BMJ  2005;330:374-375 (19 February), doi:10.1136/bmj.330.7488.374

Editorial

Clinical and communication skills

Need to be learnt side by side

Teaching clinical skills to undergraduates focuses on examination, planning treatment, safe prescribing, and procedures such as venepuncture, suturing, and cardiopulmonary resuscitation.¹ Curriculums for communication skills aim to develop effective (clear and sensitive) communication with patients, carers, and colleagues. Skills include being able to take a history and share information, particularly explaining procedures and discussing treatment options and their effects.¹ When working with patients and colleagues, communication and clinical skills are practised simultaneously, yet most medical school curriculums teach them separately, albeit in parallel.

The current practice of teaching communication skills separately from clinical skills reflects a reductionist paradigm—by breaking down the complex phenomenon of a consulatation to its basic components. This may be helpful at an early stage of learning, but it may limit the coherence needed to ensure that doctors communicate satisfactorily with patients.

Those who teach communication skills have moved on from establishing the importance of their discipline in good clinical care to researching the theoretical base. They now need to return to the clinical workplace to develop further the pragmatics of their teaching. The teaching of clinical skills, by contrast, has enjoyed a time honoured central position in the medical curriculum. The separate development of these two skills has separated them in practice.

In the United Kingdom and United States, the divergence has been compounded by evidence that most complaints are related to poor communication.² This has led to a greater emphasis on communication skills. The increasing predominance of early community based learning where communication skills are emphasised has also contributed to this dichotomy.

Teaching communication and clinical skills separately does not mirror clinical experience and may lead to unbalanced doctors. Clinicians with sound clinical knowledge may be appraised of the latest research evidence yet unable to translate their skills into effective clinical care.³ Poor communication can often lead to poor health management.^{4 5}

Learning communication and clinical skills side by side would address how important skills for clinical practice can be improved. For example, examination of the abdomen—a clinical skills exercise—requires rapport and clear explanations—a communication exercise. At a more advanced level, evidence based practice integrates patients' values.⁶

A recent challenge in medical education in Europe has been the generally positive imposition of the European Working Time Directive.⁷ The shortened hours of work with limited windows of opportunity for training oblige us to make the most of the time available, and are conducive to integrated models of medical education. The relevant quality agenda has been addressed by Modernising Medical Careers.⁸

An example from postgraduate education of effective side by side learning is the work on developing non-technical skills by using simulated operating theatres for training anaesthetists.⁹ Debriefing, using video review, allows equal emphasis on technical clinical skills and on the social skills for team communication.

Such integrated learning is at an embryonic level in the undergraduate curriculum, but examples include hospital clinicians working side by side with social scientists on simulated patient teaching,¹⁰ and a feasibility study where students worked in a scenario based environment requiring them to communicate with a patient while conducting a procedure. Students perceived this to be a realistic and powerful learning experience.¹¹

Evidence from randomised controlled trials that interactive continuing medical education is effective in changing clinical performance positively¹² has stimulated the development of other models of integrated learning. These include the patient pathway tutorial, in which students have to perform a series of tasks that represent the temporal sequence of clinical and communication skills needed for management. For example, the tutorial for chronic obstructive pulmonary disease consists of stations in history taking, examination, discussion of differential diagnosis, writing the prescription, explaining treatment, reviewing the chest radiograph, sharing bad news, written clinical communication, and a discussion with colleagues and carers if appropriate. At the end of each task the learner is encouraged to reflect and then provided with feedback.

Organising a cohesive faculty of teachers of communication skills as well as hospital clinicians in medical schools helps in developing a single integrated course for communication and clinical skills. Even in teaching something as skills based as resuscitation, encouragement to learn about effective communication with other team members may also help save lives. The scenario also gives students an opportunity to practise talking to patients and relatives, who report lasting impact from doctors' communication skills at a time of crisis. Learning side by side also implies that trainee professionals of different disciplines learn some team skills together so that interpersonal communication and role linkages become embedded.

Medical Teaching Centre, Warwick Medical School, Coventry CV4 7AL (jane.kidd{at}warwick.ac.uk)

Medical Teaching Centre, Warwick Medical School, Coventry CV4 7AL

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Competing interests: None declared.

References

1. General Medical Council. Tomorrow's doctors. London: GMC, 2002.
2. Audit Commission. What seems to be the matter: communication between hospitals and patients. London: HMSO, 1993.
3. Pyorala K, Lehto S, De Bacquer D, De Sutter J, Sans S, Keil U. Risk factor management in diabetic and non-diabetic patients with coronary heart disease. Findings from the EUROASPIRE I and II surveys. Diabetologia 2004;47: 1257-65.[ISI][Medline]
4. Kaplan SH, Greenfield S, Ware JE. Assessing the effects of physician-patient interaction on the outcomes of chronic disease. Med Care 1989;27: s110-27.
5. Little P, Everitt H, Williamson I, Warner G, Moore M, Gould C, et al. Observational study of effect of patient centredness and positive approach on outcomes of general practice consultations BMJ 2001;323: 908-11.[Abstract/Free Full Text]
6. Lockwood S. "Evidence of me" in evidence based medicine? BMJ 2004;329: 1033-5.[Free Full Text]
7. Council Directive 93/104/EC. Official Journal of the European Community 1993;L307: 18-24.
8. Department of Health. The next steps—the future shape of foundation, specialist and general practice training programmes. London: DoH, 2004.
9. Maran NJ, Glavin R. Low- to high fidelity simulation. Med Educ 2002;37(suppl 1): 22-8.
10. McManus IC, Vincent CA, Thom S, Kidd J. Teaching communication skills to clinical students. BMJ 1993;306: 1322-7.
11. Kneebone R, Kidd J, Nestel D, Asvall S, Paraskevas P, Darzi A. An innovative model for teaching and learning clinical procedures. Med Educ 2002:36: 628-34.[CrossRef][Medline]
12. Davis D, O'Brien MA, Freemantle N, Wolf FM, Mazmanian P, Taylor-Vaisey A. Impact of formal continuing medical education. Do conferences, workshops, round and other traditional continuing education activities change physician behaviour or health care outcomes? JAMA 1999;282: 867-74.[Abstract/Free Full Text]

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