Documente Academic
Documente Profesional
Documente Cultură
Celia Roberts,1 Val Wass,2 Roger Jones,2 Srikant Sarangi3 & Annie Gillett1
Background There is still a great deal to be learnt about Findings Analysis revealed important differences in
teaching and assessing undergraduate communication communicative styles between candidates who scored
skills, particularly as formal teaching in this area highly and those who did poorly. These related to:
expands. One approach is to use the summative empathetic versus ‘retractive’ styles of communicating;
assessments of these skills in formative ways. Discourse the importance of thematically staging a consultation,
analysis of data collected from final year examinations and the impact of values and assumptions on the
sheds light on the grounds for assessing students as outcome of a consultation.
‘good’ or ‘poor’ communicators. This approach can Conclusion Detailed discourse analysis sheds light on
feed into the teaching ⁄ learning of communication skills patterns of communicative style and provides an
in the undergraduate curriculum. analytic language for students to raise awareness of
Setting A final year UK medical school objective their own communication. This challenges standard
structured clinical examination (OSCE). approaches to teaching communication and shows the
Methods Four scenarios, designed to assess communi- value of using summative assessments in formative
cation skills in challenging contexts, were included in ways.
the OSCE. Video recordings of all interactions at these Keywords Education, medical undergraduate ⁄ *stand-
stations were screened. A sample covering a range of ards; *communication; educational measurement;
good, average and poor performances were transcribed curriculum; clinical competence; England.
and analysed. Discourse analysis methods were used to Medical Education 2003;37:192–201
identify ‘key components of communicative style’.
Detailed maps of OSCE consultations give Our research was set in the final examinations on the
students a new analytic language for monitoring Guy’s and St Thomas’ campus of the now merged
their own and others’ communication skills. Guy’s, Kings and St Thomas’ medical school (GKT)
in June 1999. These examinations involved a
24-station OSCE. This included several communi-
the long case to methods such as the objective struc- cation stations, each of 7 minutes duration, using
tured clinical examination (OSCE).9,10 However, there standardised simulated patients. The OSCE ran over
is much more we need to understand about appropriate 2 days.
teaching techniques and assessment methods.11 For We designed four OSCE scenarios to present partic-
example, students’ performance in OSCE communica- ular challenges to final year students and to reflect a
tion stations is assessed on a checklist of criteria, such multicultural student and patient population. The
as ‘establishes rapport’ and ‘uses closed and open scenarios are detailed in Fig. 1. Two stations were
questions appropriately’.12,13 Yet the details of what included each day. Each station was marked by one
makes students good or bad communicators are not examiner, who was experienced in assessing communi-
necessarily obvious. A more fine-grained understanding cation skills, used a checklist of criteria and gave a
of the attributes of good and poor medical communi- global rating, and by the role player, who also awarded
cation is needed to improve communications teaching a global rating. The project was approved by the
and the validity of its assessment. Why not, therefore, relevant local research ethics committees, and informed
look at OSCE performance itself to try and unravel consent was obtained from all students.
these questions? Spencer reminds us of ‘the tremen-
dous gold mine of data that systematic, progressive
Data collection and screening
OSCE-type examinations offer to the researcher’.14
In order to use assessment as a formative (as well as a Sequential audio-visual recordings were made of all
summative) tool and to mine the gold that lies hidden students taking these stations on the successive days. A
in OSCEs, a research approach is needed that will slow total of 179 students took the OSCE and all agreed to
down the whole process and fix our gaze on each be video-recorded. In all, 358 recordings were made,
1. Cancer: an older white woman is advised to have a bronchcoscopy because of possible tumour recurrence, although she denies the
possibility that the cancer may have returned
2. Sexually transmitted disease : a young Muslim women has had unprotected sex and is concerned that she might have caught
something. She also feels very upset about what has happened.
3. Alcohol: a Chinese businessman has come for the results of liver function tests. The results indicate he may be drinking too much.
4. Drugs: a young Afro-Caribbean man is seeking a methadone prescription because he says he has lost the one recently given to him at
the drug rehabilitation centre.
but 49 were rejected for technical reasons. This relatively involved or detached they appear, are based
generated a database of 309 7-minute video interac- on styles of communicating. These have developed as
tions (86Æ3% of the total). A total of 28 consultations a result of longterm exposure to networks of relation-
were fully transcribed (just under 10%). These inclu- ships in the home, school and community, so that a
ded consultations by the 12 candidates who were particular communicative style is the product of
judged to have failed at least one of the specially social ⁄ cultural experiences: ‘‘‘style’’ is not something
designed OSCE scenarios, together with equal numbers extra, added on like frosting on a cake. … style refers
of top-rated and middle-ranking encounters. to all the ways speakers encode meaning in language
The 309 video-recorded consultations were all and convey how they intend their talk to be under-
viewed and notes made of each interaction to identify stood.’18 Communicative style therefore relates to talk
emergent patterns in the data, such as particularly and interaction at all levels, from the most fleeting
awkward or responsive moments, formulaic responses intonation pattern to the wider assumptions about
and styles of presentation based on the assumptions how, for example, to relate to patients. These wider
brought along to the encounter. These viewing notes assumptions are part of the ideological values and
formed the basis for identifying the components of principles about professional identity and how to
communicative style and were used to select the 28 conduct oneself in interaction that are brought along
consultations for transcription. The screening of a to any encounter and which appear as evidence in the
relatively large database produced patterns that were data.
confirmed in the detail of the transcribed data as well as Interactional sociolinguistics, in common with most
disconfirming evidence, which led to the reinterpreta- forms of discourse analysis, uses naturally occurring
tion of some aspects of the detailed transcriptions. In examples of talk. The OSCE interactions are, on one
this way, larger data sets and micro-analysis of inter- level, examples of authentic talk in that they represent
actional moments support each other. actual occurrences within a vital examination. At
another level, they are strictly timed role-plays,
institutionally based synthetic encounters, and this
Discourse analysis
puts constraints on both candidates and actor-
Discourse analysis looks at the ways in which speakers patients. Both are working from scripts ) the actor
design the content of each turn at talk, at how is given a set of symptoms and an identity, while the
interactions are sequenced and managed and also at candidate has a set of medical scripts to work from )
speakers’ choices in terms of vocabulary, grammar, but each interaction is subtly (or, in some cases,
intonation and rhetoric. These detailed features con- radically) different, depending on how each partici-
tribute to our understanding of how social relations are pant interprets and responds to the other. The
managed in talk: how the patient and doctor establish interactions are further complicated by the fact that
relations of relative equality, how together, for example, the ‘patients’ are also assessors and often voice
they may use various face-saving strategies and take feelings and attitudes that are either kept hidden or
account of the other’s relative knowledge and emotional managed in more indirect ways in real consultations.
state. The emphasis here is on talk rather than non- These vocal actor-patients tend to trigger more
verbal communication, as the physical setting of the formulaic responses from weaker candidates, who
OSCE and some of the inevitable institutional con- have been trained in rapport words but cannot achieve
straints make it difficult to assess aspects such as body rapport work. This is an example of how the
movement and gaze. institutional constraints of the OSCE can magnify
The approach used here, interactional sociolinguis- differences between weak and poor candidates. How-
tics, draws on ethnography and conversation analysis ever, it also serves to contrast these scenarios with
to look at how individuals differ in the ways in which real patient)doctor communication, and, as such, it
they interact with and understand one another.14)16 could be used to argue against research on synthetic
Understanding presupposes a level of conversational consultations. However, while OSCEs are used to
involvement in which both sides share ways of assess students’ communication skills and while they
interpreting what the other has said. However, there continue to be treated as an adequate way of doing
is also an emotional dimension to involvement, which so, there is a case for analysing the interactional
connects it to rapport and affiliation, and this aspect details which account for relative success or failure in
presupposes a level of understanding. Thus, involve- them. Moreover, gaining understanding of what
ment and understanding go hand in hand.17 Individ- makes for a successful OSCE result is worthwhile
ual differences between speakers, which affect how from the students’ point of view.
can: candidate
act: actor-patient
(.) short pause
(( nods etc. )) non-verbal communication
…….. section of the transcription omitted
= word =
= word = overlapping speech i.e. two speakers speaking at the same time
Figure 3 Transcription conventions; e.g. can: did the partner you had sex = with did he have =
simplified version based on Gumperz J & act: = yeah =
Berenz N22. ‘erm’ sound used to fill a pause at the beginning or in the course of an utterance
Example 5: Schema-driven progression and patient labelling medical checklist concerning pregnancy and so on,
(lines 56)65) which he takes the patient through.
can: any rashes or
Example 7: Insensitivity to patient levels of understanding
act: no don’t think so (lines 46)54)
can: discharge (.) have you yourself had any can: right ok (1Æ0) erm (6Æ0) did (.) this patient have
discharges at all any er overt signs of any sexual disease did he have
any rashes at all or
act: no
act: sorry
can: any erm (.) irritation down there
can: did the (.) did the partner that you had sex ¼
act: no
with did he have ¼
can: any pain when you’re passing water
act: ¼ yeah ¼
act: no
can: any (.) sort of signs of (.) sexually transmitted
can: erm (.) any blood in your urine diseases
act: no act: ((shakes head))
Here the medical agenda is driven through and, The candidate’s initial question confuses the patient
as this happens, the consultation becomes interrog- in a number of ways, including by the slip of the tongue
atory, with the patient giving minimal and categor- where he talks about ‘patient’ instead of ‘partner’.
ical responses that do not allow for any negotiation However, the problems of understanding are due
of meaning. This is in marked contrast to example 1. largely to the medical register in which the question is
The third and fourth types of retractive style concern expressed and to the assumption that the patient would
problems of understanding, sometimes when the can- know what the symptoms of sexually transmitted
didate has failed to take in what the patient is saying diseases are like. Such jargon will distance the candi-
and at others concerning the use of medical jargon. date from the patient. In addition, in his attempt to
Examples 6 and 7 illustrate this, the first demonstrating repair the error, in assuming too much medical know-
what we term ‘storage failure’ and the second providing ledge, the candidate shifts down to give a specific
an example of insensitivity to the patient’s levels of example (‘any rashes’) without showing through words
understanding. or intonation that he is doing so. His attempt at
clarification when the patient fails to understand is no
Example 6: Storage failure (lines 18)22) more helpful because he is still using medical jargon. As
well as these distancing elements of his style, the long
act: no it’s complete one it’s my first time yeah (.)
pauses and repairs seem to produce a degree of
because I come from a traditional muslim culture
interactional discomfort in the patient, as evidenced
can: right by her minimal responses and, finally, only a head
shake.
act: er we don’t have boyfriends in our culture
It is worth stressing that no single question or
can: right response is necessarily empathetic or retractive. An
empathetic move such as ‘responsive listening’, which
(56 seconds later)
often depends on making inferences from the patient’s
can: right erm (.) have you ever ha- been pregnant at remarks, may, in another context, be treated as high
all inferencing and produce the negative labelling of a
patient. For example, a question such as: ‘You’re not
act: no
worried about …’ may be an attentive response to a
Here the candidate fails to take in the fact that the patient’s narrative or may make the patient feel they are
patient has never had sex before and carries on with his being labelled as ‘a worrier’, in which case it may not be
checklist of questions, which includes a question about perceived as empathetic at all. Similarly, one candi-
pregnancy. His failure to remember the earlier infor- date’s reassuring moves, which contribute to an overall
mation may well be reinforced by the schema-driven high grade, may appear as set responses, or what we call
‘trained empathy’, in another candidate. The success, visual impression of difference. It also connects a
or not, of a particular remark or question by the typology of the whole with specific examples from the
candidate depends on its location in the whole inter- transcripts. Figure 4 shows two contrasting maps of the
action and the kind of climate which their communi- cancer scenario, again one of a high-rated and one of a
cative style has already established. low-rated candidate.
If we contrast the high-rated candidate (examples Here, an older white woman resists advice to have a
1–3) with the candidate who failed (examples 4–7), it is bronchoscopy to assess whether her cancer has
clear that the overall empathetic or retractive climate returned.
results from a layering of good or bad aspects of The good candidate gradually and sensitively took
communicative style. The weak candidate is interroga- the patient through the consequences of not having a
tory, focuses narrowly on the medical agenda, does not bronchoscopy. She staged her case for this further
use more personal authority to reassure, assumes the investigation so that each time the patient rejected her
patient is concerned about risks or has had abnormal sex advice, she still had some persuasive resources to bring
and is responsible for several misunderstandings. In to the consultation. Examples 8 and 9 are extracted
addition, his overall staging of the consultation means from the maps in Fig. 4 to highlight their differences.
that towards the end, when he does try to show some
empathy, this comes across in a formulaic or trained Example 8: Good thematic staging
way. This staging of themes represents a further The strong candidate sequenced her case for the patient
component of communicative style. having a bronchoscopy as follows:
1 we need to exclude the worst;
Thematic staging 2 we need to investigate in more detail;
3 we would like to do a bronchoscopy;
The global impression of the candidates and the quality
4 we want to exclude the possibility of a tumour;
of their communicative style did not depend only upon
5 you had a tumour before, and
empathetic or retractive questioning and responding.
6 there is the possibility of a recurrence of the tumour.
The issue of how questions and responses were posi-
tioned or sequenced in the consultation to cover By contrast, the weak candidate staged the argument
particular themes was also significant when the whole differently. He introduced the fact that the patient had
interaction was examined. In other words, how the cancer of the kidney much earlier on in the consultation
different themes of the consultation were staged affected and then had no strong reasons left with which to
its overall emotional climate and helped to define the persuade the patient as the consultation continued.
candidate’s communicative style.
Each interaction had a key moment or crux (or, in Example 9: Poor thematic staging
most cases, a number of cruces) around which much of The weak candidate sequenced his case for the patient
the interaction was organised, such as the moment having a bronchoscopy as follows:
when the Chinese businessman asked, ‘Am I an
1 we need to do more investigations;
alcoholic?’; the drug addict asked for a repeat meth-
2 the possible recurrence of the tumour;
adone prescription; the young muslim woman con-
3 the possible recurrence of the tumour;
veyed her feelings of self-disgust, or the bad news was
4 it would be better to have the bronchoscopy, and
broken to the cancer patient. How candidates built up
5 do you have any other worries?
to, realised and followed up these crucial moments
affected the whole climate of the interaction and the Whereas the strong candidate built up to the most
success or otherwise of its outcome. This thematic persuasive argument, the weak candidate brought in the
element contributed to the relatively empathetic or worst case scenario early on (at line 90, 60 lines before the
retractive style of the whole encounter, as well as strong candidate). This produced a confrontational
progressing the medical agenda. response from the patient. The consultation then tailed
In attempting to account for the overall impact of the off as the candidate ran out of persuasive resources, with
role-played encounters, the analysis has to integrate the some general exhortations that ‘it would be better’, and
local, turn-by-turn empathetic and retractive moments an elicitation about any other worries (as if the possibility
with the staging of the whole encounter. In an adapta- of a return of the cancer was not bad enough!).
tion of the sociolinguistic idea of mapping conversa- These contrastive examples show that candidates not
tions,19 interactional maps were made of the 28 only need to design their questions and responses
transcribed scenarios. This mapping gives an immediate sensitively, but need to be aware of the overall staging
Cand. B
Cand. A
Thematic Retractive Thematic Empathetic
Empathetic
1-10 1-6
Establish identity Establish identity
E1/20
R1/12 7-19
11-34 Negotiating purpose
E3/36 Eliciting
feeling?
worried?
R3/23 20-48
E3/41 Eliciting
What complaining
35-50 about?
E3/48 Result giving
R3/49
49-52
E1/62 51-70 Result giving
Stating intention (treatment)
R1/54
E2/63 53-55
CRUX – 1
Stating intention
(exclude worst)
E2/69 CRUX– 2
R1/63 CRUX - 1
(investigate)
CRUX – 3
E3/69
(bronchoscopy) 55-106
R1/66
Negotiating commitment
E1/79 E2/80
R3/78 CRUX – 2
E3/91 (kidney recurrence-repeated)
70 -131 CRUX – 3 E2/100
Negotiating commitment (bronchoscopy)
E3/116
R1/85 R2/85-93
CRUX – 4
E3/121 (exclude tumour) 107-111
Explaining
E3/132 132-149
Eliciting
112-169
E3/166 R1/113 Negotiating commitmen
t
CRUX – 5
(tumour before)
E2/188 169-174
150-200 Eliciting: other worries; cough
E2/192 Negotiating commitment
CRUX- 6 R1/183
175-182
(tumour recurrence)
Offering treatment
E3/194
(antibiotics)
Figure 4 Contrasting maps of the cancer patient scenario: one of a high-rated and one of a low-rated candidate. E1–3 refer to the
three empathetic styles (see examples 1–3). R1–4 refer to the three retractive styles (see examples 4–7). The number after each of
these codes refers to the line number in the transcription.
of an encounter, particularly where persuasion, nego- ideologies concerning medical expertise, patient-cen-
tiation or reassurance are the focus of the consultation. tredness and authority underpinned their communica-
This awareness may be brought to the encounter by tive style.14,16 At a general level, candidates tended to
either type of candidate, but the candidate with a highly present themselves on a spectrum from a position of
rated communicative style stages the themes in a personal authority and conviction on the one hand to,
responsive way, designing the progress of the consul- on the other, one that relied on the authority of medical
tation to fit the particular local interactional context evidence and procedures. A balance between the two
produced by the patient. seemed the most successful.
Similarly, the candidates managed the notion of
patient-centredness in different ways. There was a
Values and assumptions
contrast between stronger candidates, who were sensi-
A final element in the candidate’s overall communica- tive to patients’ levels of knowledge and understanding
tive style related to the assumptions they brought along and did not label candidates as ‘being worried’ or
to the encounter. These concerned beliefs, values and ‘heavy drinkers’, and weaker candidates, who tended to
ideologies about their relationships with patients, use set or trained elicitations such as ‘How do you feel
together with more deeply held views about social about that?’ too early in the consultation and ⁄ or who
issues related to alcohol, sex and drugs. Candidates’ labelled patients in the way they designed their elicita-
tions and responses (see above ‘patient labelling’ as a to the ideological underpinnings of individuals’ styles.
retractive strategy). When these assumptions about the We have used the device of interactional maps, which
patient were made explicit (e.g. ‘We cannot force you to can be readily compared and contrasted, to shed light
take the test’), they were often retractive rather than on the differences in communicative style between
empathetic. strong and weak candidates.
There was also some evidence among weaker candi- We also need to assess the value of this form of
dates that their own moral assumptions influenced the analysis and classification in a teaching context.
design and staging of questions. The most obvious of Recently, preliminary evaluations of the objective struc-
these was a gendered ideology about normal sex. tured video examination (OSVE) have focused on
Several male candidates responded as if the young specific cognitive aspects of communication skills and
Muslim woman’s feelings of disgust and dirt were the their assessment, including students’ recognition and
result of abnormal sex. Thus, for example, when the understanding of the consequences of various commu-
actor-patient expressed these feelings and admitted, ‘It nication skills.20 Our collection of video-recorded
was a massive mistake’, some of the male candidates interactions and the associated analysis could take the
immediately asked, ‘What kind of sex … ?’ instead of OSVE one step further. The taxonomy of communica-
attending to her feelings. The weak candidate illustra- tive style used with examples taken from this OSCE data
ted above displayed these assumptions. In data example can develop students’ analytical skills and provide them
4, he seemed to assume that she felt terrible because she with a new analytic language. This approach should be
had put herself physically at risk, whereas throughout generalisable across consultations, while, at the same
the consultation these negative feelings were clearly time, alerting students to the fine tuning of particular
related to the act of sex itself and the patient’s responses to individual interactions.21 An approach to
emotional response to what she had done. analysing communication which accounts for the
success of the whole and is sensitive to the local context
of interaction is also transferable to naturally occurring
Discussion
consultations. Although the detailed examples may not
This research approach, using interactional sociolin- be relevant, the method, incorporating the analytic
guistics, provides new insights into the fine grain of components and the interactional maps, should also
communication in medical encounters. Whilst high- prove useful in analysing real patient–health profes-
lighting some of the complexity of the use of language, sional communication.
it also enables us to work towards a taxonomy of
communicative style. We are particularly struck by the
Contributors
way in which strong candidates stage their consulta-
tions, and design their turns in context-sensitive ways, Complete and detailed transcriptions of the scenarios
tuning in to the particular moment. This ability to tune referred to in the text are available from Celia Roberts.
in is hard to teach and, certainly, trying to improve Celia Roberts collected and analysed the data and was
communication skills with standard phrases and the lead writer. Val Waas designed the study and was a
‘trained empathy’ appears, from the evidence of our co-author. Roger Jones contributed to the design of the
data, likely to be counter-productive. study and was a co-author. Srikant Sarangi collected
Although we are confident that we have identified the data, contributed to the analysis of the data and was
key components of weak and strong communicators, a co-author. Annie Gillett contributed to data collec-
and are working towards a new taxonomy to accom- tion and analysis.
modate these, we recognise that much further work
needs to be done. We need, for example, to undertake
Acknowledgements
further discourse analysis to establish to what extent we
can map the features of communicative style that we We thank Stevo Durbaba for his invaluable technical
have identified so far onto other scenarios. We are also assistance and all the students who so kindly co-
aware that several of the aspects of empathetic and operated with this study.
retractive styles illustrated here are widely recognised in
the communication skills literature. Where our analysis
Funding
differs, however, is in its attempt to look at good and
poor communicators in the local context of specific This study was supported by a grant from the King’s
interactions, to link specific styles of questions and Fund. We are also grateful to King’s College Teaching
responses to the overall staging of the consultation and Fund for a further grant, which enabled us to make a
training video entitled Developing Empathy from the performance on an OSCE format examination. Acad Med
teaching material generated by this work. 1998;73:993–7.
13 Schwartz MH, Colliver JA, Bardes CL, Charon R, Fried ED,
Moroff S. Global ratings of videotaped performances versus
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