Communication skills and the problem with fake patients
Is an obsession with communication compromising our ability to care?
Susan was sitting in the clinic room as I entered, her head in her hands. Appearing to fight back tears, she looked up at me expectantly. Moments earlier she’d discovered that her pregnancy had ended prematurely, and it was up to me to explain to her that she’d had a miscarriage.
Sitting down with her, I found myself trying to care. Or, more accurately, trying to show that I cared. If I’m sounding cold hearted, it’s because I’m worried that medical school might be training me to be so.
Susan wasn’t a real patient. She was an actor at an objective structured clinical examination (OSCE) station—a medical school examination that uses role play to test a student’s ability to practise as a doctor.
The use of OSCEs in medical schools is controversial. They’ve been called “box ticking exercises,” and condemned for promoting a narrow understanding of clinical medicine. Some dislike the artificial nature of the exams. “It doesn’t seem like real life; you forget things that you would normally do,” remarked one student in a study on the topic.
OSCE stations that test communication skills are particularly open to criticism. Although OSCEs can simulate clinical examinations or history taking scenarios with relative ease, encounters that test students’ ability to express empathy provide other challenges. A friend told me how a mixture of nerves, poor acting, and the gesture of giving a patient an imaginary leaflet—something many tutors encourage their students to do—had provoked a giggling fit during the exam. Another had failed a station because he misunderstood the brief, given to him seconds before the test, and did not play the character he was supposed to.
Since the introduction of OSCEs in communication skills, trainee doctors have been tested on their ability to act. Many students perceive that a script should be followed. Communication skills training teaches the appropriate spiel tailored to various scenarios: the angry patient, the patient with dementia, or the grieving patient.
The use of these protocols in clinical practice risks frustrating patients. A patient writing in The BMJ criticised the Ideas, Concerns and Expectations checklist that students are taught to use at the beginning of each consultation, arguing that it does nothing to build rapport with patients and raises more problems than it solves. “Did anyone ask patients how these questions make them feel?” the author wondered.
Research indicates that the answer to that question is probably no, they did not. A randomised trial published in the Journal of the American Medical Association investigated how communication training affected patient care by following 232 internal medicine doctors over the course of eight teaching sessions. The researchers asked 472 patients to rate the quality of their doctor’s communication and care before and after the training, and found that the teaching had made no difference to the rating when compared with 240 internal medicine doctors who had not received the training.
Although previous studies had analysed the effect of communication training on examination results, this was the first to measure outcomes reported by patients. In the words of the researchers, the findings raised important questions about the problem of “skills transfer from simulation training to actual patient care.”
The researchers also screened patients for symptoms of depression before and after the doctors received the training. Interestingly, patients cared for by doctors who had attended the workshops were more likely to experience depression-like symptoms than those who were cared for by clinicians who hadn’t received communication training.
The researchers suggested that the doctors were more likely to initiate difficult conversations about end of life care, which may have predisposed their patients to depression.
But writing in the New York Times, two directors of the Cleveland Clinic, an academic hospital in Ohio, had a different explanation for the results of the study. “As we devote more time to teaching students communication techniques, we risk muting their authentic human voices,” the directors noted. “Instead of learning to connect, [students] apply rote tools and scripts.”
Losing my voice
It was this “authentic human voice” I’d become aware of losing as I sat in my OSCE, willing myself to care for someone I knew to be acting. Here we were, a class of students who had supposedly chosen medicine because of our enthusiasm for caring for people, now learning to feign that we cared. The supposed virtues of a doctor—integrity, transparency, and empathy—had been sidelined by a customer service approach to medicine.
Yet when I spoke to a non-medical friend about my realisation that doctors were being taught to act rather than to care, she seemed unfazed. “I couldn’t care less whether my doctor was a ‘good person,’” she replied, “as long as they are able to diagnose and treat their patients.”
She isn’t alone in holding this view. An article in the Journal of Medical Ethics epitomises the communication skills dogma that has gripped medical education. “The role of the doctor is moving towards that of a service provider,” the authors commented. “The skills required are not broadly different from those required by other providers of goods. If doctors can perform their tasks with skill and courtesy, this should be enough.” Their message? That good communication could compensate for a lack of genuine compassion.
The value of empathy
But we shouldn’t be too hasty in discounting the value of empathy. A 2011 study published in Academic Medicine identified that doctors who were emotionally invested in their job were more likely to see improvements in their patients’ physical health. The researchers monitored biological markers of diabetic severity in 891 patients, alongside doctors’ capacity for empathy using an established psychometric test. Over the course of a year, patients under the care of doctors who scored highly on empathy tests were more likely to have good control of their diabetes than those managed by doctors who had moderate or low empathy scores.
A second study by Italian researchers recorded the number of acute complications experienced by 20 961 patients with type 1 or type 2 diabetes over one year. Again, patients under the care of empathic physicians experienced fewer adverse events. Although it’s unclear how doctors can develop their capacity for empathy, or how empathy directly improves their patients’ health, these findings suggest that empathy is an effective clinical intervention. This is likely to be particularly true for patients with chronic conditions such as diabetes.
Trying to care
However, rather than nurture empathy, medical school does the opposite. When medical students’ ability to empathise is measured, researchers find a disturbing trend. With each year of their course, students’ capacity for empathy decreases.
“We must ensure that we are not converting people who genuinely care about their patients into people who only sound as if they care,” warned the directors of the Cleveland Clinic. Yet our medical school curriculums might be doing exactly that.
Richard Thomson, clinical subdean for Northumbria Foundation Trust, has a broadly positive view of teaching using role play, but draws attention to the “mismatch in power relationships” between simulations and clinical practice. “In real life you have a scared patient seeking reassurance from a doctor. In simulated scenarios you have a relaxed actor and a scared student who is preoccupied with putting on a good show for the observer.”
Others are less willing to admit that simulated role plays have their drawbacks. Sue Reid, who organises communication skills teaching at Newcastle University, told Student BMJ that she “generally finds no problems when using actors to teach communication skills. The only potential problem is if the student does not suspend their belief in a role play.” However, Reid did admit that “there can be a tendency for students to say the ‘right thing’ without actually meaning it.”
The real thing
So what’s the alternative? Angela Rowlands, senior lecturer in communication skills at Barts and the London School of Medicine, has pioneered a scheme of teaching communication skills using real patients rather than actors. Rowlands “was concerned whether communication skills training was transferred into clinical settings and was conscious that there was little research to address this issue.” The project saw her observe students in pairs while they took histories from patients on hospital wards. Afterwards, Rowlands and the patients gave feedback on the students’ performance.
The students evaluated the experience positively, and the opportunity to “practise in an authentic environment, with real patients in real settings” was a major theme of their feedback. Since the project, Rowlands tells me, other medical schools have adopted similar teaching strategies.
Some institutions are trialling more innovative approaches. Writing in The Atlantic, Anu Atluru, a physician at Harvard Medical School, describes how she benefited from enrolling in an improvisation course while at university. She believes that “improv’s fundamental principles—honesty and spontaneity” taught her to go “off script” with patients. She suggests that improvisational comedy taught her to understand patients in a way that being “coached to acknowledge feelings with ‘I understand’ or ‘I am sorry to hear that’” had ignored.
Elsewhere, tutors are recognising the value of empathy over basic communication skills and are using schemes designed to improve participants’ empathy. Empathetics is one such programme, founded by Helen Riess, a psychiatrist at Massachusetts General Hospital. The organisation’s workshops and online courses are targeted at physicians, nurses, and other healthcare workers. Several Boston hospitals now require their doctors to undergo the training, and preliminary research has been positive. Studies indicate that doctors who have completed the course receive better feedback from patients compared with their colleagues who haven’t.
“The secret of the care of the patient is in caring for the patient” wrote Harvard lecturer Dr Francis Peabody in his 1927 essay, The Care of the Patient. When first introduced, communication skills training was designed to address criticism being levelled at a medical profession seemingly unable to respectfully interact with its patients. As researchers question the effectiveness of communication teaching and explore the potential value of empathy, another possibility is coming into focus. What if it wasn’t a crisis of communication which plagued doctors, but a crisis of empathy? Ninety years after the publication of Peabody’s essay, its lessons still resonate in the field of medical education.
Back to Susan and my OSCE station. I’d managed to fumble through the exam, expressing platitudes in the right places and following the stage directions set by my curriculum. But one student in my year hadn’t. He had failed the station, and his feedback sheet simply read that he had shown “no empathy” in the role play. Perhaps medical educators should consider what their “communication skills” assessments teach students to do—develop a capacity for empathy, or simply the ability to feign it.George Gillett, fourth year medical student
University of Oxford
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally peer reviewed.
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