It is well accepted within the medical community (i.e., physician, veterinary, nursing, etc.) that communication is a core clinical competency and an essential component of education for students in healthcare fields [1
]. Learning “best practices” in communication is a benefit to both patients and healthcare professionals [5
], and in veterinary medicine it is also a benefit to the client [9
]. The literature on communication in physician, nursing and pharmacy training is extensive [8
], but less research has been conducted on communication in veterinary student training. Despite this limitation, extrapolation from other medical professions has allowed progress in establishing best practices for face-to-face interviews between veterinarians and their clients [28
]. Specific communication models adapted from human medicine include the Calgary-Cambridge Observation Guide, “relationship-centered care” and the “four core communication skills of highly effective practitioners”, which include: (1) asking open-ended questions, (2) expressing empathy, (3) using reflective listening, and (4) awareness of nonverbal communication [3
One expanding platform for healthcare communication is the telephone. In human medicine, telephone communication has become an integral part of clinical practice, with telephone calls accounting for one fifth of physician-patient contacts in fields including general practice, general internal medicine, pediatrics, and obstetrics/gynecology [33
]. Public satisfaction with medical telephone consultation is high, with patients identifying less waiting, reduced travel time, and the possibility of increased frequency of contact as benefits [34
]. Medical professionals, however, have reported concerns regarding telephone communication, including an inability to use touch as a communication aid, formality, and relative anonymity [34
]. Recognizing the importance of telephone communication in patient care and understanding the unique challenges this mode of communication presents, nursing, pharmacy, and medical schools have designed curricula to teach various aspects of telephone communication [14
]. Specific skills recommended for telephone communication with healthcare clients include: active listening; frequent paraphrasing to ensure the message sent by one party is the message received by the other party; awareness of paralanguage, including pace of speech, pauses, and voice intonation; and offering opportunities to ask questions [34
From these reported findings, it is clear that healthcare professionals encounter unique challenges when counseling patients and patient caregivers (i.e., veterinary clients) over the phone, and that this form of communication deserves deliberate attention in the veterinary education curriculum. Unfortunately, very little research has focused on telephone communication in veterinary medicine [38
]. In 2010, Cary et al. [39
] reported on integration of a telephone communication training exercise into the junior surgery lab at Washington State University; and, in 2016, Grevemeyer et al. published a framework for vertical implementation of telephone communication skills training for third year veterinary students at Ross University [38
]. Both of these exercises were designed to use veterinary staff or faculty as simulated clients who participated in one or more clinical scenarios and provided structured feedback to students. Results reported by Cary et al. [39
] indicated that veterinary students valued client-telephone communication exercises as part of their junior surgery lab and, in open-ended responses, revealed that they experienced fear about making telephone calls and felt challenged by the amount of time required to prepare for discussions with clients. In the study by Grevemeyer et al., [38
] simulated clients reported that veterinary students were most effective at communication skills relevant to the introduction phase of the telephone interview and were least effective at using open-ended questions, funneling, using lay terminology, and closing the interview. Similar to findings in medical education, these authors concluded that telephone communication skills do not naturally develop on the job and require specific training.
At present, North Carolina State University’s (NSCU) College of Veterinary Medicine (CVM) uses simulated clients for veterinary student communication skills training, but only for face-to-face interviews. There are currently no experiential learning exercises for telephone communication in the three-year communication curriculum at NC State. Prior to designing training exercises for telephone communication, we wanted to gain a better understanding of the current level of telephone communication competence of students who have completed our current curriculum. Therefore, the goal of this study was to analyze authentic, recorded telephone calls between 4th year veterinary students and clients of our veterinary teaching hospital to determine which “basic” communication strategies taught in our 1st through 3rd year curriculum are being used for telephone communication during the 4th clinical year. We complemented this data with a voluntary hospital-wide clinician survey, asking faculty, residents, and interns questions about what communication skills they think students use during telephone communication with clients, how they instruct their students regarding telephone communication, and what they think students should learn from client telephone communication. Our overall goal for this project is to use this data to inform design, and measure impact, of telephone specific education and training that will be incorporated into our existing veterinary communications curriculum.
The primary goal of this project was to determine the level of communication competency of final year veterinary students during authentic telephone conversations with clients. Students at our university receive three years of didactic and experiential communication training prior to entering their final clinical year; therefore, we hypothesized that students’ telephone communication would benefit from this training and would, at minimum, include elements of core communication skills relevant for telephone communication (open-ended questions, reflective listening, empathy statements). However, our results do not support this hypothesis. While most students identified the patient by name and explained the purpose of the call to the client, only a few students identified themselves and their role, provided a preview of the call, or incorporated core communication skills such as reflective listening, open-ended questions, and empathy. We speculate that these communication deficiencies could be due to lack of a structured approach and dedicated practice, anxiety around telephone communication, and/or lack of attention to preparation and planning. This position is supported by previous work by Grevemeyer et al., who report that veterinary students felt fearful of, and had difficulty preparing for, telephone conversations with simulated clients [38
]. It is also possible that trying to accomplish multiple tasks at once (taking ownership of a patient case, organizing medical knowledge, processing diagnostic test results, and communicating with a client) increased students’ cognitive load [43
], which adversely impacted their ability to communicate competently.
When presented with our preliminary findings, some clinical faculty within our veterinary teaching hospital were concerned that “routine phone updates” may not be an adequate way to assess student communication, as some core communication skills (i.e., reflective listening, empathy statements) could be deemed unnecessary in this context. In other words, some clinicians may view telephone communication about routine updates, prescription questions, or discharge follow up as not requiring “best practices” in client communication the way more complex conversations do. While we concede that most of the student calls in our study did not deal with significant conflicts or high-stakes decision-making, we would hope to convince veterinary educators and students alike that every client telephone call is an extension of veterinary healthcare services that could be improved with effective, thoughtful, and purposeful communication.
Findings suggest that telephone skills used by students in the first half of the clinical year vs. the second half of the clinical year do not change significantly. For veterinary educators this is somewhat disheartening, since general expectations are that 4th year DVM students who are about to graduate should be performing at a higher level, both cognitively and technically, than students at the beginning of their clinical year. However, it is hardly surprising, since previous evidence clearly indicates that in the realm of medical communication, “experience alone is a poor teacher” [44
]. Because clinical year students at NCSU are not required to receive feedback or coaching on their telephone communication skills, and only 42% of clinician educators do so voluntarily, students are clearly in need of formalized training, practice, and coaching before expectations for improvement over the course of clinical training will be realized. While it is also important to note that additional research would be needed to determine whether individual veterinary students’ telephone communication skills improve over the course of their clinical year, we plan to focus future education and research efforts on formalized coaching and assessments.
To further inform our understanding of this data and to gain the perspective of veterinary educators on student training in telephone communication, we surveyed veterinary faculty and house officers. Results from this survey indicate that clinicians see student-client communication as an extension of veterinary care, feel students can learn from telephone conversations with clients, and generally have higher expectations for student telephone communication competency than our recorded data analysis indicates. From these findings, we conclude that additional training is required to familiarize students with expectations regarding telephone communication, including reviewing the case thoroughly, preparing to answer questions and provide explanations, following organizational protocol, and incorporating chunk and check, open-ended questions, reflective listening, and empathy. Moving forward, this data will inform design, and help to measure impact, of telephone specific education and training that will be incorporated into our existing veterinary communications curriculum.
In summary, this research points to further opportunities to develop students’ telephone communication skills. We recommend developing clear expectations regarding telephone communication including thoroughly reviewing the case, preparing to answer questions and provide clear explanations, following organizational protocol, and incorporating chunk and check, open-ended questions, reflective listening, and empathy. We also recommend experiential training during the clinical year to facilitate development of students’ telephone communication skills, including coaching them in preparation of making calls so they will be able to provide informed updates and instructions and anticipating client questions so they are able to communicate in a way that clients will deem valuable. Finally, we recommend recording student phone conversations and providing them with specific, detailed feedback regarding these interactions.