Clinical communication

Chapter 30


Clinical communication




Introduction


The importance of clinical communication is now taken for granted. It is routinely taught and tested at the undergraduate and postgraduate level, often with a set of ‘communication skills’ in mind which are perceived as the conduit for patient-centred medicine. A key document which drew attention to the literature and placed the issue centre stage was the so-called Toronto Consensus Statement (Simpson et al 1991): the most fully developed list of skills derives from Silverman et al (2005) and is available online. Maguire and Pitceathly (2002) give a brief summary of ‘key communication skills’, and von Fragstein et al (2008) outline a consensus on the undergraduate curriculum for the UK.


Mainstream research links skills such as ‘eye contact’ or ‘listening’ with desirable outcomes such as patient satisfaction and better health (but for a detailed critique, see Skelton 2008). The communication skills movement has been of exceptional importance in reworking a timeless theme for a contemporary audience: the good doctor needs more than clinical knowledge. However, scrutiny of what constitutes ‘good skills’ has tended to divert attention from the wider context in which communication is practised.


Firstly, there is at present considerable attention on aspects of (nonclinical) professional competence. In the UK, this has been closely linked to the heart searching following the Shipman tragedy and the events at Bristol which led to the Kennedy Report (2001). The latter asks for a broader definition of ‘clinical competence’, and the range of issues with which communication is bracketed is instructive (see Box 30.1). Secondly, teaching has centred on a particular kind of professional interaction: spoken, doctor–patient, with a broadly counselling approach. Other communication types are mentioned below.



Box 30.1


Broadening the notion of clinical competence


Greater priority than at present should be given to nonclinical aspects of care in six key areas in the education, training and continuing professional development of healthcare professionals:



From Kennedy I: The report of the public enquiry into children’s heart surgery at the Bristol Royal Infirmary 1984–1995 (‘The Kennedy report’), paragraph 57, London, 2001, HSMO, (www.bristol-inquiry.org.uk/final_report/rpt_print.htm), with permission.


However, the centrepiece of most clinical communication teaching remains doctor–patient interaction through role play.



Using role play



Rationale


‘Role play’ is an unfortunate label: even in the UK, it has overtones of amateur dramatics, and in the United States it has perhaps even less credibility. But alternative labels for similar activities (e.g. ‘simulated patients’) are unfortunately used in different ways, so I have retained the term ‘role play’ to mean a serious, challenging educational activity.


The fundamental rationale for role play is that you cannot become a better communicator except by practising communication any more than you can become a good driver except by driving. Role play provides a safe environment for mistakes and experimentation and can offer the same, educationally useful, performance repeatedly.


Behind this rationale are other important characteristics. Education through role play is essentially inductive in nature; it moves from a focus on a particular case to a discussion which seeks to induce general principles. For example, ‘Mr Smith responded in this way – is this typical of how people might respond in these circumstances?’ It therefore fits well with contemporary educational practice in starting with individual cases rather than lecture-based generalities. It also fits neatly into the common pattern of clinical life: contact with patients, one by one.



image Role play is a serious, challenging, and above all educational activity. It isn’t a piece of drama.



Formats for role play


There are unlimited variations of the role play formats outlined below, which are indicative rather than prescriptive.



1. Forum theatre: One role player, one or two facilitators. Audience of any size up to several hundred. In lecture theatre or similar large venue. One hour in length.


    Role player and facilitator act out a scenario in a less-than-perfect way. Facilitator subsequently invites comments from audience (or second facilitator does, with roving microphone). Repeat scenario, building in changes suggested. Draw conclusions.


2. Large group: Role player and facilitator, audience of 8–20. This can be done as a version of forum theatre, but the smaller group size makes it more flexible. Two hours in length. ‘Time outs’ can be introduced, so that everyone (including role player and facilitator) can stop, review, ask questions or make suggestions.


    With a group of this size, it becomes reasonable to ask participants to play the part of the doctor. Depending on levels of confidence, other participants can offer detailed advice beforehand (this shares the burden of responsibility if things go badly) or none at all.


    With a group of up to 20, it isn’t usually realistic to offer everyone a chance to role play. Notoriously, those most in need are least likely to volunteer, but it may be reasonable to allow some to take a back seat, participating in targeted observation. This means asking individuals to look for certain key elements – ‘How is the doctor achieving empathy?’ or, at a lower level, ‘How many open questions is the doctor asking?’ (A variant of this, particularly with students on attachment, is to make explicit use of the clinical tutor as a model, with students looking at the tutor’s clinical communication in practice). This kind of activity can form part of the feedback offered. Discussion often lasts at least as long as the role play itself, and is at least as interesting. This is particularly so with qualified health professionals who have more experience to draw on and often more confidence to discuss.


    The best role players are essentially educators, and contribute detailed feedback.



image When you set up role play, be confident, matter-of-fact and serious. If you’re not relaxed about it, the learners won’t be.


3. Small group: Role player and facilitator, or facilitator only, group of up to 8. With this number of participants it becomes realistic to offer everyone a chance to role play, either seeing a consultation through from beginning to end or undertaking part and then handing over to someone else during a time out.


    Educators often suggest asking health professionals to take the part of patients, on the grounds that this will help them to understand what it’s like to be on the receiving end of bad news, a peremptory doctor, etc. Where the budget doesn’t run to a professional role player, this is inevitable. Most people can at least play a version of themselves tolerably well (‘Just imagine that you personally are in this situation’).


    A standard (but costly) variant is to subdivide a larger group into smaller groups of four to six, each with a facilitator, and with a number of role players rotating round the groups.


4. Single participant role play: Role player-facilitator, or role player plus facilitator, one participant.


    It’s clear that this is an expensive resource but, particularly in cases where the aim is remedial support, the intensity of the contact and the possibility of very detailed discussion make it cost-effective. A 2-hour session can make a real difference. And it is very likely to reveal a great deal about other areas such as attitude.



Conducting a role play session


Of central importance prior to the interaction is that the atmosphere is right. If participants have never undertaken role play before, they may be nervous and, often for this reason, sceptical. It’s therefore vital that the facilitator and role players are confident, matter-of-fact and serious. (If you Google the phrase ‘the dreaded role play’ you’ll find plenty of examples of trainers anxiously saying, ‘It’s not that bad, really’: exactly the line not to take). There needs to be a shared understanding that all participants are there to support each other and engage together in learning.


This brings us to the question of feedback. At an elementary level (for example, with junior undergraduates, or for remedial support), there is a need for feedback centred on the basic skills: the use of questioning styles, appropriate body language, checking of understanding and so on. This is vital partly because it may be done poorly, but mostly so that participants are made aware of these skills and have a vocabulary with which to discuss them.


This is, however, basic stuff: a course in ‘advanced eye contact’ is hardly plausible. One of the real values of role play is the opportunity it gives for discussion at a higher level, for reflection about oneself and others and about the profession. There is a basic hierarchy of questions, in fact (see Box 30.2), which perhaps most people employ, but which is seldom made explicit. At the heart of the issue here is that good communication is not a matter of the mechanical application of skills, but judicious, insightful choices about when and how to deploy them.



Box 30.2   Hierarchy of question types after role play





Higher-order questions


Related posts:

  1. Clinical skills centre teaching
  2. Simulated/standardized patients
  3. Instructional design
  4. Basic sciences and curriculum outcomes

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Dec 9, 2016 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Clinical communication

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