E

S S A Y

Essential Elements of Communication in Medical

Encounters: The Kalamazoo Consensus Statement
Participants in the BayerFetzer Conference on PhysicianPatient Communication in Medical Education
ABSTRACT
In May 1999, 21 leaders and representatives from major
medical education and professional organizations attended an invitational conference jointly sponsored by
the Bayer Institute for Health Care Communication
and the Fetzer Institute. The participants focused on
delineating a coherent set of essential elements in
physicianpatient communication to: (1) facilitate the
development, implementation, and evaluation of communication-oriented curricula in medical education and
(2) inform the development of specific standards in this
domain. Since the group included architects and representatives of five currently used models of doctorpatient
communication, participants agreed that the goals might
best be achieved through review and synthesis of the
models. Presentations about the five models encompassed
their research base, overarching views of the medical
encounter, and current applications. All attendees

A growing emphasis on physicianpatient communication in medicine and

medical education is reflected in international consensus statements,1,2 guidelines for medical schools,36 and standards for professional practice and
education.712 In May 1999, with work
in these areas and related research1317
as a backdrop, 21 people from medical
schools, residency programs, continuing
medical education providers, and prominent medical educational organizations
in North America convened for three

The conference participants are listed in a box at the

end of the text.
Correspondence and requests for reprints should be
addressed to the Bayer Institute for Health Care
Communication, 400 Morgan Lane, West Haven,
CT 06516; e-mail: bayer.institute@bayer.com.

390

participated in discussion of the models and common elements. Written proceedings generated during the conference were posted on an electronic listserv for review
and comment by the entire group. A three-person writing
committee synthesized suggestions, resolved questions,
and posted a succession of drafts on a listserv. The current
document was circulated to the entire group for final approval before it was submitted for publication. The group
identified seven essential sets of communication tasks: (1)
build the doctorpatient relationship; (2) open the discussion; (3) gather information; (4) understand the patients perspective; (5) share information; (6) reach agreement on problems and plans; and (7) provide closure.
These broadly supported elements provide a useful framework for communication-oriented curricula and standards.
Acad. Med. 2001;76:390393.

days in Kalamazoo, Michigan, for the

BayerFetzer Conference on PhysicianPatient Communication in Medical Education. The aim of this invitational conference was to identify and
specifically articulate ways to facilitate
communication teaching, assessment,
and evaluation.
The group used an open-ended, iterative process to identify and prioritize
topics for discussion. A major topic of
interest to the entire group was delineating a set of essential elements in physicianpatient communication. Participants expressed three goals for the
discussion:
1. Reaching consensus on a short
list of elements that would characterize
effective communication in several
clinical contexts.

2. Providing tangible examples of

skill competencies that would be useful
for licensing bodies, organizations that
accredit medical schools and residency
programs, and directors of medical education programs at all levels.
3. Ensuring that the product generated by the group would be evidence
based and appropriate for teaching, assessment, and evaluation.
Since the group included architects
and representatives of five currently
used models of doctorpatient communication, participants agreed that
the goals might best be achieved
through review and synthesis of the
models essential elements. Toward that
end, brief presentations were delivered
about each of the five models:

ACADEMIC MEDICINE, VOL. 76, NO. 4 / APRIL 2001

Bayer Institute for Health Care Communication E4 Model18

Three Function Model/Brown Interview Checklist19
The CalgaryCambridge Observation
Guide20
Patient-centered clinical method21
SEGUE Framework for teaching and
assessing communication skills22

Each presentation included an explicit description of the model, encompassing its research base, overarching
views of the medical encounter, and
current applications. After discussion of
the models, attendees from the Accreditation Council for Graduate Medical
Education (ACGME), the CanMEDS
2000 Project, the Educational Commission for Foreign Medical Graduates
(ECFMG), and the Macy Health Communication Initiative provided information about their efforts to develop
criteria for teaching and evaluating
physicianpatient communication. The
group then began looking for commonalities among the models as well as
points of departure. This process was
enriched by the number and diversity of
organizations represented by conference
participants.
THE ESSENTIAL ELEMENTS
Consensus on the essential elements of
physicianpatient communication was
reached by using the three goals outlined above to guide and ground discussion. The groups perspective on essential elements is consistent with the
task approach, a concept that has been
well supported in communication skills
teaching since the early 1980s.3,1825 As
noted by Makoul and Schofield,2 focusing on tasks provides a sense of purpose for learning communication skills.
The task approach also preserves the individuality of [learners] by encouraging
them to develop a repertoire of strategies and skills, and respond to patients
in a flexible way.
By identifying specific communication tasks, the group worked to highlight behaviors that are embedded in
existing consensus statements, guide-

lines, and standards. While the list is by

no means exhaustive, the intent was to
make it easier for people working in this
area to identify not only the key tasks,
but the relevant knowledge, skills, and
attitudes as well. References for the supporting research are listed and discussed
in a number of texts.20,21,2328
Build a Relationship: The
Fundamental Communication Task
A strong, therapeutic, and effective relationship is the sine qua non of physicianpatient communication.29,30 The
group endorses a patient-centered, or
relationship-centered, approach to care,
which emphasizes both the patients disease and his or her illness experience.31,32 This requires eliciting the patients story of illness while guiding the
interview through a process of diagnostic reasoning. It also requires an awareness that the ideas, feelings, and values
of both the patient and the physician
influence the relationship.2,15,33 Further,
this approach regards the physicianpatient relationship as a partnership, and
respects patients active participation in
decision making.3436 The task of building a relationship is also relevant for
work with patients families and support
networks. In essence, building a relationship is an ongoing task within and
across encounters: it undergirds the
more sequentially ordered sets of tasks
identified below.

Understand the Patients Perspective

Explore contextual factors (e.g., family, culture, gender, age, socioeconomic status, spirituality)
Explore beliefs, concerns, and expectations about health and illness
Acknowledge and respond to the patients ideas, feelings, and values

Share Information

Use language the patient can understand

Check for understanding
Encourage questions

Reach Agreement on Problems

and Plans

Encourage the patient to participate

in decisions to the extent he or she
desires
Check the patients willingness and
ability to follow the plan
Identify and enlist resources and supports

Provide Closure

Ask whether the patient has other issues or concerns

Summarize and affirm agreement with
the plan of action
Discuss follow-up (e.g., next visit,
plan for unexpected outcomes)
CONCLUSION

Open the Discussion

Allow the patient to complete his or

her opening statement
Elicit the patients full set of concerns
Establish/maintain a personal connection

Gather Information

Use open-ended and closed-ended

questions appropriately
Structure, clarify, and summarize information
Actively listen using nonverbal (e.g.,
eye contact) and verbal (e.g., words
of encouragement) techniques

This outline of essential elements in effective physicianpatient communication provides a coherent framework for
teaching and assessing communication
skills, determining relevant knowledge
and attitudes, and evaluating educational programs. In addition, the outline can inform the development of specific standards in this domain. Most of
the elements included in this document
are present in each of the five models
examined during the process of consensus building. A major strength of the
outline is that it represents the collaboration and consensus of individuals
with a variety of backgrounds and in-

ACADEMIC MEDICINE, VOL. 76, NO. 4 / APRIL 2001

391

terests in medical education. Further,

the basic outline can be tailored to
meet the needs of different specialties,
settings, and health problems. Conscientious efforts to address these essential elements across practice settings
will help increase the efficiency
and effectiveness of physicianpatient
communication,37 enhance patient and
physician satisfaction,38,39 and improve
health outcomes.40
Gregory Makoul, PhD, director of the Program in
Communication and Medicine at Northwestern
University Medical School, provided leadership
in the writing process.
The BayerFetzer Conference on PhysicianPatient Communication in Medical Education was
held May 1114, 1999. The Bayer Institute for
Health Care Communication is a non-commercial, nonprofit, organization whose mission is to
improve health through education, research, and
advocacy in the area of clinicianpatient communication. The Fetzer Institute is a nonprofit,
private operating foundation that supports research, education, and service programs exploring
the integral relationships among body, mind, and
spirit. The conference site was Seasons, A Center
for Renewal, owned and operated by the Fetzer
Institute, in Kalamazoo, Michigan.
This consensus statement reflects the views of the
conference participants; it does not necessarily
imply endorsement by their institutions or associations.

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Participants in the BayerFetzer Conference on PatientPhysician Communication

in Medical Education, May 1999
Patrick H. Brunett, MD

Forrest Lang, MD

Assistant Professor of Emergency Medicine, Oregon Health Sciences

University; member of Society for Academic Emergency Medicine

Vice Chair, Department of Family Medicine, East Tennessee State

University; member of Society of Teachers of Family Medicine

Thomas L. Campbell, MD

Anne-Marie MacLellan, MD

Professor of Family Medicine and Psychiatry, University of Rochester

School of Medicine; member of Society of Teachers of Family
Medicine; Advisory Council, Bayer Institute for Health Care
Communication

Faculty of Medicine, McGill University; member of Association of

Canadian Medical Colleges

Kathleen Cole-Kelly, MS, MSW

Associate Professor of Family Medicine, Case Western Reserve
University School of Medicine; Director of Curriculum and Faculty
Development at Case Western for the Macy Health Communication
Initiative

Deborah Danoff, MD
Assistant Vice President, Division of Medical Education, Association
of American Medical Colleges

Robert Frymier, MD
National Director, Educational and Partnerships Division, Veterans
Affairs Learning University; Associate Professor of Family Medicine,
Case Western Reserve University School of Medicine

Michael G. Goldstein, MD
Associate Director, Clinical Education and Research, Bayer Institute
for Health Care Communication; Adjunct Professor of Psychiatry,
Brown University School of Medicine

Geoffrey H. Gordon, MD

Gregory Makoul, PhD

Associate Professor and Director, Program in Communication and
Medicine, Northwestern University Medical School

Steven Miller, MD
Director, Pediatric Medical Student Education, Columbia University
School of Medicine; Council on Medical Student Education in
Pediatrics

Dennis Novack, MD
Professor of Medicine and Associate Dean for Education, Medical
College of Pennsylvania Hahnemann School of Medicine; member of
American Academy on Physician and Patient

Elizabeth A. Rider, MSW, MD

Clinical Instructor in Pediatrics and Instructor in Medical Education,
Harvard Medical School; Office of Educational Development, Harvard
Medical School

Frank A. Simon, MD
Director, Division of Graduate Medical Education, American Medical
Association

Associate Director, Clinical Education and Research, Bayer Institute

for Health Care Communication; Assistant Clinical Professor of
Medicine and Psychiatry, Yale University School of Medicine

David Sluyter, EdD

Daniel J. Klass, MD

Susan Swing, PhD

Director, Standardized Patient Project, National Board Medical

Examiners

Director of Research, Accreditation Council for Graduate Medical

Education

Suzanne Kurtz, PhD

Wayne Weston, MD

Professor of Communication, Faculties of Medicine and Education,

University of Calgary

Professor of Family Medicine, University of Western Ontario; member

of College of Family Physicians of Canada

Jack Laidlaw, MD

Gerald P. Whelan, MD

Head, Division of Education, Cancer Care Ontario; Advisory Council,

Bayer Institute for Health Care Communication

Vice President for Clinical Skills Assessment, Educational Commission

for Foreign Medical Graduates

Vice President for Education, Fetzer Institute

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