Viewpoint: Power and Communication: Why Simulation Training Ought to Be Complemented by Experiential and Humanist Learning

ArticleinAcademic Medicine 81(3):265-70 · April 2006with20 Reads
Impact Factor: 2.93 · DOI: 10.1097/00001888-200603000-00016 · Source: PubMed
Abstract

The authors present an analysis of communication training for medical students using simulation patients, and its possible influence on later doctor-patient relationships. Many empirical studies have shown the various benefits of using simulation patients to teach communication skills, but theoretical sociology and humanistic reflection shed light on some fundamental differences between the student-doctor/actor-patient interactions practiced in simulation encounters and real doctor-patient relationships. In contrast to the usual power dynamics of a doctor-patient relation, those of simulation encounters are inverted and overwritten by an entirely different set of power relations, namely, those of the evaluator-student relationship. Since the power dynamics of real doctor-patient relations are generally overlooked, the altered dynamics of the simulation encounter are not readily perceived, and simulation encounters are thus often mistaken as accurate representations of clinical reality. Exclusive reliance on this pedagogic approach of simulation training may be encouraging students to become "simulation doctors" who act out a good relationship to their patients but have no authentic connection with them. The authors propose that liberal-arts learning and encounters with real patients should be used to cultivate students' abilities to create good doctor-patient relationships, as a compliment to the pedagogic benefits of simulation encounters.

    • "...e and judgment rest with the simulated patient rather than with the physician student " (page 266) [55] . De la Croix and Skelton identify a higher number of interruptions from role-players across 100 th..."
      The movement in recent years towards patient-centredness and shared decision making has not fundamentally altered this, since asymmetry stems at least partly from the doctor's knowledge [54]. But in simulated consultations, candidates must manage the fact that " the power relation is inverted, because knowledge and judgment rest with the simulated patient rather than with the physician student " (page 266) [55] . De la Croix and Skelton identify a higher number of interruptions from role-players across 100 third-year OSCE exams, suggesting a position of greater interactional power compared to findings on the linguistic behaviour of real-life patients323334.
    [Show abstract] [Hide abstract] ABSTRACT: Assessment of consulting skills using simulated patients is widespread in medical education. Most research into such assessment is sited in a statistical paradigm that focuses on psychometric properties or replicability of such tests. Equally important, but less researched, is the question of how far consultations with simulated patients reflect real clinical encounters – for which sociolinguistics, defined as the study of language in its socio-cultural context, provides a helpful analytic lens. Discussion In this debate article, we draw on a detailed empirical study of assessed role-plays, involving sociolinguistic analysis of talk in OSCE interactions. We consider critically the evidence for the simulated consultation (a) as a proxy for the real; (b) as performance; (c) as a context for assessing talk; and (d) as potentially disadvantaging candidates trained overseas. Talk is always a performance in context, especially in professional situations (such as the consultation) and institutional ones (the assessment of professional skills and competence). Candidates who can handle the social and linguistic complexities of the artificial context of assessed role-plays score highly – yet what is being assessed is not real professional communication, but the ability to voice a credible appearance of such communication. Summary Fidelity may not be the primary objective of simulation for medical training, where it enables the practising of skills. However the linguistic problems and differences that arise from interacting in artificial settings are of considerable importance in assessment, where we must be sure that the exam construct adequately embodies the skills expected for real-life practice. The reproducibility of assessed simulations should not be confused with their validity. Sociolinguistic analysis of simulations in various professional contexts has identified evidence for the gap between real interactions and assessed role-plays. The contextual conditions of the simulated consultation both expect and reward a particular interactional style. Whilst simulation undoubtedly has a place in formative learning for professional communication, the simulated consultation may distort assessment of professional communication These sociolinguistic findings contribute to the on-going critique of simulations in high-stakes assessments and indicate that further research, which steps outside psychometric approaches, is necessary.
    Full-text · Article · Dec 2016 · BMC Medical Education
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    • "...cal students must learn how to " be good doctors, rather than merely to act like good doctors [18, 22, 23] " . Others also assert that behavioral professionalism tempts students to behave in ways that f..."
      Even as professionalism became identified as an area of medical competence, some medical educators' reflections on the topic continued to reveal a discomfort with behavioral pedagogical approaches, instead advocating for developing, reinforcing, and sustaining deeply held attitudes and values [17, 21]. As Hanna and Fins write, medical students must learn how to " be good doctors, rather than merely to act like good doctors [18, 22, 23] " . Others also assert that behavioral professionalism tempts students to behave in ways that fulfill others' expectations of professionalism without actually believing in the virtues or principles that underpin these behaviors [24], resulting in an emphasis on surface impression management [25] .
    [Show abstract] [Hide abstract] ABSTRACT: Medical school curricula, although traditionally and historically dominated by science, have generally accepted, appreciated, and welcomed the inclusion of literature over the past several decades. Recent concerns about medical professional formation have led to discussions about the specific role and contribution of literature and stories. In this article, we demonstrate how professionalism and the study of literature can be brought into relationship through critical and interrogative interactions based in the literary skill of close reading. Literature in medicine can question the meaning of "professionalism" itself (as well as its virtues), thereby resisting standardization in favor of diversity method and of outcome. Literature can also actively engage learners with questions about the human condition, providing a larger context within which to consider professional identity formation. Our fundamental contention is that, within a medical education framework, literature is highly suited to assist learners in questioning conventional thinking and assumptions about various dimensions of professionalism.
    Full-text · Article · Jun 2015 · Philosophy Ethics and Humanities in Medicine
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    • "...education (Barrows, 1968) and are commonly used to teach physicians' communication skills (Hanna & Fins, 2006). Hanna and Fins (2006) outlined several advantages of simulated patients. ..."
      " Simulated Role Plays (SRP) refer to role-play situations where trained actors portray clients in clinical vignettes (Melluish et al., 2007). SRP is a longtime staple of medical education (Barrows, 1968) and are commonly used to teach physicians' communication skills (Hanna & Fins, 2006). Hanna and Fins (2006) outlined several advantages of simulated patients.
    Full-text · Article · Jan 2013 · Journal of Cognitive Psychotherapy
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