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1 Research papers Implementing a communication skills programme in medical school: needs assessment and programme change Toni Suzuki Laidlaw, 1 Heather MacLeod, 1 David M Kaufman, 1 Donald B Langille 2 & Joan Sargeant 3 Introduction Communication skills training (CST) in medicine, once considered a minor subject, is now ranked a core clinical skill. To assess the state of formal and informal CST at Dalhousie Medical School a needs assessment was undertaken in 1997 with the goal of using these ndings to plan and implement a new communication skills curriculum. Objectives This article brie y describes the relevant ndings of the needs assessment, the subsequent development of an integrated cross curriculum CST programme, and early programme evaluation results. Method Surveys were completed by undergraduates at the end of pre-clinical (n ˆ 65), and clinical phases (n ˆ 82), residents (n ˆ 54), and faculty (n ˆ 117). Results revealed learners' and faculty's appreciation of the importance of CST, learners' assessment of training weaknesses in the delivery of CST, learners' weakness in higher order patient±doctor communication skills, and faculty weakness in assessing learners' communication skills competency. The results also indicated that CST was generally not being addressed either formally or informally in clinical medical education. Results The paper describes and discusses the subsequent implementation (beginning in 1998) of CST into the medical school curriculum. There is a description of programme development and evaluation at the preclinical, clerkship and postgraduate levels, a description and discussion of faculty development, and discussion of the importance of nancial and administrative support for the programme. Conclusion Programme evaluation results at all levels are positive. Keywords *Communication; education, medical/ *standards; needs assessment/*standards; curriculum; programme evaluation. Medical Education 2002;36:115±124 Introduction Many medical schools are now considering how to integrate communications skills training (CST) across the continuum of medical education. The importance of an integrated approach is crucial as research reveals that communication skills can not only be learned in medical school, but also forgotten if training is not suf ciently targeted and reinforced throughout medical education. 1±3 Given the widespread de cits in patientdoctor communication reported in academic research literature, large-scale consumer surveys and complaints 1 Division of Medical Education, 2 Department of Community Health and Epidemiology, 3 Department of Continuing Medical Education, Dalhousie University, Halifax, Canada Correspondence: T Suzuki Laidlaw, Division of Medical Education, Dalhousie University, Clinical Research Centre, Rm C-115, 5849 University Avenue, Halifax, Nova Scotia, Canada B3H 4H7. Tel.: ; Fax: ; [email protected] to professional medical associations, increased training emphasis on communication skills competency is essential. 4,5 The consequences of effective teaching strategies are far reaching since good patient-doctor communication has been shown to have positive in uences on patient recall and understanding, adherence, symptom resolution and physiological outcomes, patient and physician satisfaction and the frequency of malpractice claims. 6,7 Communication skills in medicine, once considered a minor subject, are now ranked a core clinical skill. 8 Despite this shift in awareness, there have been substantial dif culties in establishing comprehensive communications programmes in medical education. 9 Lack of institutional and faculty support has been a major factor. 10 Traditionally, CST has been restricted to a few sessions in the rst years of medical education. 11 During the postgraduate years, when physicians specialise in a particular medical discipline, even less 115

2 116 Implementing a communication skills programme in medical school T Suzuki Laidlaw et al. Key learning points Communication is a core clinical skill requiring ongoing training, practice and feedback across the continuum of medical education. A comprehensive needs assessment is a valuable tool for implementing a communication skills programme since it can provide valuable information about the needs and skill levels of all constituent groups. After providing an introductory course in CST, it is advantageous to integrate CST with the teaching of other clinical skills, using a consistent teaching model that allows for the progression of skill development. Ongoing programme evaluation is crucial for ensuring quality and making modi cations as needed. attention is given to CST. 12 Although research literature provides numerous models of individual communication skills course curricula, there are comparatively few papers that detail an integrated, cross-curriculum communication skills programme. The Maastricht Medical School model 13 and the University of Calgary model 14 are two notable exceptions. While cross-curriculum CST is important, it must also be responsive to the uniqueness of each medical school's learning environment and curriculum. Dalhousie Medical School rst tackled the need to enhance CST by appointing a director in 1996 to conduct research and develop an integrated curriculum in communication skills. Prior to this initiative, CST was addressed formally in undergraduate education by ve sessions in the rst year. Other CST was provided sporadically and on an ad hoc basis, and was rarely addressed in either the clerkship or residential years. To assess the state of formal and informal CST at Dalhousie Medical School, a needs assessment was undertaken in 1997 with the goal of using these ndings to plan and implement a new communication skills curriculum. This article brie y describes both the signi cant ndings of the needs assessment, the subsequent development of an integrated cross-curriculum CST programme, and the early programme evaluation results. Learning context At Dalhousie Medical School, there are approximately 360 undergraduate medical students, 450 residents and 233 full time faculty. The rst two years are spent in a problem-based learning (PBL) curriculum, which forms the framework for learning the sciences basic to medicine. Students spend three 2-hour tutorials weekly in groups of 7±8, facilitated by a faculty tutor. The tutorial process is an important aspect of the curriculum, and students must pass this component of each unit, in which they are assessed on aspects of their knowledge and skills in interpersonal and group relationships. There are also 3±5 hours of lectures weekly, an elective experience, laboratory and patient experiences. Units run sequentially through the curriculum, each lasting from 4 to 10 weeks. The Patient±Doctor experience, electives, and a Critical Thinking & Clinical Epidemiology unit run horizontally throughout the rst two years. The Clerkship is two years in length and is divided into two phases. In Phase 1, students undertake a onemonth Introduction to Clerkship, followed by four 12-week experiences in Women, Children and Youth; Medicine; Surgery and Behavioural Medicine, and Primary care. The second phase includes 12 weeks of elective experience, and 12 weeks of experience in continuing preventive care. Assessing the learning environment To determine both faculty and learners' assessment of Dalhousie Medical School's CST, a needs assessment was conducted in 1997, consisting of a 10-page questionnaire. These were sent to undergraduate students at the end of their pre-clinical (Medical 2) and clinical (Medical 4) phases, as well as to residents and faculty. We received responses from 65 out of 84 Medical 2 students; 82 out of 82 Medical 4 students, 54 out of 450 residents and 117 out of 233 full-time faculty. The questionnaire comprised the following sections common to both learners and faculty: background characteristics; assessment of CST at Dalhousie Medical School, and attitudes toward medical communication. The reliability coef cient for the 41-item locally developed attitude scale was quite acceptable for this study (alpha ˆ 0á78). Respondents were asked to assess the existing CST at the medical school and to comment speci cally on three areas: communication with patients, communication for speci c illnesses or health topics, and communication with health care professionals. Faculty were asked to assess learners' performance in these areas, and learners were asked to assess their own performance. Completed questionnaires were coded and analysed using frequencies and means to assess and compare learners' and faculty's perceptions. The most relevant ndings are described below.

3 Implementing a communication skills programme in medical school T Suzuki Laidlaw et al. 117 Learners' assessment of CST in medical education Learner assessment of CST included responses from second and fourth year medical students and residents. The three groups rated the importance of CST highly, re ecting positive attitudes towards CST. Residents responded more af rmatively both to survey statements re ecting the importance of CST, and to items identifying educational de ciencies in this area, thereby indicating the need for improved CST. Awareness of medical communication complexity was also greatest with residents, suggesting that more patient interaction increases appreciation of the challenges involved in medical communication. Overall, learner responses revealed the need for: more training in complex medical communication skills such as breaking bad news; integrating CST components throughout the medical curriculum; and faculty to be better role models with knowledge on the theory and practice of patient-physician communication. Faculty assessment of learners' CST and performance Faculty were asked to rate the quality of clerks' and residents' CST and performance in three areas: communication with patients, communication for speci c illnesses or health topics and communication with health care professionals. The results were as follows: 50% of faculty were unsure if clerks and residents were receiving communication skills training, and 30% indicated that they were unable to rate learner performance in communication skills, revealing that a large percentage of faculty were unable to assess either the communication skills training or performance of medical learners working with them. This indicated that CST was generally not being addressed either formally or informally in clinical medical education, nor did faculty understand how to assess learners' performance in these skills. 20% of faculty did rate the communication skills training and performance of clerks and residents. Rating was done on a 5-point Likert scale, with 1 equalling `poor' and 5 equalling `excellent'. Faculty rated clerks' and residents' performance in taking a medical history most highly, with residents being rated higher than clerks. Faculty rated both residents' and clerks' performance lower in more complex communication skills such as delivering bad news, dealing with angry patients, adolescent sexuality and con ict resolution. Integrating communication skills training into the curriculum Much of what we found in the needs assessment con- rmed what the research literature has revealed ± that CST is formally addressed in the early years of medical school only, is generally not reinforced in the clerkship years or residency, is not adequately evaluated and requires greater faculty teaching expertise. 8,9 The needs assessment was instrumental in several ways: (1) it provided a baseline measure in various areas related to communication skills, which can be reassessed after the programme has been in operation for several years; (2) it pointed to de ciencies in the existing programme; (3) it identi ed speci c areas in which to provide training; and (4) it was instrumental in convincing the administration that the communication skills programme warranted curriculum time and nancial support. There was also evidence that the students, clerks, residents and faculty who responded acknowledged the importance of teaching and assessing communication skills as a necessary component of medical education across the medical continuum. The challenge became one of effectively introducing such a programme into the existing medical curriculum where there are numerous competing demands for time and priority. Programme development and assessment of skills To integrate CST across the curriculum, it was essential to provide a consistent framework for teaching and evaluating communication skills that is evidencebased. We chose the in uential communication skills model of the medical interview, the Calgary-Cambridge Observation Guide (CCOG). 15 The CCOG, which is evidence-based, provides a framework for structuring the medical interview and delineates the speci c skills involved. It also takes a patient-centred and collaborative approach to the medical interview. 16 See Table 1 for a cross-curriculum programme synopsis. Pre-clinical training (Years 1 & 2) During Year 1, the primary objective is to introduce students to the framework for conducting a comprehensive medical interview. Using the CCOG as the framework, emphasis is placed on initiating the session, gathering information (focusing on initial exploration of the patient's problem and exploration of the patient's perspective of the illness), building a relationship with the patient, summarising the session, and communicating with a diversity of patients.

4 118 Implementing a communication skills programme in medical school T Suzuki Laidlaw et al. Table 1 Cross-curriculum CST Learners CST Programme focus Methods Examination Programme evaluation Year 1 Developing core clinical skills (27 h of Initiating the session Small group tutorials; 3 OSCEs; CCOG 1 Student questionnaires formal CST) Gathering information didactic material, role-play; Building a relationship with the patient SPs; videotaping; feedback Summarising the session and practice using CCOG 1 Communicating with a diverse patient population Year 2 Expanding the interview process (48 h of Gathering information CST incorporation into PBL clinical cases, 7 station pass/fail year end Student questionnaires, integrated Explanation and planning physical exams & medical history taking; OSCE incorporating history OSCE results CST) Providing structure to the interview didactic material; videos; role-play; SPs; taking, physical exam and Closing the session feedback and practice using CCOG 1 communication skills Clerkship Consolidating communication skills (years 3 & 4) Consolidation of interviewing skills CST in Introduction to Clerkship and in 6 station OSCE at Student questionnaires, Explanation and planning one of the four rotations; didactic material; the completion of each rotation OSCE results Dif cult situations (breaking bad news videos; role-play; SPs; feedback and practice assessing history taking, physical anger, addictions, violence, abuse issues) using CCOG 2 exam and communication skills CST orientation for international Small group tutorials; didactic material, No examination Student questionnaires students entering in third year role-play, SPs; videotaping; feedback and (4 sessions) practice using CCOG 1 Residents Agenda-led training Appoint & train a preceptor for each OSCEs; workshops based on needs identi ed Ongoing observation; checklist Resident questionnaires department by residents; outside experts; didactic material; evaluation at the end of each Determine residents' needs in CST videos; role-play; SPs; feedback and practice rotation; written & oral Design programmes based on CCOG using CCOG 1 & 2; individual assistance certifying exam 1&2 Expand on challenging, complex issues Faculty Teaching & evaluating CST Identify role models & `champions' Workshops; outside experts; workshop banks; No examination Faculty evaluation forms Provide training in teaching and evaluation web site; case development; media resource library; opportunities to participate in research

5 Implementing a communication skills programme in medical school T Suzuki Laidlaw et al. 119 There are two primary objectives in Year 2. These are to build on the skills learned during the rst year, and to expand these skills as students learn more medical content. Emphasis at this time is placed on gathering information (integrating an exploration of the disease framework with the patient's perception of the illness), beginning the process of explanation and planning, providing structure to the interview, and closing the session. A focus in the second year is the integration of communication skills training into existing medical curricula. This is accomplished by integrating a major communication skills component into one case in each of the four PBL units (Brain and Behaviour; Skin, Glands and Blood; Respiratory/ Cardiovascular; and, Genitourinary, Gastrointestinal and Musculoskeletal). Students spend nine hours per unit at the Learning Resources Centre conducting history taking and physical examinations, and practising communication skills with the use of standardised patients (SPs). Assessment is undertaken at the end of the year through a seven station pass/fail OSCE. One station focuses speci cally on communication skills, and all seven stations incorporate communication skills checklist items in the examination. Clerkship training and evaluation (Years 3 & 4) The primary objectives for CST during clerkship, in addition to consolidating past skills, are to become pro cient in explanation and planning, and to address communication challenges (e.g. breaking bad news, anger, loss, cross-cultural issues, and violence). In 1999/2000, signi cant changes were introduced into the clerkship curriculum, providing us with the opportunity to introduce CST systematically into the curriculum. The new clerkship programme is now divided into four rotations: Women, Children, Youth and Obstetrics/Gynaecology; Medicine; Surgery; and Behavioural Medicine & Primary Care, with three months spent in each unit. During the one-month Introduction to Clerkship, students receive one session on `explanation and planning during the medical interview', and another on `breaking bad news'. There is a CST component in development for each of the four rotations focusing on `explanation and planning', and dealing with more complex communication skills. At the completion of each rotation a six-station OSCE assesses skills in history taking, physical examinations and communication. All stations incorporate communication checklist items, whether used for training or evaluation purposes. During the summer, a four-session communication skills orientation is provided for students from the International Medical University in Malaysia, entering the Dalhousie Medical School programme at third year. This orientation is particularly important as it addresses the frequent communication barriers that international students face in medical school when they are encountering a new culture, and English is their second language. Postgraduate training and evaluation Although only one in nine residents responded to the needs assessment, those who did strongly identi ed the importance of CST during their training. The large number of departments and residents involved in postgraduate medical education creates a challenge for providing ongoing, integrated CST. Our focus for the programme has been to: attempt to appoint and train a communication skills preceptor within each university clinical department; determine the needs of residents within individual departments; design programmes based on the core principles and methods adapted to meet individual departmental needs; review and re ne components of the undergraduate programme as needed, and broaden the scope of skills to expand upon challenging, complex issues, and stress the importance of role-modelling. Our strategy of having each department identify a faculty member as the communication skills preceptor was aided by two signi cant factors. The Royal College of Physicians and Surgeons of Canada guidelines on General Standards of Accreditation require mandatory assessment of residents' communication skills from the year 2000 onwards, 17 and there is strong support by the Associate Dean for postgraduate medical education. To date we have offered two day-long workshops attended by a total of 60 faculty over the course of 15 months, with a third offered in the Spring of As a result of these initiatives, faculty facilitated CST has been provided for residents in medicine, family medicine, obstetrics/ gynaecology, paediatrics and surgery. Others are planned for anaesthesiology and psychiatry. Our goal is to offer twice-yearly workshops for faculty, using outside experts whenever possible to encourage full attendance. With respect to evaluation, preceptors are expected to observe residents on an ongoing basis. At the end of every rotation, they are required to submit a written evaluation, consisting of checklist items, and some communication skills items are included in the

6 120 Implementing a communication skills programme in medical school T Suzuki Laidlaw et al. checklists. While individual programmes develop their own evaluations, all are encouraged to use the Can- MEDS 2000 guidelines. 18 At the end of residency training, there is a nal comprehensive evaluation required by the certifying agency. This assessment involves both written answers and patient interaction, and includes an evaluation of some communication skills. In order to encourage development of CST across all postgraduate programmes, our of ce provides ongoing assistance for implementation of new curriculum initiatives. This assistance includes workshop design and preparation, case development, literature reviews, a large bank of media resources, the provision of SPs for use in training residents, and a selection of standardised workshop kits including breaking bad news, handling dif cult situations, and giving effective feedback. We also offer individual training for residents identi ed by their departments as needing enhanced development of their communication skills. Faculty development As the needs assessment clearly demonstrated, faculty members require assistance both in teaching and in assessing their learners' communication skills. They also have a signi cant part to play as role models for their students, clerks and residents. Our goals are to identify role models and `champions' and provide training in the teaching of communication skills, and in feedback and evaluation skills. We offer CST workshops for faculty that focus on teaching communication skills, evaluating, and providing feedback. However, the number who take part in these workshops is relatively small in relation to the over 450 Dalhousie Medical School faculty who are involved in medical education. To reach a larger number, we have developed a website designed specifically as a faculty support initiative ( dal.ca/medcom). The web site provides information and resources on CST in medicine for all interested faculty members, and, in particular, for those who may not be aware of the issues, research and teaching strategies related to this important skill in medicine. Financial and administrative support Results of the needs assessment were an important factor in attaining a commitment of nancial support from the Administration in 1998 for implementing an integrated communication skills programme that spanned the medical continuum, including faculty development. With a director already in place, targeted initiatives were launched to facilitate curriculum development and evaluation, and to co-ordinate the integration of cross-curriculum programmes. Financial support was crucial to these developments in order to obtain resources for the programme. These included expansion of a research literature database, and related written, audio and visual materials, payment for the training and use of simulated patients (SPs) and faculty in targeted areas, provision for both formative and summative evaluations, including OSCEs, and costs for use of external experts, as necessary. Much of the existing programme budget for CST is designated as `seed' money, or funding earmarked for the development of curriculum and evaluation. Our approach has been that the communication skills programme nances the rst year of any new training initiatives, including providing resources, developing cases and OSCE stations, and training faculty and SPs. During subsequent years, when costs are substantially lower, the nancial responsibility for continuing these training initiatives is turned over to the appropriate department. Programme evaluation results Programme evaluation is an essential component in developing a new programme, as it can provide systematic and helpful data to identify weaknesses and suggest improvements. 19 The results from our programme evaluation to date are presented here, organized according to level of learners. Years 1 and 2 Course evaluation Students complete a course evaluation questionnaire at the end of the Year 1 Patient-Doctor Unit. They rate the interviewing skills component, as well as the full unit. Table 2 shows the students' ratings of the various course components over the past two years. As seen, the topics addressed in the introductory class evolved with time. Three areas (group leader, role play, and videotape review) were rated consistently highly, though overall ratings remain constant. In year 2, students provide an overall rating of the Patient-Doctor Unit, of which CST is an integrated component. High satisfaction levels were reported during the 1999±2000 academic year (mean rating over 83 students ˆ 4á0 on a ve point Likert scale ranging from 1 equalling `very dissatis ed' to 5 equalling `very satis ed'). The speci c sessions that involved CST with SPs were rated extremely high (mean rating over 86 students ˆ 4á8on a ve-point Likert scale).

7 Implementing a communication skills programme in medical school T Suzuki Laidlaw et al. 121 Table 2 Students' evaluation of Year 1 Interviewing Skills course 1 Area rated October 1999 (n ˆ 82) mean (sd) 2 October 1998 (n ˆ 83) mean (sd) Intro: Principles/Theory (responses) `Clinical interview ± What's it all about' 4á3 (0á51) 3á8 (0á42) Calgary-Cambridge Observation Guide I 3á5 (0á15) na 3 Clinical interview with simulated patient 4á0 (0á31) 4á1 (0á49) Providing feedback in small groups 3á7 (0á32) 3á7 (0á56) Gender/language/cultural sensitivity 3á2 (0á52) 3á5 (0á45) Patient-centred clinical method 4á0 (0á38) 3á9 (0á42) Handouts 3á7 (0á31) na 3 Group leader Punctual 4á6 (0á35) na 3 Knowledgeable of subject 4á6 (0á33) 4á6 (0á53) Stressed important information/skills 4á5 (0á26) 4á5 (0á58) Facilitated discussion equitably 4á5 (0á32) 4á5 (0á58) Appropriate feedback 4á6 (0á36) 4á5 (0á53) Role play Awareness of importance Pt-Dr 4á4 (0á20) na 3 communication Insight perceptions of illness experience 4á3 (0á28) 4á2 (0á51) Reinforced skills/repeated practice 4á1 (0á28) 4á2 (0á45) Participation by simulated patient 4á4 (0á32) na 3 Videotape review Self-awareness of student potential 4á3 (0á52) 4á5 (0á45) Constructive feedback 4á3 (0á26) 4á4 (0á43) Development of personal style 4á4 (0á30) na 3 Increased con dence in ability 4á1 (0á49) 4á2 (0á32) 1 One component of the Patient±Doctor Unit in Year 1. 2 Based on a ve-point Likert scale, where 1 ˆ poor and 5 ˆ excellent. Means and standard deviations are based on the means of the 11 groups. 3 Item was not included in Table 3 Evaluation of workshop for clinical clerks on dealing with angry patients/families Item November 1999 (n =8) mean (sd) 1 May 2000 (n = 12) mean (sd) 1 August 2000 (n = 12) mean (sd) 1 The cases presented were appropriate 4á5 (0á53) 4á7 (0á49) 4á3 (0á62) The cases were realistic 4á3 (0á71) 4á4 (0á90) 4á4 (0á67) If you were only able to watch, it was 4á4 (0á53) 3á9 (1á27) 4á1 (0á94) still a worthwhile learning experience Too long Just right Too short The time allowed was: 3% 97% 0% 1 Means and standard deviations base on a ve-point Likert scale, from 1 ˆ disagree to 5 ˆ agree. Years 3 and 4 Clerkship Table 3 presents clerks' ratings of three workshops on `Dealing with Angry Patients/Families'. The results show that clerks found the cases appropriate (mean ˆ 4á5 on a ve-point Likert scale) and realistic (mean ˆ 4á3). They reported that the workshop was still a worthwhile learning experience even if they were only able to watch rather than practice with the SP (mean ˆ 4á4). All students but one agreed that the time allowed was `just right'.

8 122 Implementing a communication skills programme in medical school T Suzuki Laidlaw et al. End of Year 3 OSCE The results of the rst OSCE given in the spring of 2000 at the end of Year 3 of the new clerkship were encouraging. Students taking this examination would not have received the revised and expanded communication skills course in Year 1, but would have received integrated CST in Year 2. Eight communication skills items, taken from the Calgary-Cambridge Observation Guide One, were embedded into the rater's checklist for most `interviewing' OSCE stations. Four items were embedded into the rater's checklist for most physical examination stations. In this way, communication skills were integrated with history-taking and physical examination skills. A total of 86 students participated in the OSCE, with approximately one-quarter of the class assigned to one of four different tracks. Three tracks consisted of six stations, while one (surgery) had ve stations. The combined results showed that only 2% of the 494 ratings of students (clerks) were given a rating of `fail'. Other ratings were: `borderline' (12%); pass (75%); and `outstanding' (10%). The combined means on each item, over all students across all stations, were quite high, with 71% for the interviewing stations and 92% for the physical examination stations. In the interviewing stations, the highest-rated items were: (1) introduces self to patient (mean ˆ 97%); (2) refers to patient by name (mean ˆ 90%); and (3) establishes presenting problem/reason for visit (mean ˆ 94%). The three items rated the lowest were: (1) explores patient's feelings and ideas about the presenting illness experience (mean ˆ 33%); (2) asks if all of the patient's concerns have been addressed (mean ˆ 48%); and (3) brie y summarises information obtained (mean ˆ 51%). These skills are an integral part of the revised CST programme in Year 1 introduced in 1998, after these students had completed their rst year. However, these students were exposed to the integrated programme in Year 2, including conducting physical examinations. The OSCE results in the physical examination stations are promising with respect to the new programme's effectiveness: (1) explains procedures during exam (mean ˆ 96%); (2) uses concise, easily understood language (mean ˆ 91%); (3) shows sensitivity to patient's comfort during examination (mean ˆ 88%); and (4) thanks the patient (mean ˆ 74%). Residents We have just received funding to begin a comprehensive CST intervention for the PGY1 and PGY2 residents across all specialties in the Medical School. A randomised clinical trial is being planned to assess its effectiveness. Faculty The results from two faculty development workshops were extremely positive (see Table 4). The overall mean rating for the workshop on `Feedback Principles and the Calgary-Cambridge Observation Guide One' was 4.2 (on a ve-point Likert scale). The area needing improvement (mean ˆ 3.1) is to provide more time for faculty to interact with colleagues. The second workshop for communication skills tutors also rated very high (mean global rating ˆ 4.5 on a ve-point Likert scale). All workshop aspects were rated highly. The early programme evaluation results reported here are only the beginning of ongoing assessment to be incorporated into all aspects of the communication skills programme. Although learners regularly provide their opinions and perceptions about activities, the more meaningful aspects of programme evaluation are the OSCEs given at the end of second year (preclinical) and end-of-rotations (clinical), as well as in residency training. These OSCEs provide our most valuable information for identifying strengths and areas that need improvement. This information also points to speci c topics and skills that need to be emphasised in the programme. Therefore, programme evaluation is integral to its success. Limitations Several limitations to the results reported in this paper should be noted. First, the response rates to the needs assessment survey were somewhat low for faculty (50%) and very low for residents (15%). Although a 50% response rate for faculty is reasonable for a lengthy survey administered in a single mailing, it is possible that some bias may be present, e.g. more faculty with positive attitudes toward communication may have responded. However, no signi cant differences were found in the response rates of males vs. females, nor between the surgical/medical specialties vs. Family Medicine/ Paediatrics, Obstetrics, and Psychiatry specialties. With respect to the very low response rates of residents, we must interpret these ndings very cautiously, as representing the views of a subgroup of residents committed enough to this area to take the time to respond. The results of the programme evaluation, although encouraging, also represent only a few communication skills programme experiences. Therefore, these should be viewed as preliminary indicators that the programme

9 Implementing a communication skills programme in medical school T Suzuki Laidlaw et al. 123 Table 4 Evaluation of faculty development workshops Item Mean SD I. Feedback Principles and the Calgary-Cambridge Observation Guide One (n = 12) The workshop: 1. Increased my awareness of feedback principles. 4á8 0á45 2. Increased my awareness of the Calgary-Cambridge Observation Guide. 4á7 0á49 3. Allowed me to learn from the experiences of my colleagues. 4á3 0á45 4. Provided enough time for interaction with colleagues. 3á1 0á83 5. Allowed me time to practice skills in feedback using the 3á8 0á87 Calgary-Cambridge Observation Guide. 6. Was enhanced by use of the selected videos. 4á3 0á75 7. Was a worthwhile use of my time. 4á7 0á49 8. Overall global rating of this session. 4á2 0á62 II. Communication Skills Tutors' Workshop (n = 8) 1. The objectives of the session were clearly de ned. 3á8 1á04 2. The facilitator was knowledgeable and well prepared. 5á Opportunity was provided for participants to actively 4á8 0á46 participate in the agenda, discussion, questioning, etc. 4. An appropriate number of ideas evolved considering the time frame. 4á4 0á52 5. Extracts of the content were practical for implementation in 4á6 0á79 my own small group or clinical teaching setting. 6. Overall global rating of this session. 4á5 0á56 is working, rather than as more de nitive process or outcome indicators. Finally, it should be noted that the needs assessment and programme evaluation data are based primarily on self-report, rather than performance. There is a need for more formal evaluation to reinforce our conclusions. Conclusion The results of our needs assessment re ect the literature, which now widely acknowledges that communication skills training is a core clinical skill, requiring ongoing training, practice and feedback across the continuum of medical education. While conducting a comprehensive needs assessment is both time consuming and costly, the advantages are considerable. Results provide a picture of the current state of CST, areas that need development or improvement, and stakeholders' content priorities. Along with existing literature, it also serves as a basis upon which to present a rational and defensible case for supporting a communication skills programme in medical school. Our experience suggests that in order to introduce a sustained, coherent and integrated CST programme into the medical curriculum, suf cient nancial and administrative support is required as well as student and faculty interest. If this support is forthcoming, it is possible to create a communication skills programme that allows for the training and practice of core communication skills, expansion of these skills over time, and integration of these skills into existing clinical courses as students become more familiar with medical knowledge. Early programme evaluation results support this view. While logistical problems exist at the postgraduate level, new expectations and requirements from external licensing bodies greatly enhance the willingness of departments to offer CST to their residents. At this level, the residents themselves should determine the agenda for the learning sessions, and they should be given a number of opportunities both to practice their skills and to receive ongoing feedback. Finally, faculty development, while perhaps the most challenging curriculum to implement in a sustained way, is nonetheless crucial for the effective delivery of CST. Offering a variety of learning opportunities to faculty including workshops, outside experts, access to resources and assistance, and the use of a website, have all facilitated faculty development in our medical school. Ultimately, it is through the efforts, involvement and effective role modelling of faculty skilled in CST that medical students' competency in communication skills will increase and better prepare them for the demands of contemporary medical practice. Based on our experience, we would recommend that other medical schools interested in implementing a communication skills programme begin by assessing the needs of their various stakeholder groups. Once this is completed, the results of the assessment can form the foundation for both content and process of a cross-curriculum programme. In addition, selecting

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