Effect and Durability of an In-depth Training Course on Physician Communication Skills

Effect and Durability of an In-depth Training Course  on Physician Communication Skills


James T Hardee, MD1; Thomas F Rehring, MD2; Joseph E Cassara, MD3; Karl Weiss, MBA4; Nicholas Perrine, PhD5

Perm J 2019;23:18-154 [Full Citation]

E-pub: 01/17/2019


Introduction: Effective clinical communication skills are integral to a successful and therapeutic clinician-patient relationship and are associated with improvement in adherence, outcomes, and lower medicolegal risk. However, in stark contrast to other clinical and cognitive skills, practicing physicians generally receive little ongoing training or assessment of individual performance in communication.
Objectives: To assess the effect of an in-depth physician communication course on patients’ perception of clinician skill in communication.
Methods: We analyzed the effect of a 3-day dedicated course on clinical communication skills among 65 clinicians assessed by a randomized patient survey.
Results: Patients were significantly more satisfied with their physician on 6 specific communication skills after the physician received the Communication Skills Intensive training. The effect persisted at 12 months’ follow-up. In addition to the improved patient satisfaction scores, attendees stated that they learned many practical communication skills and valued the course.
Conclusion: Health systems looking to improve patient-reported outcome measures should consider focused training, resources, and time for practitioners to engage in a communication skills intensive course.


Effective clinician-patient communication is fundamental to building a therapeutic relationship,1,2 enhancing diagnostic accuracy,3 improving both physician and patient satisfaction,4,5 reducing burnout,5 and mitigating medicolegal risk.6,7 Well-established clinical communication skills include a warm greeting and introduction, eliciting the patient’s perspective, demonstrating empathy, active listening, delivering an appropriately detailed explanation, and shared decision making. These skills are key components of many commonly used communication models such as the Four Habits (invest in the beginning, elicit the patient’s perspective, demonstrate empathy, and invest in the end),8 the E4 model (engaging, empathizing, education, and enlisting),9 ALERT (Always: Listen carefully, Explain understandably, Respect what the patient says, and manage Time perception),10 and ILS (Invite, Listen, Summarize).11

Although attention to clinical communication is now common in many medical school and residency curricula,12-15 there remains a need for practicing clinicians to refresh and refine their communication skills. The consequences of workload compression and reduced visit times can threaten the effectiveness of clinician communication. Modern practices are faced with time constraints, increasing patient demands, high medical complexity, financial difficulties, and electronic medical record charting. A number of organizations have sought to address and reinforce communication skills for practicing physicians, including university training programs, medical groups, and independent companies. The programs offered run the gamut from online modules and videos, to one-on-one coaching, brief lectures, half-day and full-day classes, and multiday intensive courses. Each of these requires resource allocation, not only for participating in the program itself but also indirect costs from taking clinicians out of the patient care environment for that time. The aim of this study was to assess the effect of an in-depth physician communication course on patients’ perception of clinician skill in communication.


Course Description and Study Sample

Kaiser Permanente Colorado offers a biannual Communication Skills Intensive (CSI) course for clinicians wishing to improve their communication by providing them with the opportunity to learn and practice new skills outside the examination room. The Kaiser Permanente Colorado CSI course consists of 3 full days of training among a group of 16 to 20 participants. The course was designed and implemented following a similar program created by Stein16 using content-based lectures, small-group skills practice with care actors, group feedback, and self-reflection. Participation in the CSI is completely voluntary; although most participants self-selected to participate, a lesser number were encouraged to attend. Absolutely no participants were forced or coerced to join the program, and attendance was never made a condition of employment. The mechanism by which a particular attendee arrived at the course was confidential and not made known to faculty or other participants. The participant-to-faculty ratio was 2:1, which allowed for a high degree of coaching and facilitation.

Participants included for this assessment were 75 clinicians who attended the course between 2010 and 2016. Ten of those clinicians were also in leadership positions and were removed from the analysis because their primary duty was as a leader, not as a clinician, and they therefore received unique training on “Staff Coaching” and “Leadership Conversations.” Thus, 65 participants who attended the CSI training between 2010 and 2016 were included in this analysis. Three (5%) of the 65 clinicians who attended CSI training were physician assistants, and the remaining 62 (95%) were physicians. Forty-four (68%) of the clinicians were from primary care departments (Internal Medicine, Family Medicine, Pediatrics). The remaining 21 clinicians (32%) were medical specialists or surgeons (eg, emergency medicine, gynecology, psychiatry). Twenty-nine (45%) of the clinicians attending the CSI course were men. Years of practicing medicine at Kaiser Permanente ranged from 0 to 27 years, with a mean of 6.27 years and median of 3 years.               

Art of Medicine/Patient Feedback of Clinician Communication

Patient ratings of clinicians’ communication skills were assessed using a commercial standardized survey (Art of Medicine [AoM], HealthCare Research, Denver, CO). The AoM patient survey collects a minimum of 75 completed surveys per clinician per year. Patients with a recent clinician encounter are randomly selected to complete a brief survey about the clinician on several aspects of their communication (eg, listening, explaining, treating with courtesy/respect, understanding the patient’s concerns, managing fear and anxiety, and an overall interaction rating). Data collection for the AoM program is continuous. The 65 clinicians who completed the CSI course had AoM survey data for the year before and the year after the clinician’s attendance at CSI.

Data Analysis

The effectiveness of the CSI training was assessed using paired-samples t-tests before and after the CSI training performance on the AoM patient survey program. Specifically, paired-samples t-tests compared patient ratings of a clinician’s communication effectiveness from the year before the CSI training against ratings from the year after CSI training. Additionally, the annualized pre- and post-CSI training data were aggregated by month across all 65 clinicians who attended CSI training, to compare patterns in monthly performance for the 12 months leading up to and 12 months after training.


Six separate paired t-tests were performed comparing pre- and post-CSI training performance on key communication skill items from the AoM patient survey (Table 1). Results from those statistical tests suggest that patients were significantly more satisfied with their physicians on all 6 AoM communication skills questions after CSI training compared with their ratings before attending the CSI training. For example, the average patient rating of “Overall interaction” before training and after training was 73.8% and 77.0%, respectively (Figure 1).

Whereas results from the paired-samples t-test suggest that patient ratings of clinician’s overall interaction was significantly higher after clinicians completed the communication skills training compared with before receiving training, the findings do not indicate the practical effect or clinical importance of the training. Dividing the mean change in overall interaction (3.23%) by the difference in standard deviation between pre- and posttraining (0.122) yields a Cohen d effect size of 0.26. Although t-tests provide an indication of statistical importance (ie, is the change in patient ratings owing to the intervention or is it owing to random chance), the Cohen d effect size quantifies the practical significance of the training. A Cohen d effect size of 0.26 is somewhere between a small and medium effect size.17 One interpretation of this effect is that the mean patient rating of overall interaction among clinicians who completed training is better than 60% of clinicians before receiving training (ie, at least a 10-percentage point improvement in mean performance between the distribution of scores before and after training). More importantly, a patient’s satisfaction with his/her clinician is related to improved compliance and adherence with treatment plans.18 Specifically, patient compliance with and adherence to recommended treatment plans increase as patient satisfaction with a clinician increases. Therefore, training programs with even small effect sizes that demonstrate positive impact on patients’ ratings of their physicians could mean the difference, for example, between a patient taking medications as prescribed vs skipping days or discontinuing a medication once visible signs of disease disappear.

The mean performance of the 65 clinicians who completed the CSI course changed from a score of 73.8% before course completion to a postcourse completion score of 77%. This improvement in average performance after completing the communications course resulted in 5 additional clinicians averaging a patient rating greater than 74% a year after course completion (34 clinicians before vs 39 after; Figure 2.)

At the conclusion of each CSI course, attendees were asked to provide anonymous written evaluations pertaining to their experience and learnings. Comments were overwhelmingly positive in terms of practical learnings and perceived value of the program (see Sidebar: Feedback from Attendees of the Communications Skills Intensive Course).

Effect and Durability of an In-depth Training Course  on Physician Communication Skills

Effect and Durability of an In-depth Training Course  on Physician Communication Skills

Effect and Durability of an In-depth Training Course  on Physician Communication Skills

Effect and Durability of an In-depth Training Course  on Physician Communication Skills


A variety of virtual and in-person clinical communication training programs exist, but little is known about their short- or long-term effectiveness, specifically, when it comes to patient ratings of physicians. In 1999, Brown et al19 reported that clinician participation in a 2-day (10-hour) communication skills training program did not improve patient satisfaction ratings on the AoM survey. Although participants’ self-reported ratings of their communication skills increased, the mean AoM score actually improved more in the control group than in the participant group, leading the authors to postulate whether communication skill training programs needed to be longer and more intensive.

Perhaps taking the aforementioned suggestions to heart, Stein16 in 2007 published the results of a 10-year retrospective study looking at the outcomes of a multiday, residential CSI program. Similar to our program, Stein’s residential course required a substantial commitment of time and resources. Participants in both trainings completed prework reading, participated in didactic lectures and group discussion, and then practiced communication skills with highly trained improvisational care actors.20 Peer feedback and self-reflection were also key components of both courses. Stein demonstrated a significant and sustained improvement in Member Patient Satisfaction scores after attendance at her program, concluding that the benefit extended to physicians, patients, and health care organizations.

Fallowfield et al21 enrolled 160 UK oncologists into a 3-day communication skills training course (using structured feedback, videotape review, role-play with simulated patients, and interactive discussion). They demonstrated significantly improved use of open-ended questions and expressions of empathy but did not specifically monitor actual patient satisfaction. Building on the notion that cancer care physicians need especially good communication skills, Lenzi et al22 enrolled Italian oncologists in a 3-day intensive workshop also focusing on lectures, small-group work, and role-play. Improvement was seen when the researchers compared before and after questionnaires on practitioners’ self-knowledge of communication skills and assessment of patients’ fears and concerns, but again patient satisfaction scores were not evaluated.22

In our study, patient evaluation of specific communication skills was universally improved as a result of the 3-day intensive communication skills course across a range of medical specialties. Our program was not limited to a single specialty communication focus (ie, oncologists only). Perhaps most importantly, the “overall” rating of the physician was statistically significantly higher. This effect was durable and found to persist up to 12 months after the course.

In reviewing the outcomes from these studies, one might wonder why the outcomes seem more robust with the passage of time. Certainly, there has been increased focus on the importance and value of excellent clinical communication skills.23 Medical schools and residency training programs now place a strong emphasis on clinical communication in their curricula, meaning that physicians are beginning their practices much more skilled in this area. In addition, patient satisfaction with their clinicians’ communication skills has become increasingly publicized, whether in a rigorous reporting format (Consumer Assessment of Healthcare Providers and Systems survey)24 or more informal Web sites such as third-party reviews and social commentary. Thus, clinicians’ awareness of this critical aspect of their practice has likely increased.

Figure 1 illustrates the statistically significant improvement in patient ratings among clinicians who completed the CSI course. Figure 2 portrays improvement in patient ratings in terms of individual clinician performance. Specifically, 5 additional clinicians exceeded the 74% patient rating threshold after participating in communications training. An examination of the lower-performing clinicians from Figure 2 suggests that 7 clinicians had an average performance below a 60% threshold before training compared with just 1 clinician performing below 60% after completing communications training. Clinical leaders should be encouraged by these findings that otherwise skilled physicians who might struggle with certain aspects of communicating with patients are able to improve that critical aspect of their medical practice. Generalizability of our results to other communication intensive courses would depend on many factors, including participant selection and engagement, course content and design, and faculty quality.

A final question pertaining to these and similarly published results is “So what?” Maybe it is not surprising that taking a group of professionals off-site and equipping them with practical communication skills leads to improved patient satisfaction scores. Perhaps the more important outcomes occur later, indirectly and beyond easily measurable parameters. That patients are statistically significantly more satisfied with their physician’s communication skills is admirable, but if this effort ultimately leads to improved adherence, better health outcomes, lower malpractice risk, stronger therapeutic alliances, reduced physician burnout, and health care cost savings, then the investment would seem to be more than worth it.


A 3-day concentrated educational effort to enhance clinician communication skills is an effective method of improving patients’ satisfaction scores with their physician. Patients were significantly more satisfied with clinicians on 6 specific communication skills after training compared with prior results. The effect was persistent at a mean of 12 months of follow-up. Health systems looking to improve patient-reported outcome measures should consider focused training, resources, and time for physicians to engage in an intensive communication skills course.

Disclosure Statement

The author(s) have no conflicts of interest to disclose.


Kathleen Louden, ELS, of Louden Health Communications provided editorial assistance.

How to Cite this Article

Hardee JT, Rehring TF, Cassara JE, Weiss K, Perrine N. Effect and durability of an in-depth training course on physician communication skills. Perm J 2019;23:18-154. DOI: https://doi.org/10.7812/TPP/18-154

Author Affiliations

1 Department of Internal Medicine, Colorado Permanente Medical Group, Denver

2 Department of Vascular Surgery, Colorado Permanente Medical Group, Denver

3 Department of Gastroenterology, Colorado Permanente Medical Group, Denver

4 HealthCare Research, Denver, CO

5 Department of Care Experience, Colorado Permanente Medical Group, Denver

Corresponding Author

James T Hardee, MD, (james.t.hardee@kp.org)

1. Stewart MA. What is a successful doctor-patient interview? A study of interactions and outcomes. Soc Sci Med 1984;19(2):167-75. DOI: https://doi.org/10.1016/0277-9536(84)90284-3.
 2. Stewart MA. Effective physician-patient communication and health outcomes: A review. CMAJ 1995 May 1;152(9):1423-33.
 3. Ranjan P, Kumari A, Chakrawarty A. How can doctors improve their communication skills? J Clin Diagn Res 2015 Mar;9(3):JE01-4. DOI: https://doi.org/10.7860/jcdr/2015/12072.5712.
 4. Suchman AL, Roter D, Green M, Lipkin M Jr. Physician satisfaction with primary care office visits. Collaborative Study Group of the American Academy of Physician and Patient. Med Care 1993 Dec;31(12):1083-92. DOI: https://doi.org/10.1097/00005650-199312000-00002.
 5. Boissy A, Windover AK, Bokar D, et al. Communication skills training for physicians improves patient satisfaction. J Gen Intern Med 2016 Jul;31(7):755-61. DOI: https://doi.org/10.1007/s11606-016-3597-2.
 6. Moore PJ, Adler NE, Robertson PA. Medical malpractice: The effect of the doctor-patient relations on medical patient perceptions and malpractice intentions. West J Med 2000 Oct;173(4):244-50. DOI: https://doi.org/10.1136/ewjm.173.4.244.
 7. Beckman HB, Markakis KM, Suchman AL, Frankel RM. The doctor-patient relationship and malpractice. Lessons from plaintiff depositions. Arch Intern Med 1994 Jun 27;154(12):1365-70. DOI: https://doi.org/10.1001/archinte.154.12.1365.
 8. Frankel RM, Stein T. Getting the most out of the clinical encounter: The four habits model. Perm J 1999 Fall;3(3):79-88. DOI: https://doi.org/10.7812/TPP/99-020.
 9. Keller VF, Carroll JG. A new model for physician-patient communication. Patient Educ Couns 1994 Jun;23(2):131-40. DOI: https://doi.org/10.1016/0738-3991(94)90051-5.
 10. Hardee JT, Kasper IK. A clinical communication strategy to enhance effectiveness and CAHPS scores: The ALERT model. Perm J 2008 Summer;12(3):70-4. DOI: https://doi.org/10.7812/TPP/07-066.
 11. Lin CT, Platt FW, Hardee JT, Boyle D, Leslie B, Dwinnell B. The medical inquiry: Invite, listen, summarize. J Clin Outcomes Manage 2005 Aug;12(8):415-8.
 12. 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 Sep;58(3):265-70.
 13. Smith RC, Lyles JS, Mettler J, et al. The effectiveness of intensive training for residents in interviewing. A randomized, controlled study. Ann Intern Med 1998 Jan 15;128(2):118-26. DOI: https://doi.org/10.7326/0003-4819-128-2-199801150-00008.
 14. Choudhary A, Gupta V. Teaching communication skills to medical students: Introducing the fine art of medical practice. Int J Appl Basic Med Res 2015 Aug;5(Suppl 1):541-4. DOI: https://doi.org/10.4103/2229-516x.162273.
 15. Cinar O, Ak M, Stutcigil L, et al. Communication skills training for emergency medicine residents. Eur J Emerg Med 2012 Feb;19(1):9-13. DOI: https://doi.org/10.1097/mej.0b013e328346d56d.
 16. Stein T. A decade of experience with a multiday residential communication skills intensive: Has the outcome been worth the investment? Perm J 2007 Fall;11(4):30-40. DOI: https://doi.org/10.7812/TPP/07-069.
 17. Cohen J. Statistical power analysis for the behavioral sciences. 2nd ed. Mayway, NJ: Academic Press; 1988. p 12.
 18. Barbosa CD, Balp MM, Kulich K, Germain N, Rofail D. A literature review to explore the link between treatment satisfaction and adherence, compliance, and persistence. Patient Prefer Adherence 2012;6:39-48. DOI: https://doi.org/10.2147/ppa.s24752.
 19. 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 Dec 7;131(11):822-9. DOI: https://doi.org/10.7326/0003-4819-131-11-199912070-00004.
 20. Hardee JT, Kasper IK. From standardized patient to care actor: Evolution of a teaching methodology. Perm J 2005 Summer;9(3):79-82. DOI: https://doi.org/10.7812/TPP/05-030.
 21. Fallowfield L, Jenkins V, Farewell V, Saul J, Duffy A, Eves R. Efficacy of a cancer research UK communication skills training model for oncologists: A randomized controlled trial. Lancet 2002 Feb;359(9307):650-6. DOI: https://doi.org/10.1016/s0140-6736(02)07810-8.
 22. Lenzi R, Baile WF, Constantini A, Grassi L, Parker PA. Communication training in oncology: Results of intensive communication workshops for Italian oncologists. Eur J Cancer Care (Engl) 2011 Mar;20(2):196-203. DOI: https://doi.org/10.1111/j.1365-2354.2010.01189.x.
 23. Platt FW, Keller VF. Empathic communication: A teachable and learnable skill. J Gen Intern Med 1994 Apr;9(4):222-6. DOI: https://doi.org/10.1007/bf02600129.
 24. Consumer Assessment of Healthcare Providers and Systems (CAHPS): Surveys and tools to advance patient-centered care [Internet]. Rockville, MD: Agency for Healthcare Research and Quality; 2018 [cited 2018 May 30]. Available from: www.cahps.ahrq.gov.


ALERT, clinician-patient communication, doctor-patient relationship, E4 model, four habits, ILS, medical education, patient experience, training

etoc emailClick here to join the eTOC list or text TPJ to 22828. You will receive an Email notice with the Table of Contents of each issue.

The Permanente Journal advances knowledge in scientific research, clinical medicine and innovative health care delivery. It is a peer-reviewed journal of medical science, social science in medicine, and medical humanities.

The Permanente Press

The Permanente Press publishes The Permanente Journal and books related to health care. For information about subscriptions, missing issues, billing, subscription renewal, and back issues, Email: permanente.journal@kp.org.


27,000 print readers per quarter, 15,350 eTOC readers, and in 2018, 2 million page views of TPJ articles in PubMed from a broad international readership.


The Kaiser Permanente National CME Program designates this journal-based CME activity for 4 AMA PRA Category 1 Credits. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

ISSN 1552-5767 Copyright © 2019 thepermanentejournal.org.

All Rights Reserved.