Katherine Heathcock of Birmingham University Medical School talks about the importance of using simulated patients to train medical students, a tool that gives students a unique insight into their own communication, character and consultation style.
In October 2002, my partner at the time had been riding a bicycle through the streets of Singapore, scouting the route for the Singapore marathon, for which he was the race director, when he was hit by a taxi travelling at 50 miles per hour. He was thrown high into the air and landed on his right side, with his head 2 inches from the kerb. A piece of his scalp was missing and he sustained some nasty bruising, but the main injury was acetabular – the head of his right femur had been forced through its cup-shaped socket in his pelvis. He needed to be on traction and to undergo pelvic reconstruction at Singapore General Hospital before being allowed to return home. The surgery and treatment he received in that hospital was exemplary and after 3 weeks I was able to fly out to bring him back to Britain.
I accompanied him to the first consultation with the orthopaedic specialist registrar at our local hospital. The registrar was astounded by the history and incredulous at how quickly Pete had recovered, moving out of his wheelchair and walking only with the assistance of a stick. I don’t think he fully believed the story, until he saw the x-rays, showing extensive metal work in Pete’s pelvis. He was clearly impressed by the quality of the workmanship. But I shall never forget the words that escaped him that day. He said to Pete “We would expect patients with this kind of injury either to die at the scene of the crash, or to limp to the grave”.
Though his utterance was likely motivated by the esteem he felt for his colleagues in Singapore, from the patient’s perspective, neither of the options on offer was particularly attractive, but Pete had thankfully not died at the scene, which left him with the other choice: that of limping to the grave. Being a very proud Welshman, he downright refused to alter his gait, despite his pain. I was shocked by the registrar’s statement but what must it have felt like to the patient? Perhaps the registrar judged wisely and could see the grim determination that had pulled Pete through this traumatic event and was man-on-man encouraging and rewarding his fortitude? In that moment, he was likely completely oblivious to the imbalance of power that is always present in the doctor/patient dynamic, that exaggerates the influence of any statement a doctor makes, whether newly qualified foundation doctor or senior consultant, the difference in status being obvious to the professionals, but less visible to the trusting patient.
The registrar’s initial disbelief and his subsequently insensitive and dismissive language in fact only served to stiffen Pete’s resolve to walk straight and upright and never to limp. But it could have gone a very different way. The registrar had no insight into how his words might be perceived or their potentially negative effect upon the patient and his recovery. He was likely blissfully unaware that his words were hurtful and potentially damaging to the psychological well-being of the patient in front of him. And I don’t suppose today that he would have the slightest recollection of having said those words; whereas for us, they will never be forgotten. Much has been written on the power of language but to quote Sigmund Freud “Words have a magical power. They can bring either the greatest happiness or the deepest despair”.
People generally enter medicine or related professions in order to help people and yet many patients and relatives, certainly in the UK have a similar story to tell of inadequate or unsympathetic communication. So why do healthcare professionals so often get it wrong? Can we really be content to blame the system with its undeniable pressures of underfunding and under resourcing? Undoubtedly, the economic and temporal pressures form part of the picture but the system is made up of human beings, interacting with other human beings and given the right insight and training, the choices they have about how they communicate with each other and with patients can be clearer.
At Birmingham University’s College of Medical and Dental Sciences, the Interactive Studies Team teaches Clinical Communication to healthcare undergraduates. We currently work across Medicine, Dentistry, Pharmacy and Physician Associate programmes, using role play as our main methodology. Our simulated patient (role player) team is made up of over 100 professionals with backgrounds as diverse as the performing arts and the military. We have dancers and nurses and martial artists and researchers and students and retirees on our books but all have an interest in developing the healthcare workers of the future.
Members of our team are trained to pick up a scenario, with a richly detailed background based on a real case and to simulate (or act out) that scenario with students. The role player will be required to play a patient with a certain condition or set of symptoms, or a relative or colleague. There is no script just background information, which might include past medical history, history of the presenting complaint, social history etc.; there will be learning outcomes for the scenario, which might have to do with handling the anxious relative of a patient, for example. The student is required to engage with the scenario, which will play out according to the behaviours of that individual student. In other words, if the student behaves in a way that reassures the anxious relative, the role player will respond accordingly.
If the student is dismissive or unassertive for example, the simulated patient will respond in role with corresponding behaviours, which may include increased anxiety or perhaps disengagement for example. The interaction is watched by a group of between 3 – 10 other students, depending on the programme and year group, all or some of whom will get the chance to role play subsequently with different scenarios.
Following the scene’s conclusion, the student will be asked to reflect out loud upon how well they think they handled the interaction and if there were moments when they felt uncomfortable or would, in hindsight, like to have done something differently. The observers will be consulted for their impressions of what took place, what they appreciated in their peer’s handling of the situation and what, if anything they would do differently. Then comes perhaps the most valuable part of the learning experience: the role player’s feedback.
Our role players are trained to give feedback ‘out of role’, in other words as themselves, describing the effect of the student’s language, non-verbal communication, questioning, listening, empathy, rapport-building etc. on the patient/relative/colleague they were representing. We ask for it ‘out of role’ because these sessions can be emotional for students and the added objectivity of third-person feedback, helps to decrease any heightened feelings in the room and to protect the simulator from personal criticism. This feedback can be powerfully formative. It enables insight for the student into how they may be perceived in communication. It creates a sense of positive ‘self-consciousness’, which is necessary in the formation and development of self-reflective practitioners. And the role player’s perspective can’t be argued with. When a role player says “when you did this, Mrs Jones felt that”, who can contradict? As a facilitator of these small groups, before the role player feedback I may ask the student observers how they thought the role playing student made the patient (for example) feel. There may be several opinions and these may be debated. However, when a role player makes the statement to the student about the impact on his or her character of the student’s behaviours, it is incontrovertible, potentially generalizable and often the cause of a great deal of reflection. Any anxieties on the part of students about role play generally evaporate in the intense engagement with these discussions. Role players are trained to give balanced feedback in a way that is palatable to the students, so as to minimise defensiveness, which we rarely, if ever see.
This feedback may be a springboard into a more general discussion about empathy and listening. If a role player were to say in feedback “when you told my character that patients with this kind of injury usually ‘die at the scene of the crash, or limp to the grave’, my character felt shocked and defeated”, this would be a powerfully influential experience for the student and may trigger a group discussion about how the choice of words can have an enormous impact on a patient’s recovery and the attitudes that may underpin, and are expressed by, what we say.
In our teaching sessions, the learning is for all participants and observers can learn as much from the interventions as those actively playing in role. (Incidentally, we never ask our students to be anyone other than themselves). A health professional has enormous scope to benefit his or her fellow humans. It is imperative that all learn the power of their own language and attitudes and that their unique and individual way of communicating is flexible; each of us makes choices about what and how we speak and behave towards others and the more self-aware our doctors, dentists, nurses and other healthcare professionals become, the better will be their choices and the consequent impacts on the people in their care.
Katharine Heathcock, is a full time Teaching Fellow for the College of MDS at Birmingham University Medial School, teaching Clinical Communication across the MBChB, Pharmacy and Dentistry courses, with responsibility for MBChB years 1 and 2 and GEC. She also teaches at postgraduate level. Katharine has experience as a coach facilitator on the Referred Student programme. She is a Personal Mentor and has responsibility for academic programming for the Biomedical Science International Summer School. She has a background in theatre, professional role play, training and assessment but her passion is teaching.
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