An attending physician is supervising a resident team caring for Ms. H, a woman with advanced dementia and recurrent aspiration pneumonia who is approaching end of life. During a recent family meeting, Ms. H's health care proxy elected to focus her care on intensive comfort measures. After morning rounds, the attending returns to the bedside to offer support and make sure the family's questions are answered. During the afternoon, the attending observes the residents rushing to complete discharges and call consultants. Seeing how busy they are, she offers to call Ms. H's primary care clinician to update him on Ms. H's decline. A few days later, after Ms. H has died, she phones the patient's daughter from her office, expressing her condolences on behalf of the inpatient team.
As inpatient clinician educators, we have observed a pattern in our practice: we often address the communication needs of patients, families, and colleagues by ourselves. As the residents check boxes off their to-do lists, we try to support them by “just handling” these everyday interpersonal moments. From our office phones and car rides home, we call families to offer updates, listen to their concerns, and provide emotional support. We reach out to our patients' outpatient clinicians, brainstorm with specialists, and counsel colleagues struggling with a challenging case. Among our faculty colleagues, we observe a similar tendency. They take the lead with complex patients, resolve disagreements among clinicians, and tell patients when they cannot safely go home. During a single block of inpatient service there are probably hundreds of these small and commonplace moments. We believe that these fleeting communications are rich yet underrecognized opportunities to teach interpersonal and communication skills (ICS).
Inpatient faculty report that they often teach communication skills during difficult encounters (such as those involving family conflict) and less frequently during routine inpatient visits.1 In our own practice, we often focus our communication teaching on the big events, delivering a life-altering diagnosis or conducting a goals of care conversation. And yet, we may miss the smaller moments as valuable teaching opportunities. Expert guidance on communication skills teaching may reinforce this emphasis on challenging moments, often highlighting this work in the context of “difficult conversations” with the seriously ill.2,3 Yet, we believe there is potential for educational improvement. In this communication, we invite inpatient faculty to identify the smaller daily encounters that can provide rich ICS education and share them with trainees as part of their teaching practice.
Why Are Small ICS Moments So Important?
ICS form a core competency in residents' training, encompassing effective communication with patients, caregivers, and the interprofessional team.4 When given attention, ICS are often siloed to sessions involving lectures and simulated practice, away from the clinical arena.5 Trainees desire more opportunities for real-time observation and feedback regarding their communication skills,6,7 and the limited instruction they do receive may be focused on threshold events such as formal family meetings. Internal medicine faculty report a lack of time and training as key barriers to teaching ICS effectively.1,8
Yet, we believe that faculty do not need to wait for the big moments or be communication experts to teach these skills well. In reviewing our own recent inpatient attending blocks, we have identified many opportunities to practice and debrief ICS during everyday care (Table 1). In these moments, learners can receive feedback on essential communication skills, including the use of jargon-free language when sharing information, empathy when responding to emotion, and respectful, curious problem-solving when discussing a patient's care with interprofessional colleagues. Indeed, adopting a mindset that ICS opportunities abound in daily practice is a key first step toward using these moments for teaching.
What Strategies Can Help Us Maximize Small ICS Moments?
We have identified 5 strategies that may support inpatient faculty in teaching communication through small ICS moments (Table 2). These strategies are drawn from our experience as clinical teachers and from established frameworks for effective bedside teaching described by experts in health care communication and palliative care.2,3,9,10
At the beginning of a rotation, attendings can establish ICS learning as a goal. Doing so sets a clear expectation that ICS are a clinical priority, akin to other medical and procedural skills, and can normalize the practice of debriefing encounters. Attendings can also anticipate small ICS moments before they arise (eg, while reviewing one's inpatient list before morning rounds) and pause before encounters they might otherwise manage alone to consider the educational value of involving a trainee.
Preparing for a shared visit with a learner is the next crucial step in teaching ICS effectively in clinical settings. Faculty can highlight for the learner that the upcoming encounter may be an opportunity to practice their communication skills, to make clear that ICS teaching and feedback are about to happen. Faculty should then establish which parts of the visit the learner will lead and how the attending will provide support if the learner feels stuck in the conversation.2 Inviting learners to say “Dr. [Attending], do you have anything to add?” can give them language to ask explicitly for the attending's help.3 Similarly, the phrase “Could I add something?” can be a clear yet supportive way for faculty to insert themselves into the conversation if needed.10 Setting such clear expectations regarding roles and responsibilities before shared clinical work can enhance learners' psychological safety—their perception that the learning environment is safe for taking risks and being vulnerable—allowing them to be less self-conscious and more present for the clinical task and learning at hand.11,12 Additionally, trainee involvement in leading communication during inpatient encounters may range from purely observing to independently leading the conversation (Figure). Over the course of a rotation, in our experience, faculty will become aware of each trainee's skill level and readiness to lead larger portions of the encounter.
Finally, attendings should debrief with trainees after shared ICS moments. Table 2 highlights helpful questions for exploring learners' strengths and growth edges. Closing the debrief by asking trainees for a takeaway learning point can help them consolidate their learning and identify a single skill they can practice moving forward.3 In our experience, using such directed questions can ensure that debriefing is time-efficient, often completed in 5 minutes or less.
We believe that by employing these strategies, inpatient faculty may more easily identify small ICS moments in daily practice and maximize them for residents' learning. While the educational impact of teaching ICS through such routine encounters is not known, experts have identified direct observation and feedback regarding real-time encounters as a preferred strategy for teaching ICS in graduate medical education.13 Additionally, brief real-time faculty-led coaching interventions have been shown to increase residents' preparedness for higher-stakes conversations, including goals of care discussions.14
Use of these strategies also does not obviate the need for more robust faculty development in this area. As faculty vary widely in their own communication skill levels and their competence in teaching communication to trainees, residency programs have been encouraged to invest in faculty development programs that focus on ICS.8 Some programs offer a structured approach to teaching communication in the clinical environment and can effectively prepare faculty to evaluate and debrief real-time patient-learner interactions.15
We invite inpatient teaching faculty to expand their view of what constitutes a meaningful ICS encounter, placing greater emphasis on small daily interactions with patients, families, and colleagues. When given attention, we believe these moments can provide meaningful opportunities to practice and exchange feedback on essential communication skills. Attendings can maximize these moments by establishing an ICS goal early in the rotation, anticipating teachable encounters before they arise, preparing for shared visits with trainees, and debriefing afterward to solidify learning.