Communication Skills Training for Physicians Improves Patient Satisfaction
Communication Skills Training for Physicians Improves Patient Satisfaction
Amy K. Windover 2
Dan Bokar 2
Matthew Karafa 1
Katie Neuendorf 2
Richard M. Frankel 0 2
James Merlino 4
Michael B. Rothberg 3
0 Indiana University School of Medicine , Indianapolis, IN , USA
1 Quantitative Health Sciences, Cleveland Clinic , Cleveland, OH , USA
2 Office of Patient Experience, Center for Excellence in Healthcare Communication, Cleveland Clinic , Cleveland, OH , USA
3 Center for Value-Based Care Research, Medicine Institute, Cleveland Clinic , Cleveland, OH , USA
4 Press Ganey Associates, Inc. , Chicago, IL , USA
BACKGROUND: Skilled physician communication is a key component of patient experience. Large-scale studies of exposure to communication skills training and its impact on patient satisfaction have not been conducted. OBJECTIVE: We aimed to examine the impact of experiential relationship-centered physician communication skills training on patient satisfaction and physician experience. DESIGN: This was an observational study. SETTING: The study was conducted at a large, multispecialty academic medical center. PARTICIPANTS: Participants included 1537 attending physicians who participated in, and 1951 physicians who did not participate in, communication skills training between 1 August 2013 and 30 April 2014. INTERVENTION: An 8-h block of interactive didactics, live or video skill demonstrations, and small group and large group skills practice sessions using a relationshipcentered model. MAIN MEASURES: Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CGCAHPS), Jefferson Scale of Empathy (JSE), Maslach Burnout Inventory (MBI), self-efficacy, and post course satisfaction. KEY RESULTS: Following the course, adjusted overall CGCAHPS scores for physician communication were higher for intervention physicians than for controls (92.09 vs. 91.09, p < 0.03). No significant interactions were noted between physician specialty or baseline CGCAHPS and improvement following the course. Significant improvement in the post-course HCAHPS Respect domain adjusted mean was seen in intervention versus control groups (91.08 vs. 88.79, p = 0.02) and smaller, non-statistically significant improvements were also seen for adjusted HCAHPS communication scores (83.95 vs. 82.73, p = 0.22). Physicians reported high course satisfaction and showed significant improvement in empathy (116.4 ± 12.7 vs. 124 ± 11.9, p < 0.001) and burnout, including all measures of emotional exhaustion, depersonalization, and personal accomplishment. Less depersonalization and greater personal accomplishment were sustained for at least 3 months. CONCLUSIONS: System-wide relationship-centered communication skills training improved patient satisfaction scores, improved physician empathy, self-efficacy, and reduced physician burnout. Further research is necessary to examine longer-term sustainability of such interventions.
communication; patient experience; patient satisfaction; CGCAHPS; HCAHPS; burnout; empathy; physician; J Gen Intern Med 31(7); 755-61 DOI; 10; 1007/s11606-016-3597-2 © Society of General Internal Medicine 2016
There is growing evidence that patient experience impacts
clinical health outcomes, and, in turn, how organizations
deliver care. This is driven in part by the Centers for Medicare
and Medicaid Service (CMS) requirements to publicly report
patient experience scores (Hospital Consumer Assessment of
Healthcare Providers and Systems; HCAHPS) as a condition
for full reimbursement of hospital services.1 HCAHPS scores,
which measure inpatient care, are tied to the discharging
physician. Because the average inpatient sees at least 3.6
physicians during a hospital stay,2 and patients are frequently
unaware of different physicians’ roles in their care,3 HCAHPS
may be a poor measure of experience and satisfaction with a
specific physician. In contrast, the outpatient experience
survey (Clinician and Group Consumer Assessment of
Healthcare Providers and Systems; CGCAHPS) is provider-specific,
may soon be required, and may provide more reliable data on
which to base improvement efforts.4 Because experience
scores are an important element of determining reimbursement
under value-based purchasing, hospitals and physicians have a
strong incentive to improve HCAHPS and CGCAHPS scores.
However, there are few proven methods for doing so.
Physician communication constitutes one important
element of both HCAHPS and CGCAHPS scores, and it is the
only metric that directly relates to the care provided by
physicians. Multiple studies have shown that communication
skills can be improved with effective training, and that
effective communication improves medical outcomes, safety,
patient adherence, patient satisfaction, and provider satisfaction
and efficiency.5–14 Organization-wide communication skills
improvement programs are rare and reports are limited to case
studies.15 We designed and implemented an experiential,
relationship-centered communication skills course and
measured its impact on patient satisfaction, physician empathy,
burnout, and self-efficacy in a large, multispecialty academic
We included all employed, attending physicians at the
Cleveland Clinic who were mandated to attend an 8-h, internally
offered, experiential communication skills training, between
and 30 April 2014, during their regular work
hours. The Cleveland Clinic is a nonprofit multispecialty
academic medical center that employs approximately 3,220
physicians and scientists and 1,793 residents and fellows in
training. Physicians who had participated in an earlier version
of the 8-h experiential training (1 August 2010 to 3
) and those who had not yet taken the course were
included as controls. Physicians were excluded if they did
not have direct patient contact (e.g., pathologists), were
residents or fellows, or if they did not have at least five pre- and
five post-HCAHPS scores (for the HCAHPS analysis), or five
pre- and five post-CGCAHPS scores (for the CGCAHPS
analysis) (Fig. 1).
Data was entered into a registry approved by the Cleveland
Clinic Institutional Review Board. All participants had the
option to exclude their data from the registry. The study, which
used existing data, was deemed exempt.
In 2013, the Cleveland Clinic Center for Excellence in
Healthcare Communication developed an 8-h experiential
communication skills training called R.E.D.E. (pronounced
Bready^) to Communicate: Foundations of Healthcare
Communication (FHC)SM. FHC is based on the R.E.D.E.SM model,
a conceptual framework for teaching and evaluating
relationship-centered healthcare communication (eFigure 1)
that emphasizes genuine relationship as a vital therapeutic
agent. The R.E.D.E.SM model applies empirically validated
communication skills to three phases of Relationship:
Establishment, Development, and Engagement.16 FHC (eFigure 2)
is a CME-accredited program that focuses on experiential
skills practice, the elements of which have been shown to be
effective in improving physician communication.17,18 Each
course was co-facilitated by two practicing clinicians trained
in relationship-centered communication, adult learning theory,
performance assessment, and group facilitation. Each group
contained no more than 12 participants who proceeded
through a series of interactive didactic presentations, live or
video-based skill demonstrations, and small group skills
practice sessions aligned with the three phases of the model. A
lengthier skills practice integrating all three R.E.D.E.SM
phases followed, and was based on communication challenges
experienced in participants’ clinical practices.
Physicians were asked to complete pre- and post-course
surveys on the day of training and at 3months post-course. The
surveys included demographic information, self-assessment of
communication skills, knowledge and attitudes, the Jefferson
Scale of Empathy (JSE), the Maslach Burnout Inventory
(MBI), and post-course satisfaction. The JSE and MBI were
used with permission.
For each participant, we also extracted physician
information from a database maintained by our office of professional
staff affairs that included gender, race/ethnicity, years in
practice, specialty/subspecialty, and setting.
We conducted separate analyses for HCAHPS scores and
CGCAHPS scores. Physicians who had both types of scores
were included in both analyses. For each analysis, we
controlled for secular changes associated with other patient
experience initiatives by creating a comparison group of physicians
who did not take the course during the specified time period.
Each control physician was matched by assigning a pseudo
course date to correspond with an intervention physician’s
course date. We then collected HCAHPS and CGCAHPS
scores for physician communication for 6months before and
6months after the course date (or corresponding pseudo course
date) using their National Provider Identification (NPI)
To assess the impact of our intervention, we assessed
CGCAHPS scores 6months before and after the assigned date
for the intervention and control groups. Differences in pre- and
post-scores were adjusted for baseline differences in gender,
race, years in practice, and baseline scores.
We then performed two subgroup analyses to examine
whether the impact of the course varied by specialty or initial
CGCAHPs scores. We compared the adjusted mean values at
6months for participants and controls and examined the
interaction between intervention and baseline CGCAHPS
tertile. A significant interaction would indicate a
difference between baseline tertile groups as to the effect the
intervention had on their adjusted 6-month CGCAHPS
score. We performed a separate similar analysis for
To assess the impact of our intervention on hospitalized
patient satisfaction, we performed the same analyses for
Data are presented as mean ± standard deviation or median
[25th, 75th percentiles] for continuous variables and N (%) for
categorical variables. Univariate analysis was performed to
compare pre- and post- course survey results for physicians
by Wilcoxon sign rank sum test for continuous variables, and
by McNemar test for top box comparison of categorical
variables. Top box refers to an Balways^ designation on a
fourpoint Likert scale (HCAHPS), and a BYes definitely^
designation on a three-point scale (CGCAHPS). We analyzed each
physician’s score as the percent of top box scores they
received for that category. Analysis was performed using SAS
software (version 9.3, Cary, NC). An overall significance level
of 0.05 was used for all comparisons. When adjusting for
multiple comparisons, a Bonferroni correction was used.
1 August 2013
to 30 April 2014, 1543
participants completed the FHC course. Of these, six (0.4%)
declined to participate in the study, for a final sample of
1537 (response rate 99.6%). Due to item-specific
nonresponse, available response counts are listed in the results
where appropriate. Table 1 shows the characteristics of
FHC participants and controls for the HCAHPS and
CGCAHPS analyses. For CGCAHPS and HCAHPS
groups, intervention physicians had more years in practice
and were more likely to be male.
After adjusting for gender, race/ethnicity, specialty, years in
practice, and baseline scores, post course date overall mean
CGCAHPS scores were higher for intervention physicians
than for controls (92.09 vs. 91.09, p = 0.03) (Table 2).
Specifically, the domains of ‘Conveyed clear information’ and
‘Know patient’s medical history,’ achieved statistical
significance. Subgroup analysis by specialty revealed no significant
interaction between specialty and the impact of course
exposure (p < 0.05) (eTable 1). A second subgroup analysis by
tertile of baseline scores revealed no significant interaction
between baseline scores and the impact of course exposure
*Values presented as Median [P25, P75] or N (column %)
†p values: a = ANOVA, b = Kruskal-Wallis test, c = Pearson’s chi-square test, d = Fisher’s Exact test
For the HCAHPS analysis, intervention physicians were
more likely to be male, with more years in practice, and higher
baseline scores than controls (Table 1). After adjusting for
gender, race/ethnicity, specialty, years in practice, and baseline
HCAHPS scores, intervention physicians had higher overall
post-course date scores, but the difference was not statistically
significant (83.95 vs. 82.73, p = 0.24) (Table 3). Intervention
physicians did, however, show greater improvement in the
domain of respect (91.08 vs. 88.79, p = 0.02).
the course. Before taking the course, only 20% of physicians
‘strongly agreed’ that the course would be a valuable use of
their time, whereas after the course, 58% ‘strongly agreed’ that
it had been valuable. Less than 1% found that it was not
valuable after attending the course. Pre-course communication
self-efficacy was generally high, except for managing time
and patient emotion (eTable 3). Despite this, post-course
selfefficacy significantly increased in all 13 domains (p < 0.001).
At baseline, physicians self-reported moderate levels of
burnout and low levels of empathy (Table 4). Following the
course, scores on all three domains of burnout (emotional
exhaustion, depersonalization, and personal achievement)
and empathy improved significantly. NPI-matched follow-up
scores were available at 3months for 16% of physicians.
Improvements in all measures except emotional exhaustion
were sustained at 3months. There were no meaningful
differences between the responders and non- responders for
3month surveys (eTable 4.1–4.2).
In this observational study in a large health system,
experiential, relationship-centered communication skills training
effectively improved outpatient scores and one domain of inpatient
scores. The course appeared equally effective for surgeons and
non-surgeons, and the improvement did not differ depending
on baseline patient experience scores. Physicians reported
high levels of satisfaction with the course in terms of it being
a valuable use of time, teaching skills that were relevant and
feasible to implement in their practice, and changing their
attitudes and enhancing their knowledge and skills. The course
*Adjusted for Gender, Ethnicity, Specialty, Years of Practice, and Baseline CGCAHPS score
significantly improved physician self-efficacy related to
performing specific relationship-centered communication
skills that have been previously shown to improve patient
and provider experience. In addition, physicians reported
significant improvement in measures of empathy and burnout,
which were sustained for at least 3months following the
Previous research examining the impact of communication
skills training on patient satisfaction has demonstrated modest
but inconsistent improvement.19 A case study by Stein et al.
(2005) reported statistically significant improvement in
outpatient satisfaction scores, measured with a regional outpatient
member/patient satisfaction survey (not CGCAHPS), for four
out of six provider cohorts (n ~ 483) who completed an
intensive 5-day interactive communication skills course.15
However, the majority of studies have been small (< 130 physicians)
and have not demonstrated statistically significant
improvements in inpatient or outpatient experience or satisfaction
measures.20–24 In addition, many of these training efforts have
been confined to specific populations25–32 or have been with
trainees.33–37 To date, more complex interventions and/or
courses aimed at specific conditions have shown the greatest
likelihood of improving patient experience.19 To our
knowledge, this is the first study of a communication skills training
intervention implemented for all physicians in a large
multispecialty setting, and which uses CMS’ measures of patient
experience. The current study demonstrates the capacity for a
straightforward and short-term experiential communication
skills training to improve provider-specific measures of patient
satisfaction for up to 6months. Whereas previous research
found that providers with lower scores tended to benefit more
than those with higher scores,15 our training model appeared
to benefit all providers, irrespective of baseline patient
In the current healthcare climate, physicians are continually
being asked to do more with less and are experiencing
increased burnout as a result.38 Conscientious steps to improve
physician satisfaction and engagement are therefore vital for
improving the quality of patient care39 and conveying the
important message that healthcare providers are valued and
respected as persons. We employed the same process to build
relationships with physicians attending the training as the one
we encouraged them to use in relating to patients. As a result,
physicians who attended the course reported significant and
lasting improvements in burnout and empathy.
Our study has several important implications. For
institutions working to raise their patient satisfaction scores or to
impact the patient experience more broadly, investing in
communication training may offer a good return on
investment. Because of the narrow range in scores nationally, even
small improvements may translate into large percentile
changes. Absolute improvements of 1-2 points, as seen in
our study, could translate into increases up to 14 percentile
points. Under value-based purchasing contracts, changes of this
magnitude could be worth a sizeable percent of Medicare
revenues. Our findings also suggest that widespread training
is beneficial, regardless of baseline patient satisfaction scores,
since physicians with the highest patient satisfaction scores
were just as likely to show improvement as those with the
lowest scores. Finally, unlike many innovations that add to
pressures associated with job dissatisfaction and burnout, our
intervention led to improvement in both empathy and burnout.
Future studies should address ways to maintain and strengthen
Our study has a number of important limitations. First, due
to its observational nature, we could not rule out other causes
for the improvement in scores among those who took the
course. We attempted to control for secular trends in patient
experience by including a contemporary control group and
adjusting for measured differences, but there may have been
additional unmeasured confounders. Second, we included
some self-reported outcomes, and reporting was not
anonymous. Physicians may have exhibited a social desirability bias
in their responses. This seems unlikely, as they were not
hesitant to initially express their skepticism about the course.
Also, our study included only one organization with a largely
employed model. Not all organizations can mandate training,
but the study nonetheless has important implications.
Cleveland Clinic’s experience in bringing communication skills
training to physicians can serve as a model for others
considering similar initiatives. Large organizations that also use an
employed physician model, including the Mayo Clinic, the
Veterans Health Administration, and Kaiser Permanente,
together care for millions of patients. Others have invested
substantially in efforts to improve patient experience. Spread
of a model similar to ours could bring substantial change to the
quality and outcomes of communication and relationships in
today’s medical practice environment. Whether results can be
generalized to other settings will need to be tested. Our sample
size was limited by the number of physicians with sufficient
numbers of HCAHPS or CGCAHPS surveys. Although it
would have been desirable to have larger numbers of surveys
per physician, and more physicians overall, these are the
measures on which hospital reimbursement is currently based
and they are the chief target of hospital administrators. Finally,
our response rate at 3months was low and may not be
representative of all participants. Further work will be required to
show whether the impact of the course on empathy and
burnout are sustained.
In conclusion, an experiential communication skills training
based on the R.E.D.E.SM model of relationship-centered
communication successfully improved measures of patient
satisfaction, as well as participating physicians’ self-reported
empathy and burnout.
Contributors: Lu Wang assisted with early data analysis.
Funders: The study did not receive grant funding.
Prior Presentations: Neither this manuscript nor one with any part of
its essential substance, tables or figures has been or will be published
or submitted elsewhere.
Corresponding Author: Adrienne Boissy, MD, MA; Center for
Excellence in Healthcare Communication, Cleveland Clinic, 9500
Euclid Ave, NA4, Cleveland, OH 44195, USA (e-mail: ).
Compliance with Ethical Standards:
Conflict of Interest: All authors have worked or currently work for
The Cleveland Clinic Foundation. The R.E.D.E. to CommunicateSM:
Foundations of Healthcare Communication course is a commercial
product of the Cleveland Clinic. No authors receive personal revenue
from the sale of the course. James Merlino, MD is currently employed by
Press Ganey Associates, Inc. as the President and Chief Medical Officer
in Strategic Consulting.
Adrienne Boissy, MD, MA: Nothing to disclose
Amy K. Windover, PhD: Nothing to disclose
Dan Bokar: Nothing to disclose
Matthew Karafa, PhD: Nothing to disclose
Lu Wang: Nothing to disclose
Katie Neuendorf, MD: Nothing to disclose
Richard M. Frankel, PhD: Nothing to disclose
James Merlino, MD: Employed by Press Ganey Associates, Inc. as the
President and Chief Medical Officer in Strategic Consulting
Michael B. Rothberg, MD, MPH: Nothing to disclose
1. Hospital Consumer Assessment of Healthcare Providers and Systems . Centers for Medicare & Medicaid Services , Baltimore, MD. http://www.hcahpsonline.org. 2013 . http://www.hcahpsonline. org. Accessed 1 /14/ 2016 .
2. Stevens JP , Nyweide D , Maresh S , Zaslavsky A , Shrank W , Md MD , et al. Variation in Inpatient Consultation Among Older Adults in the United States . J Gen Intern Med . 2015 ; 30 ( 7 ): 992 - 9 . doi: 10 .1007/s11606-015- 3216-7.
3. Windish DM , Olson DP . Association of patient recognition of inpatient physicians with knowledge and satisfaction . J Healthc Qual . 2011 ; 33 ( 3 ): 44 - 9 . doi: 10 .1111/j.1945- 1474 . 2010 . 00123 .x.
4. Dyer N , Sorra JS , Smith SA , Cleary PD , Hays RD . Psychometric properties of the Consumer Assessment of Healthcare Providers and Systems (CAHPS(R)) Clinician and Group Adult Visit Survey . Med Care . 2012 ; 50 ( Suppl ): S28 - 34 . doi: 10 .1097/MLR.0b013e31826cbc0d.
5. Marvel MK , Epstein RM , Flowers K , Beckman HB . Soliciting the patient's agenda: have we improved? JAMA . 1999 ; 281 ( 3 ): 283 - 7 .
6. Brock DM , Mauksch LB , Witteborn S , Hummel J , Nagasawa P , Robins LS . Effectiveness of intensive physician training in upfront agenda setting . J Gen Intern Med . 2011 ; 26 ( 11 ): 1317 - 23 .
7. Mauksch LB , Dugdale DC , Dodson S , Epstein R . Relationship, communication, and efficiency in the medical encounter: creating a clinical model from a literature review . Arch Intern Med . 2008 ; 168 ( 13 ): 1387 - 95 . doi: 10 . 1001/archinte.168.13.1387.
8. Abraham NS , Naik AD , Street RL Jr. Shared decision making in GI clinic to improve patient adherence . Clin Gastroenterol Hepatol: Off Clin Pract J Am Gastroenterol Assoc . 2012 ; 10 ( 8 ): 825 - 7 . doi: 10 .1016/j.cgh. 2012 . 06 .001.
9. Mazor KM , Beard RL , Alexander GL , Arora NK , Firneno C , Gaglio B , et al. Patients' and family members' views on patient-centered communication during cancer care . Psycho-Oncology . 2013 ; 22 ( 11 ): 2487 - 95 . doi: 10 . 1002/pon.3317.
10. Robinson JD , Hoover DR , Venetis MK , Kearney TJ , Street RL Jr. Consultations between patients with breast cancer and surgeons: a pathway from patient-centered communication to reduced hopelessness . J Clin Oncol: Off J Am Soc Clin Oncol . 2013 ; 31 ( 3 ): 351 - 8 . doi: 10 .1200/ JCO. 2012 . 44 .2699.
11. Stewart M , Brown JB , Donner A , McWhinney IR , Oates J , Weston WW , et al. The impact of patient-centered care on outcomes . J Fam Pract . 2000 ; 49 ( 9 ): 796 - 804 .
12. Stewart M , Brown JB , Hammerton J , Donner A , Gavin A , Holliday RL , et al. Improving communication between doctors and breast cancer patients . Ann Fam Med . 2007 ; 5 ( 5 ): 387 - 94 .
13. Roter DL , Hall JA , Kern DE , Barker LR , Cole KA , Roca RP . Improving physicians' interviewing skills and reducing patients' emotional distress. A randomized clinical trial . Arch Intern Med . 1995 ; 155 ( 17 ): 1877 - 84 .
14. Kelley JM , Kraft-Todd G , Schapira L , Kossowsky J , Riess H. The influence of the patient-clinician relationship on healthcare outcomes: a systematic review and meta-analysis of randomized controlled trials . PLoS One . 2014 ; 9 ( 4 ):e94207. doi: 10 .1371/journal.pone. 0094207 .
15. Stein T , Frankel RM , Krupat E. Enhancing clinician communication skills in a large healthcare organization: a longitudinal case study . Patient Educ Couns . 2005 ; 58 ( 1 ): 4 - 12 .
16. Windover A , Boissy A , Rice T , Gilligan T , Velez V , Merlino J . The REDE model of healthcare communication: Optimizing relationship as a therapeutic agent . J Patient Experience . 2014 ; 1 ( 1 ): 8 - 13 .
17. Berkhof M , van Rijssen HJ , Schellart AJ , Anema JR , van der Beek AJ. Effective training strategies for teaching communication skills to physicians: an overview of systematic reviews . Patient Educ Couns . 2011 ; 84 ( 2 ): 152 - 62 . doi: 10 .1016/j.pec. 2010 . 06 .010.
18. Merckaert I , Libert Y , Razavi D . Communication skills training in cancer care: where are we and where are we going? Curr Opin Oncol . 2005 ; 17 ( 4 ): 319 - 30 .
19. Dwamena F H-RM , Gaulden CM , Jorgenson S , Sadigh G , Sikorskii A , Lewin S , Smith RC , Coffey J , Olomu A , Beasley M . Interventions for providers to promote a patient-centred approach in clinical consultations . Cochrane Database of Syst Rev . 2012 ( 12 ). doi: 10 .1002/14651858. CD003267. pub2 .
20. Frostholm L , Fink P , Oernboel E , Christensen KS , Toft T , Olesen F , et al. The uncertain consultation and patient satisfaction: the impact of patients' illness perceptions and a randomized controlled trial on the training of physicians' communication skills . Psychosom Med . 2005 ; 67 ( 6 ): 897 - 905 . doi: 10 .1097/01.psy. 0000188403 .94327. 5b .
21. O 'Leary KJ , Darling TA , Rauworth J , Williams MV . Impact of hospitalist communication-skills training on patient-satisfaction scores . J Hosp Med: Off Publ Soc Hosp Med . 2013 ; 8 ( 6 ): 315 - 20 . doi: 10 .1002/jhm. 2041 .
22. Brown JB , Boles M , Mullooly JP , Levinson W. Effect of clinician communication skills training on patient satisfaction. A randomized, controlled trial . Ann Intern Med . 1999 ; 131 ( 11 ): 822 - 9 .
23. Fossli Jensen B , Gulbrandsen P , Dahl FA , Krupat E , Frankel RM , Finset A . Effectiveness of a short course in clinical communication skills for hospital doctors: results of a crossover randomized controlled trial (ISRCTN22153332) . Patient Educ Couns . 2011 ; 84 ( 2 ): 163 - 9 . doi: 10 .1016/ j.pec. 2010 . 08 .028.
24. Fujimori M , Shirai Y , Asai M , Kubota K , Katsumata N , Uchitomi Y . Effect of communication skills training program for oncologists based on patient preferences for communication when receiving bad news: a randomized controlled trial . J Clin Oncol: Off J Am Soc Clin Oncol . 2014 ; 32 ( 20 ): 2166 - 72 . doi: 10 .1200/JCO. 2013 . 51 .2756.
25. Bays AM , Engelberg RA , Back AL , Ford DW , Downey L , Shannon SE , et al. Interprofessional communication skills training for serious illness: evaluation of a small-group, simulated patient intervention . J Palliat Med . 2014 ; 17 ( 2 ): 159 - 66 . doi: 10 .1089/jpm. 2013 . 0318 .
26. Gulbrandsen P , Jensen BF , Finset A , Blanch-Hartigan D . Long-term effect of communication training on the relationship between physicians' self-efficacy and performance . Patient Educ Couns . 2013 ; 91 ( 2 ): 180 - 5 . doi: 10 .1016/j.pec. 2012 . 11 .015.
27. Fallowfield L , Lipkin M , Hall A . Teaching senior oncologists communication skills: results from phase I of a comprehensive longitudinal program in the United Kingdom . J Clin Oncol: Off J Am Soc Clin Oncol . 1998 ; 16 ( 5 ): 1961 - 8 .
28. Schell JO , Green JA , Tulsky JA , Arnold RM . Communication skills training for dialysis decision-making and end-of-life care in nephrology . Clin J Am Soc Nephrol: CJASN . 2013 ; 8 ( 4 ): 675 - 80 . doi: 10 .2215/CJN. 05220512.
29. Rao JK , Anderson LA , Inui TS , Frankel RM . Communication interventions make a difference in conversations between physicians and patients: a systematic review of the evidence . Med Care . 2007 ; 45 ( 4 ): 340 - 9 . doi: 10 . 1097/01.mlr. 0000254516 .04961. d5 .
30. Levinson W , Roter D. The effects of two continuing medical education programs on communication skills of practicing primary care physicians . J Gen Intern Med . 1993 ; 8 ( 6 ): 318 - 24 .
31. Canivet D , Delvaux N , Gibon AS , Brancart C , Slachmuylder JL , Razavi D . Improving communication in cancer pain management nursing: a randomized controlled study assessing the efficacy of a communication skills training program . Support Care Cancer : Off J Multinat Assoc Support Care Cancer . 2014 . doi: 10 .1007/s00520-014- 2357-2 [doi]
32. Gibon AS , Merckaert I , Lienard A , Libert Y , Delvaux N , Marchal S , et al. Is it possible to improve radiotherapy team members' communication skills? A randomized study assessing the efficacy of a 38-h communication skills training program . Radiother Oncol: J Eur Soc Ther Radiol Oncol . 2013 ; 109 ( 1 ): 170 - 7 . doi: 10 .1016/j.radonc. 2013 . 08 .019.
33. Smith RC , Lyles JS , Mettler J , Stoffelmayr BE , Van Egeren LF , Marshall AA , et al. The effectiveness of intensive training for residents in interviewing. A randomized, controlled study . Ann Intern Med . 1998 ; 128 ( 2 ): 118 - 26 .
34. Yedidia MJ , Gillespie CC , Kachur E , Schwartz MD , Ockene J , Chepaitis AE , et al. Effect of communications training on medical student performance . JAMA : J Am Med Assoc . 2003 ; 290 ( 9 ): 1157 - 65 . doi: 10 .1001/jama. 290.9.1157.
35. Deveugele M , Derese A , De Maesschalck S , Willems S , Van Driel M , De Maeseneer J. Teaching communication skills to medical students, a challenge in the curriculum? Patient Educ Couns . 2005 ; 58 ( 3 ): 265 - 70 . doi:S0738- 3991 ( 05 ) 00171 - 0 [pii].
36. Bragard I , Etienne AM , Merckaert I , Libert Y , Razavi D . Efficacy of a communication and stress management training on medical residents' self-efficacy, stress to communicate and burnout: a randomized controlled study . J Health Psychol . 2010 ; 15 ( 7 ): 1075 - 81 . doi: 10 .1177/ 1359105310361992.
37. Lienard A , Merckaert I , Libert Y , Bragard I , Delvaux N , Etienne AM , et al. Transfer of communication skills to the workplace during clinical rounds: impact of a program for residents . PLoS One . 2010 ; 5 ( 8 ):e12426. doi: 10 .1371/journal.pone. 0012426 .
38. Dyrbye LN , West CP , Satele D , Boone S , Tan L , Sloan J , et al. Burnout among U.S. medical students, residents, and early career physicians relative to the general U.S. population . Acad Med: J Assoc Am Med Coll . 2014 ; 89 ( 3 ): 443 - 51 . doi: 10 .1097/ACM.0000000000000134.
39. Romani M , Ashkar K. Burnout among physicians . Libyan J Med . 2014 ; 9 : 23556 . doi: 10 .3402/ljm.v9. 23556 .