Evidence based management of acute bronchitis; sustained competence of enhanced communication skills acquisition in general practice

Abstract

Objective

To determine if a communication skills training program for general practitioners involving context-rich learning experiences and ‘peer review’ of consultation transcripts results in communication skills acquisition and maintenance, while preserving time-efficiency in consultations.

Methods

A pre-test–post-test evaluation of training 20 general practitioners (GPs) in enhanced communication skills. Audio taped consultations with simulated patients in routine practice conducted before, within 2 weeks and again 6 months after communication skills training were analysed and consultation length measured. Transcripts were scored for specific skills to determine differences in short and longer-term competence of GPs for the communication skills.

Results

There was good evidence that GPs acquired key communication skills after training and that these were maintained over 6 months. Consultations remained within normal consultation length in primary care.

Conclusion

Specific communication skills for acute bronchitis can be successfully acquired by GPs through context-rich communication training with peer review of transcripts with simulated patients, without making consultation length unfeasible.

Practice Implications

This approach to skill acquisition is useful for enhancing communication skills competence in general medical practice.

Introduction

Unnecessary antibiotic prescribing in primary care remains an important public health threat in an era of increasing antimicrobial resistance [1]. It is particularly common in lower respiratory tract infections (LRTI) where approximately 80% of patients receive a prescription for antibiotics despite evidence for little or no benefit [2], [3], [4], [5]. LRTI is one of the most common reasons for people to consult general practitioners (GPs), and use of broad-spectrum antibiotics is increasing for this indication [6], [7], [8]. General practitioners are aware that they over prescribe antibiotics for LRTI [3], [4], [9]. Diagnostic uncertainty and non-clinical factors, such as time-pressure, perceived patients’ expectations and the desire to maintain good relationships play an important role in the decision to prescribe antibiotics [10], [11], [12], [13], [14], [15]. However, patient satisfaction is influenced more by the quality of information provision and physical examination than by whether or not an antibiotic is prescribed [9], [15], [16]. Moreover, diagnostic uncertainty needs to be minimised through appropriate clinical assessment and additional testing to exclude pneumonia, rather than through prescribing antibiotics to cover the eventuality of a bacterial aetiology [11], [17].

The quality of communication between physicians and patients is a critical factor for optimal medical care generally. In acute bronchitis, GPs need sophisticated communication skills to manage non-medical influences within the consultation by efficiently identifying and responding to the patient's agenda, setting realistic expectations about the natural course, exploring the possible benefits and harms of antibiotic treatment, describing self management strategies and appropriate re-consultation. Communication skills training for GPs focussing on these issues may lead to higher quality consultations, where patients accept evidence based prescribing decisions and become more confident about self management, without feeling ‘sent away’ with unsatisfactory explanations.

Rollnick et al. developed an innovative communication skills training method which proved to be practical and acceptable to experienced clinicians [18], [19]. We adapted the training method and communication skills content for training GPs in advanced communication skills for LRTI consultations. While GPs may show enhanced short-term competence directly after training, sustainable performance in daily general practice requires demonstrable longer-term competence [20]. This study aimed to determine if GPs trained in the enhanced communication skills could apply these skills in a routine practice setting, and whether GPs could maintain these acquired skills over the longer-term.