“Relationship Express” is a 3-session, 4.5-hour communication skills curriculum for anesthesiology residents that is brief enough to fit into a busy clinical program. In session 1 (1.5 hours), residents demonstrate their communications skills in 2 encounters with standardized patients (SPs), actors trained to convey a patient scenario in a reliable and consistent manner,6
and receive checklist feedback from the SPs and oral feedback from observing faculty. Session 2 consists of a 1.5-hour communication skills workshop. In session 3 (1.5 hours), residents reencounter the same SP cases as in session 1 and receive checklist feedback, allowing them to compare preworkshop and postworkshop performances.
The Relationship Express model teaches residents how to build effective relationships in a limited time using the C2
was developed by one of the authors (B.B.) after extrapolating key elements from The Kalamazoo Consensus Statement for Essential Elements of Communication in Medical Encounters.7
The tool was developed to respond to the time constraints of a busy anesthesiology practice. Accordingly, residents are expected to develop skills to establish effective relationships in a limited period of time, simulating the clinical anesthesiologist's experience in the perioperative setting. C2
presents a highly focused, simple method to rapidly build relationships by presenting 6 objectives the clinician can reasonably be expected to attain within a 10-minute visit: C
oncerns—identify concerns; C
oncerns—validate concerns; U
nderstanding—ensure understanding; B
uy-in—assure patient agreement with diagnosis and plans; E
nvironment—create a warm relationship environment; and E
nvironment—create a collaborative environment (box
served as both a learning tool in the workshop and a feedback tool in the SP encounters. It formed the basis of the checklist the SPs used to provide feedback to the residents on their communication skills both before and after the workshop.
box Elements of C2UBE2 Checklist
Buy-in—assure patient agreement with diagnosis and plans
Environment—create a warm relationship environment
Environment—create a collaborative environment
All 7 anesthesiology residents from the first year of clinical anesthesiology training consented to participate in this pilot program in 2008. Two anesthesiology faculty members and 2 educators from the Clinical Learning and Simulation Skills (CLASS) center conducted the program. Faculty instructors participated in a 1.5-hour development session with CLASS educators to standardize the faculty in assessing residents and giving feedback. The SPs were recruited from a pool used by George Washington University and received 4 hours of training using standard protocols. Uniformity of assessment and feedback was tested with sample cases via video to confirm that faculty and SPs were providing similar scoring.
The three 1.5-hour sessions of the program were presented on consecutive Monday afternoons during protected educational time (). In the first session, the residents encountered 2 cases: communicating a Bad Result I and Cultural Competency I, selected from the George Washington CREATE (Cross Residency Exercises for ACGME Training and Examination) communications workshops. Anesthesiology faculty adapted these cases for anesthesiology residents. The online appendixes 1 and 2 outline the Bad Results I case instructions for the SP and the resident, respectively.
Process of Relationship Express Workshop
Residents were given 10 minutes to conduct each interview. All residents performed the Cultural Competency I case first, then the Bad Result I case. The SPs used a checklist based on the C2UBE2 tool to conduct a formative assessment of the resident after each case (online appendix 3). The instrument used a 5-point Likert scale ranging from “strongly disagree” (1) to “strongly agree” (5). Faculty observers using real-time video monitors watched residents perform the Bad Results I case and completed the same checklist as the SPs.
In the second session, the residents were given a workshop presenting the C2UBE2 approach. Faculty summarized the C2UBE2 objectives, demonstrated sample skills to achieve the objectives, and challenged residents to personalize the skills to suit their communication styles. Residents practiced the C2UBE2 method by critiquing a video of a George Washington University anesthesiology faculty member's mock interview of an SP portraying the original Bad Result I case. The video demonstrated the case twice: first with weak communication skills, and second with strong communication skills based on C2UBE2 objectives. Residents then practiced the method at a higher level by interviewing 2 SPs portraying a Bad Result II and a Cultural Competency II case. In the third session, the pretest Bad Result I case and the Cultural Competency I case were reintroduced to the residents as a posttest in the form of an objective structured clinical evaluation. This program was internally funded by the CLASS center and approved by The university's Institutional Review Board.
Data for this pilot project were collected from 2 instruments. The first was a communications self-assessment questionnaire based on the C2
checklist, which the residents completed retrospectively. It consisted of 7 items rated on a 5-point Likert scale, with 5 being the best score (online appendix
4). During the third session, residents were asked to self-assess their communication skills prior to the program versus their current perceptions (retrospective premethod/postmethod). Residents assessed the program using an adaptation of the Brookfield Critical Incident Questionnaire (online appendix
We identified themes from their narrative comments, focusing on comments made by 2 or more residents. The C2
checklist was completed by SPs and used to provide feedback to residents on their performance on the pretest and posttest SP exercises. Only 4 residents completed the entire program, because of call obligations and scheduled vacations, and no quantitative analyses were conducted.