Editor's Note: This Commentary is a companion piece to the Article by Hanna and Fins on page 265. The authors of that paper rightly ask, what are the power dynamics of medical students' and residents' encounters with simulated patients? How are their performances affected by being observed and evaluated? Do the communication skills they learn transfer to their interactions with actual patients? And what types of communication training will best promote robust relationships with those patients? These are questions of central importance to medical education. This Commentary complements the position set forth by Hanna and Fins, while offering readers a slightly different perspective.
In Contemporary Issues in Medicine: Communication in Medicine, a 1999 report for the Association of American Medical Colleges' Medical School Objectives Project (MSOP), I wrote that “the apprenticeship model and a conception of communication as ‘bedside manner' or ‘history taking' is giving way to more formalized instruction and a reconceptualization of communication as a fundamental clinical skill.”1 This perspective has become codified over the past several years: Interpersonal and communication skills are now considered a core area of competency for medical students, residents, and practicing physicians.2–5 Along the way, simulated patient encounters have become an increasingly recognized method of teaching and assessing communication, especially at the medical school level.
The Viewpoint article in this issue by Drs. Michael Hanna and Joseph Fins, “Power and Communication: Why Simulation Training Ought to Be Complemented by Experiential and Humanist Learning,” is provocative on several levels. In this Commentary, I articulate important differences in the application of simulated patients, elaborate on the issue of power and authority, and focus on three interrelated questions that emerge from consideration of interpersonal power in real and simulated medical encounters:
1. To what extent do medical students “perform” (i.e., put on an act) in the context of teaching and assessment that involves simulated patients?
2. How might medical educators increase the likelihood that students will apply to subsequent practice the core skills and strategies learned in their communication skills training?
3. How can different learning modalities—in this case, experiential, humanist, and simulation approaches—complement one another in communication skills training?
From the standpoint of someone who has long been involved in communication skills teaching, assessment, and research as well as worked on curricula and consensus statements with colleagues from many academic medical centers, I think it safe to say that the questions noted above are on the minds of most faculty actively engaged in communication skills education per se. Broadening the focus from communication skills to the overall curriculum, one sees that the issues of performance, subsequent application (i.e., internalization and integration), and effective learning modalities pervade medical education, whether in terms of improving clinical skills or taking basic science knowledge from bench to bedside. Thus, Hanna and Fins raise issues that merit thought and discussion throughout the medical education community.
Hanna and Fins chose the term “simulation patients” to describe people who are trained to simulate patients in medical encounters. As their use of the term encompasses both teaching and assessment, it is useful to disentangle these applications of simulated patients in clinical skills training (see Table 1). In general, when simulated patients are incorporated into teaching, they serve as “patient instructors” (PIs) who may change their general demeanor and/or the personal details of the patients they are portraying as they move from one student encounter to another. For instance, a PI may adopt the role of a quiet patient with one student, an anxious patient with another, and an angry patient with yet another. Similarly, with different students, the PI may portray patients with different types of relationships, lifestyles, work situations, health risks, and so forth. Feedback from PIs and/or observers may focus on particular learning issues. When involved in assessments, however, simulated patients function as “standardized patients” (SPs). The term “standardized” warrants emphasis, since the SPs are, in effect, the test. Thus, truly standardized patients are trained to enact the same patient role—with the same demeanor and same information content—during each student encounter. They are also trained to use consistent criteria for evaluating each student.
Power and Authority
Hanna and Fins apply a Foucauldian perspective to their discussion of the physician–patient relationship, which adds the dimension of power to the common-sense perspective that trainees' encounters with simulated patients are different than encounters with real patients. However, their analysis of the power dynamic between the “real” patient and the physician is reminiscent of the traditional medical model, which reflects and reinforces the belief that patients are essentially passive. In this model, patients fully accept physicians' authority, particularly the legitimate authority associated with the medical profession; the expert, or competent, authority associated with clinical knowledge and skill; and the personal, or referent, authority associated with relational factors. While the attitude and behavior of some doctors, medical students, and patients may evoke the medical model, there is little question that the biopsychosocial model, the consumerist movement, access to medical information, and patient-centered care initiatives have left their mark on everyday clinical practice. In any case, Hanna and Fins are certainly correct in their assertion that the power dynamics in simulated encounters are different than those of “real” encounters, primarily because the simulated patient is not truly vulnerable and the student is being evaluated. That said, it may not be a bad thing that part of the learning process takes place in a context that increases the relational power of patients, provided that trainees have the opportunity to consider issues of power and control.
The Issue of “Performance” versus “Actual” Behavior
The fact that students are being observed and evaluated by the simulated patients with whom they work—and sometimes by attendings, residents, or peers—has the potential to alter their behavior during encounters. Hanna and Fins tend to overstate this argument (e.g., “Whatever the student physician says to the simulation patient is in fact said to impress the faculty observer”). Still, it is important and instructive to consider the extent to which observation, evaluation, and simulation drive students' performance. While the notion of performance has long been a concern when communication is observed, research indicates that the presence of cameras does not significantly alter interactions either in medical encounters or in other contexts.6–9 Similarly, if peers, residents, or attendings are observing the encounter, their presence is unlikely to alter trainees' behavior provided they are unobtrusive. The knowledge that interactions are, at some level, being evaluated will make some trainees nervous, and put most on their best behavior. From this perspective, clinical skills evaluations provide a conservative estimate of what students are not doing (i.e., communication tasks not accomplished during an evaluation are not likely to be accomplished in everyday interactions; attention to other tasks may diminish when not observed). More troubling is the possibility that students will perform in the sense of putting on an act to satisfy evaluation goals. This is a very real possibility if students have not had the opportunity to think through, discuss, and experiment with different skills and strategies to accomplish communication tasks.1 In other words, if—consciously or not—communication skills presented to students or residents as a script or, in terms invoked by Hanna and Fins, “tricks of surface communication” or “a set of acting techniques.”
Before moving on, the simulated aspect of these encounters deserves attention. Consider this excerpt from “Cutting the Cord: Five Stories about the First Year of Medical School,”10 a documentary produced by Northwestern's Program in Communication and Medicine:
The coolest part about medical school so far was the first time we went in for our patient instructor session. The first session we had, I'd just be coming in and introducing myself—meeting the patient. Before I knocked on the door I thought to myself: This is it. This is like the real thing. This is, you know—not even that it was just practice or play or just an exercise, but this is really what it's all about. This is me going in, meeting a patient for the first time, starting to make a relationship, learning everything about that patient, and starting to analyze what is going on with that patient—what we can do to make that patient's life better. And it was like this whole revelation that happened before I knocked on the door, before I walked in the room. And actually opening the door walking into the room saying, “Hi my name's Chip Alpert; I'm a medical student working with Dr. so and so” was awesome.
This example illuminates a key issue. Students know that interactions with simulated patients are an “exercise” but take them very seriously, at least when the PIs and SPs are well prepared. Accordingly, it is unlikely that the simulation itself engenders “performance” in the sense of inducing artificiality. My experience suggests that, rather than learning to act as “simulation doctors” when working with simulated patients, students are learning to negotiate the nonlinear nature of human communication, the complexity of emotion, and the sometimes competing agendas of physicians and patients.
Increasing the Application of Communication Skills and Strategies to Practice
While the key to learning any skill is practice, it is important that students also be provided with a context for building their communication skills via an introduction to communication concepts and an explication of communication tasks. The task approach encourages students and physicians to develop a repertoire of communication strategies and skills and respond to patients in a flexible way. For instance, they can explore patient perspectives through a variety of equally effective means, choosing one that fits their style, the patient, and the situation. This approach provides a foundation for practice, review, and reflection, encouraging students to move beyond a mechanized approach to skill building. A model or framework that outlines key communication tasks can provide a coherent and useful underlying structure for teaching, provided that the framework is seen as an organizational guide and not a rigid script. Further, rather than simply telling students why effective communication skills are important or useful, it is essential that educators encourage them to discuss and debate these issues. Again, this is likely to decrease students' sense of “going through the motions” and facilitate their integration of associated knowledge, attitudes, and skills. As noted by Hanna and Fins, activities that foster personal awareness as well as consideration of patient perspectives are absolutely essential components of this process.
The Value of Different Learning Modalities
Hanna and Fins set up a bit of a straw man in suggesting that any medical school or medical student would engage in “exclusive reliance on this pedagogic approach of simulation training.” Trainees' encounters with simulated patients are opportunities for practice, reflection, evaluation, and feedback. While certainly valuable, it is hard to imagine simulation training in a controlled environment as the sole mode of learning about communication and interpersonal skills. Incorporating humanistic learning in the service of personal awareness, professional growth, and sensitivity to patient perspectives is relevant throughout the continuum of medical education. But the humanities are not a panacea, a direct route to being “good doctors from inside the heart.” Humanistic learning is likely to be most useful if combined with teaching and learning about clinical skills rather than offered as a stand-alone activity. Hanna and Fins also note the importance of experiential learning. Indeed, clinical exposure in a medical student's first two years and the clinical clerkships that follow are a crucible for learning—or unlearning—these skills. There has been renewed attention to the hidden curriculum (i.e., what students learn outside of formal teaching activities by watching and listening to their role models), and promising efforts are underway to measure how the hidden curriculum affects communication and patient-centeredness.11
I agree wholeheartedly with Hanna and Fins that students' communication skills and relational abilities should be cultivated in encounters with real patients. For instance, direct observation of trainees' encounters with real patients is a critical component of the education and evaluation process. However, in many medical centers, the interpersonal and communication skills of students and residents are often assessed indirectly, via presentation of information they have obtained from a patient rather than actual observations.12 This, in and of itself, sends a negative message about the importance of communication skills. The process could be enhanced if trainees were routinely asked not only about histories and differential diagnoses, but also about their patients' knowledge and concerns about their health problems, how the problems affect their lives, and their expectations of medical care.1 Feedback from patients is another promising yet underutilized endeavor, one that can send a very positive message by explicitly recognizing the unique and essential nature of patient perspectives.12,13 Accordingly, it will be important for medical educators to develop, test, and implement methods of having real patients gauge the interpersonal and communication skills of the students and physicians with whom they interact. Similarly, encouraging students to reflect upon and discuss their patient encounters can prove extremely valuable, and the Internet makes it relatively easy to create discussion groups that work well despite the time crunch and geographic dispersion endemic to the clinical years.14
In sum, communication skills education is not encapsulated by a particular span of weeks or readings within the curriculum that highlight this topic. Nor is it limited to simulated encounters. The Viewpoint article in this issue reminds the medical education community to consider the big picture. I hope Drs. Hanna and Fins will continue to develop their arguments and ideas regarding the productive integration of different learning modalities that can lead to effective healing relationships.
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