Language, Philosophy, and Medical Education.

ISSUE: When medical schools began to recognize, a generation ago, that clinical "communication skills" could not be taken for granted among students, a process began of researching them, and introducing the results into curricula. This allowed for a discussion, for the first time, about how doctors should talk to patients, and manage interviews with them. However, there was a focus on a set of behavioral processes which were often unsophisticated with respect to the role of language in communication, or of language as a means of sustaining and describing ambiguity, or language as the primary impetus for educational reflection. EVIDENCE: This paper looks at literature from language studies, the philosophy of language and the philosophy of education to establish the point that, where natural languages are concerned, it is possible and useful to talk of the purposes for which language is used. It is also important to recognize that the meaning of a particular language use is to a substantial extent defined by context: and that languages are excellent vehicles for maintaining and describing ambiguity, where it is impossible to reduce a state of affairs to the well-defined conclusion of empirical research. IMPLICATIONS: In the light of this understanding, there is a need for "communication," and particularly the methodologies through which it is taught, to reflect these points. Simulation exercises, designed to develop clinical communication, should be clear that there is no single correct way of "talking to patients," no set of behavioral processes which is always effective. It is, in the end, the awareness and wisdom of the doctor, selecting from among a range of available approaches, which is at stake. In addition, methodologies should account for the recognition that awareness comes only from reflection, and that helping medical students and doctors alike to reflect is central to good practice.

Understanding professional development: Case studies of remedial support.

This study reports on work undertaken by the Interactive Studies Unit (ISU), University of Birmingham. A total of 727 doctors were referred to the ISU for one-to-one remedial support in a variety of non-clinical areas between 2010 and 2018. The close-in scrutiny which one-to-one support offers provides an opportunity to study and reflect on such issues as values and professionalism, which are notoriously difficult to define or reach objective judgments about. There are fundamental difficulties, in particular, in inferring underlying values from an individual's behavior. The basic taxonomy of referrals the ISU works with, and which echoes those developed elsewhere, considers problems as being at the level of the self, interactions with others, or working in an institutional or societal context. Six common generic problems are identified, and presented and discussed as generic cases. These are designed to be representative of the complex manner in which behavior and values interact, and problems at the three levels above impinge on each other. All cases are accompanied by details of suggested educational activities.

The need for education on health related-quality of life.

BACKGROUND: Health-related quality of life is increasingly recognised as an important outcome measure that complements existing measures of clinical effectiveness. The education available on this subject for different healthcare professionals is varied. This article describes the design, implementation and evaluation of a Special Study Module on Health-Related Quality of Life for undergraduate medical students at the University of Birmingham. METHODS: The course involves 10 hours of "guided discovery learning" covering core concepts of Health-Related Quality of Life assessment including methodological considerations, use in clinical trials, routine practice and in health policy followed by self-directed learning. The taught components aim to provide students with the skills and knowledge to enable them to explore and evaluate the use of quality of life assessments in a particular patient group, or setting, through self-directed learning supported by tutorials. RESULTS: The use of case studies, recent publications and research, and discussion with a research oncology nurse in task-based learning appeared to provide students with a stimulating environment in which to develop their ideas and was reflected in the diverse range of subjects chosen by students for self-directed study and the positive feedback on the module. Course evaluation and student assessment suggests that quality of life education appears to integrate well within the medical curriculum and allows students to develop and utilise skills of time-management and independent, self-directed learning that can be applied in any context. CONCLUSION: We suggest that education and training initiatives in quality of life may improve the quality of studies, and help bridge the gap between research and clinical practice. Resources for curriculum development on health-related quality of life have been developed by the International Society for Quality of Life Research and may prove a useful tool to educators interested in this area.

Learning from patients: trainers' use of narratives for learning and teaching.

BACKGROUND: There is a growing interest in how doctors learn from narratives about individual cases, reflected, for example, in the use of e-portfolios. AIM: This study aimed to evaluate how GP trainers conceptualised 'learning from patients', and what use they currently made of narrative recounts in training. DESIGN & SETTING: Thematic analysis (TA) and corpus-linguistic (CL) analysis, with data collected from a convenience sample of trainers in the UK, Ireland, and Spain. METHOD: GP trainers in the three settings were contacted, and volunteers recruited (22 in UK, 24 in Ireland, and 16 in Spain). Volunteers were interviewed and asked to offer a narrative about 'a patient you learned from' and whether they used narratives as a training device. RESULTS: There were no differences between settings. Trainers described an engaged and personal relationship with patients. They described learning about themselves, the human condition, and about how to live and die well. Their narratives were structured in various ways. At times, they led to precise conclusions: at times, they were perceived as meaningful, but resisting analysis. As regards teaching through narrative, it was reported as commonly used, but present practice appears ad hoc rather than planned. DISCUSSION: The lack of difference between settings suggests a degree of commonality about how trainers perceive learning and teaching in the areas explored, but cannot be generalised further. The level of personal engagement was more than anticipated, and suggests the label 'doctor-patient relationship', as the term is used, may not be adequate to describe the nature of some interactions.

Everything you were afraid to ask about communication skills.

'Communication skills' is now very well established in medical education as an area that needs to be taught at both undergraduate and postgraduate level. But it is a discipline with a low level of challenge--it allows itself constantly to take seriously questions about its fundamentals (such as whether it works at all) although common sense and everyday experience tell us that skills are indeed improved through training and practice. This slows progress. Much research has also concentrated on listing and defining a set of skills, yet although all doctors must understand and utilise a range of skills as a precondition for good communication, the findings themselves are often equally common-sensical, and are not, in any case, restricted to medicine. They often tend to form part of a general consensus in favour of lay-centredness, which has been studied in other types of professional encounter, particularly the language of teachers and pupils. Moreover, insofar as teachers of medical communication limit their aims and their own classroom language to terms associated with skills, they offer little scope for more important questions about how these skills should be deployed, and about the attitudes to medicine and professional life that underpin them. A central educational question is: should we concentrate on teaching skills in the belief that attitudes will follow, or attitudes in the belief that they will generate appropriate skills?

A concordance-based study of metaphoric expressions used by general practitioners and patients in consultation.

BACKGROUND: All languages use metaphoric expressions; some deliberately chosen, some (for example, 'digesting information') not usually perceived as metaphoric. Increasingly, it is suggested metaphoric expressions constrain the way we conceptualise the world, as well as being a means of achieving stylistic effect. AIM: To study metaphoric expressions used by doctors and patients in general practice. DESIGN OF STUDY: Concordance-based language analysis of spoken data. METHOD: A database containing transcriptions of 373 consultations with 40 doctors in a UK general practice setting was scrutinised for metaphoric expressions, using 'concordancing' software. Concordancing enables identification of strings of text with similar lexical properties. Comparators (for example, 'like'), selected verb-types (for example, of feeling), and the verb 'to be' were used as starting points for systematically exploring the data. Quantitative and qualitative thematic methods were used in analysis. RESULTS: Doctors and patients use different metaphors. Doctors use mechanical metaphors to explain disease and speak of themselves as problem-solvers' and 'controllers of disease'. Patients employ a range of vivid metaphors, but fewer metaphors of machines and problem/solution. Patients use metaphors to describe symptoms and are more likely to use metaphoric language at the interface of physical and psychological symptoms ('tension, 'stress'). CONCLUSION: The different patterns of metaphoric expression suggest that doctors make limited attempts to enter the patients' conceptual world. This may not be a bad thing. One function of the consultation may be to reinterpret vivid and unique descriptions as accounts of the familiar and systemically comprehensible. Doctors may use different conceptual metaphors as a reassuring signal of expertise.

Gender as a variable in the assessment of final year degree-level communication skills.

AIM: To investigate possible bias due to gender combination of students, role players and examiners in a high-stakes assessment. SETTING: Valid oral interactive contextualized examinations (VOICEs) is a long-station OSCE-style exam in general practice (GP). At the time of writing it consisted of 65% of the student's final GP mark. METHOD: In the VOICE, students undertake six tasks--four vivas and two role-plays. "Patient" roles are taken by professional role players who work regularly on the undergraduate curriculum. During the role-play, the student's clinical competence is assessed by an observing GP examiner. The communication skills marks are awarded by the role player and the examiner together, by negotiation. Data have been recorded detailing the role player's initial marks, the examiner's initial marks and their final (awarded) agreed marks for 1024 consultations. SAMPLE: 512 final year medical students, 28 role players and 48 examiners. There were no inclusion or exclusion criteria. All those present on exam day became part of the data. RESULTS: There was a significant relationship between gender and performance for some, but not all, stations. Correlations for multiple comparisons removed the significance. Female students perform better across the board than male students. While not always significant, this did affect grading. There was no significant association between the genders of role players and examiners with the question choices. There has been a significant worsening of male results since 1999. Differences exist in the way that pairs of mixed or single genders score students.

Hitting the mark: negotiated marking and performance factors in the communication skills element of the VOICE examination.

INTRODUCTION: Communication skills assessment is complex. Standardised patient use is widespread, but anxiety exists around the use of role players as assessors of competence in high stakes examinations. This study measures the level of agreement between scoring examiners and role players, and considers their influence on each other. Examiner status and question choices are analysed as variables. METHOD: The valid oral interactive contextualised examination (VOICE) is a general practice examination styled as an objective structured clinical examination (OSCE) of six 15-minute stations, which include two role-played consultations with professional role players. The examination candidates are final year medical students. Clinical components are examined by a general practitioner (GP). Communication skills are assessed by these examiners in conjunction with the role players, through a process of negotiation. Descriptive professionalism/attitude bandings are used as percentage-scoring guidelines. Checklists are not used. For this study, the initial (independently) perceived marks of the two scoring groups and their agreed final (awarded) marks were recorded, along with other variables including gender, performance factors, demographics and the nature of the question. Data represents 512 students undertaking 1024 simulated consultations, examined by 28 role players and 46 examiners. Analysis was carried out using SPSS Version 10. RESULTS: Results show that the examination and negotiation process is consistent. Role players have a direct influence on scoring. The examiner's background is a significant variable [F9,1014 = 4.207, P < 0.001]. Students perform less well on questions involving higher degrees of clinical information giving. Question choice is not significant [F30,3039 = 1.397, P=0.074]. DISCUSSION: The variables in the examination do not indicate any discrepancy substantial enough to bias a student's grade. Negotiated marking in this context is considered safe and reliable.

"I" and "we": a concordancing analysis of how doctors and patients use first person pronouns in primary care consultations.

BACKGROUND: It is widely accepted that "partnership" with patients is desirable, and that patients should be enabled to participate in decisions, but it is not clear to what extent doctor-patient interactions represent partnership in action. OBJECTIVE: Our aim was to measure aspects of doctor-patient interaction through the deployment of the first person pronouns "I", "me", "we" and "us" in general practice consultations. METHODS: The study design was a concordance-based language analysis of spoken data. Concordancing software was used to interrogate a database of 373 consultations with 40 doctors in UK general practice. The frequency and function of first person pronouns used in these consultations were scrutinized. Concordancing enables identification of strings of text with similar lexical properties and uses specialized statistics to assess relationships between words and phrases ("collocates" being words commonly found together) as well as their patterns of use (MI, mutual information, describes the likelihood of two words or phrases being associated). Analysis is therefore quantitative and qualitative. RESULTS: Doctors use the word "we" far more often than patients or companions do (doctors 23.5% and patients 2.9% of all personal pronoun occurrences). Doctors are far less likely to use "I", after which a verb of thinking is usually selected (38 collocates with MI >3). However, after 'we', doctors select verbs of physical activity or auxiliary verbs. Three types of doctor use of "we" were distinguished: to include patients ("you and I"), exclude them ("we doctors" or "we as a practice") or to mean "all of us as human beings". CONCLUSIONS: The findings suggest a prototypical pattern of interaction in primary care: PATIENT: I suffer. Doctor: I think. We will act. This, within the current paradigm which values partnership between doctor and patient, might seem encouraging; but there is evidence to suggest that power relationships in the consultation may still be unequal.

Simulated patients in the community pharmacy setting. Using simulated patients to measure practice in the community pharmacy setting.

BACKGROUND: Performance measurement and quality of care in community pharmacy settings is problematic because of the lack of formal patient registration and the resultant risk of selection bias. Although simulated patients have been used for teaching and education purposes, particularly in medical settings, their use as a research tool requires exploration in other health settings. The purpose of this paper is to describe how we used simulated patients to measure professional performance of community pharmacy staff. METHOD: Sixty pharmacies participated in a randomised controlled trial (RCT) to evaluate the effectiveness and efficiency of two guideline implementation strategies in the community pharmacy setting. The primary outcome measure for the study was derived from assessment forms completed by simulated patients following covert visits to participating pharmacies. RESULTS: Of the 420 simulated patient visits scheduled, 384 (91%) were completed. Nine visits were reported by pharmacy staff using reply-paid postcards, four of which concurred with known SP visits. Each detected visit was made by a different SP. In a post-intervention survey, 26 (52%) pharmacists stated they had been apprehensive about the use of simulated patients as part of the study, however, 41 (82%) pharmacists agreed that SP visits were an acceptable research method to use in a community pharmacy setting. DISCUSSION: Simulated patients are a feasible method of assessing professional performance in community pharmacy settings and overcome the methodological problems of other measurement methods. Further research is needed to assess the reliability and validity of simulated patients.