The concept of critical appraisal has made it possible for the realization of the improvement of quality and cost of healthcare. This is made possible through getting the best evidence (research evidence) on the results of health care intercessions by identifying the strengths and weaknesses of research, assessing the usefulness, and validating the findings. In a critical appraisal, assessment of the suitability and the methodological features of the study design are of utmost importance.
This work was aimed at evaluating the Randomized Controlled Trial by Lesley Fallowfield, Valerie Jenkins, Vern Farewell, Jacky Saul, Anthony Duffy, and Rebecca Eves on communication skills and training; by considering its validity, results, and implications for practice. The findings of this trial which states that “training courses significantly improve key communication skills”, has been critically analyzed.
VALIDITY OF THE TRIAL
This trial authenticates the effectiveness of training courses in the improvement of communication between the doctors and patients. It explains that effective communication is a core clinical skill that needs thorough training, just as other medical sciences. To validate this finding, let us consider and evaluate the effectiveness of the methods used in the collection of the information.
This controlled trial randomized 160 clinicians from 34 cancer centres in UK. Four groups, A, B, C and D were formed with group A containing 39 clinicians for written feedback and course, group B containing 41 clinicians for course only, group C containing 41 clinicians for written feedback only, and group D containing 39 clinicians for the control. The number of patient participants was 2407 and in each of the two assessments, consultation done with six to ten patients per doctor videotaped. The aim of this was to compare the clinicians who attended training course with their counterparts who did not. The random selection of the 160 doctors out of the 200 who applied, and the replacement of those who withdrew and those who violated the rules, was not hit by any bias. Also, the reasons for non-completion were not dependent on the researchers; it was fully dependent on the respondents and they included pregnancy, illness, emigration, unexpected absence and impedance by senior colleagues. There was no bias whatsoever.
Validity of this research vests on the modes of the analysis of the data. The quantities measured were not normally distributed and this called for a statistical method of analysis which performs best with such data. The choice of Spearman’s correlation method was the best. The examination of the reliability of the inter-rater by the ANOVA interclass correlation method which is best for mixed models further proves that adequate precautionary measures were put in place to ensure that the final finding was valid. This method accounts for variability within and between the raters. The basis of the analysis employed the use of Poisson regression model which, to a great extent is valid fro Poisson distributions which are characterized by rate functions. However, the estimation equations with exchangeable correlation structure that was used in the correlation between consultations for the same doctor, took a generalized case, not considering the individual factors. This lowered the accuracy of the results. Also, in the analysis of responses to cues, only the consultations which patients offered cues were considered. In this analysis, generalized estimating equations were used. This also lowered the accuracy.
In the trial, all the clinicians in groups A and B completed the communication skill course. The clinicians in C and D were also allowed to attend the course on their own volition after T2 and only 61 out of the 80 attended. The total number of clinicians who attended training summed up to 141. The clinicians admitted that they had difficulties with communication. This, being a first-hand information from the concerned parties themselves, is true beyond any reasonable doubt.
From randomization, there was no clear-cut between answering the questions and having no difficulties in communication. From the results, we are told that only six doctors had either no difficulties in communication or not answered the questions. Of the 141 clinicians, 135 generated 428 different patient’s characteristics found to be most difficult to handle during consultation. Three quarters (76%) of the clinicians (102 out of 141) indicated that dealing with patients with explicitly emotional personalities was the most common problematic characteristic. Communication problems within clinicians themselves were also noted by 136 of the 141 clinicians. Giving complex information and extracting informed sanction from patients was the most common problem indicated by 71 clinicians (52%).
During the training, we are told that most doctors found the courses to be informative, interesting, and highly relevant to their own profession. This was another indication that communication skills are very necessary for clinicians. The fact that more than half of the clinicians had interest in further training indicates the importance of the training to doctors. Clinicians who attended the course communicated in a proper way than their counterparts who did not. We are told that groups A and B had greater number of focused questions, expressions and appropriate response to patients’ cues. From the statistical analysis, appropriate response was 1.46 times greater in groups A and B than C and D. For those who attended training, the mean number of focused was 4.85, focused and open was 6.50 and leading questions was 1.22 compared to 3.61, 5.16 and 1.55 respectively on other hand. A great difference was realized for focused questions.
There are several difficulties encountered by clinicians when communicating with their colleagues, cancer patients, and patients’ relatives. The intensive three day draining, which they were subjected to, created a very big difference in their communication skills that time and experience could not. The training featured the integration of various activities aimed at creating simultaneous skills development, knowledge acquisition, and awareness of how they affect both doctors and patients. Even though the clinicians were more competent in their communication skills after the training, various factors affect this. They include the clinical environment, the nature of work, and the type of patient.
This study had mainly positive findings, however, certain limitations exist. Some of the important findings could not be quantified due to their rare occurrence. This complicated the analysis to a great deal lowering the accuracy of the study. It was very difficult to demonstrate the changes that occurred to doctors in their communication skills after the training since several factors influence human behavior.
The results of this trial are undoubtedly true. Proper communication is one of the vital skills needed by clinicians as everything revolves around it. Proper funding should therefore be allocated to cater for trainings in communication skills.