All physicians require effective communication skills. Physician interpersonal and communication skills improve health outcomes for their patients and improve treatment adherence [1,2,3]. Because communication is vital to good care, many frameworks exist that guide communication learning in residency training, such as CanMEDS [4], the Accreditation Council for Graduate Medical Education (ACGME) framework [5], or the Scottish Doctor [6]. Despite the availability of current communication models, many models do not address the nuances specific to different specialties. Specifically, in psychiatry, where communication is the primary modality of diagnosis and treatment, advanced and contextualized communication models are required to assist in teaching and assessing learners to diagnose and treat patients.

There are several general frameworks describing physician communication. Kurtz and Silverman [7] first published their communication guide, known as the Calgary-Cambridge referenced observation guide. In Canada, medical schools now widely use the Calgary-Cambridge guide to teach communication skills to medical students. In postgraduate medical education, Canadian and many other jurisdictions worldwide use the CanMEDS framework to inform the communication skills that residents should achieve during their training [4].

Despite the importance of communication skills and communication skills training in medical education, communication literature specific to psychiatry education remains sparse. Evidence from the literature dating back 40 years that educators recognized beginning psychiatry residents can have skills gaps, such as hesitancy to touch on emotional issues, difficulties in handling challenging patients, and struggles in managing countertransference [8]. Decades later, the opinion remains that communication skills training is critical, poorly taught in other specialties, and not often taught well or observed even for psychiatry residents [9]. More recently, a meta-analysis of communication skills training for psychiatrists identified only twelve studies, most frequently focusing on training in specific aspects of interviewing. No studies studied skills retention over time [10]. While psychotherapy training literature does lend some important concepts to psychiatry residency training (e.g., conceptualizations of the therapeutic alliance [11, 12]), most psychiatry-specific communication skills remain understudied [13].

As such, this project sought to examine faculty perceptions of the progression of how skilled communication in psychiatry residents develops from the start of residency training to readiness for practice. Teaching faculty were chosen as the starting point for model development as they routinely supervise and assess trainees. Given that psychiatrists have identified gaps in psychiatry resident communication skills [8, 9], perceptions of this group in how skills development occurs will provide information that can be assembled into a model that can then be tested and validated in real communication scenarios. The specific research objectives included (1) determining what competencies skilled faculty educators use to define a good communicator in psychiatry; (2) stratifying these competencies along a spectrum of increasing complexity; (3) determining the degree of context-dependence faculty use in understanding and assessing communication abilities; and (4) developing a preliminary model of this communication development.

Methods

This study used a constructivist grounded theory approach to explore faculty educators’ perceptions of the progressive development of psychiatry residents’ communication abilities [14]. Constructivist grounded theory is a qualitative research methodology that seeks to explore social processes where no prior theory exists [14]. In addition, it acknowledges that researchers’ and participants’ perspectives can influence the construction of data [14, 15]. As such, it is noted that this research was carried out by four clinician-educators from the fields of medicine and psychology and one PhD scientist trained in medical education research. The team discussed their stances on communication competency before analysis. N. S. is a psychiatrist and junior faculty member who actively teaches and supervises psychiatry residents. M. Z. is a critical care registered respiratory therapist with graduate training in health professions education and qualitative methodologies, practicing outside of mental health and lending an outsider perspective. R. M. is a clinical psychologist, researcher, and co-lead of the McMaster University psychiatry mentorship program. M. M. is an experienced PhD education scientist working within the area of medical education. J. S. is an emergency physician who supervises and teaches in the McMaster University emergency medicine residency program, is the co-editor of the CanMEDS Framework, and led the implementation of a national CBME curriculum for emergency medicine in Canada.

The Hamilton Integrated Research Ethics Board approved this study (no. 5910). Recruitment then proceeded through purposive sampling. Participants were eligible to participate if they were faculty members within the Department of Psychiatry and Behavioural Neurosciences who regularly supervised psychiatry residents one of the two core residency campuses (Hamilton & Waterloo, ON). Participants were recruited from three different disciplines that regularly supervise psychiatry residents (psychiatry, psychology, and social work faculty). Faculty members were approached using a standardized email recruitment script, with one initial email and one follow-up sent within 2 weeks.

Fourteen faculty members participated in one-on-one interviews, including nine psychiatrists, four psychologists, and one social worker. Practice settings included inpatient, outpatient, child, geriatric, medical/surgical consultation, emergency, and chronic care. Nine faculty were female, and five were male. All faculty had supervised residents regularly throughout their tenure in the department, ranging from a minimum of 2 years for newly graduated or newly recruited faculty to over 30 years for the most senior departmental faculty.

Informed consent was obtained from each faculty member before data collection. Interviews ranged in length from 28 to 68 min. The primary author conducted all interviews. Interviews were semi-structured, and the interview guide was updated iteratively throughout the data collection process [14, 16]. The interview guide is available on request from the corresponding author. All interviews were audio-recorded, transcribed, and personal identifiers were removed from the text before analysis. NVivo software was used for data management.

Initial transcripts were coded line by line using thematic analysis to create a code set that was refined and used to analyze all further data [14, 17]. The primary author (NS) did all the initial coding with the second author co-coding 50% of the transcripts to improve analytic rigor [17, 18]. Constant comparative analysis was used during the process of data collection and analysis to ensure all emerging themes and relationships were captured [16] and the research team met regularly during data analysis to discuss analytic themes. Any differences were resolved by discussion and consensus [18]. Data gathering continued until thematic sufficiency was achieved and no new themes were emerging from the data [16].

Once the initial analysis was complete, member-checking was used to validate the themes [18]. All faculty participants were emailed an anonymized summary of the analysis and asked for their opinions on it. Two weeks were allowed for response time. Seven of fourteen faculty members responded to the member-checking email containing the initial analysis, providing written feedback by email. The feedback was used to further refine the analysis.

Results

Five themes were identified, arranged in a staged progression of ability. The first three themes represented foundational abilities and included refining common foundational relational abilities, developing foundational specific psychiatric communication abilities, and managing the internal self. From those foundational abilities, psychiatry residents develop an adaptive and responsive interviewing process (theme 4) that allows them to partner with patients in co-developing care plans (theme 5) (Fig. 1). Table 1 provides a summary.

Fig. 1
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The McMaster Advanced Communication Competencies Model

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Table 1 Summary of the themes from the McMaster Advanced Communication Competencies Model
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Theme 1: Refining Common Foundational Communication Abilities

The data demonstrated that residents were expected to have a set of common foundational communication abilities coming into residency, which anchored all other abilities in this model. Most of the faculty participants noted that they expected residents to enter a psychiatry residency program with established core communication skills learned in medical school and build on this early in residency. Faculty particularly noted that residents needed to build on core skills, including empathy, listening and summarizing, validation, and using appropriate nonverbals. They noted that they expected junior residents to focus on how using these skills can enhance rapport building and trust, which was deemed the foundation on which specialized psychiatric skills were built.

“You know, they’re empathic, they’re respectful, they’re clear, they’re focused, they’re honest in what they’re saying, and they check out with the patient that they’ve understood what they’re saying…” (Interview 1)

Faculty noted that junior residents ought to approach patients in a non-judgmental and respectful way to allow the beginning of a collaborative, helpful therapeutic relationship. Particularly over time, this allows trust to develop and is the foundation of therapeutic rapport. Additionally, some faculty noted that maintaining a genuine stance, which is considered a key foundational psychotherapy skill, was a struggle in early residency, as the resident was focused on trying to develop their other abilities, such as conducting a complete diagnostic interview. Faculty noted that they would frequently redirect junior residents to listening closely as the core ability to focus on if the interaction was becoming overwhelming or challenging to manage.

“I think the listening part of it is hard because they are often thinking about, “What do I need to ask next or not forget?” and then they can miss so much that can happen, what the patient is giving them… I think if junior residents can learn to be present in interviews and listen, I think that makes a huge difference.” (Interview 2)

Theme 2: Developing Specific Foundational Psychiatric Communication Abilities

Alongside core relational abilities, faculty participants identified precise abilities that are consistently taught, learned, and acquired specifically during psychiatry residency. Faculty identified a broad repertoire of psychiatric communication abilities that developed in residency. These included gathering accurate psychiatric diagnostic data from patient assessments efficiently, learning how to do a good suicide risk assessment, learning violence de-escalation techniques, setting boundaries and limits with patients, learning specific psychotherapeutic interventions to use from various modalities, and providing clear psychoeducation to patients while limiting the use of jargon.

“It’s much more than engaging people in conversation. It is our instrument. It's our stethoscope, by way of analogy, and so using the probe, or the instrument, in a focused way to get the necessary information in the most efficient manner.” (Interview 4)

Psychotherapeutic techniques, including providing a mindfulness intervention, using a grounding technique, or understanding a patient’s psychological defenses develop during structured training in the different psychotherapies in residency. Faculty participants identified this as a core set of abilities that they constantly relied on later in practice and encouraged their more senior residents to use within daily interactions.

“I think also the specific skills around CBT [cognitive behavioural therapy] and DBT [dialectical behavioural therapy] that are taught during psychiatry training and… being able to use some of those are also helpful in continuing practice. Even if one is not doing formal CBT or DBT, being able to use some of those tools and tricks in practice I would say is helpful.” (Interview 3)

Faculty emphasized that the further a resident was in residency training, the more they could discern what interventions might be helpful in a certain instance and apply it skillfully for the intended outcome during a patient interaction.

Theme 3: Managing the Internal Self

The third set of core abilities that faculty participants identified as important for residents included managing their emotional reactions and the use of reflection.

Regarding emotional management, faculty participants described that emotional expression should be intentional. Early in residency training, many faculty participants noted that internal anxiety could be high when interviewing patients, and junior residents may have discomfort or avoid asking about certain areas (e.g., a patient’s feelings) due to this internal anxiety. This experience of internal anxiety can also make it more difficult to manage interviews skillfully and can lead residents to not being fully able to attend to what is happening in the moment.

“I’m actually curious about what was going on for them on the inside when they’re communicating. Because I can see from the outside and I might think [they] were stuck and weren’t sure what to ask and I have my theory about what happened, but I find it very interesting to hear their feedback… ‘Actually I was feeling afraid,’ or, ‘I was just so nervous being watched that I couldn’t think.’ ” (Interview 2)

Furthermore, many faculty participants also noted that patients frequently cause emotional reactions in their psychiatrists. Skillful communication means identifying that one is feeling those emotions and using that to inform an intervention. Faculty also noted that even though some patients may cause a negative emotional reaction, psychiatrists must skillfully manage their own personal emotional reactions during session so that what is shared is done so that is beneficial for the client and maintenance of therapeutic rapport.

“I use the term when I talk about ‘leaking.’ So I had a senior resident, in a group with probably one of the most interpersonally challenging patients that I've ever worked with in a group, because he came and was openly sort of hostile and dismissive of everything we did… Like I absolutely could see where things were going, but she leaked how irritated she was, you could absolutely feel it and read it and anyways we had to talk afterwards about not leaking. And she was surprised, she didn’t realize, she thought she was keeping a calm front, but we talked about the kind of ways that it was coming out that she was leaking her frustration.” (Interview 7)

Frequently and unprompted, faculty also described the importance of reflection in their practice. They described that to be an excellent practitioner, one must always reflect on one’s own practice and strive for improvement. Some faculty described their own process of reflecting on that day’s encounter with a certain patient to try and modify it for the next encounter to be more therapeutic and helpful. Some faculty shared experiences where they had reflected on their practice, recognized an error they had made in the moment, and discussed the experience of integrating their newfound knowledge into future practice.

“And so I was seeing this person outside the ECT [electroconvulsive therapy] room one day, while she was waiting for treatment… I mentioned that her lack of response could be attributed to the fact that she didn’t come [to all her recommended treatments], and she and her husband were very upset because they felt it was the wrong time and the wrong place for me to address that issue and in retrospect they were quite right.” (Interview 11)

While faculty noted that guided reflection should occur in junior residency, they generally saw reflection as an ability that continues to develop and requires ongoing attention by senior residents and faculty.

Theme 4: Developing Adaptive and Responsive Interviewing

With the trio of core abilities increasingly acquired, faculty participants described that residents began to develop an adaptive, responsive, and personalized interviewing style that could meet patient and contextual needs in the moment.

Participants noted that residents could engage fully in the complexity of a patient interview with more skill in senior residency. They noted that residents became more attuned to what is needed in the moment and can adjust away from their planned approach in response to the patient’s changing needs. Faculty described that interviews begin to flow more nicely, with fewer awkward pauses or missteps. They attributed the improved flexibility to residents applying different abilities skillfully at different times.

“A senior resident would have the ability to adjust, to adjust their language, their tone, their volume, the way they're doing things, the level of validation, the level of structure. The follow up questions, like they can adjust to all of that to match what the person can manage in the moment or what would be best for that person in the moment. So that you get the best information or the best rapport or the best opportunity for building a therapeutic relationship, whatever it is you're trying to manage.” (Interview 7)

With more training and further skill development, it appears residents’ anxiety levels in their skills and ability to manage all the complexities of an encounter decrease. This decrease in anxiety was described to reduce the cognitive load of interviewing and increase comfort and flexibility. Faculty described that as abilities become better integrated, senior residents can acknowledge what is going on in the room, reflect on their own interventions and what information the patient is providing verbally and nonverbally, and adjust in the moment as necessary.

“Somebody said, years ago, that, a good interview is like a painting, you know, it’s not just a checklist, it flows and it, it’s blended nicely. That’s sort of the ultimate creation, a painting where everything fits together.” (Interview 1)

Theme 5: Partnering with Patients to Co-create Treatment Plans

Once a psychiatry resident develops the foundational communication abilities and can flexibly use and integrate them into interviews in different clinical scenarios, they can then skillfully partner with patients to co-create treatment plans. Faculty participants repeatedly identified that flexibly and strategically applying various abilities from the three core sets allowed psychiatrists to create strong therapeutic alliances. This approach helped find common ground, created shared expectations and mutual accountability, and allowed a negotiated treatment plan with patients. Faculty described that mutually negotiated plan more easily occurred with patients who generally had a similar idea of treatment goals as the psychiatrist did. However, additional ability was required to work with patients with contrasting treatment goals or with highly complex medical and mental health issues, and this was considered an advanced ability.

The faculty described these patient encounters as more challenging. They expected senior residents to have the ability to handle them better and achieve a co-created treatment plan with buy-in from both sides. This process involved the ability to clearly articulate your role as a psychiatrist, describing to the patient the process of a psychiatric interview and treatment planning. It also involved understanding your limitations, building strong patient rapport even when there are contrasting goals or intense affect, and then finding some common ground to move towards a therapeutic intervention that both sides agree may be helpful. Faculty noted that the more a resident recognizes their role and limitations, the less their emotions get in the way of understanding where a patient is coming from and aiding in treatment planning.

“I think the resident took a lot of time to validate the patient experience which then allowed the patient to actually open up as to their fears about the medication or around potential for side-effects. Information that they had heard from other patients, from online, from television ads that they had seen, which then allowed the resident to explore those to correct some of those things…. [The resident was] more confident in his own limitations in being able to persuade a patient and was comfortable with the idea at the end of the day that if this patient didn’t want to take their pills, they would not take them. And having let go of the idea that ‘it is my responsibility to force this patient to take their pills’ was actually then being able to validate the patient experience and explore their resistance more thoroughly.” (Interview 3)

Co-created plans are informed both by the psychiatrists’ foundational medical knowledge and also by their knowledge of this specific patient and their unique context. This plan is frequently negotiated and frequently integrates components of both parties’ agendas and ideas on treatment. Some faculty also described the importance of leveraging one’s relationship with the patient to push them towards mutually agreed upon change.

“I think as you approach the end of residency, starting to think about things like using your relationship as leverage with a client and how that changes the way that you communicate with somebody in terms of asking somebody for something because you both think it’s important.” (Interview 14)

Participants frequently brought up the idea of an interview as therapeutic. They noted that skillful integration of different interventions would allow the patient to take away something helpful from the interview, be it a feeling of being support, a better understanding of themselves, or hope in a new treatment plan.

At this stage of ability development, many faculty participants identified that residents should be able to articulate a deep understanding of every patient that they are seeing. They note that residents ought to integrate medical knowledge of specific psychiatric disorders within their treatment, and integrate the patient’s context and the patient’s unique social issues. Finally, they expected residents to integrate a theoretical understanding of how the patient’s psyche may work. This understanding can inform the resident’s flexible use of interventions and allows the development of a co-created treatment plan that may lead to positive change for the patient.

Discussion

Faculty perceptions of the progression of how skilled communication in psychiatry residents develops identified five core domains, represented by the McMaster Advanced Communication Competencies Model for Psychiatry (MACC) model (Fig. 1). During early residency, residents should develop their (1) general and (2) psychiatric-specific communication abilities, and (3) demonstrate an ability to manage their own reactions. During later residency, faculty note that senior residents develop an ability to (4) interview adaptively and responsibly, which allows them to (5) co-create treatment plans in even the most challenging patient interactions. This leads to the conclusion that to be a competent communicator in psychiatry, not only should a graduating resident have a fulsome set of techniques, but must also be self-aware enough that they can implement different abilities in the moment. It should be furthermore noted, as is reflected in Fig. 1, that faculty members did note some inherent bidirectionality within their perceptions. As such, although faculty identified core skills as beginning to develop early, this progression of skill development continued through residency, with the ability to flexibly combine abilities and skillfully negotiate complex scenarios being seen as the key abilities of nuanced communication.

In considering the MACC Model, there are areas where this model differs from general communication models currently in use, such as CanMEDS. Most prior frameworks have focused on general abilities that residents across specialties must attain as part of their general communication competency. By contrast, the MACC Model defines a clear, psychiatry-specific model for developing psychiatry residents’ communication abilities. Compared to the commonly used CanMEDS Communicator framework [19], the MACC Model has significant areas of overlap, but also areas that are unique to psychiatry as a specialty. This difference is key as it demonstrates that communication in psychiatry may have some unique elements to be taught and assessed within psychiatry residents as they progress through their training. In terms of similarities, there is a clear emphasis in the CanMEDS framework on patient-centered communication [19], which largely encompasses the relational abilities described in the first theme of this research. Patient-centered communication is indicated as a core milestone that residents must demonstrate to establish therapeutic relationships with their patients. CanMEDS also emphasizes managing internal emotions regarding emotionally charged and conflictual situations [19]. However, the degree of emphasis on managing emotions in CanMEDS is significantly less, as is only represented in milestones and not as a key competency. In contrast, in our project, this ability was identified as essential. This is the most significant difference in emphasis between the two frameworks. Finally, the CanMEDS framework also emphasizes adaptability in interviewing style. However, the framework states residents should “[c]onduct a focused and efficient patient interview, managing the flow…” [19], which is described as a foundational ability for most residents. Instead, our model demonstrates that psychiatry educators expect that most gains in this area will be made in senior residency training. This expectation may reflect that, in psychiatry residency, an adaptable approach is considered challenging to master to the degree required to be a proficient psychiatrist. In contemplating the differences, our model suggests that there may be areas where psychiatry educators can increase their focus in order to allow psychiatry residents to more efficiently develop their skill set.

Of course, this model is preliminary and will require further research and validation in order to establish its utility and efficacy for use in psychiatry training. As this was a study of faculty perceptions, further research should be conducted to validate this model in real-world scenarios, for example, by used taped scenarios and a rubric based on this model to score various aspects of communication across the years of residency training.

This paper has several limitations. This research was a single-institution study of faculty educators in a psychiatry residency program limiting the transferability of findings to other contexts. Purposive sampling of psychiatrists and psychotherapists, residency training sites, and practice locations was used to increase transferability. However, this diversity may not reflect diversity in perspectives of residency communication development beyond this institution. Finally, all interviews for this study were conducted by the primary author, who is a practicing psychiatrist and a member of the department in which she conducted the interviews. Even though the primary author does not hold any position of power over the participants, her direct involvement within the department may have made some faculty more hesitant to share particular experiences or biased how they shared the information.

In conclusion, the medical profession has acknowledged that adequate communication skill is essential for all physicians. Psychiatry uses communication as the primary modality of diagnosis and treatment, so it is crucial to understand the nuances of communication competencies in this context. Despite the availability of generic physician communication frameworks, attention to the needs of psychiatry training is lacking. The MACC Model defines a clear, psychiatry-specific model for developing psychiatry residents’ communication abilities. Future research should evaluate the MACC Model in other contexts to strengthen the validity and transferability of the model, which may allow its further development and eventual use in refining how psychiatry residents are trained and assessed in their communication skill.