Teaching communication: Practice for students

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Part of medical undergraduate training today involves giving medical students the opportunity to try out their abilities with an actor representing the patient, or family member.

These sessions for ten to fifteen students are facilitated by a medical professional (of which I was one). An agreed scenario is prepared ahead of time by the facilitator and actor to explore specific aspects of the doctor- patient exchange.

Early in the doctor’s training the tasks set are fairly simple but nonetheless important. The student may need to explain the meaning of a diagnosis (for example what is a kidney stone?) or what happens during an investigation. For example, if you are about to have an abdominal ultrasound it helps to know what to expect. The student will explain that you will need to take your place on a couch. The abdominal skin is then covered with a (rather cold) gel. This emollient improves the contact of the radiographer’s probe or wand with the abdominal wall in order to clarify the image. The probe is moved steadily over the skin as the radiographer studies the internal organs. You can usually see what the scan shows on the screen beside you. However, these are shadowy images, difficult for the layman to interpret. Often the professional also needs to develop the images and study them at leisure.

All this explanation makes the patient experience much more acceptable and less intimidating. So, medical communication is not all challenging but is often the distillation of common sense and experience.

As students progress through their training the communication scenarios become more demanding until immediately before qualification some of the most dreaded challenges are explored.

Many students have reported that although these later lessons were painful at the time, they were grateful that when the real occasion occurred, they were able to remind themselves that they had lived through something like it before.

Here is an example of what students need to prepare for.

Gerald, a man in his seventies, told his wife Mavis that he felt some ‘indigestion’ after breakfast. Nevertheless, he set off to play nine holes of golf. At the third tee he suffered a severe heart-attack, and his golfing partners were unable to resuscitate him. An ambulance was called, and Gerald was brought in dead (b.i.d.) to the casualty department. His wife was telephoned and asked to come into the casualty department.

The task facing the medical student is to imagine and practice how to break the news to Mavis about her husband’s death: an unenviable task.

It is not surprising that some of society’s most challenging issues find their way into the consulting room.

Here is another story to illustrate the difficulties of some cultural differences.

Bahnaz, a sixteen-year-old Pakistani woman, came one day to consult her GP.

She was complaining that her asthma had recently become worse. She appeared to be extremely anxious about talking about herself.

The student’s task in this case was to listen carefully to Bahnaz’ story and react accordingly.

An insensitive line of questioning, which concentrated on the asthma alone, could easily miss an underlying issue. One important question presents itself. Why was Bahnaz’ asthma suddenly deteriorating? An empathic student, one who listens and questions sensitively, could gain Bahnaz confidence and discover that the cause of her anxiety, and the aggravation of her asthma, could both be traced to a serious deterioration in her relationship with her father. When the student examined Bahnaz and listened to her lungs, a series of bruises was visible down Bahnaz’ back. Further questioning revealed that her father had lost his temper with her and thrown her against a wall. It transpired that he had confiscated his daughter’s passport and arranged to send her back to Pakistan to marry a cousin, much older than herself. This was totally unacceptable to Bahnaz who was enjoying her college education. As a result, Bahnaz was essentially a prisoner in her home. The only way she could justify to her family a brief escape was to consult a doctor about a previously accepted medical condition.

How important was it for the doctor (in our example, a student) to establish the true story? Experience has sadly demonstrated how vital it was to provide Bahnaz, at this consultation, with a follow-up appointment in a few days to monitor her safety. In addition, she needed the phone number for a Pakistani Women’s refuge.

At either this appointment, or the next, the doctor might need to raise with Bahnaz the issue of reporting to the Forced Marriage Unit of The Foreign, Commonwealth and Development Office.

This case is in my view, a good example of how important it is for doctors to listen attentively, note a patient’s body language and physically examine them. Without ‘sensitive antennae’ it would be easy for the ‘minefield’ of the true problem to remain undiscovered. The consequences could be ruinous to the hopes of a young woman, or even fatal.

In modern Britain doctors need to be aware of numerous cultural differences. Another example arises in some very religious Christian groups such as among West African or Caribbean communities. Rather than consult a British doctor, some patients seek the advice of their Pastor or Church. For example, the hospitals of south London are aware of the need to target public health messages directly to the wider community and the Churches that serve them. Direct communication and cooperation with local churches could reap considerable benefit. If doctors and clergy were familiar with each other and had established paths of communication, it would help their patients/congregations.

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