International Journal for Quality in Health Care 14:359-367 (2002)
© 2002 International Society for Quality in Health Care
Paper |
Impact of supervision and self-assessment on doctor–patient communication in rural Mexico
1Center for Communication Programs, Johns Hopkins University, School of Public Health, Baltimore
5Quality Assurance Project, Center for Human Services, Bethesda, MD, USA
2Fronteras, The Population Council, Regional Office, Mexico City
3Instituto Mexicano del Seguro Social, Programa Solidaridad (IMSS/S), Mexico City
4Universidad Veracruzana, Veracruz, Mexico
Objective. To determine whether supervision and self-assessment activities can improve doctor–patient communication.
Setting and participants. Six supervisors, 60 doctors in their last year of training, and 232 primary health care patients at rural health clinics in Michoacan, Mexico.
Design. The main evaluation compared post-intervention measures in control and intervention groups. A small panel study also examined changes from baseline to post-intervention rounds in both groups.
Intervention. Over a 4-month period, specially trained supervisors added 1 hour of supervision on interpersonal communication and counseling (IPC/C) to regular site visits. Doctors, who had received prior IPC/C training, periodically audiotaped and assessed their own consultations.
Main outcome measures. These comprised frequency of doctors’ facilitative communication, doctors’ biomedical information-giving, and patients’ active communication.
Results. The performance of all doctors improved markedly over the study period, but gains in facilitative communication and information-giving were significantly greater in the intervention than the control group. No single component of the intervention was responsible for the improvement; it resulted from the combination of activities. The doctors appreciated the more supportive relationship with supervisors that resulted from the intervention and found listening to themselves on audiotape a powerful, although initially stressful, experience.
Conclusion. Supportive supervision and self-assessment activities can reinforce IPC/C training, prompt reflection and learning, and help novice doctors improve their interpersonal communication skills.
Keywords: communication, quality of care, physician–patient relations, self-assessment, supervision
Research shows that the quality of communication between doctors and their patients contributes to health outcomes as well as patient satisfaction [1–5]. Doctors make more accurate diagnoses and more effective treatment plans when patients fully disclose their symptoms, concerns, and personal circumstances. Patients feel more committed and better prepared to carry out a plan of action when doctors clearly explain the diagnosis, treatment options, and instructions.
Good communication and counseling skills are especially important in rural areas of Mexico, where there are wide cultural differences between indigenous communities and doctors. To provide health care services to rural populations, the Mexican Institute of Social Security/Solidarity (IMSS/S) places resident doctors in rural clinics for a 9-month rotation as part of their training. Typically, one of these resident doctors and a nurse staffs a two-room clinic. Most resident doctors come from urban backgrounds, are middle to upper class, and speak Spanish. In contrast, the patients they serve come from a lower socioeconomic class and mostly speak indigenous languages. While most resident doctors establish a good rapport with patients and take time to ask questions and explain matters, formative research shows that they are less skilled in listening to clients, encouraging them to speak, and responding to individual client needs.
IMSS/S has introduced training in interpersonal communication and counseling (IPC/C) to narrow the communication gap between young resident doctors and rural patients. While experience elsewhere has demonstrated the effectiveness of IPC/C training [6,7], one-time training has not been sufficient to guarantee that health personnel apply new communication skills on the job and maintain them over time [8]. Two opportunities exist for cost-effective reinforcement of IPC/C skills among resident doctors at IMSS/S clinics. The first possibility is using the routine supervision system already in place. Competent and experienced physician supervisors make regular 1-day site visits to IMSS/S clinics to monitor technical standards of care. With training and appropriate tools, they also could assess IPC/C performance and provide direct feedback to resident doctors. The second possibility is asking resident doctors to engage in self-assessment and self-directed learning, an approach that has maintained and improved health providers’ communication skills in Indonesia, even in the absence of outside supervision and support [8].
In 1998–99, IMSS/S pilot tested both of these approaches at rural clinics in the state of Michoacan. This study examines the impact of a combined intervention of supervision and self-assessment on the communication performance of resident doctors. Specific objectives are: (1) to determine if supervision and self-assessment help doctors to apply newly learned communication skills on the job and to improve those skills over time; and (2) to identify which activities (including supervision visits, audiotaped consultations, self-assessment, homework logs, and job aids) are effective and acceptable to doctors.
Methods
This study assessed a cohort of resident doctors who began their assignment at an IMSS/S clinic in Michoacan, Mexico in the summer of 1998. Soon after they arrived, all of the doctors attended a 2-day workshop on IPC/C, followed by a half-day refresher course 5 months later. Baseline data were collected immediately after the refresher course. The doctors were assigned to intervention and control groups depending on which supervision zone their clinics belonged to; the supervision zones included in the study were randomly divided into control and experimental conditions as described below. During the following 4 months, doctors in the intervention group received visits from supervisors who were specially trained in IPC/C and who evaluated doctors’ interactions with clients; some of these doctors also conducted IPC/C self-assessment exercises. Doctors in the control group also received regular supervision visits, but their supervisors were not trained in IPC/C and did not review how well they communicated with clients. At the end of the 4-month intervention period (which also marked the end of the doctors’ assignment at the rural clinics), a second round of data was collected.
The data are analyzed in two different ways: a cross-sectional comparison and a panel study. The cross-sectional analysis compares post-intervention measures in the intervention and control groups, and has the advantage of a larger sample size. The panel study examines changes over time from the baseline to post-intervention rounds in both the intervention and control groups. It provides a more conservative measure of the intervention’s impact, since it takes into account changes in the control group during the intervention period. However, the power of the panel study is limited by its small sample size.
Study sample
The study took place in the Zamora region of Michoacan, which is divided into seven supervision zones, each overseen by a single supervisor. One zone was excluded from the study because the high proportion of indigenous peoples made it atypical. The remaining six zones were randomly distributed into control (two zones) and experimental (four zones) conditions. This analysis uses data from a larger study conducted by IMSS/S, which included all 115 rural clinics in the six zones, eliminating the need for random sampling. A team of two research assistants visited each clinic for a day, and audiotaped and interviewed the first three patients to come for services. These patients represented a small proportion of the 
15–30 patients who might be expected to visit a rural clinic in the course of a day. The larger study involved 631 patients, 82 resident doctors, 33 general practitioners, and 115 nurses.
The present study includes a subset of patients who were attended by resident doctors and for whom complete data exists, including audiotapes, observations, and interviews. Technical difficulties, including dead batteries, poor volume control, and excessive background noise, rendered many audiotapes unusable. In addition, some of the resident doctors had already left the rural clinics when the research assistants arrived to collect the post-intervention data. Post-intervention data for the cross-sectional comparison are available for a total of 157 patients and 60 doctors from 60 clinics scattered across all six supervision zones. Of these, 95 patients and 36 doctors were in the intervention group, while 62 patients and 24 doctors were in the control group.
The panel study includes every doctor for whom there is matching baseline and post-intervention data. Matching data are available for a subgroup of 28 doctors, who were recorded with a total of 147 patients. Of these, 21 doctors were in the intervention group, and they saw 57 patients in the baseline round and 54 patients in the post-intervention round. The remaining seven doctors were in the control group, and they saw 18 patients in the baseline round and 17 patients in the post-intervention round.
Data collection
Audiotaped consultations, which were coded for content, are the primary source of data for this study. Based on an interaction analysis of 15 consultations recorded earlier at the study site, researchers adapted the Roter Interaction Analysis System (RIAS) to code the consultations [9]. RIAS was designed to analyze doctor–patient interactions and has been extensively tested in medical settings in both developed and developing countries; studies have reported adequate inter-coder reliability [7,8,10,11]. The system assigns each utterance made by a doctor or patient to one of 48 mutually exclusive coding categories (utterances consist of a phrase or sentence that conveys a complete thought). Some examples of coding categories are: gives medical information, asks open-ended lifestyle question, shows concern or worry, or checks for understanding.
Two Mexican physicians, both of whom were familiar with the services of IMSS/S, performed the RIAS coding. One physician coded all of the baseline data and then trained and supervised a second physician to code the post-intervention data. As they listened to the audiotapes, the physicians used a computerized data entry screen to assign codes to each utterance. The coders were blind to the intervention status of the doctors. To test for inter-coder reliability, the first physician also coded 22 consultations from the post-intervention round. Agreement between the two coders exceeded 90%. The coders also calculated the length of each consultation, based on the counter numbers on the tape recorder. To ensure the consistency of these measurements, the same brand and model of tape recorder was used to audiotape all consultations.
Data on the sociodemographic characteristics and work experience of the supervisors, doctors, and patients were collected in individual interviews.
Qualitative data were collected at the end of the study to help explain the findings. Providers participated in focus group discussions while supervisors were interviewed individually. Facilitators and interviewers explored their reactions to the intervention and their perceptions of its impact. Researchers also used unstructured observations made during the implementation process to help explain the findings.
Supervision, self-assessment, and self-learning intervention
As described above, each doctor attended a 2-day workshop and a half-day refresher course on IPC/C. The curriculum was designed to help the doctors develop skills in counseling, verbal and non-verbal communication, interviewing, listening, and helping the client to make a decision. This curriculum was institutionalized by IMSS/S in a previous project and had become a standard part of training by the time this study took place. Thus, all of the doctors—whether in the intervention or control groups—received the same IPC/C training. However, doctors in the intervention group were given instructions on the intervention itself during the refresher course.
The supervision, self-assessment, and self-learning intervention was designed to reinforce this training, to help young doctors apply communication skills on the job, and to improve those communication skills over the course of their residency at IMSS/S clinics. Participating supervisors attended a 3-day training course that covered the importance of interpersonal communication, a five-step supervision model for evaluating its quality, and key supervision skills. They were trained on how to conduct IPC/C supervision using a specially designed assessment tool, and they focused on six skill areas deemed essential to the quality of care: listening, being responsive to clients, expressing positive emotions, eliciting information, giving information, and encouraging patient participation.
The 4-month intervention has been called ‘partnership supervision’ because responsibility for enhancing communication skills was shared by supervisors and doctors. Supervisors visited the doctors at 2-month intervals and engaged in a series of special IPC/C activities: they observed a consultation, used a checklist to assess the doctors’ communication skills, gave feedback, discussed issues raised by the doctor, and helped doctors identify specific communication skills that needed work. The doctors recorded these assignments in a homework log and reviewed their progress with the supervisor during the next visit.
Between supervision visits, the doctors continued to work on improving their communication skills, especially those listed in the homework log. Doctors were encouraged to consider every encounter with a patient as an opportunity to practice desired behaviors and to improve their communication skills. To prompt self-assessment and self-learning, they were also given a more formal assignment in the form of the following:
- Each doctor was supposed to audiotape two consultations a month, with the permission of the patients.
- The doctors listened to the tapes and assessed their communication performance with the help of a job aid.
- Some doctors also completed written self-assessment forms focusing on specific communication skills. (Their supervisors received additional training to support this activity.)
In the control group, doctors also received IPC/C training, but there was no follow up or reinforcement. Although supervisors made their usual 1-day visits to control clinics, they were not trained in IPC/C supervision nor were they given the special assessment tool. Researchers asked the two supervisors in the control condition to be on a waiting list so as not to contaminate the experiment. Therefore, doctors in the control group did not receive IPC/C supervision, nor did they receive the job aid, a tape recorder, or any other intervention materials. They continued with their usual routine of reviewing issues in the technical quality of care and in the adequacy of medical supplies during monthly supervision visits.
Outcome measures
The main outcome measure is doctor facilitative communication, i.e. communication that promotes an interactive relationship between patient and doctor by fostering dialogue, rapport, and patient participation. This concept has been developed by some of the authors over the course of previous studies analyzing client–provider interaction in family planning consultations in Kenya and Indonesia [8,12,13]. Facilitative communication is operationally defined as a set of RIAS coding categories that past research suggests is related to clients playing an active role in the consultation. These include partnership building, showing agreement or understanding, discussion of personal and social issues, expression of positive emotions, and asking or giving information on lifestyle and psychosocial issues. Four of the intervention’s six IPC/C content areas were designed to encourage facilitative communication: active listening, being responsive to patients, encouraging patient participation, and expressing positive emotions.
Information-giving by doctors is a second outcome measure. Earlier qualitative studies conducted in Michoacan found that giving insufficient information was a common weakness among resident doctors and that patients wanted better explanations. One of the intervention’s IPC/C content areas encouraged doctors to provide more and better medical and technical information to patients.
In theory, facilitative communication by doctors should encourage patients to take a more active part in the consultation. Hence a third outcome measure is patient active communication, which includes: asking questions, asking for clarification, expressing an opinion, expressing concerns, and discussing personal and social issues.
Data analysis
The analysis consistently examines the frequency of each outcome variable (i.e. the number of utterances per consultation) rather than its proportion. In the cross-sectional study, ANOVA was performed to test the significance of differences between the control and intervention groups. In the panel study, ANOVA was used to test the significance of changes over time (from the baseline to the post-intervention rounds) within the intervention and control groups. The Wald test was used to test the significance of differences in the rate of change between the intervention and control groups. Multiple regression analyses were conducted as part of the cross-sectional and panel studies to control for three potential confounding factors: the purpose of the visit, the sex of the doctor, and the length of the session.
Results
Characteristics of study participants
Most patients were married (84%), women (80%), and had a primary education or less (81%). The age of the patients, but not their marital status, sex or educational level, varied with the purpose of the visit. About half (48%) of the patients came for general medical services, such as colds, stomach pain, and diabetes; their average age was 51 years. One-third (34%) came for reproductive health services, including prenatal care, family planning, sexually transmitted infections (STIs), and adolescent counseling; their average age was 22 years. About one-fifth (18%), usually mothers, brought a child who was sick or needed immunization.
The average age of the resident doctors was 25 years, and 36% of them were male. All of the supervisors were male physicians, and their average age was 37 years. All worked full-time as supervisors for IMSS/S, and they had an average of 7 years experience in the job.
Process evaluation
Supervision. Doctors in both the control and intervention groups received an average of 1.7 visits from supervisors during the 4-month study period, i.e. about one every 2 months. In the control group, none of these visits included supervision on IPC/C. In the intervention group, all of the visits included 1 hour of supervision on IPC/C. During most visits in the intervention group, supervisors and doctors reviewed the homework log together (1.4 times).
In focus group discussions, doctors in the intervention group reported that supervisors offered them more and better feedback on communication and counseling issues after the intervention began. Doctors also noted changes in supervisors’ interpersonal communication: supervisors began working with the doctors as partners, listening to their ideas, and engaging them in discussion, and were more appreciative of their efforts. While doctors praised supervisors for being kind, accessible, and not scolding, some wanted more time with supervisors and more specific feedback from them.
Self-assessment and self-learning. Doctors audiotaped an average of 7.2 consultations, a little less than the eight tapes they were asked to make, and performed an average of 23.1 self-assessments, about four in each of the six IPC/C skill areas. Thus, doctors listened to each tape several times, assessing a different skill each time. Each self-assessment and self-learning session included listening to an audiotaped consultation, and took 30–60 minutes. Nearly all doctors (97%) reported using the job aid regularly and found it useful. Doctors reported using the homework log 8.6 times, on average, as part of their self-improvement efforts.
According to focus group discussions, doctors initially found the self-assessment process stressful, especially those who did not receive written self-assessment forms and instructions. The doctors worried about asking patients for permission to record the session, they were afraid of hearing their own mistakes on tape, they were anxious about following the steps laid out in the job aid, they felt nervous and self-conscious while the taping was going on, and they were anxious about sharing the tapes with supervisors or nurses. With repetition, however, doctors became proficient at self-evaluation and found that listening to themselves on tape was a powerful and eye-opening experience. The tapes helped them recognize their strengths and weaknesses and provided strong motivation to improve.
Impact on length of sessions and utterance rate
There was no significant difference in the length of the consultation in the intervention and control groups (13.4 and 11.8 minutes, respectively). The panel study found the average length of the consultation increased significantly over the 4-month study period in both the intervention (from 7.0 to 13.3 minutes, P < 0.01) and control groups (6.3 to 9.8 minutes, P < 0.001).
These numbers mask a significant change in the amount of conversation exchanged between providers and clients. The number of utterances (phrases or sentences expressing a complete thought) per session was significantly greater in the intervention than the control group (196 versus 128, P < 0.001) at the end of the study, and both providers and clients contributed to the disparity. In other words, both providers and clients in the intervention group uttered more thoughts per minute than their peers in the control group. According to the panel study, providers’ utterance rate increased significantly over the study period in the intervention group (from 6.9 to 9.3 utterances per minute, P < 0.001) but not in the control group (from 7.5 to 8.7, not significant). The client utterance rate increased more among the intervention (3.6 to 5.7, P < 0.001) than the control group (4.0 to 5.0, P < 0.05).
A qualitative review of the audiotapes identified three behavioral changes that led to increased utterance rates in the intervention group. Firstly, providers spent less time in silence while writing notes on the patient’s chart. Secondly, providers lectured less. Thirdly, providers paused more frequently to allow clients to speak.
Impact on doctors’ communication
Facilitative communication. Doctors in the intervention group outperformed the others during the post-intervention round, with an overall frequency of facilitative communication of 48 compared with 30 for the control group (P < 0.001) (Figure 1). Even after controlling for the purpose of the visit, the sex of the doctor, and the length of the session, the intervention showed a significant impact on facilitative communication (ß = 0.28, P < 0.001). As Figure 2 shows, doctors in the intervention group performed significantly better than those in the control group on three of the six types of facilitative communication: partnership building (12.7 versus 7.3, P < 0.001), acknowledgement (12.3 versus 6.2, P < 0.001), and expressing positive emotions (5.9 versus 2.9, P < 0.001).
|
|
The panel study confirms the intervention’s impact on facilitative communication. While doctors’ communication improved markedly over time in both groups, the gains were significantly greater in the intervention than the control group (P = 0.004). Levels of facilitative communication rose 238% in the intervention group (from 13.6 to 45.9, P < 0.001) and 124% in the control group (from 14.6 to 32.7, P < 0.001) (Figure 3). After controlling for other factors in a multiple regression analysis, this rise was significant in the intervention group (ß = 0.23, P < 0.01) but not in the control group (ß = 0.20, not significant). In anecdotal reports, doctors and supervisors said the initial IPC/C training, daily practice with patients, weekly outreach services in the community, and supervision had helped doctors become better communicators. Since the control group also attended IPC/C training, received routine supervision, and learned from their growing experience with patients, it is no wonder that their levels of facilitative communication increased as well.
|
A series of multiple regression analyses were conducted to determine which components of the intervention were most effective. These analyses controlled for: (1) the purpose of the visit, which varied between the two data collection rounds, and between control and intervention groups; (2) the sex of the doctor, which was associated with levels of facilitative communication; and (3) the length of the session, which varied widely. When the impact of each component on facilitative communication was assessed separately, a significant positive association was found with the number of supervision visits received (ß = 0.25, P < 0.001), the number of sessions audiotaped (ß = 0.20, P < 0.01), the number of self-assessments performed (ß = 0.19, P < 0.01), and the number of times the homework log was used (ß = 0.13, P < 0.05). (It was impossible to assess the impact of the job aid, since all doctors reported using it frequently.) Only the number of supervision visits remained significant, however, when all of the intervention components were entered in the regression (ß = 0.20, P < 0.05).
Information-giving. Following the intervention, doctors in the intervention group provided 63% more biomedical information and counseling than those in the control group (27.5 versus 16.6, P < 0.001) (Figure 1), and this difference remained significant even after controlling for other factors (ß = 0.26, P < 0.001). The panel study confirms this finding: information-giving increased from 7.8 to 25.1 (P < 0.001) in the intervention group, compared with a rise from 7.7 to 16.6 (P < 0.001) in the control group (Figure 4). After controlling for other factors, these increases remained significant both in the intervention (ß = 0.44, P < 0.001) and control groups (ß = 0.42, P < 0.05). However, the rate of change was significantly greater in the intervention than control group (P = 0.0001). RIAS coding does not permit us to measure the quality of information provided, such as its accuracy and relevance.
|
Multiple regression analyses found a somewhat different pattern of associations between individual intervention components and information-giving than was revealed for facilitative communication. After controlling for other factors, just two components had a significant impact: the number of times the homework log was used (ß = 0.18, P < 0.01) and the number of audiotapes made (ß = 0.17, P < 0.01), while the number of supervision visits was of borderline significance (ß = 0.14, P = 0.052). Once all of the intervention components were entered in the regression, none of the individual components remained significant.
Qualitative findings. In focus group discussions, doctors reported that their new communication skills not only improved their interactions with patients but also carried over to their relationships with nurses, supervisors, community members, friends, and family. Doctors also said they found it more satisfying to view their patient in a larger context, as a person rather than as a diagnosis. Thus they felt the intervention had contributed to their personal and professional lives, both for the present and in the future.
Impact on patients’ communication
The frequency of patient active communication did not differ significantly between the intervention and control groups (13.3 compared with 11.4, respectively, not significant). The panel study showed that the frequency of patient active communication increased dramatically over the study period in both the intervention (from 2.4 to 12.7, ß = 0.07, P < 0.001) and control groups (from 2.6 to 13.0, ß = 0.13, P < 0.01), with no significant difference in the rate of change between the two groups. This general increase in active communication may be due to providers’ growing experience and the increased length of the sessions, rather than the indirect impact of the intervention. These also may explain qualitative reports by doctors in the intervention group: in focus group discussions, they said patients noticed and responded to the changes in their interpersonal communication, appreciated the additional time spent on talking about their problems, opened up more, and were more likely to make return visits.
Discussion
Supportive supervision and self-assessment changed providers’ communication patterns, increasing the amount of facilitative communication, shortening their utterances, and accelerating the exchange of conversations. These alterations suggest that doctors adopted a more client-centered, less authoritarian approach to care along with a more participatory style of communication—changes that researchers have found produce better health outcomes [2–5,14].
In contrast, changes in patient behavior due to the intervention were neither observed nor expected, since the intervention could have only an indirect impact upon them. However, patient active communication in both the intervention and control groups increased over time, probably due to the growing familiarity between patients and doctors. The resident doctors were strangers when they first arrived at the IMSS/S clinics. Over the course of their 9-month stint at the clinic, which included making home visits 1 day a week, the doctors gradually met the local people, gained an appreciation of the local culture, and came to know their patients. By the end of their stay, they had forged a personal relationship with many patients, making it easier for patients to speak out.
Studying these young doctors offered both benefits and challenges. Because they had just finished training and had not yet established patterns of communication with patients, these resident doctors may have been more open to the influence of the intervention than veteran health care providers. Indeed, two studies of nurses in the UK found that clinical supervision, including its educational component, had a far greater impact on the least experienced and most junior nurses [15,16]. However, it can be difficult to assess the impact of an intervention on doctors just entering practice because their skills rapidly improve with experience. The panel study enabled us to distinguish between the impact of the intervention and doctors’ naturally steep learning curve, since doctors in the control group shared the same IPC/C training, routine supervision, and patient experiences as the intervention group.
The study suffers from certain other limitations. Audio taping, while less intrusive than having an observer present, inevitably affects the behavior both of the doctors, who may try harder, and the patients, who may feel inhibited. The scope of the analysis also was limited by technical difficulties with the audio recording and the departure of some doctors prior to the post-intervention round of data collection. About one-quarter (27%) of the resident doctors who participated in the study were dropped entirely from the analysis, and less than half (47%) of those remaining were included in the panel study. Due to the lack of random sampling, the findings must be interpreted with caution. Since the data lost, however, was due to recording problems and scheduling difficulties, there is no reason to believe it systematically biased the results.
This intervention is rooted in new, supportive approaches to supervision that have broadened the supervisor’s responsibilities in an effort to improve the quality of care [17,18]. According to a widely accepted model, clinical supervisors have three primary functions: (1) normative, ensuring that staff adhere to standards; (2) formative, facilitating learning and professional development by staff members; and (3) restorative, providing emotional support to, and ensuring the personal well-being of, staff members [15,19].
The supervision intervention implemented in Mexico acknowledged the continuing importance of supervisors’ normative function in the creation of an observation checklist to assess doctors’ IPC/C performance. However, the emphasis on feedback, two-way discussion, and the homework log added a formative, educational dimension that helped doctors improve their skills. Training in interpersonal communication also helped supervisors perform the restorative function, which takes on even more importance when young, inexperienced doctors are assigned to live and work in isolated rural clinics where they have no peers or support network.
Research also points to the importance of reflection for professional decision making and adult learning [20]. Reflective practice requires active observation of events and, later, reflection on them to understand better and learn from experience. While supervisors can and do prompt reflection [19], this study demonstrates that listening to yourself on audiotape also stimulates reflection, self-assessment, and self-learning. For doctors, listening to the audiotapes was a powerful experience, and self-criticism was a more compelling motivator than outside criticism. While health care providers in Indonesia successfully performed IPC/C self-assessments without using audiotapes, relying on memory alone was difficult, and providers were not as deeply moved by the process [8].
Partnership supervision may not be suitable for all settings, however. Above all, it requires that a functioning supervision system be in place. Because IMMS/S already had competent and experienced supervisors making regular visits to rural clinics, it was relatively easy to add IPC/C supervision to their responsibilities. In many developing countries, however, supervisors are few in number, poorly trained, and lack transportation to visit facilities [20–22]. Even in developed countries, the costs of time and training pose a barrier to supervision of clinical personnel [19,23]. When the supervision system is not fully functioning, alternative approaches become more attractive; for example, self-assessment, reflective diaries, and peer review [8,23]. Yet the Mexican experience points to practical limitations here as well. While audiotaping consultations proved to be an effective learning tool, IMMS/S found it difficult to supply tape recorders to scattered rural clinics and maintain them in working order once the intervention was scaled up.
Because supervision and self-assessment activities and materials were designed to complement and build on each other, it is difficult to single out the effectiveness of any one component of the intervention. Results suggest instead the importance of multiple, reinforcing interventions for promoting self-learning and behavioral change. Doctors valued every element of the intervention, including the supervision visits, homework log, job aid, audiotapes, and self-assessment. Perhaps because the self-assessment process (including the audiotapes) occurred four times more often than supervision visits and occupied so much more of their time, doctors emphasized self-assessment during focus group discussions. However, they also asked for more time with supervisors and more feedback from them.
Conclusion
This study demonstrates that a combination of supportive supervision and self-assessment can reinforce IPC/C training, help doctors apply newly learned skills on the job, and contribute to continuing improvement in doctor–patient communication. Because supervision is a standard part of most health care systems, it offers a highly effective way of reaching doctors, with training and reinforcement on interpersonal communication. However, supervisors typically do not give feedback on doctor–patient interaction. Specially designed training and assessment tools can direct supervisors’ time and energy to these important issues. Self-assessment extends and magnifies the impact of supervision by sharing responsibility for performance improvement and enhancing the partnership between doctor and supervisor. Further research is needed to test different forms of IPC/C supervision and self-assessment, and to refine the balance between them.
The study was carried out by the Quality Assurance Project (QAP), Instituto Mexicano del Seguro Social/Solidaridad (IMSS/S), and Johns Hopkins University Center for Communication Programs (JHU/CCP), a sub-contractor of QAP. QAP is managed by the Center for Human Services (CHS; Bethesda, MD), and funded by the U.S. Agency for International Development (USAID) contract number HRN-C-00-96-900013. The authors thank Javier Cabral, Celia Escandon, Jesus Castellanos, Maribel Rodriguez (IMSS/S); Phyllis Piotrow, Elizabeth Costenbader, Gary Lewis, (JHU/CCP); Debra Roter, Susan Larson (Johns Hopkins School of Public Health); Jim Heiby (USAID); and David Nicholas, Bart Burkhalter, and Paula Tavrow (QAP/CHS) for their assistance.
Address reprint requests to Y.-M. Kim, Senior Research and Evaluation Advisor, Center for Communication Programs, Johns Hopkins University School of Public Health, 111 Market Place, Suite 310, Baltimore, MD 21202-4012, USA. E-mail: ykim{at}jhuccp.org 
Accepted for publication June 12, 2002.
REFERENCES
- Barry CA, Bradley CP, Britten N, Stevenson FA, Barber N. Patients’ unvoiced agendas in general practice consultations: qualitative study. Br Med J 2000; 320: 1246–1250.
[Abstract/Free Full Text] - Greenfield S, Kaplan S, Ware JE, Yano EM, Frank HJ. Patients’ participation in medical care: effects on blood sugar control and quality of life in diabetes. J Intern Med 1988; 3: 448–457.
- Kaplan SH, Greenfield S, Ware JW. Assessing the effect of the physician–patient interaction on the outcomes of chronic disease. Med Care 1989; 27: S110–S127.[ISI][Medline]
- Stewart M. Effective physician–patient communication and health outcomes: a review. Can Med Assoc J 1995; 152: 1423–1433.[Abstract]
- Roter D, Steward M, Putman SM, Lipkin M, Stiles W, Inui TS. The patient–physician relationship: communication patterns of primary care physicians. J Am Med Assoc 1997; 277: 350–356.[Abstract]
- DeNegri B, Brown L, Hernandez O et al. Improving interpersonal communication between 7 health care providers and clients. Bethesda, MD: Quality Assurance Project, 1997. Available online at http://www.qaproject.org under ‘Products’. Last accessed 29 April 2002.
- DiPrete Brown LD, de Negri B, Hernandez O, Dominguez L, Sanchak JH, Roter D. An evaluation of the impact of training Honduran health care providers in interpersonal communication. Int J Qual Health Care 2000; 12: 495–501.
[Abstract/Free Full Text] - Kim YM, Putjuk F, Basuki E, Kols A. Self-assessment and peer review: improving Indonesian service providers’ communication with clients. Int Fam Plann Perspect 2000; 26: 4–20.[Medline]
- Roter D. The Roter Interaction Analysis System (RIAS) Coding Manual. Baltimore, MD: Johns Hopkins University School of Hygiene and Public Health, 1997.
- van den Brink-Muinen A, Verhaak PFM, Bensing JM et al. The Euro-Communication Study: an International Comparative Study in Six European Countries on Doctor–Patient Communication in General Practice. Utrecht, The Netherlands: NIVEL, 1999. Available at http://www.nivel.nl/publicaties/W8.shtml. Last accessed 29 April 2002.
- Roter D, Rosenbaum J, de Negri B, Renaud D, DiPrete Brown L, Hernandez O. The effects of a continuing medical education programme in interpersonal communication skills on doctor practice and patient satisfaction in Trinidad and Tobago. Med Educ 1998; 32: 181–189.[ISI][Medline]
- Kim YM, Odallo D, Thuo M, Kols A. Client participation and provider communication in family planning counseling: transcript analysis in Kenya. Health Commun 1999; 11: 1–19.
- Kim YM, Kols A, Bonnin C, Richardson P, Roter D. Client communication behaviors with health care providers in Indonesia. Patient Educ Couns 2001; 45: 59–68.[ISI][Medline]
- Ong LM, De Haes JCJM, Hoos AM, Lammes FB. Doctor–patient communication: a review of the literature. Soc Sci Med 1995; 40: 903–918.
- Bowles N, Young C. An evaluative study of clinical supervision based on Proctor’s three function interactive model. J Adv Nurs 1999; 30: 958–964.[ISI][Medline]
- Teasdale K, Brocklehurst N, Thom N. Clinical supervision and support for nurses: an evaluation study. J Adv Nurs 2001; 33: 216–224.[ISI][Medline]
- Ben Salem B, Beattie KJ. Facilitative supervision: a vital link in quality reproductive health service delivery. AVSC Working Paper #10, 1996. Available at http://www.engenderhealth.org/pubs/workpap/wp10/wp_10.html. Last accessed 29 April 2002.
- Lammerink M. Ways of working. Health Action 1994; 8: 10.
- Kilminster SM, Jolly BC. Effective supervision in clinical practice settings: a literature review. Med Educ 2000; 34: 827–840.[ISI][Medline]
- Ahmed AM, Gavyole A, Omar HM, Munisi W. The national guidelines for supervision checklist: a tool for monitoring supervision activities at district level in Tanzania. Ann Ig 1994; 6: 161–166.[Medline]
- Combary P, Newman C, Glover K et al. Study of the Effects of Technical Supervision Training on CBD Supervisors’ Performance in Seven Regions of Ghana. Chapel Hill, NC: University of North Carolina at Chapel Hill, School of Medicine, Program for International Training in Health (INTRAH), 1999. Available at http://www.prime2.org/pdf/TR07.pdf. Last accessed 29 April 2002.
- Valadez J, Vargas W, Diprete L. Supervision of primary health care in Costa Rica: time well spent? Health Policy Plann 1990; 5: 118–125.
[Abstract/Free Full Text] - Teasdale K. Practical approaches to clinical supervision. Prof Nurse 2000; 15: 579–582.[Medline]
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||