How to Convince Clinicians that ‘Soft’ Skills Save Lives? Practical Tips to Use Clinical Studies to Teach Physicians’ Roles

This article was migrated. The article was marked as recommended. The implementation of competency-based medical education is hampered by unsupported arguments like ‘soft’ skills are important, but they don’t save lives. When implementing teaching and assessment methods targeting non-medical expert roles, student and physician buy-in is crucial. These intrinsic roles (e.g. collaborator or professional) are unfortunately misinterpreted and underused by supervisors, in part because of the false assumption that those skills have minimal impact on patient outcomes. On the contrary, although not worded in those terms, many clinical studies prove the impact of those roles on patient mortality, morbidity, readmission rate, or compliance. Whereas physicians feel that they are properly trained to give feedback, they struggle in making this connection between clinical studies and intrinsic roles in their everyday teaching habits. In this article, we provide practical tips on why and how to use high-impact clinical studies to enlighten supervisors and trainees about the educational and clinical importance of those skills. A slide kit, to be presented in clinical settings, provides a selection of 30 examples of ‘hard’ evidence on those so-called ‘soft’ skills, reinforcing the fact that intrinsic roles are intertwined with the medical expert role to improve patient care.

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Introduction
The implementation of competency-based medical education (CBME) is hampered by unsupported arguments like 'soft' skills are important, but they don't save lives (Van Luijk et al., 2012).Student and physician buy-in is crucial when implementing teaching and assessment methods targeting all the roles played by physicians (Dath and Iobst, 2010).Trainees must develop the clinical skills that combine their role of medical expert with the intrinsic roles of physicians (e.g.collaborator or professional) to provide high quality care (Sherbino et al., 2011;Steven et al., 2014;Frank et al., 2015).
Facing decisive choices, teaching the medical expert role can monopolize an unbalanced amount of time and resources on the false assumption that intrinsic roles have less impact on patient outcome (Roberts et al., 2013;Renting et al., 2017;Schmid et al., 2017).On the contrary, although not worded in those terms, many clinical studies prove the impact of all the roles played by physicians on patient mortality, morbidity, readmission rate, or compliance (examples presented in Tables 1 to 6).Physicians however struggle in making the connection between clinical topics and intrinsic roles (Roberts et al., 2013;Renting et al., 2016;Renting et al., 2017).
We wrote this article in the practical tip format to explain why and how educators can use a selection of high-impact clinical studies to exemplify the intrinsic roles of physicians for their colleagues and trainees during the transition to CBME.It will underpin the educational and clinical importance of giving feedback on intrinsic roles in daily activities, focusing on interventions with proven clinical impact, e.g.referral and counselling for smoking cessation, multidisciplinary teamwork for chronic diseases, quality of handoffs in acute care settings, quality of follow-up on laboratory results, etc. (Hassan et al., 2015).
We selected thirty studies to cover a broad range of clinical topics and disciplines.They are categorized in Tables 1 to 6 with respect to the intrinsic role predominantly involved.We chose the CanMEDS framework because of its comprehensiveness and evidence in the medical education literature supporting our problem statement (Sherbino et al., 2011;Frank et al., 2015).The definitions and keywords provided in Table 7 allows readers to make links with other competency frameworks in health sciences education (Englander et al., 2013).
By explaining our method of selection and categorization, our intent is that clinical teachers use these references, and others that they can find, to fuel their daily feedback and discussions with trainees.A slide kit, ready to be presented in clinical settings, provides a visual summary for each study (see PowerPoint© supplementary file).We believe it will reinforce the fact that, far from being an abstract construct, intrinsic roles are intertwined with the medical expert role in many successful clinical interventions.

Intrinsic roles still misinterpreted and underused
In the CanMEDS framework, non-medical expert roles (i.e., communicator, collaborator, manager, scholar, professional, and health advocate) are better named intrinsic roles (Sherbino et al., 2011;Frank et al., 2015).Although most clinical teachers are familiar with the CanMEDS roles or other competency frameworks, discourse analysis of the feedback given in the workplace shows that physicians often misinterpret the meaning of intrinsic roles (Renting et al., 2016).Feedback on efficiency, directive leadership, and resource management predominates.Patient-centered and teamwork approaches are at the essence of those roles, yet they are rarely discussed with students (Renting et al., 2016).Observations in clinical settings show that the roles are rarely explicitly named or used to structure daily interactions between residents and physicians (Renting et al., 2017).For example, in 2010, less than 50% of urology residents reported that the communicator role had been targeted by formal teaching or feedback by supervisors (Roberts et al., 2013).
Clinician buy-in is a prerequisite for competency-based medical education As summarized by experts, "[CBME] requires front-line medical teachers to understand, accept, teach, and evaluate domains of practice beyond medical expertise" (Dath and Iobst, 2010).For learning to occur after a patient encounter, the clinical teacher must reinforce intrinsic roles through feedback and supportive dialogue (Steven et al., 2014).When implementing a post-graduate CBME curricula in the Netherlands, the implementation of the intrinsic roles in the teaching habits of physicians was identified as a major barrier (Van Luijk et al., 2012).As a result, although graduates are comfortable in their medical expert role, they feel inadequately prepared in their manager, leader, and communicator roles (Schmid et al., 2017).Preparedness scores are lowest for tasks concerning management administration and leadership, research, end-of-life care, and safety-related patient communication (Schmid et al., 2017).
Patient outcome: the ultimate argument to influence teaching habits It will take efforts from clinical teachers to increase the exposure of trainees to clinical situations in which an intrinsic role is actively involved.As observed by Renting, Raat, Dornan, et al., the clinical tasks assigned to residents rarely allow them to learn the health advocate and leader roles (Renting et al., 2017).Although professional and communicator roles are often involved, all other roles total less than 20% of clinical activities and are scarcely observed by supervisors (Schmid et al., 2017).
Leaders in medical education have the power to inform and motivate their colleagues.Their arguments should target the main reasons why physicians rarely teach intrinsic roles, in particular health advocate manager, scholar, and professional: lack of time, lack of interest, and the misbelief that these roles cannot be taught (Arora et al., 2009;Whitehead et al., 2011).
Although physicians feel that they are properly trained to give feedback, they struggle in making the connection between clinical topics and intrinsic roles (Van Luijk et al., 2012).We believe that associating intrinsic roles with clinical indicators of performance can be an incentive for clinicians who usually focus their teaching and feedback on interventions with proven clinical impacts (Landon et al., 2003).
Exemplifying intrinsic roles with high-impact clinical studies Collaborator As seen in Table 1, working effectively with other professionals translates into better patient care (i.e.reduced mortality, infection rates, rehospitalization, medical errors, and adverse events).Most high-impact studies describe a structure of co-management by healthcare professionals (interprofessional or multidisciplinary) or a procedure for a complete and efficient transfer of clinical information (e.g., handovers) (McAlister et al., 2004;Friedman et al., 2009;Kim et al., 2010;Neily et al., 2010;Starmer et al., 2013).The studies demonstrating a high impact on mortality or morbidity target 'at-risk' patients in intensive care, post-operative care, and ambulatory clinics for chronic diseases, or patients transferring to another care unit.

Communicator
Communication skills will make a difference in the outcome of patients, especially if they are in a state of vulnerability, including being under stress, suffering from mental illnesses, being hospitalized, facing a terminal illness, or having under-developed literacy skills.In these populations, the quality of communication between the clinician and his or her patients (or relatives) showed benefits in the indicators of morbidity (e.g., glycemic control), understanding of and compliance with treatments, readmission rate, and quality of end-of-life care (Schillinger et al., 2003;Arbuthnott and Sharpe, 2009;Detering et al., 2010;Légaré et al., 2012;Carter et al., 2018).Selected examples can be found in Table 2.

Scholar
The scholar role certainly overlaps with other intrinsic roles.Nevertheless, studying the adherence to practice guidelines is directly related to the translation of new knowledge into clinical practice.Table 3 presents studies in which commitment to excellence in practice through professional development lead to improvement in hospitalization rates, morbidity, and survival (Davis et al., 1999;Mallett et al., 2000;Le Pen et al., 2005;Menéndez et al., 2005;Rodríguez et al., 2005).A higher impact of continuing medical education is seen when active learning occurs through interactive sessions and personal practice audits.

Health advocate
Advocating to improve the health of communities or at-risk populations is a role a physician plays everyday in his or her clinical practice and at times within the public domain.Most high-impact studies describe simple measures of preventive medicine that trainees can implement in their daily practice.Exercise prescription, tobacco cessation, vaccination, and cancer screening are some of the examples detailed in Table 4 (Nichol et al., 1994;Petrella et al., 2003;Anthonisen et al., 2005;Fenton et al., 2011;O'connor et al., 2014).In fact, the ability to provide tailored counselling and follow-up leads to a reduction in illness rates for the most common and deadly diseases of our societies.

Leader
Physicians have a responsibility regarding the delivery of high-quality care in their hospital, community, and healthcare system.Coordinating an effective team, acting as opinion leader, or conducting a stewardship program improves the quality of care and patient safety.In the selected studies showed in Table 5, physicians' leadership roles are explicitly mentioned as a key element in the success of a concerted effort (Weingarten et al., 1993;Young et al., 1997;Strasser et al., 2005;Blackwood et al., 2011;Malani et al., 2013).Some medical interventions, like the example of ventilation weaning, do not succeed unless the treating physician has the leadership skills to educate and motivate his or her team toward a common goal.

Professional
The professional role is revealed through an ethical practice, high personal standards of behaviour, and accountability to the profession and society.How physicians follow up with patients and laboratory results is a common theme in the literature and has a significant impact on readmission rates and delays in diagnoses and treatments (Nelson, Maruish and Axler, 2000;Callen et al., 2012).Physicians' behaviour and even their attire will influence patient confidence and lead to better compliance with pharmacological and non-pharmacological treatments

An incentive to find other studies
In this article we prioritized high-impact studies to cover a wide range of medical interventions and disciplines.It is not intended to be an exhaustive review of the literature.It should be seen as examples of studies that can be shared with colleagues and trainees.It should also act as an incentive to find other examples.To conduct this search in Pubmed, we used the detailed description of each role (Frank et al., 2015).Among co-authors and with clinician educators of other subspecialties, we listed examples of clinical topics (e.g.antimicrobial stewardship) and outcomes (e.g.compliance) for each role.We encourage readers to use the list presented in Table 7 as a starting point to look for other studies more specific to their context or discipline.

Conclusion
After reflecting on these examples, clinicians and trainees should be convinced of the clinical impact of the abilities developed within each intrinsic role.Hopefully, clinicians will be able to recognize when an intrinsic role is at play in a clinical study and seize this teaching opportunity.A question will remain: do we have proof that teaching those roles to students will lead to those impressive clinical outcomes?Such studies, reaching the highest level of Kirkpatrick's classification, remain exceptional in the medical education literature (Kirkpatrick, 1994;Asch et al., 2014).
All thirty examples show that that the abilities of health professionals (individually or in a team) can be improved even after years of practice: clinicians starting to work together, others improving their handovers or adhering to recent guidelines.What is meant by intrinsic roles is the combination of multiple, sometimes subtle, ways that medicine is ideally practiced.Those abilities are more easily scaffolded during training than afterwards (Arora et al., 2009;Whitehead et al., 2011;Steven et al., 2014;Renting et al., 2017).Indeed, the initial skills developed during training have a persistent impact on the overall quality of care that clinical experience may take years to catch up with (Asch et al., 2014).

Take Home Messages
Trainees must develop clinical skills that combine their role of medical expert with the intrinsic roles of physicians (e.g.collaborator) Intrinsic roles are often misinterpreted and underused by supervisors in their everyday teaching habits

Table 1 .
Selection of Clinical Studies Exemplifying the Impact of Collaboration Skills

Table 2 .
Selection of Clinical Studies Exemplifying the Impact of Communication Skills

Table 3 .
Selection of Clinical Studies Exemplifying the Impact of Scholar Skills

Table 4 .
Selection of Clinical Studies Exemplifying the Impact of Health Advocacy Skills

Table 6 .
Selection of Clinical Studies Exemplifying the Impact of Professional Skills

Table 7 .
Clinical Topics and Outcomes Related to Six Intrinsic Roles Played by PhysiciansPhysicians' intrinsic roles according to the CanMEDS framework(Frank et al., 2015)