This is the first study which has attempted to include a representative sample of hospital doctors from all somatic disciplines, trained specialists as well as doctors in internships, in a general training programme in clinical communication. The rate of attrition was limited (well under 20 per cent), and did not affect the distribution by gender, age, type of position and specialization to any significant extent. With regard to representativeness we regarded it as positive that nine of the participants (15 per cent) had weak, negative or indifferent expectations to the benefit to be gained from the course, since it is unusual for less motivated doctors to participate in this type of studies at all.
The questionnaire on self-efficacy has been used in the context of communication training for oncologists and is not especially intended for «Four good habits». We chose to use this questionnaire since the skills examined are relevant in many different situations, because the characteristics of the questionnaire have been tested, and because the training programme teaches general communication skills. Of the skills that were surveyed, only how to initiate and end the conversation and how to encourage discussion and exploration of emotions (such as anger) were practised in all the groups. Many groups also practised how to report bad news. On the other hand, no groups specifically practised how to detect serious anxiety or depression. The differences in the changes among the indicators are a sign that the group training may have had an effect, and that the doctors have made assessments of the substance of each item in the questionnaire separately. In terms of the study’s validity, it can be argued that the doctors have been prone to provide positive feedback out of regard for the instructors, or because they could not rely on remaining anonymous.
Most doctors reported an improved self-efficacy after the completion of the training course. However, the average change constituted less than half of the 1.3 points that were observed in a Danish study of doctors and nurses in a paediatric department, in an intervention that lasted for five days (5). Even though the change detected by us is statistically significant, the implications of this change remain uncertain. A sense of self-efficacy increases well-being on the job, and it has been shown that patients’ compliance with the treatment is positively correlated with the doctors’ well-being in their job (6). Ten of our doctors reported feeling less self-efficacious after the completion of the training course. This notwithstanding, they came out of the course with a more positive attitude to its learning effect than they had at the outset. In the oral evaluation session, three of the five doctors who reported the largest negative change expressed that the course had made them aware of a number of aspects of their own way of communicating, and that they perceived this as highly useful. A negative change in the perception of self-efficacy may be related to the realization of a need for improvement. Such realizations are motivating, and it would be likely to have a beneficial effect if these doctors could be given some follow-up, for example in the form of feedback based on video recordings.
Kaiser Permanente has experienced that weakly motivated doctors have welcomed «Four good habits». We find that doctors with low expectations or low initial self-efficacy perceive an equally positive change in their self-efficacy as doctors who enter the course with high expectations and high self-efficacy. Similarly we find no differences related to age or gender, or to whether the doctors are chief consultants or interns. This indicates that the level and methods applied in the course are generally useful. It would also appear that they function well across specializations, although this result should be given less emphasis, since each group consisted of relatively few doctors. We wish to underscore that an effect on self-efficacy does not necessarily imply a subsequent change in behaviour. Our findings indicate that the doctors perceived that they had benefited from the course irrespective of such factors, but it remains to be seen whether this has entailed any changes in behaviour.
Empathy, Habit III, was the habit that the fewest doctors reported they wanted to practise after returning to clinical work after the training course. We can imagine a number of causes for this observation. Many doctors expressed that they felt confident about their abilities in this respect. Others also noted that they often would refrain from discussing emotional aspects to prevent the consultation from taking too much time. The course, on the other hand, emphasizes that even small demonstrations of empathy may have a positive effect, and only rarely entail a loss of time. However, this habit is less instrumental than the others, and it may well be that we succeeded to a lesser extent in creating convincing role-play situations for this habit than for the other ones.