Rosamund Snow, a Patient Tutor at Oxford Medical School, asks if students really know if they are practising good communications skills?
Good communication includes open questions, checking for patients’ ideas, concerns and expectations, and making sure your body language is open. Right? Actually, not necessarily. Certainly those are things medical schools tend to teach. But they are broad concepts that rely on some big assumptions. In reality, there’s often quite a big difference between what clinicians assume that patients want, and what patients say is important.
Ideas, Concerns, Expectations
Inspired by a conversation with fellow patients, I recently wrote a piece for the BMJ about what it feels like when a doctor “ICE’s” you (asks about your Ideas, Concerns and Expectations).[i] The article basically described how odd and uncomfortable it feels when doctors say “what do you think is wrong?” It got retweeted again and again by patients questioning whether it’s an acceptable way to communicate.
Real patients aren’t just puzzled by it, we’re actually laughing at our doctors for doing it, and worse; one respondent shared an experience of becoming so angry at being asked the question that she walked out of the surgery without the help she needed.[ii] Similarly, “what matters to you?” – a more recent communications fad – is again making a huge assumption that the person you’re asking knows what you’re on about, and that their life is yours to unpick.
As the linguist (and patient) Dariusz Galasinski points out, we don’t always want to tell you what matters to us, and you won’t always be able to help even if we do open up.[iii] Above all, if you aren’t clear what you’re really asking for, it can be baffling for the patient.
Ask open questions; use open body language
Which brings me onto open questions. There are undoubtedly times when these are useful, particularly if patient and doctor already share a cultural understanding of what the consultation is meant to achieve. But they aren’t for everyone all the time. It’s not for people who aren’t sure what topics the doctor really has time to answer. At moments of stress, even for someone like me (stroppy, used to doctors, familiar with medical language) open questions can make things difficult; some of us like to be given a bit more direction when we are facing the unexpected and the unknown. It’s also not for people who are already coping with other mental demands. Wendy Mitchell, a blogger living with dementia, has some powerful lessons for doctors about how best to frame history-taking questions. As she describes, even asking “what kind of pain is it” can be too open and difficult to respond to when you have this challenging condition.[iv]
Does open body language work? Of course it’s better to come across as friendly and approachable, just as it is in all walks of life. But it can go too far, depending on the culture you come from. The academic Kate Fox, having studied UK ethnography and culture in depth, warned against this back in 2004:
“My advice to English doctors goes against all the touchy-feely ‘communication skills’ training they now receive, in which they are told to sit close to the patient, not use their desk as a shield, lean forward, make eye contact, etc.: all measures that seem to me calculated to make the average English person clam up entirely. Which, according to doctors I asked about this, is precisely their effect on most English patients, who do not confess to the doctor what is really bothering them until they are on their way out of the consulting room, usually with their back half turned and their hand on the door-knob.” [v]
Part of the problem here is that the key to good communication in real life is learning how to adapt to the person in front of you, but in undergraduate exams you are sometimes presented with a simulated, standardised patient who is primed to respond in roughly the same way each time.
In one way, this is ‘fairer’ – every student faces the same simulation – but you could also argue that it’s not fair at all, because real patients are all utterly different from each other; shouldn’t students learn how to handle that, and be rewarded for developing those skills? If you come across a patient who gets confused, mistrustful or angry at being asked “what do you think the problem is?”, it’s not going to be much help to know you got a perfect four doing exactly that in your comm skills OSCE.
The good news is that bit-by-bit, exams are changing. A few years ago, the GMC published its guidelines for medical schools, encouraging them to involve patients in admissions, curriculum setting, teaching and assessment.[vi] Some schools already do this through the entire course; Oxford hasn’t managed that yet. However, as you progress through your your clinical years you’ll come across patient tutors.
You may not have realised how much these tutors are helping to revamp not just teaching, but also assessment. Increasingly, patients with practical experience of particular conditions and situations are working with the medical faculty to make OSCEs better aligned with what patients want from the next generation of doctors – including testing your ability to adapt to the person in front of you.
A good example: in the fifth year, you get the opportunity to learn how to give a safe, comfortable and respectful vaginal exam, and you will be assessed on your skills by one of the lay women (Clinical Teaching Associates) who have worked together with a gynaecologist to design the curriculum and assessment for that part of the course. The women who you examine in the OSCE are all different – there is no such thing as a textbook vagina – so you will have to adapt to whoever is behind the door on the day.
They will also have taught you the importance of gaining true consent by emphasising that the woman can ask you to stop at any time, and the value of checking if she would like to use the toilet before starting, so she is more comfortable. You’ll get assessed on this. Interestingly, although students are very positive about these teaching sessions, they tell me that they rarely see senior doctors demonstrating that kind of behaviour. Does that mean these things don’t matter? As a woman who has stopped attending screening because of the mental and physical pain clinicians have caused me in the past, I have to say I think they really do matter. It’s worth knowing that many qualified doctors trained on women who were unconscious – women who were under general anaesthetic for some other cause, whose vaginas were then used for medical students to practise on. Thirty years ago, the women they used for training purposes didn’t have to give their consent for this to happen. Even where a woman is conscious and gives consent, it’s still very difficult when you are in the patient role to give active feedback on a student or doctor’s technique (I was too scared to say to any of my doctors that they had hurt me when they took a smear). That’s possibly why some doctors are less aware when their actions can be frightening, uncomfortable, or painful; because the women they trained on were either physically or psychologically unable to answer back.
Communication’s not just for fourth year
Another fascinating difference that patient-led assessments make is the level of practical communications required. There’s always a set of students who think “we’ve already done comms skills in fourth year”, and you can spot them a mile off in fifth and sixth year OSCEs; they are the ones who start beautifully (hello my name is…) and end by the book (…was there anything else you wanted to ask me today?) but wade straight into the weeds when it comes to explaining the specifics.
Take miscarriage. Women who have actually experienced miscarriage are now co-marking with the clinical assessors, and they want to know if students can answer the questions they had in real life; they are looking for detail. Of course students are still asked to be sensitive and compassionate – you are right not to talk about someone’s much-wanted baby as “the products of conception”, for example. But they also need to be practical. They aren’t just breaking the bad news of the miscarriage, but also the bad news of the painful process the woman is about to undergo. What actually happens during miscarriage in real life? How can the woman self-manage, how much blood loss is too much, what kind of painkillers will she need tonight, what range of experiences are to be expected and when should she call 999? Might she actually see the baby during this process?
How are you going to say all this to an assessor who has actually experienced miscarriage? This is communications too, the topic-specific stuff that empowers and prepares the patient rather than just reassures.
If you don’t know who set the outcomes for your OSCEs, ask. You have a right to know who decided what you will get tested on in exams. If you don’t know whether a real patient will be assessing you, ask. If we’ve helped set your exam, we’ll also be teaching you, so make the most of us. We want you to do well, and we can help you become great doctors.
Patient Involvement Lead/Patient Tutor, Oxford Medical School
BMJ Patient Editor
[i] Snow, R. I never asked to be ICE’d. BMJ 2016:354 http://www.bmj.com/content/354/bmj.i3729
[ii] I never asked to be ICE’d: Rapid Responses http://www.bmj.com/content/354/bmj.i3729/rapid-responses
[iii] Galasinski, D. What matters to you? Blog post, 2016: http://dariuszgalasinski.com/2016/08/09/what-matters-to-you/
[iv] Mitchell, W. Positive language leads to positive well-being. BMJ 2016 [in press, due Sept]
[v] Fox, Kate.Watching the English: The Hidden Rules of English Behaviour. Nicholas Brealey Publishing, 2004.
[vi] GMC. Patient and public involvement in undergraduate medical education. London: General Medical Council, 2009.