Viewpoint: Power and Communication: Why Simulation Training Ought to Be Complemented by Experiential and Humanist Learning
Division of Medical Ethics, Department of Public Health, Joan and Sanford I. Weill Medical College, Cornell University, 435 East 70 St. Suite 4J, New York, NY 10021, USA. Academic Medicine
(Impact Factor: 2.93).
04/2006; 81(3):265-70. DOI: 10.1097/00001888-200603000-00016
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.
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- "Implications for assessment are profound because the importance of authenticity challenges the validity of simulation in assessment . Perhaps, at best, simulated-patient encounters might only detect students who lack the ability, or are too overwhelmed by anxiety to appear to be concerned for a patient ; at worst, by rewarding pretence, they might inadvertently teach inauthenticity . "
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ABSTRACT: Clinical relationships are usually asymmetric, being defined by patients' dependence and practitioners' care. Our aims are to: (i) identify literature that can contribute to theory for researching and teaching clinical communication from this perspective; (ii) highlight where theoretical development is needed; and (iii) test the utility of the emerging theory by identifying whether it leads to implications for educational practice.
Selective and critical review of research concerned with dependence and caring in clinical and non-clinical relationships.
Attachment theory helps to understand patients' need to seek safety in relationships with expert and authoritative practitioners but is of limited help in understanding practitioners' caring. Different theories that formulate practitioners' care as altruistic, rewarded by personal connection or as a contract indicate the potential importance of practitioners' emotions, values and sense of role in understanding their clinical communication.
Extending the theoretical grounding of clinical communication can accommodate patients' dependence and practitioners' caring without return to medical paternalism.
A broader theoretical base will help educators to address the inherent subjectivity of clinical relationships, and researchers to distinguish scientific questions about how patients and clinicians are from normative questions about how they should be.
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ABSTRACT: We think of medical education as a process that moves novices from a state of incompetence to one of competence. This paper explores the idea that education may, at times, actually lead to incompetence as a result of over-emphasizing particular discourses that construct what competence is. This paper explores four discourses each with its own terminology and core conceptualizations of competence; each of which creates different roles for students and teachers. No one discourse is ideal and all drive teaching and assessment in particular ways. Sometimes these forms of teaching or assessment may inadvertently foster incompetence. In this paper I argue that, as with medical treatments, medical educators must pay more attention to the side-effects of the discourses that shape medical education.
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