Education for communication: much already known, so much more to understand

The need for formal communication skills teaching and learning in health care education is well established.1 A substantial body of evidence has also accumulated about the problems of communication between health care professionals and patients and the benefits of good communication.2 There is also an extensive literature about ‘how to do it’,3 although much of this is descriptive. More evidence about the ‘how?’, the ‘what?’, the ‘when?’ is to be welcomed. In this themed issue there are six papers looking specifically at teaching and learning communication. Each has intrinsic interest, but a number of themes also run through them, including the need for training and support for teachers, the timing of teaching and learning and the challenges of researching these areas. Dosanjh and colleagues at McMaster University in Canada used a qualitative approach to explore the perceptions of junior doctors about barriers to delivering bad news to patients and their relatives.4 The residents appeared to be aware of, and to understand common guidelines concerning how to break bad news, but there were many perceived barriers to their implementation which fell into two categories: personal and institutional. Personal barriers included a wide range of fears, and problems over differing perceptions of what constitutes bad news; these were perhaps predictable, as was the major perceived institutional constraint, namely, lack of time. However, inadequate support from other health professionals was also a major barrier, along with lack of time for residents to reflect on and process their own emotions. The authors’ recommendations for change include both increased skills training for residents, and a stronger support network of peers and supervisors. This echoes previous calls to take into account not only skills, but also affective factors and perceived support when designing training programmes in communication.5 Not really addressed by the authors is the need for training for established, experienced clinicians, given that many of them will have had no formal teaching in communication themselves. It is hardly any wonder that the residents’ senior colleagues were unable to provide support, since they probably shared similar fears and perceived the same barriers. Similar issues are raised by the study by Evans et al., from the United Kingdom,6 who carried out a postal survey of current practice and problems experienced in teaching consultation skills amongst a group of general practice vocational trainers. There was a wide variation in the reported frequency of such teaching, the models used and the trainers’ own training, despite the systematic approach taken locally, and also despite the fact that consultation skills are now summatively assessed at the end of vocational training. Although the majority of their respondents had had some training in teaching consultation skills, the survey did not explore the need for continuing support. The authors stress the need for on-going opportunities over time to enable learners to learn communication skills; the same is surely true for teachers to learn how to teach. Walsh and colleagues,7 in a controlled trial, compared skills performance of medical students from a traditional and a non-traditional medical school in Australia, before and after participation in an education programme about brief interventions in alcohol problems. Although students from the latter institution, where experiential skills acquisition is emphasized throughout the curriculum, performed better in both alcohol-related and general interactional skills before the programme, there were no significant differences between the two groups of students afterwards. The authors speculate about the assessment process used in the study, and in particular whether students were being expected to demonstrate competence in too complex an area after relatively limited training. This raises important questions about the timing of teaching in communication – an issue also particularly relevant to breaking bad news. Undergraduate education should establish a foundation in areas such as these; learning at this stage is necessary to sensitize students to important issues and to raise awareness and understanding early on in the careers. However, adult learning theory suggests that learning is most powerful when new skills and knowledge can be put into practice immediately. Because undergraduates do not normally have formal responsibility for patient care, reinforcement and full development of such explanation and planning skills must take place during residency and continuing medical education. Humphris and Kaney address the relationship between knowledge and skills in an interesting paper from Liverpool.8 Their cohort study aimed to look at the change in skills from early to mid stages of a new 5-year undergraduate curriculum, and to investigate the predicted significance of knowledge of skills with respect to observed performance. Gratifyingly, improvement in skills, as assessed by objective structured clinical examinations (OSCE), was found in their students between their first summative assessment at the end of first year and their next assessment following further learning opportunities 17 months later. Knowledge and understanding of communication at the start of the study, assessed by objective structured video examination (OSVE), i.e. watching a video and identifying aspects of communication, was not correlated with performance in the first assessment. However there was an unexpected later finding, in that students who scored poorly on the OSVE tended to do well in the second OSCE. The authors offer some explanations for this observation, and end with the promise of further studies to come. This reminds us of the tremendous goldmine of data that systematic, progressive OSCE-type examinations offer to the researcher. The remaining two papers describe innovative approaches to communication teaching. Hardoff and Schonmann from Israel,9 describe their experience in continuing medical education programmes for primary care physicians, tackling the difficult area of communication with adolescents. A particular feature of their programme is the involvement of teenage actors from the drama department of a local high school. This highlights the potential of looking beyond traditional boundaries, and drawing on the vast experience of other professionals as well as the lay public. The authors do not mention resources, and one assumes that the quid pro quo for their involvement in the programme was the actors’ experience that they were able to develop new improvisation skills. Others have reported the use of schoolgirls as adolescent standardized patients and the beneficial effect of the experience on them.10 However, resource constraints will always be a challenge for those wishing to innovate in this kind of area. Finally, Lau and colleagues from Hong Kong11 describe a project that looked at first-year medical students’ perceptions of skills acquisition playing either ‘interpreter’ or ‘observer’ roles in a communication skills workshop. Bravely, the authors report a study that did not achieve its hypothesized outcome, that early experience of interpreter roleplays would enable better perceived acquisition of communication skills and, in particular, non-verbal communication; this may well have been due to a fatal flaw in the study design in that most of the students were already bilingual! In this era of multiculturalism and the need to train professionals to work competently and effectively in ethnically diverse societies, the authors rightly suggest that there should be a greater focus on these issues in health education curricula. All these papers make a welcome contribution to the evidence-base of communication skills teaching and learning, and each raises issues for debate and to inform further research. The challenge now for educators in health care communication is twofold. Firstly to put what we know into practice. Communication skills teaching, a relatively ‘new kid on the block’ in health care education, has had to prove its credentials more than many established courses. This it has done, with extensive research, as witnessed by the plethora of papers on this subject published in Medical Education in the past few years. It is now time that we what we know is implemented. This needs more than the enthusiasm of communication skills programme directors and their teachers; it needs the support and backing of those in authority in medical educational institutions. Secondly, implementation should be backed up by rigorous evaluation and research. As demonstrated by these six papers, we still have much to know and the answers are not always as we would predict. We need to go further now, to ensure that what we are doing in practice will actually achieve our aim of ensuring that each generation of doctors is better equipped in communicating than the last.