Teaching Communication Micro-Skills to Cardiologists Managing Seriously Ill Patients in Asia: Challenges Encountered Amidst the COVID-19 Pandemic and Future Perspectives

Background Patients with advanced cardiac conditions value effective symptom control and empathic communication with their doctors. However, studies have shown that empathic communication with seriously ill patients does not occur adequately in cardiology. Therefore, we piloted a program for teaching communication skills in a bite-sized manner. The primary aim of the research was to understand the feasibility and acceptability of the training program and to perform a preliminary evaluation of its efficacy. Methodology Clinicians were recruited from the cardiology unit of a tertiary hospital in Singapore. Patients were also recruited for the audio recording of clinic consults. Recruited patients had to have a chronic cardiac condition and be deemed at risk of dying within one year. We utilized a pre-post intervention design. Prior to the educational intervention, clinicians were asked to audio record a single clinic consult at baseline. They were then asked to participate in a training program that consisted of video-annotated presentations and role-play scenarios. Subsequently, the audio recordings of their clinic consults with seriously ill patients were recorded. The audio recordings were evaluated by trainers and used for feedback with clinicians. Data on the completion rate of the training program were collected. In addition, changes in the clinicians’ self-rated communication skills and views on the acceptability and relevance of the training program were collected. Results Overall, five of the six clinicians (83.3%) completed all sessions in the program. One clinician only completed four out of the five sessions in the program. Clinicians deemed the program acceptable and relevant and found audio recordings to be useful for reflective learning. There was an improvement in the clinicians’ self-assessed competency. However, the planned number of audio recordings could not be completed due to the coronavirus disease 2019 pandemic. Conclusions The pilot training program was acceptable and relevant for the participants. However, it will require adaptation to allow it to be transferrable and scalable to all settings, especially in situations that limit prolonged face-to-face contact.


Introduction
Patients with advanced cardiac conditions value effective symptom relief and empathic communication with their doctors [1]. However, studies of patients with serious illnesses, including cardiac disease, show that discussions of patients' values, goals, and treatment preferences do not occur adequately [2]. A local study from Singapore showed that only 22% of advanced heart failure patients were aware that their treatments were not curative [3].
Multiple difficulties exist that prevent these medically complex conversations from happening, such as inadequate time and communication skills and personal discomfort with end-of-life conversations [1,4]. Recognizing this gap, the American Heart Association has issued a scientific statement emphasizing 1 1 2 1 1 1 the importance of communication skills training for cardiologists [5].
Although a systematic review has shown that communication skills training workshops improve the communication skills of participating clinicians in oncology [6], these communication skills training programs often include face-to-face workshops using role-play and standardized patients (SPs) with a complex set of skills all taught in the same setting.
It is unknown whether the complex set of skills learned during communication skills workshops are sustained over time or translated into clinical practice. It is also currently unclear whether the content and structure of communication skills training programs developed for other disease types and settings would be culturally acceptable in the Asian cardiology care setting, where end-of-life discussions are culturally more sensitive and patients are not as ready to discuss these topics [7][8][9].

Study rationale
The aim of this pilot study was to pilot a communication skills training program to teach communication skills in a bite-sized, culturally sensitive, multi-modal, and blended learning manner. Our primary aim was to understand the feasibility and acceptability of the training program. Our secondary aim was to have a preliminary understanding of its efficacy.

Study setting
This study was conducted in the National Heart Centre Singapore (NHCS), a national and regional referral center for cardiovascular diseases [10].

Inclusion criteria for clinician trainees/patients
Clinicians working within the cardiology department of NHCS who were registrars (in training to become consultants) or newly certified consultants (completed fellowship exit exams within the last two years) were recruited for the study. Patients recruited for audio recordings of outpatient clinic consults had to have a chronic cardiac condition and be deemed at risk of dying within one year.

Development of training curriculum
The study team that developed the curriculum was interdisciplinary in nature and included specialty content experts in communication skills. The team consisted of a range of palliative medicine physicians of differing seniority (one associate consultant, two consultants, and one senior consultant) from the NHCS, as well as medical social workers practicing in NHCS and educators from the Duke-National University of Singapore Lien Centre for Palliative Care (LCPC). A senior consultant cardiologist acted as a specialty content expert in cardiology to ensure that the content of the training scenarios was authentic to clinical practice. The training team met twice (one hour each) prior to the start of the training program to design and structure the training curriculum.

Structure of training program curriculum (Appendices)
An audio recording of each clinician's outpatient consults was obtained at baseline prior to starting the training program. Subsequently, the clinicians received an online link via email to watch a voice-annotated presentation for the theoretical teaching of communication micro-skills. Clinicians were given the flexibility to watch the presentation at their own time, and the only requirement was that it had to be seen before their first face-to-face training one month later.
Subsequently, clinicians had two face-to-face sessions (one hour each) at lunch break for role-play of communication scenarios, focusing on a small number of micro-skills each time. Clinicians were asked to perform one audio recording of a clinic consult between each face-to-face session. The audio recordings collected during training were used for giving feedback to the clinicians and used for comparison to the audio recordings collected prior to training commencement. The program then concluded with a short faceto-face session to consolidate learning.
Communication micro-skills taught included appropriate use of non-verbal skills, demonstration of empathy, information sharing, and eliciting of goals, values, and preferences for care. Audio recordings of consults were taken in an unscripted real-time environment. The audio recordings were reviewed by content experts from the study team and feedback on what was done well during the consult versus what could have been improved was shared with the clinicians via email.
The design of the curriculum was based on "Social Cognitive Theory" by Bandura, who proposed that new behaviors can be acquired by observing and imitating others [11], as well as on Schön's theory of reflective practice, whereby learners would reflect both on-action and in-action [12].

Study measures and data collection
The demographic data of clinicians and patients were collected. At the end of the program, using an online survey, clinicians self-reported their views on the acceptability and relevance of the content of the program using a four-point Likert scale (strongly agree, agree, disagree, strongly disagree). They were also asked to self-assess their competency in communication skills pre-and post-training using a five-point Likert scale (extremely skilled, very skilled, skilled, somewhat skilled, not at all skilled). Responses regarding selfassessed competency were coded from 1-5, respectively, with 5 representing "a higher level of skill" and 1 representing "not at all skilled." Outcome assessments of the training program were based on understanding the degree to which participants found training relevant and acceptable and the degree to which participants felt that they had learned and applied new skills.

Sample size and statistical analysis
We aimed to recruit at least six clinicians as a pilot sample. This would be at least 50% of all eligible participants in the NHCS at the time of the study and would satisfy our a priori definition of feasibility. Participant demographics and study measures were summarized using descriptive statistics.

Ethics
This study was approved by the Singhealth Centralized Institutional Review Board (Approval number 2019/2570). Informed consent was obtained from all clinicians and patients.

Characteristics of participants
In total, six clinicians (mean age: 33.2 years) and 11 patient participants (mean age: 64.4 years) were recruited ( Table 1).

Characteristics Mean (standard deviation) or number (%) a
Clinician characteristics

Impact of the training program
In total, five out of the six clinicians (83%) completed the training program, and one out of six clinicians only completed four out of five training sessions as the clinician was posted to another institution. In addition, due to the coronavirus disease 2019 (COVID-19) pandemic with its restrictions on face-to-face research, we could only complete two out of the three planned audio recording sessions and the final faceto-face teaching session had to be done virtually.
On a self-reported quantitative survey, clinicians' responses showed that they felt that the training duration and content were acceptable and relevant and agreed that they would recommend this program to others. In addition, focusing on a few communication skills at one time rather than teaching all skills in one setting helped them to internalize learning better.
Qualitative feedback from the clinicians on audio recordings was that they felt the training was realistic with practical advice on how to improve. Moreover, it allowed them to reflect and improve on communication skills based on actual situations that they had encountered. For example, in a real-life recording where one clinician was sharing the information "It's whether your varices have slowly bled," the patient responded and showed difficulty understanding the use of medical jargon "When you say varices, is that the one…." This clinician was given feedback to be careful not to use medical jargon while sharing information during consultations. In another scenario, where a patient had brought up concerns over prognosis for heart failure "presently I'm not in pain, but I don't know what will happen tomorrow, or day after tomorrow...," another clinician responded by saying "mmm" and changed the subject. This clinician was given feedback and a sample script on how to engage the patient further to discuss prognosis and expected outcomes.
Clinicians also appreciated that the study team managed to provide a controlled and protected environment for trial and error during the role-play. This allowed for constructive learning not only from peers but also from various members of the interdisciplinary study team. Lastly, clinicians self-perceived that they had improved significantly in their communication skills post-training. Table 2 presents the clinician responses during the training program.

Main findings
Our pilot training program was acceptable and relevant in terms of content and was feasible for busy clinicians. There was an improvement in clinicians' self-assessed competency of their communication skills. Audio recordings of clinic consults with feedback helped to cultivate an attitude of reflective learning. Clinicians were prompted to reflect on their clinical experiences and be more mindful of how they were communicating with their patients.
Although self-assessment of clinicians on their competencies showed improvement post-training due to the restrictions imposed by the COVID-19 pandemic, it was not possible to have prolonged face-to-face interactions, which limited our ability to formally carry out the full extent of the program.

Study strengths
To the best of our knowledge, this is the first study to evaluate the acceptability, relevance, and feasibility of teaching communication micro-skills in a cardiology unit in a tertiary hospital in Asia. We have demonstrated that it is possible to teach clinicians how to discuss culturally sensitive end-of-life topics. Although we only recruited registrars and newly certified consultants, this program can be used for teaching all cardiologists as the training content is relevant to daily clinical practice.

Study limitations
A limitation of our study was the absence of patient input regarding their communication experience with the clinicians. In addition, because clinicians self-assessed their improvement in skills, it could have introduced bias. However, an improvement in self-assessed competency implies that clinicians would be more confident and hence more likely to discuss medically complex topics with their patients in the future. Lastly, the sample size was small; however, because this was a pilot study, it did not intend to provide full insight into the effectiveness of the training program and primarily aimed to highlight the acceptability and feasibility of this program.

Suggestions for future studies
Future studies should continue to evaluate the role of reflective practice in communication training [13]. Possible adaptations of this communication skills training program could consider the videotapes of virtual consults which could allow evaluation of both verbal and non-verbal skills. In addition, the role of chatbots in communication could be further explored [14][15][16] as it is theoretically useful for discussions around culturally or emotionally sensitive topics, allowing ample room for trial and error on the part of the clinician, without fear of causing emotional distress on the part of the patient or family caregiver. Lastly, the use of natural language processing could be considered as it could make the process of coding conversations less resource-intensive [17].

Conclusions
This study has shown preliminarily that teaching communication skills over time, in a bite-sized manner, utilizing different modalities of teaching, is acceptable and relevant in a busy tertiary Asian cardiology care setting and can inculcate reflective practice for continued improvement. Improving communication skills is very important as it can impact doctor-patient relationships and help patients have more realistic expectations. Future iterations of this program could consider alternate ways of conducting communication practice in view of difficulties carrying out prolonged face-to-face interactions during and after the COVID-19 pandemic.