Last month, Richard Schwartzstein authored his perspective on poor communication skills among medical students and beyond (1). I read this with great interest and wanted to share my insights as a doctor in training. In the UK, it was also noted that allegations about doctors’ communication skills had risen by 69 per cent in the last year and complaints about lack of respect by 45 per cent (2). Whilst we may attempt to screen out those poor communicators early on as Richard highlights, I am not sure if this is truly beneficial.

Whilst medical schools may employ in the most part role play based sessions and OSCE style scenarios to assess communication, outcomes can be based purely on acting the part or not being able to perform due to the artificial nature of the process. In fact, if I recall my days of examined communication, despite “ticking the assessment box,” I appeared somewhat disingenuous. The multiple mini interview was listed in the article as an attempt to assess communication to a greater depth but it often utilises scenarios so far removed from clinical practice that I question its worth (explanation of a car parking mishap or a discussion about flying to attend a critical business meeting to name but a few) (3). Written tests were also highlighted as a means of screening, but again this has drawbacks. Like the Medical College Admission Test (MCAT), the UK has a similar admissions test such as the UKCAT focusing on areas of verbal reasoning, quantitative reasoning, abstract reasoning, decision analysis and situational judgment (4).The latter in fact is also revisited during the final year of medical school as a decision aid to job allocation for newly starting doctors assessing areas such as commitment to professionalism, coping with pressure, effective communication, patient focus and working effectively as a team (5). It is yet to be determined the true value of such a test on a cross university scale. Initial data however demonstrated below neutral scores as to whether the Situational Judgment Test (SJT) was a worthwhile assessment tool of the 5 domains (mean score range: 2.24-2.61) as well as concerns related to the subjectivity of responses, the ability to coach yourself for the exam, the lack of realism scenarios wise, and lack of feedback on responses (6).

I would agree with Richard’s view that the obvious deficit of true patient exposure, financial constraints, and pressured faculty time is problematic. Maybe the move towards entrustable professional activities where an individual is deemed competent after repeated graded exposure could hold value (7). Interestingly there is always a need for more financial input and selection of enthusiastic faculty, particularly those that don’t choose to mentor in order to simply advance their own CV.

On a personal level, I would say that how I interact now with patients is very different to how I was as a student, a student where I wasn’t sure of the things to ask, say or how to say them. As Ronald D Laing highlighted in Knots (8):

There is something I don’t know
That I am supposed to know.
I don’t know what it is I don’t know,
And yet am supposed to know,
And I feel I look stupid
If I seem both not to know
And not to know what it is I don’t know.

Therefore, I pretend I know it.
This is nerve-wracking
Since I don’t know what I must pretend
To know.

Therefore, I pretend to know everything.

I feel you know what I am supposed to know
But you can’t tell me what it is
Because you don’t know what I don’t know
What it is.

You may know what I don’t know, but not
That I don’t know it.
And I can’t tell you. So you will have
To tell me everything

And I put this down to the simple lack of experience at that time. Over repeated patient exposures I have developed a rapport and communication platform that is certainly more natural. Each patient is different and reflecting back to the age old ICE (ideas, concerns, expectations) acronym, we need to ensure its adoption per consultation. Patient exposure although slow to start builds over time during medical school and beyond and this is truly the only way to enhance our understanding.

As William Osler rightly said: ‘To study the phenomena of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all.’

Neel Sharma graduated from the University of Manchester and did his internal medicine training at The Royal London Hospital and Guy’s and St Thomas’ NHS Foundation Trust. Currently he is a gastroenterology trainee based in Singapore.

Competing interests: None declared.

References: 

1. Schwartzstein RM. Getting the Right Medical Students — Nature versus Nurture. New England Journal of Medicine. 2015;372(17):1586-7. PubMed PMID: 25901425.
2. GMC. Record number of complaints against doctors – GMC report 2012.
3. Eva KW, Rosenfeld J, Reiter HI, Norman GR. An admissions OSCE: the multiple mini-interview. Medical education. 2004 Mar;38(3):314-26. PubMed PMID: 14996341. Epub 2004/03/05. eng.
4. UKCAT. Test Format 2015.
5. NHS. The Foundation Programme 2015.
6. Sharma N. Medical students’ perceptions of the situational judgement test: a mixed methods study. British journal of hospital medicine (London, England : 2005). 2015 Apr 2;76(4):234-8. PubMed PMID: 25853355. Epub 2015/04/09. eng.
7. AAMC. Core Entrustable Professional Activities for Entering Residency 2014.
8. Laing RD. Knots. London: Routledge, 1999; 1970.