Accreditation councils of the medical specialties are committed to society to guarantee that certified specialists have the necessary skills and competencies for practicing their profession. This implies developing and applying evaluation tools, establishing cutoff points that determine whether or not a candidate should be accredited and, in short, making decisions that are of crucial relevance for the candidates, health and educational authorities and society in general.1–3

The function of the Mexican Accreditation Council for Rheumatology (CMR) is to annually certify all the candidates who have completed their training in rheumatology in any of the national centers accredited for that purpose. The process of certification implies a multiple-choice test utilizing case reports and a practical evaluation. Until 2012, the latter was based on “the long case” with a real patient, widely recognized for its utility in training evaluation, but it is not highly recommended for the evaluation of competencies of “high consequences”.4,5 For this reason, since 2013, the CMR implemented an objective structured clinical examination (OSCE) to evaluate clinical skills in the annual certification examination. Throughout the years, the OSCE has been found to have an adequate performance.6,7

The OSCE consists of a circuit of stations, some of which include real patients. The latter are thus known as “dynamic” stations.8 Each station (static or dynamic) is assigned a rheumatologist (examiner) who evaluates the candidates using a checklist and scale of general performance. Since 2015, the dynamic stations have an additional instrument for evaluation, designed and adapted to determine the communication skills (CS) of the candidates with respect to the patient.

Effective CS has an impact on patient satisfaction9 and on the outcome.10,11 Nevertheless, in many countries, formal training in CS is not included in the academic curriculum and is exceptional once undergraduate education is completed; as with other aspects of clinical competencies, CS declines over time and the lack of practice.12 In addition, the teaching model and the training techniques applied in CS are based on a classical model of teacher-trainee in which teaching lacks definite planning, structure and objectives. In our usual clinical work, it is common to confront situations in which communication with the patient and those around him or her is complex; the resident in training is often alone and is not being observed by a specialist with greater experience; thus there is not an adequate feedback. A subject that has been a motive for debate in the area of CS is who should evaluate these skills, the patients or an examiner. It is interesting that it has been demonstrated that standardized patients can efficiently evaluate the CS of trainees and physician examiners.13,14

In the present study, we report the experience of the CMR relative to the evaluation of CS of candidates for accreditation in rheumatology in 2015, 2016 and 2017. The specific objectives were:

• 1.

  To describe and compare the CS of candidates for accreditation in rheumatology evaluated by the patient and by a physician examiner.

• 2.

  Correlate the CS of the candidates with their performance in the OSCE.

The CMR is committed to Mexican society to guarantee that the accredited specialists have the knowledge, skills and competencies to attend to the health problems that are associated with our specialty. For this, the CMR develops and applies evaluation tools that enable the identification of eventual deficiencies in the training of our specialists; the information derived from the analysis of the evaluations is annually shared with the professors who are going to give the training courses and, jointly, strategies are proposed for the purpose of improving suboptimal areas and, therefore, the quality of our specialists.

The present report evaluates the CS of the candidates for accreditation in rheumatology over 3 consecutive years. Communication skills constitute a basic competence in establishing communication between the physician and the patient that favor a solid, effective and lasting relationship between the two. The benefits of a relationship with these characteristics are also extended to the patient's family and other support networks that integrate the health systems.10 In recent decades, international consensuses have been developed in the area of physician-patient communications,11 as well as guidelines to be applied in medical schools12 and to serve as references for professional practice,13 all of which stresses the importance of this subject.

In general, the candidates for the examination of certification in rheumatology had a good performance in CS in dealing with the patients; however, this was not homogeneous, as is expected and has been described in other populations.14 The patients gave higher scores to the trainees than to the examiners and both evaluations presented significant correlations (low and moderate) between them in more than half of the OSCE stations. Communication skills correlated with the performance of the candidates in the stations, with the overall performance in OSCE, but that was not observed with the multiple-choice test (except in 2017). The literature provides evidence that efficient CS correlated with the clinical competencies of those being evaluated10,15,16 and that the general performance of physicians improved after training involving CS17,18; in fact, there are educational interventions that have improved confidence in CS in those who had completed the program even months after having participated.10 Even more relevant is the fact that efficient CS have been associated with desired outcomes for the patients, such as better adherence to drug therapy and diet, better pain control and a better physical, functional and psychological well-being.9,19–23 Finally and within the physician-legal framework that is applied when the patients develop complications or undesirable outcomes, early and sincere communication with the patients has been shown to be crucial.24–28 It is important to point out that the OSCE has been demonstrated to have a good performance in evaluating CS and identifying specific deficits,28 combined with its adequate performance in the accreditation process.5,6

One relevant question about CS is whether the patient or an external physician should evaluate it. Interestingly and intuitively, we encountered a better correlation with the performance of the trainees in the stations (and with the OSCE) when the CS were evaluated by the patient. The best correlations were obtained in the last year, which could indicate a certain degree of apprenticeship gained by the patients (and, in general, all the participants in the OSCE), who are trained year after year to score the candidates. We should point out that the performance of the trainees was established by the examiner, using the checklist. Our results confirm published studies in which standardized patients adequately evaluate the CS of surgical residents with different years of training.16,17,24,25

The present report has certain limitations. Communication skills were evaluated utilizing an adapted tool, that included a Likert scale in which 8 domains were jointly applied. This tool was subjected to a process of validation; although both users (patient and examiner) were trained in its application, the OSCE has also been shown to be a suitable tool for the evaluation of CS.17 In each process of accreditation, 2 consecutive OSCE were applied due to limited space. This could have affected the reproducibility of the results29; nevertheless, the physical space, patients and examiners were the same in both circuits. Finally, the validity and reproducibility of the results of an OSCE are determined by its length, that is, by the number of stations included. Over 3 years, we included a maximum of 12 dynamic stations, and the results obtained may not be solid enough for making decisions, especially if the latter have important consequences.30

Currently, physicians are not independent actors in health care, but perform more like leaders or members of multidisciplinary teams3; thus, they must acquire and perfect certain professional attributes, the first of which includes CS. Our work is to establish the bases for a specific proposal: integrate residency in rheumatology into a formal, continued education directed at CS. We want to stress that training in CS is favored in the contextual setting of routine practice, with an adequate feedback31,32 and an environment that requires that those involved have protected time for teaching.18,33,34

We are what we repeatedly do. Excellence, then, is not an act but a habit.

(Aristotle, 400 BC)

None of the authors has any financial relationship that could be considered a conflict of interest in relation to this article.