verbal communication skills

VERBAL COMMUNICATION SKILLS

Medical Research in Biblical Times from the Viewpoint of Contemporary Perspective

Liubov Ben-Nun

The present book deals with communication which is an important human characteristic. In order to maintain relationships effectively humans must communicate with each other. In everyday life, there are many types of communication including with work colleagues, family, neighbors, and friends, some efficient and some inefficient. How do health care providers interact with each other? How do they interact with their patients? How do they deliver difficult issues to their patients? To their families? How do they handle conversations related to difficult medical situations? Should medical students, interns and health care providers be taught how to conduct effective conversations? How to deliver difficult messages to the patients? In order to answer these questions biblical verses related to communications skills are studied.

About the Author Dr. Liubov Ben-Nun, the Author of dozens Books and Articles that have been published in scientific journals worldwide. Professor Emeritus at Ben Gurion University of the Negev, Faculty of Health Sciences, Beer-Sheva, Israel. She has established the "LAHAV" International Forum for research into medicine in the Bible from the viewpoint of contemporary medicine.

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VERBAL COMMUNICATION SKILLS

Liubov Ben-Nun Professor Emeritus

Ben-Gurion University of the Negev, Faculty of Health Sciences, Dept. of Family Medicine Beer-Sheva, Israel

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Published By B. N. Publication House, Israel. 2015. Fax: +(972) 8 6883376 Mobile 050 5971592 E-Mail: [email protected] Distributed Worldwide Technical Assistance: Carmela Ben-Nun-Moshe. © All rights reserved

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CONTENTS MY VIEW PREFACE FOREWORD INTRODUCTION THE BIBLICAL VERSES LISTENING AND UNDERSTANDING PEOPLE WITH COMPLEX COMMUNICATION NEEDS PHYSICIAN-PATIENT COMMUNICATION COMMUNICATION WITH WORK COLLEAGUES PHYSICIAN NON-ENGLISH LANGUAGE PROFICIENCY E-MAIL FOR CLINICAL COMMUNICATION GENDER DIFFERENCES IN MEDICAL ENCOUNTER COMMUNICATION WITH YOUNG ADULTS STRESSFUL/DIFFICULT CONVERSATIONS CUES TO PERCEPTION OF REDUCED FLAPS LOW HEALTH LITERACY CULTURALLY COMPETENT COMMUNICATION EFFECTIVE COMMUNICATION PREVENTS LITIGATION HEALTH CARE PROFESSIONALS NURSES' QUALIFICATION QUALITIES PATIENTS WITH ACUTE/CHRONIC DISEASES CARDIOVASCULAR DISEASES CHRONIC OBSTRUCTIVE PULMONARY DISEASE AIDS PATIENTS DEMENTIA MENTAL HEALTH NURSING PEDIATRICS PALLIATIVE CARE ONCOLOGY TEACHING COMMUNICATION SKILLS SUMMARY ABBREVIATIONS

1 2 3 6 9 10 13 16 18 24 25 28 30 31 35 35 37 39 41 53 56

82 90 105 118 126

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Communication skills

MY VIEW MEDICINE IN THE BIBLE AS A RESEARCH CHALLENGE This is a voyage along the well-trodden routes of contemporary medicine to the paths of the Bible, from the time of the first man to the period of the People of Israel. It covers the connection between body and soul, and the unbroken link between our earliest ancestors, accompanied by spiritual yearning and ourselves. Through the verses of the Bible flows a powerful stream of ideas for medical research combined with study of our roots and the Ancient texts. It would not be too adventurous to state that if there is one book in the world that all Jews are proud of, that is the Book of Books, the greatest classic among all literary works, whose original language is not Greek or Latin, but the Hebrew that I and other Israelis speak every day, our mother tongue, the language of Eliezer Ben Yehuda. The Bible exists as evidence in the Book of Books, open to all humankind. For thousands of years it has been placed before us, still as fresh as before, the history of peoples who have disappeared and of the Jewish people, which has survived with its Holy Text that has been translated into hundreds of languages and dialects, and remains our eternal taboo. Many people ask me about the connection between the Bible and medical science. My reply is simple: the roots of science are buried deep in the biblical period and I am just the archeologist and medical researcher. This scientific medical journey to the earliest roots of the nation in the Bible has been and remains moving, exciting and enjoyable. It has created a kind of meeting in my mind between the present and those Ancient times, through examining events frozen in time. Sometimes it is important to stop, to look back a little. In real time, it is hard to study every detail, because time is passing as they appear. However, when we look back we can freeze the picture and examine every detail, see many events that we missed during that fraction of a second when they occurred. The Book of Books, the Bible, is not just the identity card of the Jewish, but an essential source for the whole world.

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PREFACE The purpose of this research is to analyze the medical situations and conditions referred to in the Bible, as we are dealing with a contemporary medical record. These are scientific medical studies incorporating verses from the Bible, without no interpretation or historical descriptions of places. Fundamentally, this Research is constructed purely from an examination of passages from the Bible, exactly as written. The research is part of a long series of published studies on the subject of biblical medicine from a modern medical perspective. This is not a laboratory research. The Research is built entirely on a secular foundation. With due to respects to people faith, this Research takes a modern look at medical practices. Each to his own beliefs.

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FOREWORD Communication is an important component of patient care. Traditionally, communication in medical school curricula was incorporated informally as part of rounds and faculty feedback, but without a specific or intense focus on skills of communicating per se. The reliability and consistency of this teaching method left gaps, which are currently getting increased attention from medical schools and accreditation organizations. There is also increased interest in researching patient-doctor communication and recognizing the need to teach and measure this specific clinical skill. In 1999, the ACGME implemented a requirement for accreditation for residency programs that focuses on "interpersonal and communications skills that result in effective information exchange and teaming with patients, their families, and other health professionals." The National Board of Medical Examiners, Federation of State Medical Boards and the Educational Commission for Foreign Medical Graduates have proposed an examination between the third and fourth year of medical school that "requires students to demonstrate they can gather information from patients, perform a physical examination, and communicate their findings to patients and colleagues" using SPs. One's efficiency and effectiveness in communication can be improved through training, but it is unlikely that any future advances will negate the need and value of compassionate and empathetic two-way communication between clinician and patient. The published literature also expresses belief in the essential role of communication. "It has long been recognized that difficulties in the effective delivery of health care can arise from problems in communication between patient and provider rather than from any failing in the technical aspects of medical care. Improvements in provider-patient communication can have beneficial effects on health outcomes". A systematic review of randomized clinical trials and analytic studies of physician-patient communication confirmed a positive influence of quality communication on health outcomes. Continuing research in this arena is important. For a successful and humanistic encounter at an office visit, one needs to be sure that the patient's key concerns have been directly and specifically solicited and addressed. To be effective, the clinician must gain an understanding of the patient's perspective on his or her illness.

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Patient concerns can be wide ranging, including fear of death, mutilation, disability; ominous attribution to pain symptoms; distrust of the medical profession; concern about loss of wholeness, role, status, or independence; denial of reality of medical problems; grief; fear of leaving home; and other uniquely personal issues. Patient values, cultures, and preferences need to be explored. Gender is another element that needs to be taken into consideration. Ensuring key issues are verbalized openly is fundamental to effective patientdoctor communication. The clinician should be careful not to be judgmental or scolding because this may rapidly close down communication. Sometimes the patient gains therapeutic benefit just from venting concerns in a safe environment with a caring clinician. Appropriate reassurance or pragmatic suggestions to help with problem solving and setting up a structured plan of action may be an important part of the patient care that is required. Counseling around unhealthy or risky behaviors is an important communication skill that should be part of health care visits. Understanding the psychology of behavioral change and establishing a systematic framework for such interventions, which includes the 5 As of patient counseling (assess, advise, agree, assist, and arrange) are steps toward ensuring effective patient-doctor communication. Historically in medicine, there was a paternalistic approach to deciding what should be done for a patient: the physician knew best and the patient accepted the recommendation without question. This era is ending, being replaced with consumerism and the movement toward shared decision-making. Patients are advising each other to "educate yourself and ask questions". Patient satisfaction with their care rests heavily on how successfully this transition is accomplished. Ready access to quality information and thoughtful patient-doctor discussions is at the fulcrum of this revolution (1). Effective communication is an essential skill in general practice consultations. The art of communication is the development of effective skills and finding a style of communication that suits the clinician and produces benefits for both patient and doctor. The essential skills are required for effective communication with a patient and clinicians consider this communication as an art that can be developed throughout a medical career. Good communication can improve outcomes for patients and doctors, and deserves equal importance to develop clinical knowledge and procedural skill. A

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therapeutic patient-doctor relationship uses the clinician as a therapeutic intervention and is part of the art of communication. Despite all the technological advances of recent caring, compassionate, healing doctors remain the best therapeutic tool in medicine. The ability of a doctor to provide comfort through their presence and their words is a fundamental component of good medical care (2). Because communication is something that is often taken for granted, many people do not consciously think about communication habits and behaviors. When patients are questioned concerning important attributes of a doctor, they say they want someone who respects and listens to them. In a time of increasing malpractice litigation, physicians need to examine their communication skills. In an increasingly more diverse world, social and cultural beliefs, attitudes, and behaviors have a considerable effect on the health of communities. Patient safety, satisfaction, and successful outcomes rely on understanding the patient's medical and cultural needs. The concept of becoming a "cultural anthropologist" is improbable, but becoming aware of the demographics of the community in which the physician serves will improve communication and lead to improved patient and physician satisfaction, better patient compliance, and improved health outcomes (3). Interpersonal communication and cooperation do not happen exclusively face to face. In work contexts, as in private life, there are more and more situations of mediated communication and cooperation in which new online tools are used. However, understanding how to use the Internet to support collaborative interaction presents a substantial challenge for the designers and users of this emerging technology. Collaborative Internet environments are designed to serve a purpose, so must be designed with intended users' tasks and goals explicitly considered. In cooperative activities, the key content of communication is the interpretation of the situations in which actors are involved. Therefore, the most effective way of clarifying the meaning of messages is to connect them to a shared context of meaning. However, this is more difficult in the Internet than in other computer-based activities. This paper tries to understand the characteristics of cooperative activities in networked environments shared 3D virtual worlds - through 2 different studies. The first used

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the analysis of conversations to explore the characteristics of the interaction during the cooperative task; the second analyzed whether and how the level of immersion in the networked environments influenced the performance and the interactional process (4). References 1. Teutsch C. Patient-doctor communication. Med Clin North Am. 2003; 87(5):1115-45. 2. Warnecke E. The art of communication. Aust Fam Physician. 2014; 43(3):156-8. 3. Lewis VO, McLaurin T, Spencer HT, et al. Communication for all your patients. Instr Course Lect. 2012;61:569-80. 4. Galimberti C, Ignazi S, Vercesi P, Riva G. Communication and cooperation in networked environments: an experimental analysis. Cyberpsychol Behav. 2001;4(1):131-46.

INTRODUCTION A successful reciprocal evaluation of social signals serves as a prerequisite for social coherence and empathy. In a previous fMRI imaging study, naturalistic communication situations by presenting video clips to participants and recording their behavioral responses regarding empathy and its components were studied. In 2 conditions, all 3 channels transported congruent emotional or neutral information, respectively. Three conditions selectively presented 2 emotional channels and 1 neutral channel and were thus bimodally emotional. Channel-specific emotional contributions in modalityrelated areas, elicited by dynamic video clips with varying combinations of emotionality in facial expressions, prosody, and speech content were reported. However, to better understand the underlying mechanisms accompanying a naturalistically displayed human social interaction in some key regions that presumably serve as specific processing hubs for facial expressions, prosody, and speech content, a reanalysis of the data were pursued. Two different descriptions of temporal characteristics within these 3 modalityrelated regions including right FFG, left AC, left AG and left dmPFC were examined. By means of a FIR analysis within each of the 3

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regions, the post-stimulus time-courses as a description of the temporal characteristics of the BOLD response during the video clips were examined. Second, effective connectivity between these areas and the left dmPFC was analyzed using DCM in order to describe condition-related modulatory influences on the coupling between these regions. The FIR analysis showed initially diminished activation in bimodally emotional conditions but stronger activation than that observed in neutral videos toward the end of the stimuli, possibly by bottom-up processes in order to compensate for a lack of emotional information. The DCM analysis instead showed a pronounced topdown control. Remarkably, all connections from the dmPFC to the 3 other regions were modulated by the experimental conditions. This observation is in line with the presumed role of the dmPFC in the allocation of attention. In contrary, all incoming connections to the AG were modulated, indicating its key role in integrating multimodal information and supporting comprehension. Notably, the input from the FFG to the AG was enhanced when facial expressions conveyed emotional information. These findings serve as preliminary results in understanding network dynamics in human emotional communication and empathy (1). A patient may become a "problem" owing to 3 groups of causes acting either independently or together. Group 1 is characteristic features of the patient including psychological problems and borderline psychiatric disorders. Group 2 is related to the physician's activity (overfatigue, poor communicative skills, etc.). Group 3 is comprised by the causes related to the peculiarities of the healthcare system structure and organization (overworked physicians, insufficient time that they can spend in direct care to an individual patient, and inadequate information the patients acquire from nonmedical sources). Poor organization of work in an outpatient facility inevitably deteriorates the quality of the provided care. The patients attending it begin making complaints against the personnel, which leads to conflicts even in the absence of serious medical errors. Practical recommendations are proposed designed to help the "problem patients" to obtain quality medical aid and avoid conflict situations (2). As pastoral care personnel are compassionate companions of the sick, we should cultivate a number of personal characteristics and communication skills that will make our ministry most effective.

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Similarly, certain common characteristics and communication styles should be eschewed because they make our ministry ineffective. Being comfortable with feelings, our own as well as others', helps patients feel free to share their emotions and troubles. Similarly, being aware of and accepting our personal identity is requisite to accepting and affirming others. Such negative personal traits as a poor self-image and a high need for control, on the other hand, can keep interactions with patients superficial. Communication styles, positive and negative, flow from personality traits, and it is important to work on both communication and personality at the same time. The pastoral care person should develop skills in attending, "dooropening," and responding, even as he or she strives to eliminate such detrimental practices as "sending solutions," evaluating the other person, and reassuring the person prematurely (3). Effective communication is essential to practice and can result in improved interpersonal relationships at the workplace. Effective communication is shaped by basic techniques such as open-ended questions, listening, empathy, and assertiveness. However, the relationship between effective communication and successful interpersonal relationships is affected by intervening variables. The variables of gender, generation, context, collegiality, cooperation, self-disclosure, and reciprocity can impede or enhance the outcome of quality communication (4). As we see, communication is an important human characteristic. In order to maintain relationships effectively humans must communicate with each other. In everyday life, there are many types of communication including with work colleagues, family, neighbors, and friends, some efficient and some inefficient. This research deals principally with human communication. How do HCPs interact with each other? How do they interact with their patients? How do they deliver difficult issues to their patients? To their families? How do they handle conversations related to difficult medical situations? Should medical students, interns and HCPs be taught how to conduct effective conversations? How to deliver difficult messages to the patients? In order to answer these questions biblical verses related to communications skills are studied.

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References 1. Regenbogen C, Habel U, Kellermann T. Connecting multimodality in human communication. Front Hum Neurosci. 2013;7:754. 2. No authors listed. How to help a "problem" patient. Klin Med (Mosk). 2011;89(6):63-5. 3. Niklas GR. Personal traits, communication skills for effective pastoral care. Health Prog. 1985;66(6):64-6, 72. 4. Grover SM. Shaping effective communication skills and therapeutic relationships at work: the foundation of collaboration. AAOHN J. 2005;53(4):177-82; quiz 186-7.

THE BIBLICAL VERSES Communication between humans is a vital interaction in our lives. This research deals with two biblical verses "Death and life are in the power of the tongue" (Proverbs 18:21) and "A soft tongue breaks the bone" (Proverbs 25:15). These verses indicate that verbal communication is an essential part of human existence. How can we deal with these verses in our everyday life? Communication is defined as the exchange information, or the use of common system of symbols, signs, behavior for this; a verbal or written message; a system of routes; techniques for the effective transmission of information, ideas, etc. (1). Communication also transfers information from one person to another (2). The main message of verses, cited above, is to show the people that their ability to communicate with each other is of vital importance for their existence. The verses have a wide range of implications for our everyday life, dealing with communication with the family, with friends, in society, at work, and with patients. Since the author of this research is a medical doctor, studying Medicine in the Bible, it is natural that this study concentrates mainly on communication in a variety of medical situations.

References 1. The Penguin English Dictionary. 2 Consultant ed. 2003. England.

ND

ED. Penguin Books. Robert Allen

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2. Examples of Non Verbal Communication. Available 15 May 2014 at yourdictionary.com/examples-of-non-verbal-communication.

LISTENING AND UNDERSTANDING The activities involved in mediating reinforcement for a speaker's behavior constitute only one phase of a listener's reaction to verbal stimulation. Other phases include listening and understanding what a speaker has said. It is argued that the relative subtlety of these activities is reason for their careful scrutiny, not their complete neglect. Listening is conceptualized as a functional relation obtaining between the responding of an organism and the stimulating of an object. A current instance of listening is regarded as a point in the evolution of similar instances, whereby one's history of perceptual activity may be regarded as existing in one's current interbehavior. Understanding reactions are similarly analyzed; however, they are considerably more complex than listening reactions due to the preponderance of implicit responding involved in reactions of this type. Implicit responding occurs by way of substitute stimulation, and an analysis of the serviceability of verbal stimuli in this regard is made. Understanding is conceptualized as seeing, hearing, or otherwise reacting to actual things in the presence of their "names" alone. The value of an inferential analysis of listening and understanding is also discussed, with the conclusion that unless some attempt is made to elaborate on the nature and operation of these activities, the more apparent reinforcement mediational activities of a listener are merely asserted without an explanation for their occurrence (1). As we celebrate the 50th anniversary of the publication of B. F. Skinner's Verbal Behavior, it is important to reconsider the role of the listener in the verbal episode. Although by Skinner's own admission, Verbal Behavior was primarily about the behavior of the speaker, his definition of verbal behavior as "behavior reinforced through the mediation of other persons" focused on the behavior of the listener (2). However, because many of the behaviors of the listener are

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fundamentally no different than other discriminated operants, they may not appropriately be termed listening. Even Skinner noted that the behavior of the listener often goes beyond simply mediating consequences for the speaker's behavior, implying that the listener engages in a repertoire of behaviors that is itself verbal. It has been suggested that listening involves subvocal verbal behavior; there are some of the forms and functions of the listener's verbal behavior (including echoic and intraverbal behavior). In conclusion, there may be no functional distinction between speaking and listening (3). As part of the epistemological transition from positivistic to relativistic science that had begun earlier in the twentieth century, the researchers attempted to update psychoanalytic thinking in formulating the empathic mode of observation (4-7). The purpose of this paper is to reassess, through a conceptual and historical lens, the considerable controversy generated by the empathic perspective. The author specifically addresses constructivist philosophical underpinnings, the use and impact of the analyst's subjectivity, the inclusion of unconscious processes, the need for additional listening perspectives, and the influence of theoretical models in the organization of empathically acquired data (8). A rhetorical form designs to clarify and sharpen the focus of the very special stance required - which must be painstakingly learned under careful supervision - in order to effectively tune in to communications coming from the unconscious of the patient. This is the hardest task that must be mastered to become truly empathic and sensitive in dyadic relationships, a unique expertise that marks the psychiatrist as a genuine specialist in medical practice. Regardless of theoretical orientation, neither the form nor content of any therapeutic intervention can be appropriate unless it is empathically based. Clinical vignettes illustrate that the lack of such empathy, and readings enhance our approach to learning this skill, borrowing especially from Kohut and Bion. The great importance of the often ignored "background" of the patient's communication is emphasized, and is illustrated from the field of music in the work of John Cage and Anton Webern. The congruence between this clinical psychiatric problem and the main thrust of Continental philosophy, which attempts to put man back in touch with himself, is described. Suggestions are offered to supervisors how to develop these skills in the novice. Finally, a discussion is presented of the effect on the

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professional and personal life of the therapist who has not developed these skills, emphasizing the dangers of "burn-out" in therapists and the implicit philosophy of life in a money-oriented practice of psychotherapy. The dangers of not attending to such matters even during residency training are pointed out in an attempt to raise the consciousness level of the therapist to the extreme importance of background practices both in the patient and in the therapist (9). In the HCPs, the results of miscommunication and misunderstanding can be costly. Stress-related ailments and burnout frequently occur. Managers therefore should examine organizational communication strategies and offer ways of dealing with stress, if necessary. One stress-reduction measure that can be undertaken at little cost is bridge building. The bridge-building process involves making a connection or link between people by careful listening and attention to their interactions with another. Bridge building may include persons from all organizational levels; the only limits are participants' willingness to risk and their desire to improve the work environment. One strategy for bridge building is the story meeting. Because stories are a representative way of addressing complex issues, they can provide a framework for handling sensitive situations. Creating a story about a department or work team allows persons to deal with inner frustrations in a nonthreatening way and to consider creative outcomes to their shared problem (10). This paper reviews empirical research which has been directly influenced by Skinner's Verbal Behavior. Despite the importance of this subject matter, the book has generated relatively little empirical research. Most studies have focused on Skinner's mind and tact relations while research that focused on the other elementary verbal operands has been limited. However, the results of empirical research that exist support Skinner's analysis of the distinction between elementary verbal operands and his distinction between the speaker and listener's repertoires. Research suggests that language training programs may not be successful if they do not provide explicit training of each elementary verbal operant and independent training of speaker's and listener's repertoires (11).

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References 1. Parrott LJ. Listening and understanding. Behav Anal. 1984;7(1):29-39. 2. Chomsky N. A Review of B.F. Skinner's Verbal Behavior. In Leon A. Jakobovits and Murray S. Miron (eds.) Readings in the Psychology of Language, Prentice-Hall. 1967, pp. 142-3. 3. Schlinger HD. Listening is behaving verbally. Behav Anal. 2008; 31(2):145-61. 4. Kohut H. Introspection, empathy and psychoanalysis. J Americ Psychoanalysis Assn. 1959;7:459-83. 5. Kohut H. The restoration of the self. New York International Press. 1977. 6. Kohut H. Introspection, empathy and the semicircle of mental health. Intern J Psycho-Anal. 1982;63:359-407. 7. Kohut H. How does analysis cure? Goldberg A, Stepansky P (eds.). Chicago: The University of Chicago Press. 1984. 8. Fosshage JL. The use and impact of the analyst's subjectivity with empathic and other listening/experiencing perspectives. Psychoanal Q. 2011;80(1):139-60. 9. Chessick RD. Psychoanalytic listening II. Am J Psychother. 1985; 39(1):30-48. 10. Ward JR. Communications bridges raise productivity, reduce stress. Health Prog. 1987;68(2):71-2. 11. Oah SZ, Dickinson AM. A review of empirical studies of verbal behavior. Anal Verbal Behav. 1989;7:53-68.

PEOPLE WITH COMPLEX COMMUNICATION NEEDS A series of PA and single-word reading tasks, which did not require spoken responses, was developed for administration to people with complex communication needs. The aims of the study were to 1] determine the construct validity of the PA tasks and 2] investigate the relationship between PA and single-word reading in adults with complex communication needs. Forty adults with physical and/or intellectual disability were administered these tasks and a standardized measure of receptive spoken vocabulary. In assessing construct validity, data from all participants, including those who used speech, were included in a factor analysis, which indicated that the PA tasks loaded onto a single factor. This factor was interpreted to be PA. The relationship between PA and single-word reading in

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adults with complex communication needs was determined using correlational and multiple regression analyses of data from 34 of the original participants who did not have functional speech skills. These analyses indicated that receptive spoken vocabulary accounted for a significant amount of variance on most tasks. Additional significant variance in performance on the single-word reading tasks was accounted for by performance on the PA tasks, in particular, Nonword Blending and Phoneme Analysis. These results indicate that the tasks developed provide a valid means of assessing PA and singleword reading skills. In addition, the results indicate that adults with complex communication needs demonstrate the same positive association between PA and reading as has been found in other groups of individuals with and without disability (1). The morphological awareness skills of fourth-grade African American children and the association between degree of AAE use and performance on written measures of morphological awareness were examined. Additional purposes were to determine whether performance on the morphological awareness tasks 1] was affected by the transparency of morphologically related words and the type of task administered, 2] was associated with other literacy and literacyrelated skills, and 3] explained unique variance on these latter abilities. Thirty fourth-grade African American children from lowincome backgrounds were administered 2 morphological awareness tasks and completed norm-referenced measures of word-level reading, reading comprehension, spelling, phonemic awareness, and receptive vocabulary. The degree of AAE use was not associated with students' performance on the morphological awareness tasks. On these tasks, significantly higher scores were obtained on items that represented a transparent relationship between a base word and its derived form. The students' performance on the morphological awareness tasks was significantly and moderately related to their performance on the word-level reading, spelling, and receptive vocabulary measures. Morphological awareness scores explained significant unique variance on measures of word-level reading and spelling, above that predicted by performance on measures of phonemic awareness and vocabulary. In conclusion, fourth-grade African American students' morphological awareness abilities are associated with select language and literacy skills. Professionals should capitalize on students' intact capabilities in morphological

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awareness during literacy instruction in an effort to maximize language and literacy performance for African American students (2). In this study, the contribution made by dialect shifting to reading achievement test scores of AAE-speaking students when controlling for the effects of SES, general oral language abilities, and writing skills were evaluated. Participants included 165 typically developing African American 1st through 5th graders. Half were male and half were female, one third was from low-SES homes, and two-thirds were from middle-SES homes. Dialect shifting away from AAE toward SAE was determined by comparing AAE production rates during oral and written narratives. Structural equation modeling evaluated the relative contributions of AAE rates, SES, and general oral language and writing skills on standardized reading achievement scores. AAE production rates were inversely related to reading achievement scores and decreased significantly between the oral and written narratives. Lower rates in writing predicted a substantial amount of the variance in reading scores, showing a significant direct effect and a significant indirect effect mediated by measures of oral language comprehension. In conclusion, the findings support a dialect shiftingreading achievement hypothesis, which proposes that AAE-speaking students who learn to use SAE in literacy tasks will outperform their peers who do not make this linguistic adaptation (3). References 1. Iacono T, Cupples L. Assessment of phonemic awareness and word reading skills of people with complex communication needs. J Speech Lang Hear Res. 2004;47(2):437-49. 2. Apel K, Thomas-Tate S. Morphological awareness skills of fourth-grade African American students. Lang Speech Hear Serv Sch. 2009;40(3):312-24. 3. Craig HK, Zhang L, Hensel SL, Quinn EJ. African American Englishspeaking students: an examination of the relationship between dialect shifting and reading outcomes. J Speech Lang Hear Res. 2009; 52(4):839-55.

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PHYSICIAN-PATIENT COMMUNICATION An understanding of means to improve patient adherence to the therapeutic regimen is a subject of increasing concern in medical care. This study examined the effects of physician interpersonal skills and teaching on patient satisfaction, recall, and adherence to the regimen. The ambulatory visits of 63 patients to 5 medical residents at a teaching hospital in Baltimore were studied. Quality of interpersonal skills influenced patient outcomes more than quantity of teaching and instruction. All the effects of physician communication skills on patient adherence were mediated by patient satisfaction and recall. These findings indicate that the physician might pay particular attention to these 2 variables in trying to improve patient adherence, and enhancing patient satisfaction is pivotal to the care of patients with chronic illness (1). The physician-patient interview is the key component of all health care, particularly of primary medical care. This review sought to evaluate existing primary-care-based research studies to determine which verbal and non-verbal behaviors on the part of the physician during the medical encounter have been linked in empirical studies with favorable patient outcomes. The literature from 1975 to 2000 for studies of office interactions between primary care physicians and patients that evaluated these interactions empirically using neutral observers who coded observed encounters, videotapes, or audiotapes were reviewed. Each study was reviewed for the quality of the methods and to find statistically significant relations between specific physician behaviors and patient outcomes. In examining nonverbal behaviors, because of a paucity of clinical outcome studies, outcomes were expanded to include associations with patient characteristics or subjective ratings of the interaction by observers. Fourteen studies of verbal communication and 8 studies of nonverbal communication met inclusion criteria. Verbal behaviors positively associated with health outcomes including empathy, reassurance and support, various patient-centered questioning techniques, encounter length, history taking, explanations, both dominant and passive physician styles, positive reinforcement, humor, psychosocial talk, time in health education and information sharing, friendliness, courtesy, orienting the patient during examination, and summarization and clarification. Non-verbal

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behaviors positively associated with outcomes included head nodding, forward lean, direct body orientation, uncrossed legs and arms, arm symmetry, and less mutual gaze. In conclusion, existing research is limited because of lack of consensus of what to measure, conflicting findings, and relative lack of empirical studies (especially of non-verbal behavior). Nonetheless, medical educators should focus on teaching and reinforcing behaviors known to be facilitative, and to continue to understand how physician behavior can enhance favorable patient outcomes, such as understanding and adherence to medical regimens and overall satisfaction (2). Medical educators and researchers recommend a patientcentered interviewing style, but little empirical data exists regarding what aspects of physician communication patients like and why. Patient responses to videotaped doctor-patient vignettes were investigated to ascertain what they liked about patient-centered and biomedical communication. Semi-structured interviews with 230 adult medicine patients who viewed videotapes depicting both patient-centered and biomedical physician communication styles were conducted. A mixed methods approach to derive a "ground-up" framework of patient communication preferences was used. Respondents who preferred different communication styles articulated different sets of values, important physician behaviors, and physician-patient role expectations. Participants who preferred the patient-centered physician (69%) liked that the physician worked with and respected patients and explored what the patient wanted. Participants who preferred the biomedical physician (31%) liked that the physician prevented harm, demonstrated medical authority, and delivered information clearly. In conclusion, patients like (and dislike) patient-centered communication for thoughtful, considered reasons that appear grounded in their values and expectations about physicians, patients, and the clinical encounter. Better understanding the diversity of patient communication preferences may lead to more effective and individualized care (3). The motivation for developing patient-centered communication stems from a desire to enhance the quality of patient care, fulfill professional competency requirements, reduce medical errors, and improve health outcomes and patient satisfaction. Patient-centered communication skills can optimize the physician-patient relationship without significantly prolonging office visits. A series of practical and

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generally effective techniques for verbal and non-verbal communication is proposed. A targeted approach for specific difficult conversations that may occur frequently in the practice of dermatology is suggested (4). References 1. Bartlett EE, Grayson M, Barker R, et al. The effects of physician communications skills on patient satisfaction; recall, and adherence. J Chronic Dis. 1984;37(9-10):755-64. 2. Beck RS, Daughtridge R, Sloane PD. Physician-patient communication in the primary care office: a systematic review. J Am Board Fam Pract. 2002; 15(1):25-38. 3. Swenson SL, Zettler P, Lo B. 'She gave it her best shot right away': patient experiences of biomedical and patient-centered communication. Patient Educ Couns. 2006;61(2):200-11. 4. Nguyen TV, Hong J, Prose NS. Compassionate care: enhancing physician-patient communication and education in dermatology: Part I: Patient-centered communication. J Am Dermatol. 2013;68(3):353.e1-8.

COMMUNICATION WITH WORK COLLEAGUES Good intercollegial communication is a relatively unstudied topic, although it is important for both health professionals and patients, contributing to enhanced well-being, self-awareness and integrity for HCPs, and positively affecting patient outcome and satisfaction. The main objective of this study was to investigate whether a communication skills training course would improve intercollegial communication in an orthopedic department, Kolding Hospital, Odense, Denmark. The study was designed as an intervention study investigating the effectiveness of an in-house training course, evaluated by means of questionnaires. A total of 177/181 (97.8%) participants answered the questionnaire before (T1), 165/169 (97.6%) immediately after (T2) and 150/153 (98%) 6 months after the course (T3). Of 6 questions about intraprofessional communication, 1 and 2 questions were significantly higher at T2 and T3, respectively. Of the 6 questions about interprofessional communication, the increase was statistically significant for 4 questions in T2 and for 5

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questions in T3, respectively. In conclusion, a communication skills training course improved health care professionals' assessment of intercollegial communication, and this was more pronounced in interprofessional rather than in intraprofessional communication, and was more pronounced 6 months after the training course than immediately after the training course. Communication skills training for HCPs is recommended, and should also include all health care professions that have patient contact (1). A systematic review of published literature was conducted to gain a better understanding of ITC in hospital setting in the field of surgical and anesthetic care. Communication breakdowns are a common cause of surgical errors and adverse events. Data sources included Medline, Embase, PsycINFO, Cochrane Database of Systematic Reviews, and hand search of articles bibliography. Of the 4,027 citations identified through the initial electronic search and screened for possible inclusion, 110 articles were retained following title and abstract reviews. Of these, 38 were accepted for this review. Data were extracted from the studies about objectives, clinical domain, and methodology including study design, sample population, tools for assessing communication, results, and limitations. Information transfer failures are common in surgical care and are distributed across the continuum of care. They not only lead to errors in care provision but also lead to patient harm. Most of the articles have focused on ITC process in different phases especially in operating room. None of the studies has looked at whole of the surgical care process. No standard tool has been developed to capture the ITC process in different teams and to evaluate the effect of various communication interventions. Uses of standardized communication through checklist, proformas, and technology innovations have improved the ITC process, with an effect on clinical and patient outcomes. In conclusion, ITC deficits adversely affect patient care. There is a need for standard measures to evaluate this process. Effective and standardized communication among HCPs during the perioperative process facilitates surgical safety (2). The aim of this systematic review was to assess the impact of surgical safety checklists on the quality of teamwork and communication in the operating room. Safety checklists have been shown to impact positively on patient morbidity and mortality following surgery, but it is unclear whether this clinical improvement

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is related to an improvement in operating room teamwork and communication. A systematic search strategy of MEDLINE, EMBASE, PsycINFO, Google Scholar, and the Cochrane Database for Systematic Reviews was undertaken to obtain relevant articles. After deduplication and the addition of limits, 315 articles were screened for inclusion by 2 researchers and all articles meeting a set of prespecified inclusion criteria were retained. Information regarding the type of checklist, study design, assessment tools used, outcomes, and study limitations was extracted. Twenty articles formed the basis of this systematic review. All articles described an empirical study relating to a case-specific safety checklist for surgery as the primary intervention, with some measure of change/improvement in teamwork and/or communication relating to its use. The methods for assessing teamwork and communication varied greatly, including surveys, observations, interviews, and 360° assessments. The evidence suggests that safety checklists improve the perceived quality of operating room teamwork and communication and reduce observable errors relating to poor team skills. This is likely to function through establishing an open platform for communication at the start of a procedure: encouraging the sharing of critical case-related information, promoting team coordination and decision-making, flagging knowledge gaps, and enhancing team cohesion. However, the evidence would also suggest that when used suboptimally or when individuals have not bought in to the process, checklists may conversely have a negative impact on the function of the team. In conclusion, safety checklists are beneficial for operating room teamwork and communication and this may be one mechanism through which patient outcomes are improved. Future research should aim to elucidate the relationship between how safety checklists are used and team skills in the operating room using more consistent methodological approaches and utilizing validated measures of teamwork such that best practice guidelines can be established (3). Many hospitals are unable to successfully implement evidencebased practices. For example, implementation of the CLB, proven to prevent CRBSIs, is often challenging. This problem is broadly characterized as a "change implementation failure." A prospective study was conducted it 2 ICUs, a MICU and a PICU, within an academic health center. Both units had low baseline adherence to

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CLB and higher-than-expected CRBSIs. This study sought to promote CLB implementation in both units through periodic QI interventions over a 52-week period. Simultaneously, it examined 1] the content and frequency of communication related to CLB through weekly "communication logs" completed by physicians, nurses, and managers, and 2] outcomes, that is, CLB adherence rates through weekly medical record reviews. The aim of the study was 2-fold: 1] to examine associations between QI interventions and communication content and frequency at the unit level, and 2] to examine associations between communication content and frequency and outcomes at the unit level. The periodic QI interventions were expected to increase CLB adherence and reduce CRBSIs through their influence on communication content and frequency. A total of 2,638 instances of communication were analyzed. Both units demonstrated an increase in "proactive" communications-that is, communication intended to reduce infection risk between physicians and nurses over time. Proactive communications increased by 68% in the MICU (p