“Communication skills” and the problem with fake patients

This article was originally published in Student BMJ, a magazine produced by the British Medical Journal for medical students. An online version can be found here.

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 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 in an OSCE station, a medical school examination used to test a student’s ability to practice as a doctor. In an OSCE, students rotate through a variety of role-plays lasting between five to ten minutes. Having been briefed with scenarios, actors play the role of various patients, while examiners assess students’ clinical professionalism.

The use of OSCEs in medical schools is not without controversy. They’ve been criticised as “box-ticking exercises” and condemned for promoting a narrow understanding of clinical medicine. Others 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 recent study on the topic.

Nowhere are these concerns more applicable than the communication skills stations. Although OSCEs can simulate clinical examinations or history-taking scenarios with relative ease, encounters where students are tested on their ability to express empathy herald a new set of challenges. A friend recently told me how a mixture of exam 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 in his exam. Another had failed a station because he had misidentified the character he was supposed to be playing on the brief given to him just seconds before.

Method acting

Ever since the introduction of communication skills stations into their exams, trainee doctors have been tested on their ability to act. And like any acting role, such an approach comes with the perception that a script should be followed. Students are taught the appropriate spiel tailored to a palette of scenarios; the angry patient, the patient with dementia or the grieving patient.

Despite scoring marks in exams, the use of these protocols in clinical practice risks frustrating patients. In a recent article, The BMJ’s Patient Editor condemned the checklist students are taught to practice – to “ICE” patients, by asking their Ideas, Concerns and Expectations at the beginning of each consultation. The article suggests the technique dose nothing to build rapport with patients and instead raises more problems than it solves. “Did anyone ask patients how these questions make them feel?” she wondered.

Research suggests the answer to that question is probably not. A study published in JAMA investigated how communication training affected patient care by following 472 clinicians over the course of eight teaching sessions. Asking patients to rate the quality of their doctor’s communication and care before and after the training, the researchers discovered a startling fact. The teaching had made no difference to either outcome.

While previous studies had analysed the effect of communication training on examination results, this was the first to measure patient-reported outcomes. In the words of the researchers, the findings raised important questions about the problem of “skills transfer from simulation training to actual patient care”.

And that’s not the worst of it. The researchers also screened patients for symptoms of depression before and after the doctors received the training. Disturbingly, patients cared for by doctors who attended the workshops were more likely to experience depression-like symptoms than those whose clinicians hadn’t.

Advocates for communication skills training explained away this phenomenon. Doctors with adept communication were more likely to initiate difficult conversations about end-of-life care, they claimed, which were likely to predispose 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. “As we devote more time to teaching students communication techniques, we risk muting their authentic human voices” they wrote. “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 midway through 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 to care for people, now learning to feign that we cared. The supposed virtues of a doctor – integrity, transparency and empathy – had been side-lined 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 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 wasn’t alone in holding this view. A recent article in the Journal of Medical Ethics epitomised 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

However, there is reason to be sceptical of arguments which consider empathy as superfluous to medical care. A 2011 study identified that doctors emotionally invested in their job were more likely to see improvements in their patients’ physical health. The researchers monitored biological markers of diabetic severity, 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 exhibit good control of their diabetes, compared to those managed by physicians with moderate or low empathy scores.

Encouraged by these findings, an Italian research group launched a similar investigation a year later. This time, researchers recorded the number of acute complications that diabetic patients experienced, such as diabetic ketoacidosis and coma. Again, the empathy of clinicians proved significant to patients’ health outcomes, with those under the care of empathic physicians experiencing fewer adverse events.

Although it’s unclear exactly how a doctor’s empathy influences patients’ health, the findings engendered an implicit recommendation. If medicine is to use effective interventions to improve the health of its patients, empathy is a tool doctors should be turning to.

But rather than nurture empathy, medical school does the opposite. When medical students’ empathy is measured, researchers find a disturbing trend. As each year of their course progresses, 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” the directors of the Cleveland Clinic had warned. Yet our medical school curricula might be doing exactly that.

When I started speaking to medical educators about the topic, further concerns were raised. Richard Thomson, Clinical Sub Dean for Northumbria Foundation Trust, has a broadly positive view of role-play teaching, but drew 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 by putting on a good show for the observer.” This raises challenges, he suggests, as to how students can “learn to use that power responsibly and effectively”.

Others were less willing to admit that simulated role-plays had 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, a Senior Lecturer in Communication Skills at Barts and the London School of Medicine, 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, as they took histories from patients on hospital wards. Afterwards, Rowlands and the patients gave feedback on the students’ performance.

The students positively evaluated the experience, and the opportunity to “practice in an authentic environment, with real patients in real settings” was a major theme of their feedback. Since the project, Rowlands tells me, medical educators from a number of other medical schools have adopted similar teaching strategies.

Other institutions are trialling more innovative approaches. Writing in The Atlantic, Anu Atluru, a physician at Harvard Medical School, described a technique she’d encountered at the university: improvisational comedy. She believes that “improv’s fundamental principles – honesty and spontaneity” taught her to go “off-script” with patients. She suggests that improv 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 using schemes designed to improve participants’ empathy head-on. Empathetics is one such program, founded by Dr Helen Riess, a psychiatrist at Massachusetts General Hospital. The organisation’s workshops and online courses are targeted at physicians, nurses and other healthcare workers. A number of Boston hospitals now require their doctors to undergo the training, and preliminary research has been positive. Studies suggest that physicians who have completed the course receive better feedback from patients compared to their colleagues.

“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. However, 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 their students to do: develop a capacity for empathy, or simply an ability to feign it.


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