Healthcare providers must concurrently espouse objective, systematic clinical reasoning and “soft” interpersonal skills to understand and treat their patients. Competently and compassionately communicating with patients to elucidate and contextualize the etiology of their symptoms is a perennially elusive craft, but it is one that is fundamentally essential for effective medical practice.
Different medical schools have adopted different approaches to help students develop the communicational proficiencies required to connect with patients, elicit their health narratives, and then parse through this information to ultimately arrive at a diagnosis – such methods have included encounters with simulated patients (“SP”s), small group practice sessions with classmates, and perhaps even structured conversations with real patients. However, there is, across all of these learning opportunities, a staunch emphasis on adhering to a rigidly defined conversational structure.
III. ETHICAL IMPLICATIONS
Mandating methodical dialogue can certainly be useful for helping medical students (especially those in their pre-clinical years) learn to formulate differential diagnoses, but actively discouraging any deviation from the proscribed sequence –I.e. in the vein of teaching students the “formal”, “professional” discourse– neglects the fluidity that is inherent in real conversations with real patients. Relying upon algorithmic conversational “scripts”, budding physicians may be dissuaded from fully ascertaining the minutiae of each patient’s respective circumstances. This may in turn contribute to unnatural, even robotic conversations that leave patients feeling like their doctor heard but did not actually listen to them.
Students ought to be empowered with a framework that is sufficiently delineated to allow them to reach the proper clinical conclusion but that is also sufficiently flexible to encourage them to modify their conversational strategies to best suit each particular patient. Ultimately, there are very clear benefits to offering guidelines to inform students’ communications with their patients (E.g., Figure 1), but medical educators ought to also acknowledge that these techniques do not represent immutable rules to which physicians are beholden in any and all cases. To that end, clinical skills curricula should specifically offer students opportunities to develop broad interpersonal skills and dynamic communicational strategies, so that they will be well-prepared to converse with real patients when the time finally comes.