International Journal for Quality in Health Care 2002; Volume 14, Number 5: 359–367

Impact of supervision and self-assessmenton doctor–patient communication in ruralMexicoYOUNG-MI KIM1, MARIA ELENA FIGUEROA1, ANTONIETA MARTIN2, RICARDO SILVA3,SIXTO F. ACOSTA3, MANUEL HURTADO4, PAUL RICHARDSON5 AND ADRIENNE KOLS1

1Center for Communication Programs, Johns Hopkins University, School of Public Health, Baltimore, 5Quality Assurance Project,Center for Human Services, Bethesda, MD, USA, 2Fronteras, The Population Council, Regional Office, Mexico City, 3InstitutoMexicano del Seguro Social, Programa Solidaridad (IMSS/S), Mexico City, 4Universidad Veracruzana, Veracruz, Mexico

Abstract

Objective. To determine whether supervision and self-assessment activities can improve doctor–patient communication.

Setting and participants. Six supervisors, 60 doctors in their last year of training, and 232 primary health care patients atrural health clinics in Michoacan, Mexico.

Design. The main evaluation compared post-intervention measures in control and intervention groups. A small panel studyalso examined changes from baseline to post-intervention rounds in both groups.

Intervention. Over a 4-month period, specially trained supervisors added 1 hour of supervision on interpersonal communicationand counseling (IPC/C) to regular site visits. Doctors, who had received prior IPC/C training, periodically audiotaped andassessed their own consultations.

Main outcome measures. These comprised frequency of doctors’ facilitative communication, doctors’ biomedical information-giving, and patients’ active communication.

Results. The performance of all doctors improved markedly over the study period, but gains in facilitative communicationand information-giving were significantly greater in the intervention than the control group. No single component of theintervention was responsible for the improvement; it resulted from the combination of activities. The doctors appreciatedthe more supportive relationship with supervisors that resulted from the intervention and found listening to themselves onaudiotape a powerful, although initially stressful, experience.

Conclusion. Supportive supervision and self-assessment activities can reinforce IPC/C training, prompt reflection andlearning, and help novice doctors improve their interpersonal communication skills.

Keywords: communication, quality of care, physician–patient relations, self-assessment, supervision

Research shows that the quality of communication between cultural differences between indigenous communities anddoctors. To provide health care services to rural populations,doctors and their patients contributes to health outcomes as

well as patient satisfaction [1–5]. Doctors make more accurate the Mexican Institute of Social Security/Solidarity (IMSS/S)places resident doctors in rural clinics for a 9-month rotationdiagnoses and more effective treatment plans when patients

fully disclose their symptoms, concerns, and personal cir- as part of their training. Typically, one of these residentdoctors and a nurse staffs a two-room clinic. Most residentcumstances. Patients feel more committed and better prepared

to carry out a plan of action when doctors clearly explain doctors come from urban backgrounds, are middle to upperclass, and speak Spanish. In contrast, the patients they servethe diagnosis, treatment options, and instructions.

Good communication and counseling skills are especially come from a lower socioeconomic class and mostly speakindigenous languages. While most resident doctors establishimportant in rural areas of Mexico, where there are wide

Address reprint requests to Y.-M. Kim, Senior Research and Evaluation Advisor, Center for Communication Programs,Johns Hopkins University School of Public Health, 111 Market Place, Suite 310, Baltimore, MD 21202-4012, USA.E-mail: ykim@jhuccp.org

2002 International Society for Quality in Health Care and Oxford University Press 359

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a good rapport with patients and take time to ask questions assignment at the rural clinics), a second round of data wascollected.and explain matters, formative research shows that they are

less skilled in listening to clients, encouraging them to speak, The data are analyzed in two different ways: a cross-sectional comparison and a panel study. The cross-sectionaland responding to individual client needs.

IMSS/S has introduced training in interpersonal com- analysis compares post-intervention measures in the inter-vention and control groups, and has the advantage of a largermunication and counseling (IPC/C) to narrow the com-

munication gap between young resident doctors and rural sample size. The panel study examines changes over timefrom the baseline to post-intervention rounds in both thepatients. While experience elsewhere has demonstrated the

effectiveness of IPC/C training [6,7], one-time training has intervention and control groups. It provides a more con-servative measure of the intervention’s impact, since it takesnot been sufficient to guarantee that health personnel apply

new communication skills on the job and maintain them into account changes in the control group during the inter-vention period. However, the power of the panel study isover time [8]. Two opportunities exist for cost-effective

reinforcement of IPC/C skills among resident doctors at limited by its small sample size.IMSS/S clinics. The first possibility is using the routinesupervision system already in place. Competent and ex- Study sampleperienced physician supervisors make regular 1-day site visits

The study took place in the Zamora region of Michoacan,to IMSS/S clinics to monitor technical standards of care.which is divided into seven supervision zones, each overseenWith training and appropriate tools, they also could assessby a single supervisor. One zone was excluded from theIPC/C performance and provide direct feedback to residentstudy because the high proportion of indigenous peoplesdoctors. The second possibility is asking resident doctorsmade it atypical. The remaining six zones were randomlyto engage in self-assessment and self-directed learning, andistributed into control (two zones) and experimental (fourapproach that has maintained and improved health providers’zones) conditions. This analysis uses data from a larger studycommunication skills in Indonesia, even in the absence ofconducted by IMSS/S, which included all 115 rural clinics inoutside supervision and support [8].the six zones, eliminating the need for random sampling. AIn 1998–99, IMSS/S pilot tested both of these approachesteam of two research assistants visited each clinic for a day,at rural clinics in the state of Michoacan. This study examinesand audiotaped and interviewed the first three patients tothe impact of a combined intervention of supervision and self-come for services. These patients represented a small pro-assessment on the communication performance of residentportion of the >15–30 patients who might be expected todoctors. Specific objectives are: (1) to determine if supervisionvisit a rural clinic in the course of a day. The larger studyand self-assessment help doctors to apply newly learnedinvolved 631 patients, 82 resident doctors, 33 general prac-communication skills on the job and to improve those skillstitioners, and 115 nurses.over time; and (2) to identify which activities (including

The present study includes a subset of patients who weresupervision visits, audiotaped consultations, self-assessment,attended by resident doctors and for whom complete datahomework logs, and job aids) are effective and acceptable toexists, including audiotapes, observations, and interviews.doctors.Technical difficulties, including dead batteries, poor volumecontrol, and excessive background noise, rendered manyaudiotapes unusable. In addition, some of the resident doctors

Methods had already left the rural clinics when the research assistantsarrived to collect the post-intervention data. Post-intervention

This study assessed a cohort of resident doctors who began data for the cross-sectional comparison are available for atheir assignment at an IMSS/S clinic in Michoacan, Mexico total of 157 patients and 60 doctors from 60 clinics scatteredin the summer of 1998. Soon after they arrived, all of the across all six supervision zones. Of these, 95 patients and 36doctors attended a 2-day workshop on IPC/C, followed by doctors were in the intervention group, while 62 patients anda half-day refresher course 5 months later. Baseline data were 24 doctors were in the control group.collected immediately after the refresher course. The doctors The panel study includes every doctor for whom there iswere assigned to intervention and control groups depending matching baseline and post-intervention data. Matching dataon which supervision zone their clinics belonged to; the are available for a subgroup of 28 doctors, who were recordedsupervision zones included in the study were randomly divided with a total of 147 patients. Of these, 21 doctors were in theinto control and experimental conditions as described below. intervention group, and they saw 57 patients in the baselineDuring the following 4 months, doctors in the intervention round and 54 patients in the post-intervention round. Thegroup received visits from supervisors who were specially remaining seven doctors were in the control group, and theytrained in IPC/C and who evaluated doctors’ interactions saw 18 patients in the baseline round and 17 patients in thewith clients; some of these doctors also conducted IPC/C post-intervention round.self-assessment exercises. Doctors in the control group alsoreceived regular supervision visits, but their supervisors were Data collectionnot trained in IPC/C and did not review how well theycommunicated with clients. At the end of the 4-month Audiotaped consultations, which were coded for content, are

the primary source of data for this study. Based on anintervention period (which also marked the end of the doctors’

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interaction analysis of 15 consultations recorded earlier at at IMSS/S clinics. Participating supervisors attended a 3-daythe study site, researchers adapted the Roter Interaction training course that covered the importance of interpersonalAnalysis System (RIAS) to code the consultations [9]. RIAS communication, a five-step supervision model for evaluatingwas designed to analyze doctor–patient interactions and has its quality, and key supervision skills. They were trained onbeen extensively tested in medical settings in both developed how to conduct IPC/C supervision using a specially designedand developing countries; studies have reported adequate assessment tool, and they focused on six skill areas deemedinter-coder reliability [7,8,10,11]. The system assigns each essential to the quality of care: listening, being responsive toutterance made by a doctor or patient to one of 48 mutually clients, expressing positive emotions, eliciting information,exclusive coding categories (utterances consist of a phrase or giving information, and encouraging patient participation.sentence that conveys a complete thought). Some examples The 4-month intervention has been called ‘partnershipof coding categories are: gives medical information, asks supervision’ because responsibility for enhancing com-open-ended lifestyle question, shows concern or worry, or munication skills was shared by supervisors and doctors.checks for understanding. Supervisors visited the doctors at 2-month intervals and

Two Mexican physicians, both of whom were familiar with engaged in a series of special IPC/C activities: they observedthe services of IMSS/S, performed the RIAS coding. One a consultation, used a checklist to assess the doctors’ com-physician coded all of the baseline data and then trained and munication skills, gave feedback, discussed issues raised bysupervised a second physician to code the post-intervention the doctor, and helped doctors identify specific com-data. As they listened to the audiotapes, the physicians used munication skills that needed work. The doctors recordeda computerized data entry screen to assign codes to each these assignments in a homework log and reviewed theirutterance. The coders were blind to the intervention status progress with the supervisor during the next visit.of the doctors. To test for inter-coder reliability, the first Between supervision visits, the doctors continued to workphysician also coded 22 consultations from the post-inter- on improving their communication skills, especially thosevention round. Agreement between the two coders exceeded listed in the homework log. Doctors were encouraged to90%. The coders also calculated the length of each con- consider every encounter with a patient as an opportunity tosultation, based on the counter numbers on the tape recorder. practice desired behaviors and to improve their com-To ensure the consistency of these measurements, the same munication skills. To prompt self-assessment and self-learn-brand and model of tape recorder was used to audiotape all ing, they were also given a more formal assignment in theconsultations. form of the following:

Data on the sociodemographic characteristics and workexperience of the supervisors, doctors, and patients were (1) Each doctor was supposed to audiotape two con-collected in individual interviews. sultations a month, with the permission of the patients.

Qualitative data were collected at the end of the study to (2) The doctors listened to the tapes and assessed theirhelp explain the findings. Providers participated in focus communication performance with the help of a jobgroup discussions while supervisors were interviewed in- aid.dividually. Facilitators and interviewers explored their re- (2) Some doctors also completed written self-assessmentactions to the intervention and their perceptions of its impact. forms focusing on specific communication skills. (TheirResearchers also used unstructured observations made during supervisors received additional training to support thisthe implementation process to help explain the findings. activity.)

Supervision, self-assessment, and self-learning The job aid consisted of six color-coded sections, eachintervention covering one of the essential IPC/C skill areas listed above.

Each section explained the meaning and the importance ofAs described above, each doctor attended a 2-day workshopthe skill, gave detailed examples of how to perform it withand a half-day refresher course on IPC/C. The curriculumwarmth, and listed behaviors to be avoided.was designed to help the doctors develop skills in counseling,

In the control group, doctors also received IPC/C training,verbal and non-verbal communication, interviewing, listening,but there was no follow up or reinforcement. Althoughand helping the client to make a decision. This curriculumsupervisors made their usual 1-day visits to control clinics,was institutionalized by IMSS/S in a previous project andthey were not trained in IPC/C supervision nor were theyhad become a standard part of training by the time thisgiven the special assessment tool. Researchers asked the twostudy took place. Thus, all of the doctors—whether in thesupervisors in the control condition to be on a waiting listintervention or control groups—received the same IPC/Cso as not to contaminate the experiment. Therefore, doctorstraining. However, doctors in the intervention group werein the control group did not receive IPC/C supervision, norgiven instructions on the intervention itself during the re-did they receive the job aid, a tape recorder, or any otherfresher course.intervention materials. They continued with their usual routineThe supervision, self-assessment, and self-learning inter-of reviewing issues in the technical quality of care and in thevention was designed to reinforce this training, to help youngadequacy of medical supplies during monthly supervisiondoctors apply communication skills on the job, and to improve

those communication skills over the course of their residency visits.

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Outcome measures with the purpose of the visit. About half (48%) of the patientscame for general medical services, such as colds, stomach

The main outcome measure is doctor facilitative com-pain, and diabetes; their average age was 51 years. One-

munication, i.e. communication that promotes an interactivethird (34%) came for reproductive health services, including

relationship between patient and doctor by fostering dialogue,prenatal care, family planning, sexually transmitted infections

rapport, and patient participation. This concept has been(STIs), and adolescent counseling; their average age was 22

developed by some of the authors over the course of previousyears. About one-fifth (18%), usually mothers, brought a

studies analyzing client–provider interaction in family plan-child who was sick or needed immunization.

ning consultations in Kenya and Indonesia [8,12,13]. Fa-The average age of the resident doctors was 25 years, and

cilitative communication is operationally defined as a set of36% of them were male. All of the supervisors were male

RIAS coding categories that past research suggests is relatedphysicians, and their average age was 37 years. All worked

to clients playing an active role in the consultation. Thesefull-time as supervisors for IMSS/S, and they had an average

include partnership building, showing agreement or under-of 7 years experience in the job.

standing, discussion of personal and social issues, expressionof positive emotions, and asking or giving information on Process evaluationlifestyle and psychosocial issues. Four of the intervention’s six

Supervision. Doctors in both the control and interventionIPC/C content areas were designed to encourage facilitativegroups received an average of 1.7 visits from supervisorscommunication: active listening, being responsive to patients,during the 4-month study period, i.e. about one every 2encouraging patient participation, and expressing positivemonths. In the control group, none of these visits includedemotions.supervision on IPC/C. In the intervention group, all of theInformation-giving by doctors is a second outcome meas-visits included >1 hour of supervision on IPC/C. Duringure. Earlier qualitative studies conducted in Michoacan foundmost visits in the intervention group, supervisors and doctorsthat giving insufficient information was a common weaknessreviewed the homework log together (1.4 times).among resident doctors and that patients wanted better

In focus group discussions, doctors in the interventionexplanations. One of the intervention’s IPC/C content areasgroup reported that supervisors offered them more and betterencouraged doctors to provide more and better medical andfeedback on communication and counseling issues after thetechnical information to patients.intervention began. Doctors also noted changes in super-In theory, facilitative communication by doctors shouldvisors’ interpersonal communication: supervisors began work-encourage patients to take a more active part in the con-ing with the doctors as partners, listening to their ideas, andsultation. Hence a third outcome measure is patient activeengaging them in discussion, and were more appreciative ofcommunication, which includes: asking questions, asking fortheir efforts. While doctors praised supervisors for beingclarification, expressing an opinion, expressing concerns, andkind, accessible, and not scolding, some wanted more timediscussing personal and social issues.with supervisors and more specific feedback from them.

Self-assessment and self-learning. Doctors audiotaped an averageData analysisof 7.2 consultations, a little less than the eight tapes they

The analysis consistently examines the frequency of each were asked to make, and performed an average of 23.1 self-outcome variable (i.e. the number of utterances per con- assessments, about four in each of the six IPC/C skill areas.sultation) rather than its proportion. In the cross-sectional Thus, doctors listened to each tape several times, assessingstudy, ANOVA was performed to test the significance of a different skill each time. Each self-assessment and self-differences between the control and intervention groups. In learning session included listening to an audiotaped con-the panel study, ANOVA was used to test the significance of sultation, and took 30–60 minutes. Nearly all doctors (97%)changes over time (from the baseline to the post-intervention reported using the job aid regularly and found it useful.rounds) within the intervention and control groups. The Wald Doctors reported using the homework log 8.6 times, ontest was used to test the significance of differences in the average, as part of their self-improvement efforts.rate of change between the intervention and control groups. According to focus group discussions, doctors initiallyMultiple regression analyses were conducted as part of the found the self-assessment process stressful, especially thosecross-sectional and panel studies to control for three potential who did not receive written self-assessment forms and in-confounding factors: the purpose of the visit, the sex of the structions. The doctors worried about asking patients fordoctor, and the length of the session. permission to record the session, they were afraid of hearing

their own mistakes on tape, they were anxious about followingthe steps laid out in the job aid, they felt nervous and self-conscious while the taping was going on, and they wereResultsanxious about sharing the tapes with supervisors or nurses.With repetition, however, doctors became proficient at self-Characteristics of study participantsevaluation and found that listening to themselves on tape

Most patients were married (84%), women (80%), and had was a powerful and eye-opening experience. The tapes helpeda primary education or less (81%). The age of the patients, them recognize their strengths and weaknesses and provided

strong motivation to improve.but not their marital status, sex or educational level, varied

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a complete thought) per session was significantly greater inthe intervention than the control group (196 versus 128,P<0.001) at the end of the study, and both providers andclients contributed to the disparity. In other words, bothproviders and clients in the intervention group uttered morethoughts per minute than their peers in the control group.According to the panel study, providers’ utterance rate in-creased significantly over the study period in the interventiongroup (from 6.9 to 9.3 utterances per minute, P<0.001) butnot in the control group (from 7.5 to 8.7, not significant).The client utterance rate increased more among the inter-vention (3.6 to 5.7, P<0.001) than the control group (4.0 to5.0, P<0.05).

A qualitative review of the audiotapes identified threeFigure 1 Frequency of the doctors’ use of facilitative and behavioral changes that led to increased utterance rates ininformation-giving communication after the intervention, the intervention group. Firstly, providers spent less time incontrol versus intervention groups. Facilitative, com- silence while writing notes on the patient’s chart. Secondly,munication that promotes an interactive relationship between providers lectured less. Thirdly, providers paused more fre-patient and doctor. quently to allow clients to speak.

Impact on doctors’ communicationImpact on length of sessions and utterance rate

Facilitative communication. Doctors in the intervention groupThere was no significant difference in the length of theoutperformed the others during the post-intervention round,consultation in the intervention and control groups (13.4 andwith an overall frequency of facilitative communication of11.8 minutes, respectively). The panel study found the average48 compared with 30 for the control group (P<0.001) (Figurelength of the consultation increased significantly over the 4-1). Even after controlling for the purpose of the visit, the sexmonth study period in both the intervention (from 7.0 toof the doctor, and the length of the session, the intervention13.3 minutes, P<0.01) and control groups (6.3 to 9.8 minutes,showed a significant impact on facilitative communicationP<0.001).(�=0.28, P<0.001). As Figure 2 shows, doctors in theThese numbers mask a significant change in the amountintervention group performed significantly better than thoseof conversation exchanged between providers and clients.

The number of utterances (phrases or sentences expressing in the control group on three of the six types of facilitative

Figure 2 Doctors’ frequency of use of six types of facilitative communication after the intervention, control versusintervention groups. Partnership, builds a sense of partnership between doctor and patient; Acknowledge, communicatesunderstanding of what patient is saying; Pers/social, includes remarks on personal or social aspects; Positive emotion,gives praise, reassurance; Info-psychosocial, provides counselling on psychosocial aspects; Ques-psychosocial, asks aboutpsychosocial aspects.

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Figure 3 Doctors’ facilitative communication: panel study. Figure 4 Doctors’ bio-medical information and counseling:panel study.

communication: partnership building (12.7 versus 7.3, information and counseling than those in the control groupP<0.001), acknowledgement (12.3 versus 6.2, P<0.001), and (27.5 versus 16.6, P<0.001) (Figure 1), and this differenceexpressing positive emotions (5.9 versus 2.9, P<0.001). remained significant even after controlling for other factors

The panel study confirms the intervention’s impact on (�=0.26, P<0.001). The panel study confirms this finding:facilitative communication. While doctors’ communication information-giving increased from 7.8 to 25.1 (P<0.001) inimproved markedly over time in both groups, the gains were the intervention group, compared with a rise from 7.7 tosignificantly greater in the intervention than the control group 16.6 (P<0.001) in the control group (Figure 4). After con-(P=0.004). Levels of facilitative communication rose 238% trolling for other factors, these increases remained significantin the intervention group (from 13.6 to 45.9, P<0.001) and both in the intervention (�=0.44, P<0.001) and control124% in the control group (from 14.6 to 32.7, P<0.001) groups (�=0.42, P<0.05). However, the rate of change was(Figure 3). After controlling for other factors in a multiple significantly greater in the intervention than control groupregression analysis, this rise was significant in the intervention (P=0.0001). RIAS coding does not permit us to measuregroup (�=0.23, P<0.01) but not in the control group (�= the quality of information provided, such as its accuracy and0.20, not significant). In anecdotal reports, doctors and relevance.supervisors said the initial IPC/C training, daily practice with Multiple regression analyses found a somewhat differentpatients, weekly outreach services in the community, and pattern of associations between individual intervention com-supervision had helped doctors become better com- ponents and information-giving than was revealed for fa-municators. Since the control group also attended IPC/C cilitative communication. After controlling for other factors,training, received routine supervision, and learned from their just two components had a significant impact: the numbergrowing experience with patients, it is no wonder that their of times the homework log was used (�=0.18, P<0.01) andlevels of facilitative communication increased as well. the number of audiotapes made (�=0.17, P<0.01), while

A series of multiple regression analyses were conducted the number of supervision visits was of borderline significanceto determine which components of the intervention were (�=0.14, P=0.052). Once all of the intervention com-most effective. These analyses controlled for: (1) the purpose ponents were entered in the regression, none of the individualof the visit, which varied between the two data collection components remained significant.rounds, and between control and intervention groups; (2) the Qualitative findings. In focus group discussions, doctorssex of the doctor, which was associated with levels of reported that their new communication skills not only im-facilitative communication; and (3) the length of the session, proved their interactions with patients but also carried overwhich varied widely. When the impact of each component to their relationships with nurses, supervisors, communityon facilitative communication was assessed separately, a sig- members, friends, and family. Doctors also said they foundnificant positive association was found with the number of it more satisfying to view their patient in a larger context, assupervision visits received (�=0.25, P<0.001), the number a person rather than as a diagnosis. Thus they felt theof sessions audiotaped (�=0.20, P<0.01), the number of intervention had contributed to their personal and pro-self-assessments performed (�=0.19, P<0.01), and the num- fessional lives, both for the present and in the future.ber of times the homework log was used (�=0.13, P<0.05).(It was impossible to assess the impact of the job aid, since Impact on patients’ communicationall doctors reported using it frequently.) Only the number of

The frequency of patient active communication did not differsupervision visits remained significant, however, when all ofsignificantly between the intervention and control groupsthe intervention components were entered in the regression(13.3 compared with 11.4, respectively, not significant). The(�=0.20, P<0.05).panel study showed that the frequency of patient activeInformation-giving. Following the intervention, doctors in

the intervention group provided 63% more biomedical communication increased dramatically over the study period

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in both the intervention (from 2.4 to 12.7, �=0.07, P<0.001) scope of the analysis also was limited by technical difficultiesand control groups (from 2.6 to 13.0, �=0.13, P<0.01), with the audio recording and the departure of some doctorswith no significant difference in the rate of change between prior to the post-intervention round of data collection. Aboutthe two groups. This general increase in active communication one-quarter (27%) of the resident doctors who participatedmay be due to providers’ growing experience and the increased in the study were dropped entirely from the analysis, andlength of the sessions, rather than the indirect impact of the less than half (47%) of those remaining were included in theintervention. These also may explain qualitative reports by panel study. Due to the lack of random sampling, the findingsdoctors in the intervention group: in focus group discussions, must be interpreted with caution. Since the data lost, however,they said patients noticed and responded to the changes in was due to recording problems and scheduling difficulties,their interpersonal communication, appreciated the additional there is no reason to believe it systematically biased thetime spent on talking about their problems, opened up more, results.and were more likely to make return visits. This intervention is rooted in new, supportive approaches

to supervision that have broadened the supervisor’s re-sponsibilities in an effort to improve the quality of care [17,18]. According to a widely accepted model, clinical supervisorsDiscussionhave three primary functions: (1) normative, ensuring that staffadhere to standards; (2) formative, facilitating learning andSupportive supervision and self-assessment changed pro-professional development by staff members; and (3) restorative,viders’ communication patterns, increasing the amount ofproviding emotional support to, and ensuring the personalfacilitative communication, shortening their utterances, andwell-being of, staff members [15,19].accelerating the exchange of conversations. These alterations

The supervision intervention implemented in Mexico ac-suggest that doctors adopted a more client-centered, lessknowledged the continuing importance of supervisors’ norm-authoritarian approach to care along with a more participatoryative function in the creation of an observation checklist tostyle of communication—changes that researchers have foundassess doctors’ IPC/C performance. However, the emphasisproduce better health outcomes [2–5,14].on feedback, two-way discussion, and the homework logIn contrast, changes in patient behavior due to the inter-added a formative, educational dimension that helped doctorsvention were neither observed nor expected, since the inter-improve their skills. Training in interpersonal communicationvention could have only an indirect impact upon them.also helped supervisors perform the restorative function,However, patient active communication in both the inter-which takes on even more importance when young, in-vention and control groups increased over time, probablyexperienced doctors are assigned to live and work in isolateddue to the growing familiarity between patients and doctors.rural clinics where they have no peers or support network.The resident doctors were strangers when they first arrived

Research also points to the importance of reflection forat the IMSS/S clinics. Over the course of their 9-month stintprofessional decision making and adult learning [20]. Re-at the clinic, which included making home visits 1 day aflective practice requires active observation of events and,week, the doctors gradually met the local people, gained anlater, reflection on them to understand better and learn fromappreciation of the local culture, and came to know theirexperience. While supervisors can and do prompt reflectionpatients. By the end of their stay, they had forged a personal[19], this study demonstrates that listening to yourself onrelationship with many patients, making it easier for patientsaudiotape also stimulates reflection, self-assessment, and self-to speak out.learning. For doctors, listening to the audiotapes was aStudying these young doctors offered both benefits andpowerful experience, and self-criticism was a more compellingchallenges. Because they had just finished training and hadmotivator than outside criticism. While health care providersnot yet established patterns of communication with patients,in Indonesia successfully performed IPC/C self-assessmentsthese resident doctors may have been more open to thewithout using audiotapes, relying on memory alone wasinfluence of the intervention than veteran health care pro-difficult, and providers were not as deeply moved by theviders. Indeed, two studies of nurses in the UK found thatprocess [8].clinical supervision, including its educational component, had

Partnership supervision may not be suitable for all settings,a far greater impact on the least experienced and most juniorhowever. Above all, it requires that a functioning supervisionnurses [15,16]. However, it can be difficult to assess thesystem be in place. Because IMMS/S already had competentimpact of an intervention on doctors just entering practiceand experienced supervisors making regular visits to ruralbecause their skills rapidly improve with experience. Theclinics, it was relatively easy to add IPC/C supervision topanel study enabled us to distinguish between the impact oftheir responsibilities. In many developing countries, however,the intervention and doctors’ naturally steep learning curve,supervisors are few in number, poorly trained, and lacksince doctors in the control group shared the same IPC/Ctransportation to visit facilities [20–22]. Even in developedtraining, routine supervision, and patient experiences as thecountries, the costs of time and training pose a barrier tointervention group.supervision of clinical personnel [19,23]. When the super-The study suffers from certain other limitations. Audiovision system is not fully functioning, alternative approachestaping, while less intrusive than having an observer present,become more attractive; for example, self-assessment, re-inevitably affects the behavior both of the doctors, who may

try harder, and the patients, who may feel inhibited. The flective diaries, and peer review [8,23]. Yet the Mexican

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experience points to practical limitations here as well. While Referencesaudiotaping consultations proved to be an effective learningtool, IMMS/S found it difficult to supply tape recorders to 1. Barry CA, Bradley CP, Britten N, Stevenson FA, Barber N.scattered rural clinics and maintain them in working order Patients’ unvoiced agendas in general practice consultations:

qualitative study. Br Med J 2000; 320: 1246–1250.once the intervention was scaled up.Because supervision and self-assessment activities and 2. Greenfield S, Kaplan S, Ware JE, Yano EM, Frank HJ. Patients’

materials were designed to complement and build on each participation in medical care: effects on blood sugar controlother, it is difficult to single out the effectiveness of any one and quality of life in diabetes. J Intern Med 1988; 3: 448–457.component of the intervention. Results suggest instead the

3. Kaplan SH, Greenfield S, Ware JW. Assessing the effect ofimportance of multiple, reinforcing interventions for pro-the physician–patient interaction on the outcomes of chronicmoting self-learning and behavioral change. Doctors valueddisease. Med Care 1989; 27: S110–S127.

every element of the intervention, including the supervision4. Stewart M. Effective physician–patient communication andvisits, homework log, job aid, audiotapes, and self-assessment.

health outcomes: a review. Can Med Assoc J 1995; 152: 1423–Perhaps because the self-assessment process (including the1433.audiotapes) occurred four times more often than supervision

visits and occupied so much more of their time, doctors 5. Roter D, Steward M, Putman SM, Lipkin M, Stiles W, Inui TS.emphasized self-assessment during focus group discussions. The patient–physician relationship: communication patterns ofHowever, they also asked for more time with supervisors primary care physicians. J Am Med Assoc 1997; 277: 350–356.and more feedback from them.

6. De Negri B, Brown L, Hernandez O et al. Improving interpersonal

communication between 7 health care providers and clients. Bethesda,MD: Quality Assurance Project, 1997. Available online atwww.qaproject.org under ‘Products’. Last accessed 29 AprilConclusion2002.

This study demonstrates that a combination of supportive 7. DiPrete Brown LD, de Negri B, Hernandez O, Dominguez L,Sanchak JH, Roter D. An evaluation of the impact of trainingsupervision and self-assessment can reinforce IPC/C training,Honduran health care providers in interpersonal communica-help doctors apply newly learned skills on the job, andtion. Int J Qual Health Care 2000; 12: 495–501.contribute to continuing improvement in doctor–patient com-

munication. Because supervision is a standard part of most 8. Kim YM, Putjuk F, Basuki E, Kols A. Self-assessment and peerhealth care systems, it offers a highly effective way of reaching review: improving Indonesian service providers’ communicationdoctors, with training and reinforcement on interpersonal with clients. Int Fam Plann Perspect 2000; 26: 4–20.communication. However, supervisors typically do not give

9. Roter D. The Roter Interaction Analysis System (RIAS) Coding Manual.feedback on doctor–patient interaction. Specially designedBaltimore, MD: Johns Hopkins University School of Hygiene

training and assessment tools can direct supervisors’ time and Public Health, 1997.and energy to these important issues. Self-assessment extends

10. van den Brink-Muinen A, Verhaak PFM, Bensing JM et al. Theand magnifies the impact of supervision by sharing re-Euro-Communication Study: an International Comparative Study in Sixsponsibility for performance improvement and enhancing theEuropean Countries on Doctor–Patient Communication in Generalpartnership between doctor and supervisor. Further researchPractice. Utrecht, The Netherlands: NIVEL, 1999. Availableis needed to test different forms of IPC/C supervision andat http://www.nivel.nl/publicaties/W8.shtml. Last accessed 29

self-assessment, and to refine the balance between them. April 2002.

11. Roter D, Rosenbaum J, de Negri B, Renaud D, DiPrete BrownL, Hernandez O. The effects of a continuing medical education

Acknowledgements programme in interpersonal communication skills on doctorpractice and patient satisfaction in Trinidad and Tobago. Med

Educ 1998; 32: 181–189.The study was carried out by the Quality Assurance Project(QAP), Instituto Mexicano del Seguro Social/Solidaridad 12. Kim YM, Odallo D, Thuo M, Kols A. Client participation(IMSS/S), and Johns Hopkins University Center for Com- and provider communication in family planning counseling:munication Programs (JHU/CCP), a sub-contractor of QAP. transcript analysis in Kenya. Health Commun 1999; 11: 1–19.QAP is managed by the Center for Human Services (CHS;

13. Kim YM, Kols A, Bonnin C, Richardson P, Roter D. ClientBethesda, MD), and funded by the U.S. Agency for Inter-communication behaviors with health care providers in In-national Development (USAID) contract number HRN-C-donesia. Patient Educ Couns 2001; 45: 59–68.

00-96-900013. The authors thank Javier Cabral, Celia Es-14. Ong LM, De Haes JCJM, Hoos AM, Lammes FB. Doctor–candon, Jesus Castellanos, Maribel Rodriguez (IMSS/S); Phyl-

patient communication: a review of the literature. Soc Sci Medlis Piotrow, Elizabeth Costenbader, Gary Lewis, ( JHU/CCP);1995; 40: 903–918.Debra Roter, Susan Larson (Johns Hopkins School of Public

Health); Jim Heiby (USAID); and David Nicholas, Bart 15. Bowles N, Young C. An evaluative study of clinical supervisionBurkhalter, and Paula Tavrow (QAP/CHS) for their as- based on Proctor’s three function interactive model. J Adv Nurs

1999; 30: 958–964.sistance.

366

Doctor–patient communication

16. Teasdale K, Brocklehurst N, Thom N. Clinical supervision and 21. Combary P, Newman C, Glover K et al. Study of the Effects of

Technical Supervision Training on CBD Supervisors’ Performance in Sevensupport for nurses: an evaluation study. J Adv Nurs 2001; 33:

216–224. Regions of Ghana. Chapel Hill, NC: University of North Carolinaat Chapel Hill, School of Medicine, Program for International

17. Ben Salem B, Beattie KJ. Facilitative supervision: a vital link in Training in Health (INTRAH), 1999. Available at http://quality reproductive health service delivery. AVSC Working Paper www.prime2.org/pdf/TR07.pdf. Last accessed 29 April 2002.#10, 1996. Available at http://www.engenderhealth.org/pubs/

22. Valadez J, Vargas W, Diprete L. Supervision of primary healthworkpap/wp10/wp 10.html. Last accessed 29 April 2002.care in Costa Rica: time well spent? Health Policy Plann 1990; 5:

18. Lammerink M. Ways of working. Health Action 1994; 8: 10. 118–125.

19. Kilminster SM, Jolly BC. Effective supervision in clinical practice 23. Teasdale K. Practical approaches to clinical supervision. Profsettings: a literature review. Med Educ 2000; 34: 827–840.

Nurse 2000; 15: 579–582.

20. Ahmed AM, Gavyole A, Omar HM, Munisi W. The nationalguidelines for supervision checklist: a tool for monitoring super-vision activities at district level in Tanzania. Ann Ig 1994; 6:

161–166. Accepted for publication 12 June 2002

367