By Kurtz Suzanne, Silverman Jonathan and Draper Juliet . Radcliffe Publishing Ltd; , 2005. , PB £35.00, 367 pp . ISBN 1‐85775‐658‐4
This very well organized and accessible volume is most impressive initially for the abundance of empirical evidence presented, which serves as a rationale and foundation for its educational approach. The authors raise a series of common challenges and questions about the need for communication training in medical education, and then proceed to address each one with research data. The findings are portrayed in a readable and powerfully persuasive fashion. For example, a series of studies are cited to indicate that doctors accurately elicit patients' complaints barely half of the time; they rarely ask patients to express their ideas; many patients express the wish to have more information or control than that offered by their doctors; and the majority of malpractice suits are related to doctors’ communication and attitudes. Doctors tend to vastly overestimate the amount of time devoted to explaining and planning with patients, and are not accurate judges of their own behaviour. Further, the evidence that experience alone is a poor teacher is described in a dramatic passage and underscores the notion that ‘While experience may be an excellent reinforcer of habits, it tends not to discern between good and bad habits’ (p. 21). For this reader at least, this served to secure my dedication to read more and to sharpen skills and awareness. The opening section successfully challenges the common sentiment that, as we all know how to communicate, and do it all the time, why should we need specific training in how to do it as doctors?
The book is organized into three sections: an overview that includes the rationale and basic pedagogical principles, the practice of teaching and learning communication skills, and curriculum development. Three appendices are included at the end, which offer a sample curriculum, a process guide assessment and evaluation instrument, and a protocol for preparing simulated cases. The authors are quite clear throughout much of the book that there is a parallel process at work: the clarity offered in the writing and explanations, and recommended for the teaching, mirrors the goals for skilful communication with patients. True to the title, the book addresses the roles of both teachers and learners, which can – and should – overlap.
A model that applies to much of the method is described as ‘helical’ referring to the design of the helix, in which the learner's progress follows a spiral, revisiting a topic on a repeated turn but at a higher level. Skills are refined and sophistication of observation grows. The relationship and patient‐centered care are primary in medical interviewing and the parallel dedication to the learner for these authors is similarly in focus. (The word ‘learner’ and other terminology are explained at the outset, to eliminate some regionally specific language differences for medical roles in the UK and North America.) The tool of restatement for medical consultations is mirrored in the book by restating at the start of each new chapter the key points covered in the previous chapter, and then outlining what lies ahead. They address both skills and attitudes and point out that attitude is insufficient for proficiency. Putting the proper attitude into action requires the proper skills. The authors offer a multitude of techniques for addressing particular challenges, including the common and difficult problem of defensiveness.
A useful metaphor offered in the book is the comparison of traditional and contemporary teaching techniques to the ‘shotput’ or ‘frisbee’. The ‘shotput’ emphasizes the delivery – a good throw – without concern for being ‘caught.’ By contrast, the ‘frisbee’ approach is distinguished by the emphasis on reciprocity – being understood and engaging in interaction. This is the favoured emphasis of the book. The spectrum of teaching methods for different group formats are described, each with related benefits and shortcomings. Other variations described are simulated patients, role play, real patients and videotaped or audio‐taped interviews. Each of these circumstances offers different opportunities to learners. In particular, practicing interviews on sensitive topics such as breaking bad news, or discussion of sexual functioning or substance abuse are best done with simulated patients rather than real ones, who could be made uncomfortable by the process. Simulated patients, or actors, can tolerate repeated practices and can give valuable feedback to learners.
The section outlining the ‘agenda led outcome based analysis’ (ALOBA) was valuable. While the name is difficult, the concept of identifying the learner's agenda and focusing feedback on selected learner‐identified goals is very useful. The focus is positive and constructive, lessening risk of defensive responses as the learner is engaged in choosing the focus. This is contrasted with the typical ‘sandwich’ approach to feedback in which the critical remarks are layered between saying something positive at beginning and end. Here the emphasis is on behaviour and value‐free language. Rather than ‘good’ or ‘bad’ interventions, ‘what works’ is discussed, along with possible alternatives. The tone is one of collaboration and teamwork rather than hierarchical evaluation.
The final section on curriculum development addresses the challenging area of assessment. There is a clear conceptual framework in which assessment is broken into component parts dealing with knowledge, competence, performance and outcomes. Each of these areas will require different methods of assessment.
Overall, this is a very useful volume which, after initial reading, is useful as a reference manual in teaching. The companion volume, ‘Skills for Communication With Patients’, was mentioned several times. This book is able to stand alone, but I suspect the other volume is similarly valuable. It is an engaging read, the sample dialogues are believable, and the tone carries an infectious enthusiasm for the honourable and challenging practice of teaching communication skills for medical interviewing.