Intervenciones de capacitación para mejorar las habilidades de los médicos para las consultas telefónicas
Resumen
Antecedentes
Desde 1879, año de la primera consulta médica telefónica documentada, la posibilidad de consultar por teléfono se ha convertido en parte integrante de los modernos sistemas sanitarios centrados en el paciente. Hoy en día, hasta una cuarta parte de las consultas asistenciales se realizan por teléfono. Los estudios han cuantificado la repercusión de la consulta médica telefónica sobre la carga de trabajo de los médicos y se ha detectado la necesidad de mejorar la calidad. Si bien los médicos reciben capacitación sistemática en materia de comunicación y consulta, ésta no necesariamente incluye aspectos específicos de la comunicación y la consulta telefónica. En varios estudios se ha evaluado el efecto a corto plazo de las intervenciones para mejorar las habilidades de los médicos para la consulta telefónica; sin embargo, no hay revisiones sistemáticas que informen desenlaces orientados al paciente ni desenlaces de interés para los médicos.
Objetivos
Evaluar los efectos de las intervenciones de capacitación en las habilidades de los médicos para la consulta telefónica y los desenlaces de los pacientes.
Métodos de búsqueda
Se hicieron búsquedas en CENTRAL, MEDLINE, Embase, en otras cinco bases de datos electrónicas y en dos registros de ensayos hasta el 19 de mayo de 2016, además se hicieron búsquedas manuales de referencias, se verificaron las citas y se estableció contacto con los autores de los estudios para identificar estudios y datos adicionales.
Criterios de selección
Se consideraron los ensayos controlados aleatorizados, los ensayos controlados no aleatorizados, los estudios controlados tipo antes y después (before‐after studies) y los estudios de series de tiempo interrumpido que evaluaran intervenciones de capacitación en comparación con intervenciones control, incluida ninguna intervención, para mejorar las habilidades de los médicos para la consulta telefónica con el paciente y la repercusión sobre los desenlaces de los pacientes.
Obtención y análisis de los datos
Dos autores de la revisión, de forma independiente, seleccionaron los estudios para inclusión, extrajeron los datos y evaluaron el riesgo de sesgo de los estudios elegibles mediante la guía estándar de Cochrane y EPOC y la certeza de la evidencia mediante el método GRADE. Se estableció contacto con los autores de los estudios cuando se necesitó información adicional. Se utilizaron los procedimientos metodológicos estándar previstos por Cochrane para el análisis de los datos.
Resultados principales
Se identificó un estudio controlado tipo antes y después muy pequeño realizado en 1989: este estudio utilizó una herramienta validada para evaluar los efectos de una intervención de capacitación sobre las habilidades para completar la historia clínica y para la gestión de los casos de residentes de pediatría. No se informaron diferencias en comparación con ninguna intervención, pero los autores no informaron análisis cuantitativos ni pudieron aportar datos adicionales. Este estudio se consideró con alto riesgo de sesgo. Según GRADE, la certeza de la evidencia se consideró muy baja, por lo que no se sabe si esta intervención mejora las habilidades telefónicas de los médicos.
No se encontraron estudios que evaluaran el efecto de las intervenciones de capacitación para mejorar las habilidades de los médicos para la comunicación telefónica sobre los desenlaces principales de los pacientes (desenlaces de salud medidos con herramientas validadas o marcadores biomédicos, o el comportamiento, la morbilidad o la mortalidad y la satisfacción de los pacientes, la exactitud de la evaluación de urgencia o los eventos adversos).
Conclusiones de los autores
Las habilidades para la consulta telefónica forman parte de un conjunto más amplio de habilidades para la consulta a distancia, cuya importancia está en aumento constante debido a que cada vez más la atención médica se efectúa a distancia, con el apoyo de la tecnología de la información. No obstante, no se dispone de evidencia procedente específicamente de estudios de consulta telefónica, y la capacitación de los médicos tiene que guiarse hasta el momento por estudios y modelos basados en la comunicación presencial, que no consideran las diferencias entre estas dos dimensiones comunicativas. Se necesitan con urgencia más estudios de investigación que evalúen el efecto de diferentes intervenciones de capacitación sobre las habilidades de los médicos para la consulta telefónica y el efecto sobre los desenlaces de los pacientes.
Resumen en términos sencillos
Intervenciones de capacitación para mejorar las habilidades de los médicos para las consultas telefónicas
¿Cuál es el objetivo de esta revisión?
El objetivo de esta revisión Cochrane fue determinar si algunas intervenciones de capacitación son más efectivas que otras para mejorar las habilidades de los médicos para la comunicación telefónica y los desenlaces de los pacientes.
Mensajes clave
Un estudio muy pequeño no informó diferencias entre una intervención de capacitación y ninguna intervención sobre las habilidades telefónicas de residentes de pediatría, pero la certeza de la evidencia fue muy baja, por lo que no se sabe si esta intervención implica una diferencia en las habilidades de los médicos para la comunicación telefónica.
No se encontraron estudios que evaluaran el efecto de una intervención de capacitación para mejorar las habilidades de los médicos para la comunicación telefónica sobre los desenlaces de los pacientes.
No hay evidencia que sirva de base para la capacitación de los médicos en habilidades de comunicación telefónica, por lo que actualmente hay que guiarse por estudios y modelos basados en la comunicación presencial que no tienen en cuenta las diferencias entre estas dos dimensiones comunicativas.
¿Qué se ha estudiado en esta revisión?
Desde su invención, el teléfono ha sido cada vez más utilizado por los médicos y los pacientes para gestionar los problemas de salud. Hoy en día, hasta una cuarta parte de las consultas médicas se realizan por teléfono. De estudios de investigación anteriores se sabe que las habilidades telefónicas de los médicos son de calidad baja, y los médicos reciben una capacitación específica deficiente en su formación. El desarrollo y la mejora de estas habilidades profesionales importantes y delicadas se dejan a la intuición y al criterio de cada médico. En general, los estudios de investigación en medicina telefónica indican claramente que las consultas telefónicas pueden desempeñar un papel importante en la prestación de atención sanitaria, con un impacto cuantitativo en la carga de trabajo de los médicos, la atención hospitalaria, los desenlaces de los pacientes y los niveles de satisfacción laboral.
Se buscaron los estudios en los que médicos, enfermeras y otros profesionales de la salud se sometieran a intervenciones de capacitación para desarrollar y mejorar las habilidades de consulta telefónica con los pacientes. Se incluyeron estudios de todos los ámbitos y se excluyeron los que sólo trataban de la comunicación entre médicos.
¿Cuáles son los desenlaces principales de la revisión?
Esta revisión no encontró estudios que evaluaran el efecto de las intervenciones de capacitación para mejorar las habilidades de los médicos para la comunicación telefónica sobre los desenlaces principales de los pacientes, medido con herramientas validadas o marcadores biomédicos, sobre el comportamiento, la morbilidad o la mortalidad y la satisfacción de los pacientes, la precisión de la evaluación de urgencia o los eventos adversos. Se encontró un estudio muy pequeño, realizado hace más de 25 años, que no informó diferencias entre una intervención de capacitación y ninguna intervención sobre las habilidades sobre las habilidades para completar la historia clínica y para la gestión de los casos de residentes de pediatría. Este estudio no proporcionó datos cuantitativos.
Esta revisión no encontró evidencia específica para informar con respecto a la capacitación sobre las habilidades de los médicos para la consulta telefónica; se necesitan con urgencia estudios de alta calidad en este campo.
¿Cuál es el grado de actualización de esta revisión?
Los autores de la revisión buscaron estudios que se habían publicado hasta mayo de 2016.
Authors' conclusions
Summary of findings
| Training intervention compared with no intervention for improving telephone consultation skills in clinicians | |||
| Patient or population: health professionals Settings: primary care Intervention: training intervention Comparison: no intervention | |||
| Outcomes | Impact | No of studies (participants) | Certainty of the evidence |
| Patient health outcomes | Not assessed | 0 | No evidence available |
| Patients mortality | Not assessed | 0 | No evidence available |
| Patients morbidity | Not assessed | 0 | No evidence available |
| Patient satisfaction | Not assessed | 0 | No evidence available |
| Urgency assessment accuracy | Not assessed | 0 | No evidence available |
| Adverse events | Not assessed | 0 | No evidence available |
| Clinicians' telephone consulting skills | It is uncertain whether the intervention improves clinicians' history‐taking and management skills | 1 (11) | ⊕⊝⊝⊝ |
| GRADE Working Group grades of evidence | |||
| aThe overall quality/certainty of the evidence was judged to be very low because the initial level of confidence about the only included study was low (non‐randomised evidence), and we downgraded the confidence further due to serious risk of bias (incomplete outcome data management and selective outcome reporting) and because of the impossibility to assess consistency of effect, imprecision, indirectness and publication bias due to lack of other studies. | |||
Background
Description of the condition
Since 1879, the year of the first documented medical telephone consultation, the ability to consult by telephone has become an integral part of modern, patient‐centred healthcare systems (No author 1879, Evans 2003). In the USA, doctors have spent at least one eighth of their professional time assessing clinical cases on the telephone for decades (Bergman 1966), with upwards of a quarter of all care consultations being conducted by this method today (Mendenhall 1981; Patel 1997). More recently, the British Medical Association (BMA) has provided guidance for general practitioners (GPs), entitled Consulting in the Modern World: Guidance for GPs (BMA 2001), advising that "telephone consultations, when correctly conducted can be considered to be safe and acceptable practice". Reisman 2005 described how telephone communication is the primary mode of communication between physicians and patients outside of an office visit. Car 2004 and Patel 2005 argued that telephone consulting is both a feasible and effective form of clinical intervention.
Bunn 2004 described telephone consulting as a process whereby patients receive medical advice by one or more qualified healthcare professionals via the telephone. The authors concluded that telephone consultations appear to be safe and that healthcare users were just as satisfied with them as with face‐to‐face consultations. They also suggested that telephone consultations appear to decrease the number of immediate visits to doctors without increasing attendance to emergency departments. A recent large study found otherwise, reporting that telephone triage merely redistributes GP workload away from face‐to‐face consultations and towards more telephone consultations or nurse‐led care (Campbell 2014).
Clinicians and patients use telephones for a range of healthcare services, including routine and emergency care, prescription renewals, laboratory investigations and health promotion (Car 2003, Giesen 2011). Examples of telephone consultations include the management of conditions such as heart failure (Clark 2007; Riegel 2002), asthma (Gruffydd‐Jones 2005; Patel 2009; Pinnock 2003), and palliative care (Pimentel 2015; Zhou 2012).
Telephone consultations may reduce doctors' face‐to face workloads and enhance access to care without the inconvenience and cost associated with physically attending a consultation, thus increasing the flexibility and availability of service (Campbell 2014; Hallam 1992; Patel 2005).
Katz 2008 and Car 2008 highlighted some of the existing safety concerns in relation to telephone consultations, such as the vulnerability of patients to errors in management and of clinicians to malpractice claims. The authors suggested that the most effective risk‐management strategy is to improve the quality of telephone care and service to patients. They also suggested that prevention should include a more disciplined approach to documentation, improved workload systems, increased skills training and an upfront commitment to evaluation.
Bunn 2004 pointed to remaining questions about the effect of telephone consultations on service use. Since telephone consultations play a role in patient management, it is essential that when consulting via the telephone, healthcare professionals feel confident with their skills to conduct and document the interview with accuracy and clinical competency. It is therefore important that they receive adequate training to enable them to carry out their clinical roles effectively.
Purc‐Stephenson 2012 found that overall patient adherence with triage advice provided by tele‐nurses was 62%, and adherence was influenced by the interplay between patient perceptions and the quality of provider communication. The authors highlight the need for communication skills training in a telephone consultation context that is patient centred and specifically addresses active listening and advising skills, providing guidance on how to structure the call.
Description of the intervention
As with face‐to‐face consulting skills, the ability of consulting via the telephone requires adequate training. This training may occur at any stage of a professional's career. We used the term training as defined within the Medical Subject Heading (MesH) of the US National Library of Medicine vocabulary thesaurus, under the MesH term of education (www.ncbi.nlm.nih.gov/mesh/68004493). Essentially, we used the term within the context of medical education.
Training can employ varied educational interventions such as traditional one‐way teaching methods (e.g. lectures) as well as more interactive techniques (e.g. simulation software).
One‐way methods
One‐way training usually consists of lectures, reading materials, or both. A survey found that only a few internal medicine programmes offer teaching in telephone management, and when it is part of the curriculum, it is delivered via a single and informal lecture (Flannery 1995).
Interactive methods
Medical education increasingly uses simulated patients. As early as 1983, Evens and colleagues described patient simulators to teach telephone communication skills without testing it in a controlled study (Evens 1983). In a controlled study, Greenberg 1999a used a non‐validated tool to assess a telephone management educational programme with standardised patients to train paediatric residents. A cross‐sectional analysis by Derkx 2009a reported that the telephone incognito standardised patient (TISPs) method can be valuable both for training and assessment of performance in telephone consultation carried out by doctors, trainees and other personnel involved in medical services.
Computerised training programmes use specially designed software to simulate calls and provide pertinent feedback. These programmes can be delivered either online or via CD‐ROM. Ottolini 1998 designed a randomised controlled trial where healthcare professionals used an interactive CD‐ROM programme with scripts representing the 10 most common complaints to simulate telephone conversations with the parents of paediatric patients. Unfortunately the tool used to assess the results had not been previously validated.Kosower 1991 described a non‐experimental programme called TALK to teach telephone communication skills by allowing residents to analyse recorded calls in group and to participate in individual feedback sessions. In a controlled before‐after study, Wood 1989 used several testing tools to assess a specially developed role play telephone management curriculum on history‐taking and management skills.
Structured tools
Marshall 2009 described a randomised controlled trial assessing a communication tool for improving the quality of telephone clinical referrals between health personnel. This study used final year medical students to measure the effect of the intervention on the content and clarity of telephone referrals.
Multifaceted approach
Interventions may often incorporate different types of training, including both one‐way and interactive methods. In a before‐after study without control, King 2007 developed and evaluated a continued educational programme called the Effective Patient Teaching and Problem Solving (EPT‐PS) course. The intervention consisted of several sessions incorporating didactic presentations with modelling, demonstrations of taught skills and interactive group exercises.
The purpose of this review is to identify and measure the effectiveness of these types of interventions on clinicians' telephone skills.
How the intervention might work
The intervention should aim ultimately to improve patient care. We hypothesise that this can be achieved by successfully changing clinicians' behaviour, which would affect specific areas of practice.
It is vital that any training intervention changes clinicians' behaviour in the desired manner. Grimshaw 2002 described some of the factors that may influence change.
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Implementation of effective change strategies through understanding the determinants of physician behaviour and identification of barriers.
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More evidence‐based strategies of implementation and dissemination.
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Emphasis on population‐based improvement in clinical outcomes.
This review looked at the various determinants of clinicians' behaviour as described in the previous section to help understand how training programmes can ensure the desired outcomes. Results may inform the appropriate programme implementation and dissemination.
It is also worth applying relevant theoretical considerations in efforts to change clinicians' behaviour. Many theories of behavioural change and learning theory exist. Slotnick 2002 described some of the ways in which various theories may be applied. Grol 2002 described the following six elements of effective change.
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The complex reality of clinical practice needs to be considered: this may relate to clinician workload, resources and experience in relation to telephone consulting.
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Specific attention must be directed toward the designed change/improvement: the same intervention may lead to different outcomes for different learners. This review aimed to address the reasons for this through the variety of variables it assessed (e.g. age, sex, professional specialty, etc.).
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A diagnostic analysis of the target group and setting: this review aimed to help understand learning needs and environments that are conducive to effective training.
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A mix of actions including training, rewards, feedback and organisational measures addressing the needs and problems of the target groups and the barriers is needed: this review aimed to inform the development of any multifaceted training programme that incorporates more than one of these elements.
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It is necessary to develop a plan indicating which actions will be taken when, by whom and in what order: the results of this review aimed to inform organisations (such as educational institutions) on how to develop, design and implement effective training programmes for telephone consulting.
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Continuous monitoring, feedback and adaptation of strategies should be implemented as needed: an effective training programme for teaching telephone consulting skills must include appropriate evaluation and feedback methods to ensure learning objectives are being achieved. This review aimed to identify and analyse the existing evidence in this area.
Why it is important to do this review
There is an important role for telephone consultations within healthcare, so it is important to know which is the best way to provide the adequate skills to the relevant healthcare professionals.
The need for effective training
Although the need for telephone skills training was first documented in the 1970s (Brown 1974), there is still no systematic review reporting which interventions are most effective in training clinicians.
As BMA 2001 noted, during a telephone consultation the doctor "cannot see, touch, examine, investigate, smell or, in the strictest terms, even hear the caller/patient." We believe that the differences in telephone consulting compared to face‐to‐face warrant specific, evidence‐based training. This review was conducted to provide the evidence base for effective clinicians' training in telephone consulting and to develop telephone‐specific consulting models.
In the same way as in face‐to‐face consulting, we argue that there should be robust studies to investigate the best ways to teach telephone consulting skills. Modern face‐to‐face consultation models have been developed with an emphasis on informed information provision; exploration of patients' concerns, ideas and expectations; patient centeredness; and patient satisfaction. An increasing body of evidence supports the use of a patient‐centred approach to healthcare (Hayden 2003). Models of face‐to‐face consulting include Balint's model (Balint 1964), Berne's transactional analysis (Berne 1968), Byrne and Long model (Byrne 1976), Middleton agenda model (Middleton 1989), Neighbour's inner consultation (Neighbour 1987), Pendleton's consultation model (Pendleton 1984), and Stott and Davis model (Stott 1979). Developing an evidence base on teaching telephone consulting skills can contribute to the achievement of a similar patient‐centred consulting approach or model for this context.
Ultimately, we think that improved clinician skills can lead to improved clinical outcomes. This can be achieved through identifying an evidence base, transferring appropriate skills and providing consistent delivery of services.
Evidence base
Ideally, training interventions should be evidence‐based. Car 2003 argued that training targeted at telephone consultations, protocols for managing common scenarios, dedicated time for telephone contacts, documentation of all consultations and a low threshold for organising a face‐to‐face consultation may help to ensure quality and safety of telephone consultations. The telephone is a communication tool that poses several disadvantages for patient consultations from the clinician perspective, including an absence of visual clues and non‐verbal communication. Toon 2003 highlighted how, despite this, there has been little study of telephone consulting skills and little critical thinking about how best to work on its limitations or what background and training users need. Developing and utilising this evidence base for training in telephone consulting skills will be necessary for their improvement.
Transfer of appropriate skills
A healthcare professional trained in telephone consultation skills is expected to have a more refined appreciation of verbal cues and focused history‐taking to compensate for their inability to examine the patient (Car 2004), and training can improve these skills (Foster 1999).
Improving outcomes
Reisman 2005 argued that increasing familiarity with common challenges when consulting with patients over the telephone may help healthcare professionals decrease the likelihood of negative outcomes. A randomised, prospective, controlled comparison of residents' management of two telephone calls concluded that the use of a CD‐ROM telephone management programme was associated with better postintervention telephone management (Ottolini 1998). Marklund 1989 evaluated the effect of a teaching programme on telephone advice, finding that the educational programme resulted in improved quality of advice, confidence and satisfaction among participating nurses. Lattimer 1998 evaluated the safety and effectiveness of nurse telephone consultation in out‐of‐hours primary care. A key recommendation was that further testing in the selection and training of nurses may improve outcomes.
Consistency
O'Cathain 2003 examined the consistency of triage outcomes when nurses used telephone communication supported by computerised decision support software in out‐of‐hours emergency services by NHS Direct in the UK. The study found that there was variability in the ways nurses dealt with the calls, in particular, the triage outcomes such as recommending self‐care versus advising attendance to accident and emergency services. The authors claimed that effective training on telephone consultation skills in the specific setting can enable nurses to answer calls in a more standardised manner.
Potential effects of changing clinicians' behaviour
Training may lead to several potential outcomes through modified clinician behaviour. Grimshaw 2001 described how multifaceted interventions targeting different barriers are more likely to effectively change provider behaviour. Importantly, the authors also concluded that future educational activities should be informed by the findings of systematic reviews of professional behaviour change interventions. Current evidence suggests that training in telephone consultation skills could help to overcome a variety of perceived barriers.
Addressing the perceived lack of training
Elnicki 2000 reveals that practicing physicians and residents can benefit from regular review of telephone cases, both for educational purposes and for making practice policies. Interestingly, Patel 2009 showed that primary care physicians do not feel a need for specific training, as they perceive telephone consultations as just another form of history‐taking. Another study, Reisman 2005, reported that only 6% of residency programmes in the USA teach any aspect of telephone communication. The authors suggest the paucity of training in telephone medicine in residency programmes may be a significant contributor to telephone communication errors.
Improving clinician satisfaction and confidence
Hannis 1996 found that primary care physicians are often dissatisfied with telephone encounters and that their level of confidence is lower when consulting via a telephone than when seeing patients face–to‐face.
Improving consultation techniques
Innes 2006 highlighted that when attending via the telephone, physicians adopt a more dominant approach than with face‐to‐face consultations. Telephone exchanges also tend to be rich in biomedical and poor in psychosocial aspects. Derkx 2009b assessed the quality of staff communication skills using the RICE telephone communication rating list described in Derkx 2007. The authors found the mean overall score for communication skills was 35% of the maximum feasible; staff usually asked questions about the clinical situation correctly but elicited little information about the patients' personal situation, their perception of the problem or their expectations. Clinicians usually gave advice about the outcome of triage and self‐care without checking for patients' understanding and acceptance; calls were often handled in an unstructured way, without summarising or clarifying the different steps within the consultation.
Appropriate length of telephone consultation
Innes 2006 reported that the length of interaction accounts for much of the variation seen between consultations in the domains of rapport, data‐gathering, patient education, counselling and partnership. Derkx 2009b concluded that apart from adequate communication skills, staff needed sufficient time for telephone consultation to enable high‐quality performance.
Improving clinical accuracy (history‐taking, urgency assessment, management)
Isaacman 1992 reported that advice given via the telephone within paediatric care by emergency departments revealed inadequate histories, variable advice and insufficient follow‐up care. Hallam 1989 considered the use of the telephones within primary care and found 20% of the calls to be incorrect on follow‐up as well as inappropriate in triage decisions for common problems. Derkx 2008 considered that 21% of all questions that trialists asked were obligatory, while just 54% of the obligatory questions were carried out, and required care advice was given in the 58% of the cases. Pasini 2015 found similar results.
Improving documentation
A series of case reviews of telephone‐related claims by Katz 2008 found that absent or poor documentation was present in almost all cases, highlighting the need to document all calls of significant relevance. Derkx 2010 found 22% of telephone consultations at Dutch out‐of‐hours centres were not reported at all, and in the 78% reported, reports almost always contained information about the medical reason for calling but little information about details of the clinical history. Patients' expectation, personal situation or perception of the care advice were also seldom documented.
This review assesses the impact of training and educational programmes on clinician skills and relevant care. The results of this review aim to inform training and evaluation of programmes to provide effective telephone consultations skills that could result in better clinician behaviour and ultimately improve patient outcomes.
Objectives
To assess the effects of training interventions for clinicians' telephone consultation skills and patient outcomes.
Methods
Criteria for considering studies for this review
Types of studies
We considered the following types of studies meeting the minimum criteria used by the Cochrane Effective Practice and Organisation of Care Group (EPOC 2013).
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Randomised controlled trials (RCTs).
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Non‐randomised controlled trials (NRCTs).
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Controlled before‐after (CBA) studies with a minimum of two intervention and two control sites.
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Interrupted time series studies (ITS) of interventions with a clearly defined point in time when the intervention occurred and at least three data points before and three after the intervention.
We based this decision on our initial evidence searches that identified few randomised controlled trials in this area.
Types of participants
We included clinicians (a broad term that encompasses all doctors, nurses and other health professionals) who underwent educational interventions for developing and improving telephone consultation skills with patients. We included studies from all settings including primary care, outpatient, inpatient and public health. We excluded studies regarding communication between clinicians.
Types of interventions
We considered any kind of intervention aiming at improving the clinicians' telephone consultation skills regardless of the means and the way they were delivered (computerised, written, face‐to‐face training programmes or decision support software).
The eligible comparators were any control intervention with a possible effect on the same outcomes set or no intervention.
Consequently the comparison could be, for example, an interactive e‐learning programme on telephone consultation structure versus a classroom intervention on the same topic or no intervention; or computerised decision support software versus written management algorithms or no intervention.
Types of outcome measures
We considered the following types of outcomes, as assessed through a validated tool. We use the definition of 'validated tool' provided by the Joint Commission: "an instrument that has been psychometrically tested for reliability (the ability of the instrument to produce consistent results), validity (the ability of the instrument to produce true results), [and] sensitivity (the probability of correctly identifying a patient with the condition)" (manual.jointcommission.org/Manual/Questions/UserQuestionId03Sub0015).
Primary outcomes
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Patient outcomes
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Health outcomes (e.g. biomedical markers and patient behaviour)
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Effect on morbidity/mortality
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Patient satisfaction
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Urgency assessment accuracy
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Adverse events
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Clinicians' telephone consulting skills (e.g. RICE tool, Derkx 2007)
Secondary outcomes
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Clinician knowledge gain
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Attitudes to telephone consultation (e.g. confidence, satisfaction)
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Time effectiveness (length and frequency of consultations, avoidance of face‐to‐face contact, effect on further clinical contact)
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Referral patterns
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Economic evaluation (litigation issues, resource issues, time effectiveness)
We only included studies if they assessed primary outcomes (e.g. not those with just secondary outcomes).
Search methods for identification of studies
T Rader, the EPOC Information Specialist (IS), developed the search strategies in consultation with the review authors and ran the searches of the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effects (DARE) for related systematic reviews and the databases listed below for primary studies. The most recent search was conducted on 19 May 2016.
We searched the following databases.
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MEDLINE Ovid (1946 to 19 May 2016).
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Embase Ovid (1947 to 19 May 2016).
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CINAHL EbscoHost (1980 to 19 May 2016).
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Cochrane Central Register of Controlled Trials (CENTRAL) via OVID (19 May 2016).
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Cochrane Library via Wiley (19 May 2016), including Cochrane Database of Systematic Reviews, Cochrane Methodology Register, Cochrane NHS Economic Evaluation Database, Cochrane Database of Abstracts of Reviews of Effects, Cochrane HTA Database.
We did not apply language nor date restrictions to the searches. We used two methodological search filters to limit retrieval to appropriate study designs: the Cochrane Highly Sensitive Search Strategy (sensitivity‐ and precision‐maximising version, 2015 revision) to identify randomised trials (cf. Cochrane Handbook for Systematic Reviews of Interventions 6.4d, Lefebvre 2011). To retrieve non‐randomised controlled trials, controlled before/after studies (CBAs) and interrupted time series (ITS), we applied the EPOC Group Methods Filter 2.6 (January 2013 version). For other databases, where no filter exists, we identified study designs at the screening stage (see Types of studies). We provide detailed search strategies used for searches in Appendix 1.
We devised the search strategy for the MEDLINE Ovid interface and then adapted it for the other databases. We consulted relevant individuals and organisations or information about unpublished or ongoing studies.
Searching other resources
In addition to selecting grey literature and searching Google Scholar (we screened the first 500 items retrieved), we searched the following trial registries and additional thesis resources.
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Trial registries.
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WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/en).
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ClinicalTrials.gov (clinicaltrials.gov).
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We also:
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screened individual journals and conference proceedings (e.g. handsearching);
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reviewed reference lists of relevant systematic reviews or other publications;
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contacted authors of relevant studies or reviews to clarify reported published information or seek unpublished results/data (when necessary);
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contacted researchers with expertise relevant to the review topic or EPOC interventions; and
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conducted cited reference searches in ISI Web of Science/Web of Knowledge.
Data collection and analysis
Selection of studies
Two pairs of review authors (AV and YP; RG and MA) independently assessed the eligibility of all titles and abstracts identified from electronic searches. We retrieved full text copies of all articles judged to be potentially eligible. The same review authors independently assessed the retrieved articles to determine whether they met the inclusion criteria.
We resolved all disagreements through discussion, involving an additional review author if necessary, and we agreed on the final list of included and excluded studies. Where there was insufficient detail about the study to decide whether it met the inclusion criteria, we contacted the study authors to enable a more informed decision.
Data extraction and management
Two review authors (AV, YP) independently extracted data from all included studies using a standard data recording form derived from the data extraction template provided by the Cochrane EPOC Group EPOC 2013a. We compared results and resolved disagreements by discussion and, when necessary, through the involvement of an third review author. We contacted study authors to obtain or clarify data from included studies. We planned to use Review Manager 5 (RevMan) to manage the study data (RevMan 2014).
Assessment of risk of bias in included studies
Two review authors (AV, MA) independently assessed the risk of bias of the included study using the nine standard criteria for RCTs and the seven standard criteria for ITS as outlined by the Cochrane EPOC Group (EPOC 2015). We planned to use a template to guide our assessment of risk of bias, judging each item as having a low risk of bias, a high risk of bias or unclear risk of bias, providing a description to explain the decision using the guidance outlined by the Cochrane EPOC Group and in section 8.3 of the Cochrane Handbook for Systematic Reviews of Interventions (EPOC 2015; Higgins 2008). We compared judgments and resolved any disagreements by discussion and consensus, consulting a third review author where necessary.
If we considered that all the above‐mentioned elements were at low risk of bias, we assigned a low risk of bias to the study in question. Conversely, if we found that one or more of these key elements were at high risk of bias, we planned to classify the selected study as being at high risk.
We present the results of the 'Risk of bias' assessment for the included study in table format and incorporate the results of the assessment into the review through systematic narrative description and commentary about each of the quality items.
When necessary, we contacted study authors for additional information about the included studies.
Measures of treatment effect
We reported the findings of the included study in narrative form as described by the study authors. When further studies are identified and included in this review, we plan to analyse effect measures in relation to the primary outcome measures to assess whether there are definable and significant changes in a variety of outcomes after the training intervention. We anticipate that with additional studies, the primary outcomes will reveal data that can be assessed by measures such as mean difference (MD), standardised mean difference (SMD) and proportions where appropriate.
For dichotomous data: where feasible, we plan to analyse outcomes with dichotomous data (such as confidence rating scales) with relative effect.
For continuous data: we plan to report the mean difference (MD) or standardised mean difference (SMD) (if there was a difference in measurement of scales across trials), using 95% confidence intervals (CI) as measures of the amount of random errors influencing the outcome estimates.
Future included studies could use standardised assessment tools of consulting (such as Pendleton's Consultation Rating Scale). These again could be measured using MD and standard deviation (SD) or SMD if different tools were used. If medians are used, then we will measure interquartile ranges (IQR). Where total numbers and effect sizes are not recorded then we will describe results narratively.
Unit of analysis issues
We did not identify unit of analysis issues, as we included only one study. When the review includes future studies, including cluster trials, we plan to analyse the data according to recommendations in the Cochrane Collaboration Open Learning Module on issues related to the unit of analysis (Alderson 2002).
Dealing with missing data
We contacted the authors of the included study for missing data.
Assessment of heterogeneity
We did not assess heterogeneity, as we included only one study. When future studies are included, we will evaluate heterogeneity using tables and box plots to compare effect sizes of studies grouped according to potential effect modifiers. These include:
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type of health professional;
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type of intervention;
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duration of education/intervention;
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outcomes of intervention;
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setting and contextual factors: primary/secondary care, face‐to‐face/e‐Learning;
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study design (e.g. RCT, CCT, CBA, ITS);
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methodological quality of studies.
With additional included studies, we expect to find substantial variation in the study results due to differences in types of interventions, the type of healthcare professional (targeted population), the design of the intervention, duration of the intervention and the context in which the intervention was implemented. We will conduct subgroup analyses based on type of intervention, type of health professional and study setting when two or more studies considering the same outcomes or using the same intervention in a similar population.
Assessment of reporting biases
We did not assess reporting bias, as we included only one study. When future studies are included, we plan to use funnel plots to assess the potential existence of small study bias. As there are a number of explanations for asymmetry in a funnel plot (Sterne 2001), we plan to carefully interpret results (Lau 2006).
Data synthesis
We did not perform quantitative analysis, as we included only one study.
When future studies are included, we plan to begin the data synthesis with a narrative overview of the findings and a table systematically summarising the extracted results. We will assess the participants, interventions and outcomes for comparability, which is necessary for statistical pooling. We will look for studies sufficiently similar in terms of study design, setting, intervention, follow‐up and outcome measures in order to combine the study data in a meta‐analysis. We plan to review the appropriateness to carry out a meta‐analysis collectively as a review team.
The choice of model will depend on the heterogeneity of the studies included in the meta‐analysis. We plan to conduct the analysis according to guidance in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2008). If meta‐analysis is feasible, we plan to use a random‐effects model, which provides a more conservative estimate of effect and can be used where there is moderate heterogeneity.
With additional included studies, we will measure median effect sizes across groups as originally described by Grimshaw 2004 and used by several subsequent authors (Jamtvedt 2006; Shojania 2004; Shojania 2009; Steinman 2006; Walsh 2006).This method is considered to help measure the median effect of each outcome within a study and subsequently measure the overall single effect size for that study. It is from these single effect sizes for each study that we can calculate the median effect size and interquartile range across all studies. This type of analysis is still subject to limitations, as it would assume that studies have equal weight. However, Grimshaw 2004 argued that using the median as opposed to the mean would limit the impact of outliers on the summary estimate of effect.
We will synthesise data through specific analysis of outcome measures previously described. Where possible, we plan to separately present results of studies, comparing:
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the intervention versus no intervention (e.g. telephone training programmes alone);
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the intervention versus other forms of intervention (e.g. telephone consulting training versus face‐to‐face consulting training).
Subgroup analysis and investigation of heterogeneity
We did not perform subgroup analysis. When future studies are included and where data are sufficient and it is appropriate in the context of the study, we plan to conduct subgroup analyses according to several factors (type of participants, patient characteristics, location of the study, year of publication, type of intervention, disease specific training interventions and development of protocols). This will allow the examination of the effect of certain studies on the pooled effects of the intervention.
Sensitivity analysis
We did not perform sensitivity analyses. When future studies are included, we plan to remove studies deemed to be at high risk of bias after examination of individual study characteristics from the analysis in order to examine the effect on the pooled effects of the intervention.
Summary of findings table
We summarised the findings for each primary outcome in a 'Summary of findings' table to draw conclusions about the certainty of the evidence for the main comparison within the text of the review. Two review authors independently assessed the certainty of the evidence (high, moderate, low, and very low) using the five GRADE considerations (study limitations, consistency of effect, imprecision, indirectness and publication bias) reported in the specific guidance developed by EPOC (EPOC 2013b). We resolved disagreements on certainty ratings by discussion and provide justification for decisions to down‐ or upgrade the ratings using footnotes in the table.
Results
Description of studies
Results of the search
We identified 12,209 articles through the search strategy and one additional article from experts' suggestion. We excluded 12,168 articles on the basis of abstracts considered not pertinent. We retrieved a total of 42 articles that potentially fulfilled the inclusion criteria for full text assessment. We excluded 41 with reasons: 18 did not use an experimental design, 7 were before‐after studies without control, 2 used a non‐validated tool to measure the clinicians' telephone skills change, and 14 were ineligible for other reasons. We described these studies in the Characteristics of excluded studies. Only one study fulfilled our inclusion criteria (see Characteristics of included studies). We summarise the study selection process in Figure 1.
Study flow diagram.
Included studies
One controlled before‐after study met the inclusion criteria for this review (Wood 1989). This study assessed the effect of a role play telephone management curriculum for paediatric residents on history‐taking and case management skills. Six residents participated in three, half‐hour group sessions with a role play curriculum stressing a structured approach to telephone management of two paediatric problems; each resident had the opportunity to participate in several mock telephone conversations in which one resident played the parent of a sick child and the other resident played the clinic doctor. A seven‐resident control group received no formal instruction in telephone case management. Residents received pre‐test and post‐test calls (at three months) to a particular resident assigned to function as "telephone doctor" in the residents continuity clinic. Using standardised scripts, a simulated mother played the role of a mother calling the clinic for advice concerning her sick child. The standardised rating form was composed of three scales, each consisting of weighted items that were summed and then expressed as a percentage of possible perfect score; however, we could only take into account one previously validated scale (Specific History taking Scale (SHS) and its subset Specific History Triage (SHT)).
Unfortunately, authors did not report quantitative data on specific history scale (and specific history triage scale) and could not provide additional data: the only results they stated were, "There were no differences between intervention and control groups on the Specific History taking Scale. Even when specific history‐taking scores were calculated using a subset of heavily weighted items (Specific History Triage), there were no differences between groups".
We provide more details of this study in the Characteristics of included studies table.
Excluded studies
We describe these 41 studies under Characteristics of excluded studies. We contacted the authors to be sure that there was no additional unreported information available whenever the characteristics of the study were not completely clear. We excluded Greenberg 1999a and Ottolini 1998 because, despite their agreement with all the other inclusion criteria, we found no evidence of previous validation for the tools they used in order to detect clinicians' telephone consulting skills changes (see Table 1).
| Original study | Tool | What it is known about this tool validation | Final decision | Final reason for final exclusion | ||
| From the original paper | From the authors (we explicitly asked them, "Was this instrument previously validated?") | From related publications | ||||
| GHS | Nothing | Nothing | No related publication | Data excluded | No clear evidence of tool validation | |
| SHS/SHT | see Perrin 1978 | We used the rating skills developed by Dr Ellen Perrin and colleagues (see Methods section of NEJM article). She describes inter‐rater reliability. The scoring systems were developed using expert panels, which addresses in part the issue of validity Wood 2015 [pers comm]. | Perrin 1978: "Inter‐rater reliability was 86%" (p 131, left column) | Data included | — | |
| GMS | Nothing | Nothing | No related publication | Data excluded | No clear evidence of tool validation | |
| No name | Nothing, we just know the tool maximum score is 26, so this tool cannot be PPQ used by Ottolini 1998 because PPQ maximum score is 35 (p 396, right column) | "In those days editors didn't request the names of instruments. I went through my hard copies and could not find this information. If you check my paper on giving bad news to residents in Greenberg 1999b both of the communications skills instruments [the instruments used in Greenberg 1999b and Ottolini 1998] are published in that article." | Greenberg 1999b speaks about 2 valid, reliable instruments used to assess interpersonal skills (p 1210, right column): GTS and PPQ. GTS has a maximum score of 20 points, while PPQ has a maximum score of 35 points. So none of them can be the score used in Greenberg original study. About PPQ, the paper refers to see Schnabl 1991 In the result section the paper says, "The interpersonal or counselling skills checklist was not examined for reliability" (p 1211, right column) | Data excluded | No clear evidence of tool validation | |
| PPQ | see Schnabl 1991 | "The tool was based on Barbara Korsch's work but not psychometrically validated" | The tool used is not PPQ (7 items with a maximum score of 35 points) but IPS (13 items with a maximum score of 91 points) | Data excluded | No clear evidence of tool validation | |
GHS: general history scale; GMS: general management scale; PPQ: patient perception questionnaire; SHS: specific history scale; SHT (subset of items of SHS): specific history triage.
Risk of bias in included studies
We assessed the risk of bias of the included study using the nine standard criteria suggested by the Cochrane EPOC Group (EPOC 2015). We assessed the overall risk of bias for this study to be high. See Figure 2 and Figure 3.
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Allocation
For generation and concealment of allocation sequence, EPOC considers that a controlled before‐after study – as the study we found – is at high risk by default according to suggested risk of bias criteria for EPOC reviews (EPOC 2015). Regarding baseline outcome measurements and characteristics, authors provided no data, and the risk of selection bias was unclear.
Blinding
A single trained rater who was unaware of the resident group subsequently transcribed and rated audiotapes, so the detection bias was low. Authors reported nothing about contamination, but the study design protected against it.
Incomplete outcome data
The authors excluded the unpaired audiotapes from the analysis, determining a high risk of bias for incomplete outcome data management.
Selective reporting
Many outcomes in the Results section did not appear in the Methods, so we rated the risk of reporting bias to be high.
Other potential sources of bias
No other source of bias was identified. The overall risk of bias was high because of a high risk of bias in at least one key domain.
Effects of interventions
See: Summary of findings for the main comparison
We present the available evidence in the summary of findings Table for the main comparison for the main comparisons.
One study reported effects of training intervention on clinicians telephone consulting skills and found no difference between intervention and control among 11 paediatric residents, but authors did not provide quantitative data. We did not find any eligible study that reported effects of the intervention on primary patient outcomes (health outcomes, mortality, morbidity, satisfaction, urgency assessment accuracy or adverse events).
The included study only assessed primary outcomes, so we did not evaluate any secondary outcomes.
Certainty of the evidence
We judged the overall quality/certainty of the evidence for the outcomes reported to be very low (Summary of findings table 1) because the initial level of confidence about the only included study was low (non‐randomised evidence) and we downgraded the confidence due to a high risk of bias (incomplete outcome data management and selective outcome reporting) and because of the impossibility to assess consistency of effect, imprecision, indirectness or publication bias due to lack of other studies. Based on our GRADE assessment, it is uncertain whether the intervention improves clinicians' history‐taking or management skills (very low certainty).
Discussion
Summary of main results
We identified one controlled before‐after study at high risk of bias evaluating the effect of a training intervention on clinicians' telephone consulting skills. Authors found no difference between intervention and control on history‐taking and case management skills. We did not identify any studies that assessed the effect of training interventions for clinicians on patient primary outcomes (health outcomes measured by validated tools, biomedical markers or patient behaviours, patient morbidity or mortality, patient satisfaction, urgency assessment accuracy or adverse events).
Overall completeness and applicability of evidence
We excluded several studies in the telephone medicine literature because they did not have an experimental design, and we excluded two studies that fulfilled all other inclusion criteria because they used non‐validated evaluation tools: it seems no reliable evidence is available for this research topic.
Quality of the evidence
The overall quality/certainty of the evidence was very low because the initial level of confidence about the only included study was low (non‐randomised evidence), and we downgraded the confidence further after rating the risk of bias to be serious (incomplete outcome data management and selective outcome reporting) and because of the impossibility to assess consistency of effect, imprecision, indirectness or publication bias due to lack of other studies.
Potential biases in the review process
This review did not formally explore publication bias because we only included one study.
Agreements and disagreements with other studies or reviews
To our knowledge, this is the only systematic review on this topic.
Study flow diagram.
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
| Training intervention compared with no intervention for improving telephone consultation skills in clinicians | |||
| Patient or population: health professionals Settings: primary care Intervention: training intervention Comparison: no intervention | |||
| Outcomes | Impact | No of studies (participants) | Certainty of the evidence |
| Patient health outcomes | Not assessed | 0 | No evidence available |
| Patients mortality | Not assessed | 0 | No evidence available |
| Patients morbidity | Not assessed | 0 | No evidence available |
| Patient satisfaction | Not assessed | 0 | No evidence available |
| Urgency assessment accuracy | Not assessed | 0 | No evidence available |
| Adverse events | Not assessed | 0 | No evidence available |
| Clinicians' telephone consulting skills | It is uncertain whether the intervention improves clinicians' history‐taking and management skills | 1 (11) | ⊕⊝⊝⊝ |
| GRADE Working Group grades of evidence | |||
| aThe overall quality/certainty of the evidence was judged to be very low because the initial level of confidence about the only included study was low (non‐randomised evidence), and we downgraded the confidence further due to serious risk of bias (incomplete outcome data management and selective outcome reporting) and because of the impossibility to assess consistency of effect, imprecision, indirectness and publication bias due to lack of other studies. | |||
| Original study | Tool | What it is known about this tool validation | Final decision | Final reason for final exclusion | ||
| From the original paper | From the authors (we explicitly asked them, "Was this instrument previously validated?") | From related publications | ||||
| GHS | Nothing | Nothing | No related publication | Data excluded | No clear evidence of tool validation | |
| SHS/SHT | see Perrin 1978 | We used the rating skills developed by Dr Ellen Perrin and colleagues (see Methods section of NEJM article). She describes inter‐rater reliability. The scoring systems were developed using expert panels, which addresses in part the issue of validity Wood 2015 [pers comm]. | Perrin 1978: "Inter‐rater reliability was 86%" (p 131, left column) | Data included | — | |
| GMS | Nothing | Nothing | No related publication | Data excluded | No clear evidence of tool validation | |
| No name | Nothing, we just know the tool maximum score is 26, so this tool cannot be PPQ used by Ottolini 1998 because PPQ maximum score is 35 (p 396, right column) | "In those days editors didn't request the names of instruments. I went through my hard copies and could not find this information. If you check my paper on giving bad news to residents in Greenberg 1999b both of the communications skills instruments [the instruments used in Greenberg 1999b and Ottolini 1998] are published in that article." | Greenberg 1999b speaks about 2 valid, reliable instruments used to assess interpersonal skills (p 1210, right column): GTS and PPQ. GTS has a maximum score of 20 points, while PPQ has a maximum score of 35 points. So none of them can be the score used in Greenberg original study. About PPQ, the paper refers to see Schnabl 1991 In the result section the paper says, "The interpersonal or counselling skills checklist was not examined for reliability" (p 1211, right column) | Data excluded | No clear evidence of tool validation | |
| PPQ | see Schnabl 1991 | "The tool was based on Barbara Korsch's work but not psychometrically validated" | The tool used is not PPQ (7 items with a maximum score of 35 points) but IPS (13 items with a maximum score of 91 points) | Data excluded | No clear evidence of tool validation | |
| GHS: general history scale; GMS: general management scale; PPQ: patient perception questionnaire; SHS: specific history scale; SHT (subset of items of SHS): specific history triage. | ||||||
