicate interest and concern

○ Uses receptive postures

○ Makes mutually agreeable adjustments

in distance or touch for your comfort

3. Gather Information ○ 1 ○ 2 ○ 3 ○ 4 ○ 5

1 2 3 4 5

Context ○ Does not obtain any

information about you

as a person

○ Acquires sufficient information

about you as a person

○ Seems interested in and briefly

explores your life context

○ Acquires important information about you

as a person

○ Encourages you to share freely your

reasons for seeking medical attention

Questions ○ Rarely balances open-

and closed-ended questions

○ Most questions are closed-ended

○ Questions seem mechanistic and rote

○ Balances open- and closed-ended

questions appropriately

○ Uses closed-ended questions

to check details

○ Questions are tailored to you as an individual

○ Prompts you to talk freely in

response to open-ended questions

○ Clarifies specific information or

details through closed-ended questions

Organization

and

Transitions

○ Transitions are confusing

and disorganized

○ Disconcerting, jarring,

or random topic changes

○ Explains transitions

○ Occasionally backtracks to

omitted or forgotten question

○ Transitions are seamless and smooth

○ Clear, logical transitions that may

be explicit or implicit

Physical

Exam

ination ○ Does not inform you before

performing examination maneuvers

○ Causes unnecessary pain

○ Explains some examination maneuvers

○ Alerts you before performing private

or sensitive maneuvers

○ Explains examination maneuvers

appropriately

○ Establishes dialogue about sensations

resulting from the examination

Personal

Privacy ○ Leaves you unnecessarily

exposed, inadequately draped

○ Uses adequate draping ○ Drapes respectfully

○ Checks on your comfort

○ Assures privacy in the environment





4. Understand the Patient’s Perspective ○ 1 ○ 2 ○ 3 ○ 4 ○ 5

1 2 3 4 5

Patient

Concerns ○ Doesn’t ask about your concerns

○ Ignores concerns you raise

○ Asks you to express your major

concerns at some point in the interview

○ Follows up on concerns you raise explicitly

○ Elicits your major concerns early

in the encounter

○ Consistently follows up on clues

or information you volunteer

Patientbeliefs

andPreferences

○ Does not elicit requests or

expectations for outcomes today

○ Interrupts with suggestions before

hearing your preferences

○ Denies or ignores your requests

without explanation

○ Belittles your perspective

○ Elicits your beliefs or preferences

○ Addresses most of your requests

○ Acknowledges your perspective

○ Acknowledges your elicited beliefs

and preferences

○ Consistently addresses your beliefs,

preferences, and requests

○ Responds to your perspective as

understandable and valid

Expressionof

Feelings

○ Denigrates you

○ Becomes silent and withdrawn

○ Changes the subject

when you express emotion

○ Recognizes and acknowledges

explicit expression of emotions

○ Asks about your emotions

after you have given clues

○ Facilitates the expression of your

feelings

○ Anticipates emotional reactions

you might be expected to have

○ Elicits your means of

emotional support

(Consider for particularly vulnerable patient populations, e.g., patients who use another language, have dementia or mental illness, or have marked

physical limitations that may require special accommodations.)

Specific

circumstances ○ Does not demonstrate awareness

of unusual circumstances

○ Demonstrates awareness of

unusual circumstances and

makes accommodation

○ Makes attentive, respectful,

resourceful, and effective

accommodation for unusual

circumstances

5. Share Information ○ 1 ○ 2 ○ 3 ○ 4 ○ 5

1 2 3 4 5

Vocabulary

○ Uses language you

do not understand

○ Uses inappropriate

language (slang or technical)

○ Uses language appropriate

to your educational or

intellectual level

○ Clarifies vocabulary upon request

○ Checks your understanding of technical words

and explains if necessary

○ Skillful use of technical vocabulary

Patient

understanding

ofillness

○ Does not elicit your understanding of

your illness or situation

○ Acknowledges when you volunteer

your understanding of your illness

or situation

○ Asks about your understanding of your illness

or situation

○ Highlights areas of similarity between your

understanding and medical science

Clinician

inform

ation

&explanation ○ Ignores your requests for information

○ Consistently disregards opportunities

for instruction

○ Gives information that

is specific and clear, but

not personalized

○ Gives full, clear, and thorough explanation of

what your symptoms might mean or how they

could be investigated

○ Verifies your understanding of information

○ Offers to provide additional information

6. Reach Agreement (Planning Evaluation and Treatment) ○ 1 ○ 2 ○ 3 ○ 4 ○ 5

1 2 3 4 5

Negotiation ○ No plan

○ Presents a nonnegotiable plan

○ Presents a plan and

requests feedback

○ Solicits input, negotiates a plan to

the extent you desire, and confirms

your understanding of the final plan

Implementation ○ Does not address your

ability to implement the plan

○ Ignores or denigrates your

ability to implement the plan

○ Addresses your hesitations,

suggestions, or questions

about implementing the plan

○ Assumes you are capable

of implementing the plan

○ Elicits your suggestions or questions

about implementing the plan

○ Explores barriers to implementing the

plan and facilitates possible solutions





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7. Provide Closure ○ 1 ○ 2 ○ 3 ○ 4 ○ 5

1 2 3 4 5

Patientnext

steps

○ Stops abruptly

○ No indication of next steps (e.g. get

dressed, wait in room, make another

appointment, etc.)

○ Clear explanation of next steps ○ Verifies next steps with you

(e.g. get dressed, wait in

room, make another

appointment, etc.)

Physician

conclusion ○ No conclusion ○ Polite, generic conclusion ○ Polite, personalized,

thoughtful conclusion

8. Overall Rating ○ 1 ○ 2 ○ 3 ○ 4 ○ 5

1 2 3 4 5

○ I would not return to this clinician under

any circumstances

○ I would return to this clinician ○ I would return to this clinician

above all others

○ I would want this clinician

to care for all my loved ones

Comments:





Longitudinal Effects of Medical Students' Communication Skills on Future Performance

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Transcript of Longitudinal Effects of Medical Students' Communication Skills on Future Performance