Over the past decade formal training in communication skills has become a prominent feature in the medical school curriculum. Yet patients still return from hospital outpatient clinics or from a spell on the wards with tales of doctors who are rude, patronising or simply incomprehensible. It seems that watching the ‘Breaking Bad News’ video has not improved many doctors' capacity to impart information — good or bad — or even taught some how to be civil. Indeed, despite all the talking and role-playing, and despite too the growing proportion of supposedly more empathic female doctors, the level of patients' dissatisfaction over their encounters with doctors appears to have increased. This is confirmed by the number of complaints in which failures of communication feature prominently.
The government's response to the failure of instructing medical students in communication skills is not to abandon this approach, but to extend it further — into postgraduate training. The new 2-year Foundation Programme for junior doctors (replacing the pre-registration house officer year and the first year of senior house officer training) requires doctors, ‘to demonstrate explicitly that they are competent in a number of areas, including communication and consultation skills, patient safety and teamworking’.1 Trainees will rotate through a wide range of short-term ‘career placements’ — including some in general practice — under the direction of personal ‘educational’ and ‘clinical’ supervisors.
Manchester geriatric physician Ray Tallis has argued that formal training in communication skills underestimates the inherent difficulties of the doctor–patient relationship, and ‘the incommensurability of the personal experience of illness and the scientific understanding of it’.2 These inherent difficulties have been exacerbated by the time pressures in contemporary medical practice and by trends which make relations between doctors and patients more impersonal, distrustful and conflictual.
Communications between doctors and patients — especially in general practice — rely on establishing a degree of empathy and trust and are heavily influenced by the past record of mutual interactions. As James McCormick has wisely observed, communication skills fall into the category of things that can be learned by observation and reflection in clinical situations, not taught in the classroom.3 Indeed the very attempt to teach them in a formal way underestimates the subtleties of doctor–patient contacts which generations of doctors have painstakingly acquired through the sort of apprenticeship system that is now so disparaged. The net effect of the promotion of comic-book communication skills is to elevate the banal while degrading what is profound in medical practice.4
One consequence of the new foundation programme is that, by effectively lengthening the period of medical training, it postpones the exposure of junior doctors to situations in which they are required to take clinical responsibility for patients. No doubt, the government justifies this as a measure to improve ‘patient safety’. But by reducing opportunities for gaining what Tallis describes as the ‘confidence-building experience of taking responsibility’, it delays the emergence of a mature medical practitioner. There is a real danger that the new system will produce doctors whose scientific and clinical training has been sacrificed to the cultivation of formal skills of dubious practical value. Will this make patients any safer?
The ‘independent GP’, competent on qualification, symbolised the confidence of the medical profession in the 19th century. By contrast, the ‘never quite competent’ doctor, one who requires continuous formal instruction and regulation, monitoring and mentoring, support and counselling, symbolises the abject state of the profession in the new millennium.
- © British Journal of General Practice, 2005.
