Ice, Ice baby- the hidden curriculum around communication skills

A few years ago I wrote a post about the challenges of teaching "communication skills". The YouTube video above is about the Clinical Skills Assessment (CSA)  that doctors training as GPs in the UK take. It emphasised the need to ask patients about their ideas, concerns and expectations (ICE) during a consultation. But it frames the need to do this as a requirement of an exam rather than something that will benefit patients. For example, the first clinical episode described is about a doctor feeling that they have to ask a patient who has symptoms very suggestive of a heart attack about their ideas and expectation of the consultations. This is something that the doctor seems to feel is delaying the patient's care and they may well be right about that.

So what is the take away message? What does this song tell us about how our assessments frame doctors understanding of communication skills?

Tweeting from a conference.

If you are following me on twitter you will have noticed many #comet09 tweets in the last two days. There will be more tomorrow as the conference finishes in the afternoon. So what was it about? COMET is an interdisciplinary conference in communication, medicine and ethics. It moves around the world and this year was on my doorstep in Cardiff so too good an opportunity to miss.

I decided to tweet because I thought the content would be interesting to quite a few of the people I know on Twitter. And it was. Some of the things that happened:

• @jrbtrip found out what an old colleague was up to
• @hadleybeeman and I had a discussion about whether patients had the right to not engage in partnership with their GP in their care
• @mrhyde found out about some research on how people who are obese access information on the internet.
• @vmontori who was a co-author of some work that my colleague presented was kept up to date although he was still on the other side of the Atlantic.
• @casesnetwork kept up to date with Brian Huritz's lecture.

And after seeing a presentation about using multiple modalities in drug patient information leaflets I remembered that I had seen a lightning talk about this last week at Health Camp but couldn't remember who. I tweeted and had the answer before the speaker had finished her presentation.

I do seem to have been the only person tweeting from COMET 09, but I predict that come COMET 10 in Boston there will be a few more. This was not about providing a backchannel to the conference, but simply about bringing the contents of interesting dialogues to a wider audience. So if you are listening to someone stimulating, think about tweeting. The chances are that someone you know will be glad that you have made the effort to share.

Teaching Communication Skills

It's a month since I've last posted on my blog and I am not quite sure why. I've thought about many things and wanted to write about them but I kept thinking that I had to look something more up before I could put fingers to keyboard. And while I do think it would be wonderful if I did have the time to research everything I write and place it within a context, I also think it is good to just get on with sharing reflections on work.

So, I spent this afternoon teaching a 'breaking bad news' session to 3rd year medical students. Our course is undergarduate so these students are in their early 20s. The session is 3 hours long, with 5 students, me and 5 standardized patients(actors) who cycle through the rooms and are with us for about 15-20 minutes.

This is the third of 3 communication skills in 3rd year. I was stepping in for another tutor so had not met the students before and they had bonded quite a lot together as they had been on many placements together not just this class. They were even going out to a pub quiz together.

I want to tell about two of the scenarios we discussed. No. 2 patient/actor has to be told that his long-waited for operation had been cancelled due to emergency admissions. The student psyched herself up because she and the other students had heard on the grapevine that this scenario was particularly confrontational. The others joked that if any of them could cope with this angry man then she could. And so the metaphor of battle for this consultation was set, and it continued throughout. It really did feel that they were on two opposing sides rather than her being there to support the patient. I know from talking to these students that they care deeply about patients, but in this scenario the 'game' of sparring with this actor was too strong. It had been mythologised by previous students and there was little chance for this student to come to it with her own angle. It made me think (again) about who un-natural communication skills teaching can be. I was a bit shocked when I came across this book chapter yesterday.... our exams deconstructed! And I realised that our teaching sessions can be too predictable for students as well. When he had finished acting our actor told how his real-life wife has had an operation cancelled three times in the last month. On the second occasion she had got as far as changing into her gown when she got news it was off. But the news came from the surgeon who left the theatre and came down to sit beside her bed and apologise. It was this story which made the scenario seem real for the students and they thought that perhaps the wrong approach had been taken by their colleague initially. The example of the surgeon who sat alongside his patient, rather than on the other side of the battle lines made sense to them.

We were recovering from this encounter when our next actor/patient arrived. This involved a patient returning for the results of her chest x-ray. It showed an opacity and she was to be referred urgently for a CT scan and to a chest clinic for assessment. She had a high chance of having a lung cancer. I quickly checked with the student if she was prepared as she thought she was going to have another scenario. She made an aside comment about the patient probably going to start crying and I wondered if she was in the right place. I asked her again if she knew what she was going to say and she said yes. The actor/patient was rapping on the door so we moved on. It quickly emerged, to me,that the student after talking about 'shadows' on the scan and the fact that this could mean many things.... but possibly something 'serious', was not going to discuss the possibility of cancer with the patient.

I called time out and asked the student if this was the case. She said it was and said that if the patient asked she would tell them but not otherwise. I said that I didn't think this was the best approach, but the other students said that they thought she was right. It wasn't fair to burden the patient with the possible cancer diagnosis if she didn't want to know. And we had to presume that she didn't want to know if she didn't ask. So they resumed the consultation, and it finished without the patient ever knowing that she was being referred because she might have cancer.

Afterwards the student said that she thought it was the job of the chest clinic to inform her about the possible cancer diagnosis or the actual cancer diagnosis. At the time I was quite strident in my opinion that the patient should have been informed but the students were still not coming round. One did, but just the one.

The next scenario helped us as it was about a young woman presenting with a breast lump. This student mentioned the possibility of breast cancer within her first few sentences. The consultation ran smoothly. The actor shared in the feedback that she felt it was unfair to expect the patient to raise the possibility of cancer and that it was good to get it out in the open. She called it the elephant in the room. We all laughed and told her about our debate with the previous scenario. Some of the others now also started to agree that if the patient was being referred because of the risk of cancer then it was important that they should know and that it was not fair to leave the responsibility of asking to the patients. By the end of the afternoon they all seemed to agree on this.

I framed it in the context of 'informed consent'. Could the patient really give consent to the tests they were to undergo if they didn't know what they were actually checking for?

But I recieved today "The Logic of Care" by Annemarie Mols. I haven't read it yet but I wonder if I will be so sure that I am right when I finish. She compares the logic of choice, which she says is becoming dominant in western healthcare, with the logic of care. Were the students being more caring in wanting to give a woman who has a probable cancer diagnosis her last two weeks without having had cancer overtly referred to, than I with my thoughts of empowering the patient through information? I don't know.