Soft skills for physicians : Have we addressed it enough ?

A century ago, Sir William Osler created a new approach to medical education based largely on ‘role modelling’ – that is teaching by example. Good ‘role modelling’ needs a bundle of desirable soft skills. The need to train doctors in soft skills is recognised world over. However, the focus given to this aspect of training in Sri Lanka seems to be inadequate. I hope to share my experience during my role as a trainer and a mentor for medical undergraduates and postgraduates for more than 30 years, in Sri Lanka.


Introduction
A century ago, Sir William Osler created a new approach to medical education based largely on 'role modelling' -that is teaching by example.Good 'role modelling' needs a bundle of desirable soft skills.The need to train doctors in soft skills is recognised world over.However, the focus given to this aspect of training in Sri Lanka seems to be inadequate.I hope to share my experience during my role as a trainer and a mentor for medical undergraduates and postgraduates for more than 30 years, in Sri Lanka.
I have few reasons for deciding to address about soft skills.Firstly, it is my personal view over the years that many medical students and trainee physicians, and regrettably some trainers are weak in soft skills.Many of my mentors, colleagues and nursing staff have shared my view.Secondly, I have been told by the successive Directors of the Postgraduate Institute of Medicine, that the negative aspects of the feedback that they receive from trainers in countries like the United Kingdom and Australia about our physician trainees was that our trainees were consistently weak in softs kills (personal communication).Thirdly, it is the perception by the public of Sri Lanka.Patients and their carers often voice their dissatisfaction about the way they were treated by their doctors.There are times when doctors have verbally abused nurses 1 .Sometimes, these matters are highlighted in newspapers, television and the radio 2 .
Therefore, the deficiency in soft skills amongst doctors is a matter of concern and this is an issue even in the developed world 3 .Often doctors end up on the dock not because they are technically incompetent, but because of poor soft skills such as communication skills.

Building trust as a doctor
Being a doctor is a huge privilege, but it also carries a huge responsibility.It is known that the public trusts doctors, more than any other group of professionals.Values that have earned such trust over generations are: high standards of practice, integrity, a clear sense of duty, respect for others, acknowledging limits of confidence and above all, recognizing that we accept personal responsibility to all what we do.Medical professionalism refers to these behaviours that are expected of doctors in order to maintain the high level of trust the society has in them 4 .

Where do we learn soft skills within the conventional learning domains?
Most matters concerning medical professionalism fall within the affective or attitudinal domain of learning.Affective or attitudinal domain is the learning domain where we feel about things that we do and therefore it involves emotions.If we were to learn for example, innervation to a particular muscle we would use the cognitive domain but if we were to learn about eliciting the knee jerk of a patient we would use both cognitive and psychomotor domains.Learning within the cognitive domain involve, assimilation of knowledge to be stored in the 'brain' for future use.Learning within the psychomotor domain involve, acquisitions of skills that we do with our 'hands'.If we were to learn as to how we would obtain consent to do a lumbar puncture, the learning process will involve all three domains.Most of the tasks that are learned by medical students or doctors would involve all three learning domains (Figure 1) to a variable degree depending on the task.Vol.44, Nos. 1 & 2, 2013   Soft skills for physicians Generally, medical students and doctors tend to learn what is assessed in their examinations.In other words, learning is mostly driven by assessment.It is also known that assessments at medical examinations be it undergraduate or postgraduate, is more focussed towards assessing learning in cognitive and psychomotor domains.As a result, our trainees tend to ignore training in areas where they need a greater commitment to learning in the affective domain, such as developing professionalism.

What soft skills are important to the medical profession?
Several behaviours or skills that are explicit of sound professional conduct are shown in table 1 5 .These skills are called soft skills and are less tangible and harder to quantify and are driven by the personality, compared to hard skills such as doing an intravenous cannulation, which can be taught and measured.Soft skills are subjective and are also known as 'people skills' or 'interpersonal skills'.Table 2 summarises the differences between soft and hard skills.It is easy for doctors to be trained in hard skills such as using an ophthalmoscope but it is difficult to train them to acquire soft skills such as responsiveness to the needs of patients or the society.Soft skills are mainly driven by emotional intelligence.
Soft skills get little respect but it can make or break a carrier.Hard skills determine whether a person gets called for a job interview whereas his or her success at the interview is often decided by the competency in soft skills.Hard skills can be judged based on what is stated in the curriculum vitae of job applicants, but their competency in soft skills cannot be judged on the basis of the job application and it is the interview that enables decision making on the latter.Hard skills are necessary to get a job but those alone are insufficient to retain it or to advance in it.Soft skills complement whatever hard skills which are the occupational requirements of a job and any activities outside the job 6 .
Soft skills are personal attributes that enhance an individual's interactions, job performance and career prospects.Unlike hard skills, which are about a person's skill set and the ability to perform a certain type of task or activity, soft skills relate to a person's ability to interact effectively with coworkers and patients, and are broadly applicable both in and outside the hospital or the clinic.Soft skills help doctors to become smarter, sharper and more effective.Soft skills help in improving interpersonal and communication skills; confidence and attitude building; team building and motivation.
Although there are many soft skills that are desirable for doctors, I will selectively address some of those in some detail.Healthcare teams are multiprofessional and are often lead by specialist doctors.Therefore, physicians should possess good leadership skills 7 .Leadership has no hierarchical connotation.The followers of a boss often comply with his or her orders and directives because of the fear of non-compliance.On the other hand, followers of a leader want to achieve the high goals set by the leader because they believe in, and share a common vision.Knowledge and skills contribute directly to good leadership; other attributes in relation to soft skills make him or her unique.These I will highlight few areas where Sri Lankan doctors need to improve their performance in interpersonal relationships, especially when working as a team player.Those include, handing over and taking over of patient care, completing their clinical duties to the best of their abilities, covering up duties of colleagues and informing the consultants about sick patients and serious incidents as well as informing consultants about the successes and failures.Doctors should not argue with nurses and other team members, especially in front of patients and their relatives.
Physicians have to be good listeners.They have to ensure that they take time and give clear messages to members of the healthcare team as well to their patients and carers.They have to learn to recognize subtle non-verbal clues.As mentioned earlier, many Sri Lankan doctors are weak in communication skills.Often our trainee physicians find it difficult to settle down when they start working in a different country where the health system is different and when they have to come to terms with identification of their new professional roles and relationships.Some of our trainees are weak in their written and spoken communication skills in English, as well.This is reflected in the lower bands of scores they achieve in the in the International English Language Testing System (IELTS) and the need for multiple attempts to secure the required band of score (personal communication).

Can we teach soft skills?
In Sri Lanka, where there is a milieu of learning with 'tuition' built into the educational culture and climate, most medical students and many doctors expect everything to be taught.Far from what is expected, soft skills have to be learned, rather than taught.In order to foster soft skills, trainees need good mentoring.Consultant Physicians of the Ministry of Health, University Professors of Medicine and their academic staff have a role identified as mentors or trainers in the Physician training program.Qualities that are desirable in mentors/trainers as summarised in table 3 8 .Mentors need to discuss about strengths, weaknesses and aspirations of their trainees to help developing their soft skills.
Soft skills can be learned through reflection and by observing good role modelling of their seniors and through mentoring 9 .Trainer's attitudes, actions, enthusiasm and the interest will influence the trainee.Inappropriate behaviour and unprofessional comments by trainers are bound to impart a negative impact on the trainee.Trainees have to learn through positive Although in medical undergraduate and postgraduate training programs there are curricula that are written out as documents, what is taught by the faculty and what is learned by the students do not make a perfect fit (Figure 2) 11 .Simply, not all of what is taught in medical school or in the postgraduate teaching programs is included in documents such as syllabi, hand outs, lecture notes etc 12 .As soft skills are non-tangible, they fall outside the circles shown in the figure 2 and are considered to be in the hidden curriculum.Hidden curriculum can be considered as ''processes, pressures and constraints which fall outside the formal curriculum, which are often unarticulated or unexplored.''Learning processes in the hidden curriculum are remarkably different from what takes place in overt curricula.In the hidden curriculum, six learning processes can be identified.These include loss of idealism, adoption of a ritualized professional identity, emotional neutralization and change of ethical integrity, acceptance hierarchy and learning of less formal aspects of doctoring 13 .

How can we assess soft skills?
Assessment of soft skills is not straightforward and cannot be a part of summative assessment.There are few ways by which assessment of soft skills can be done 14,15 .

1)
Mentoring: It is better to give immediate feedback on a formative basis and correct any unprofessional behaviour of trainees because summative feedback can be judgemental.Always praise and reward good professional behaviour.
2) Incident reporting: Although a single bad incident cannot draw any concrete conclusions, repetitive unsatisfactory conduct should be taken seriously as professional misconduct.
3) Peer assessments: As peers are at the same level of training and they are in close contact, they may offer unique attributes of humanistic behaviour and team skills.

4) Multi-source feedback (MSF):
This can come from patients, nurses and ancillary staff.Their views are collected by using a structured rating form and collated to be used to make a judgment about the performance.

5) Portfolios:
Portfolio differs from a logbook mainly by the fact that it is a repository of reflective practices that the trainee has been through.Portfolios can reflect professional development.

6) Teaching observation:
Teaching is a generic skill applicable within and outside clinical medicine.Observation of this task gives an opportunity to see how trainees have developed their transferable skills and skills in communication.

Concluding remarks
Soft skills may be considered something that we do not know we are teaching.Soft skills help to develop professionalism and practice of holistic medicine.Therefore, it is important to emphasize the need to consider soft skills as a major attribute of physicians and give appropriate focus during their training.