Analysis of Final Year Veterinary Students’ Telephone Communication Skills at a Veterinary Teaching Hospital

Client communication is a core clinical skill that is taught as part of the required curriculum at many veterinary colleges. Although much client communication occurs face-to-face, telephone communication is used to provide patient updates, relay results of diagnostic tests, and check on discharged patients. This research explored fourth year veterinary medical students’ telephone communication skills. We recorded and analyzed the transcripts of 25 calls students made to clients of three different services in the Veterinary Teaching Hospital. Additionally, we explored the perspectives of veterinary educators by distributing a survey to university faculty and house officers (n = 57). Results indicate that students excelled at identifying the patient and purpose of the call and incorporating professional language and clear explanations. They require development in providing structure and incorporating core communication skills. Compared with our survey results, the student findings are at odds with clinicians’ expectations of students’ communication abilities. 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 open ended questions, reflective listening, and empathy. This data will inform design, and help to measure the impact, of telephone communication education and training that will be incorporated into the existing veterinary communication curriculum.


Design
The study design was exploratory and descriptive with a mixed-methods approach. Findings from the initial quantitative analysis of 25 student-client audio recordings were used to inform design of a veterinary educator survey for secondary quantitative and qualitative analysis. In the present study, the secondary analysis helps to inform the initial set of quantitative data.

Current North Carolina State University (NCSU) Communication Training Curriculum
In 2018, the AAVMC (American Association of Veterinary Medical Colleges) introduced a new Competency Based Veterinary Education (CBVE) program that outlines nine domains of competence for veterinary graduates [40]. Each competence domain is composed of competencies and suggested subcompetencies. The 5th Domain of Competence in this framework is communication, and the competencies within that domain are: [5.1] listens attentively and communicates professionally and [5.2] adapts communication style to colleagues and clients [40]. NCSU students are currently exposed to a robust communication curriculum that spans four courses across the first three years of the Doctor of Veterinary Medicine, (DVM) program. In total, students receive 55 hours of classroom instruction in communication, participate in four simulated client interactions with detailed feedback from a communication coach, and engage in peer feedback and self-reflection. Communication instruction includes information and practice with face-to-face client interactions, team communication and collaboration, and written communication. Within this didactic and experiential curriculum, students learn how to structure a client encounter, build client relationships, and incorporate core communication skills, all of which are transferable to telephone interactions.

Authentic Student-Client Telephone Communication
All NCSU fourth year veterinary students enrolled in equine medicine, small animal internal medicine, and small animal orthopedic surgery clinical rotations were invited to participate in the study during a one-year period. Students on rotation from other accredited veterinary colleges were excluded from the study group. One designated telephone in each clinical service area was equipped to digitally capture all audio recordings. Student use of the designated telephone was completely voluntary. Client consent for audio recordings of telephone conversations is a routine question on the admitting paperwork for the veterinary teaching hospital.
Recorded calls were stored as audio files in an online call database, organized by clinical service area. Access to the database was password protected and limited to the study's principal investigators and research staff. From the database of recordings, calls were randomly selected by transcribing every 7th call in the list. Transcribers screened selected calls to ensure that calls by the same student had not been previously transcribed, and that the call had at least three conversational "exchanges" between the student and the client. If the randomly selected call failed to pass quality control measures, the next call was selected as a replacement. Of the 25 students randomly selected, 13 were on orthopedic surgery rotation, 6 were on equine medicine rotation, and 6 were on internal medicine rotation. Transcription was completed by research assistants.
A standardized rubric (see Appendix A) was used to analyze transcribed calls for four different themes of veterinary-client communication: (1) students incorporating appropriate identification, (2) students providing call structure, (3) students incorporating core skills, and (4) students communicating professionally. Within these four themes, 16 elements were noted as missing/no or complete/yes, with an 'optimal' performance score of 16/16. Calls were coded by 2 different evaluators. Inter-rater reliability was calculated for 72 percent of the sample and showed moderate agreement between coders, k = 0.75 as assessed using Cohen's Kappa [41]. The coders reconciled any discrepancies collaboratively.

Educator Questionnaire
All clinical educators of the Veterinary Teaching Hospital, including senior faculty, interns and residents, were invited via email to complete an anonymous online questionnaire created with Google Forms (see Appendix B). The questionnaire included 19 yes/no questions that addressed educator expectations for student telephone communication strategies (15 items) and training (4 items), as well as two open-ended questions that addressed preparation and learning outcomes for telephone communication experiences on clinical rotations. Respondents were asked to indicate their veterinary career stage as faculty, intern, or resident. Of the clinical educators surveyed, 35 were faculty, 8 were interns, and 14 served as residents in a teaching hospital.

Data Analysis
Data were analyzed using both quantitative and qualitative methods. The quantitative survey data was analyzed using SPSS, version 25 IBM Corp., Armonk, NY, USA) where Chi-square tests were performed to identify statistically significant differences between groups. Graphpad Prism 7 version (Graphpad Software, LaJolla, CA, USA) was used to calculate and compare the mean (± SE) rubric score of student telephone calls grouped by time of year, using an unpaired, two-tailed student's t test with Welch's correction. The qualitative survey data was analyzed using NVivo, version 10, a qualitative software package (QSR International, Melborne, Australia). The two open-ended question responses were coded in two phases. The first was inductive, using open and axial coding to gather emerging trends in the data. The second was a deductive coding process in which responses were coded in comparison to the developed standardized rubric [42].

Ethical Considerations
The study was approved by the North Carolina State University Institutional Review Board (No. 6589). Table 1 includes a complete breakdown of student performance. First, students were not adept at appropriate identification during telephone conversations. Only 3 students (12%) identified themselves by their full name and identified their role as a student within the hospital to clients. At the beginning of the calls, 14 students (56%) identified the recipient by name, whereas 22 students (88%) identified the patient. With regard to students communicating professionally, only nine students (36%) provided clear explanations to clients. Despite the fact that a majority of students (n = 17; 68%) used professional language, nine students (36%) also engaged in unprofessional behaviors such as laughing at inappropriate points in the conversation. Providing structure to the conversation is an important telephone communication skill. This includes explaining the purpose of the call, previewing topics, summarizing, and repeating instructions. Most students (n = 20; 80%) explained the purpose of the call, but not one student provided a preview to the topics that would be discussed. Only 13 students (52%) summarized or reiterated next steps, and just nine students (36%) repeated instructions for the client in closing. Students' also require development at incorporating core communication skills. Only two students (8%) asked an open-ended question, nine (36%) practiced reflective listening, and three (12%) were able to communicate without incorporating vocal segregates such as "um". Despite having opportunities to communicate empathy in all 25 phone calls, only five students (20%) included an empathetic statement. The rubric used to code student calls consisted of 16 elements, giving an "optimal" communication score maximum of 16. Calls were divided into 2 groups by time of year (May-August vs. September-March), based on the clinical year calendar of May-April. While we speculated that student telephone communication rubric scores would be higher for students with more clinic experience, there was no statistically significant difference between the average rubric score of the two groups (p = 0.5521) (see Figure 1).
Of the clinical educators surveyed, almost all of them (n = 55, 97%) felt that student-client telephone interactions are an extension of the veterinary care offered by the veterinary teaching hospital and that students should further develop their communication skills as part of the client interactions. Based on qualitative analysis of open-ended survey responses, clinical educators see participation on rotations and communicating with clients over the telephone as opportunities to learn how to communicate complex information and enhance their core communication skills. Despite this finding, only 35 clinical educators (61%) responded that they provide specific guidelines to students for how to communicate with clients over the phone. When asked how they advise students to prepare for calling clients, the most frequent open-ended responses among clinical educators were: to review the case before calling, check on the up to date status of the patient, and anticipate questions the client may have. They also encourage students to seek help from a clinical educator if they do not know something. The feedback students receive with respect to their telephone communication skills varies with 24 clinician educators (42%) indicating that they listen to student phone calls and provide feedback. Clinical educators prefer to serve as examples with the majority of participants (n = 52, 91%), indicating that they allow their students to listen to their conversations with clients over the phone.

Discussion
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.

Conclusions
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.