learners being only transientlypart of the ‘microsystem’ that isthe clinical workplace, and thusisolated from the qualityimprovement systems that rely ongood communication and cyclesof review. Their article proposes

that Flexner would be displeasedby the ‘rotational dance’ in whichtrainees are engaged, and headvocates strongly for reforms tothe system to allow competency-based training, educational con-tinuity and improved quality.

REFERENCE

1. Flexner A. Medical Education in the

United States and Canada: a Report to

the Carnegie Foundation for the

Advancement of Teaching. New York:

Carnegie Foundation for the Advance-

ment of Teaching; 1910.

Meaning what you saySalmon P, Young B. Creativity in clinical

communication: from communication

skills to skilled communication. Med Educ

2011;45:In press.

Communication skills trainingis well-embedded within medicalcurricula. It seems to be a self-evident truth: students need to betrained in the distinct skills ofinterpersonal communication inorder to assemble them intocomprehensive clinical communi-cation competencies for use inthe workplace.

Dr Peter Salmon and Dr BridgetYoung (psychologists from theUniversity of Liverpool, in the UK)both have extensive experience inclinical communication training.Their paper in this month’s issue ofMedical Education presents thesomewhat provocative propositionthat clinical communication can-not be taught and assessed asdiscrete skills, but rather as aholistic and creative process. Thismust come as a relief to clinicianswho have felt uncomfortableabout the complexities of clinicalcommunication being reduced to aseries of check-box micro skills,taught in the same step-by-stepfashion as the skills of informationgathering through history andexamination. Is it really possibleto treat something as organic asclinical communication as if itwere a ritualistic dance?

In the evaluation of commu-nication skills (for studentassessment or research purposes),this ‘atomisation’ of complexbehaviours into actions that canbe observed and coded misses

much of the creativity of success-ful communication. The authorsgive examples of experiencedpractitioners intuitively ‘depart-ing from the rules’ in order to get abetter outcome for patients. Theskilled clinician makes a lightningjudgement about the needs oftheir particular patient at thatparticular moment, and presentsinformation in the most appropri-ate way. Their example of a sur-geon telling a cancer patient thather prognosis lay ‘in the hands ofGod’ is particularly compelling.The creative nature of clinicalcommunication is presented asmeaning that there are no rigidrules for effective communicationwith every patient in everycontext.

Salmon and Young takeparticular exception to the use ofthe word ‘skills’ to describecommunication tasks. Whereas aneye surgeon has a set of skills toimplant a lens in a certain way or

a pilot has the skill to land aplane in a thunderstorm, thecommunicating clinician is deal-ing with a situation in which thepatient’s response is far less pre-dictable than that of an isolatedorgan or a plummeting plane. Thepatient’s experience of theclinician’s communication isentirely subjective, influenced bytheir personal and social con-texts. The authors also decry thefocus on linking communicationskills with specific outcomes,given that employing the sameskill can achieve extremelyvariable results in differentpatients. So, too, a skill that isused without sincerity rings hol-low in the patient’s ears. Mypersonal belief is that studentsshould be disciplined for parrot-ing the phrase ‘I can see thatmust be difficult for you...’ with-out meaning it.

The paper comes to theconclusion that a reductionist

Clinicalcommunication

cannot betaught andassessed as

discrete skills,but rather as a

holistic andcreative process

68 � Blackwell Publishing Ltd 2011. THE CLINICAL TEACHER 2011; 8: 67–70

approach to communicationtraining is in conflict with thebelief that communication is

intuitive and imaginative. It isan art rather than a science, andso ideas for effective training

may lie more within a humanis-tic paradigm than a scientificone.

Getting real: encounterswith patients duringproblem-based learningDiemers AD, van de Wiel MWJ, Scherp-

bier AJJA, Heineman E, Dolmans DHJM.

Pre-clinical patient contacts and the

application of biomedical and clinical

knowledge. Med Educ 2011;45:In press.

These researchers from theNetherlands venture intoimportant territory as they probethe impact of pre-clinical patientcontact with the early learning ofstudents. A concise introductionoutlines the approach that expe-rienced clinicians take to solvingproblems, activating their ‘infor-mal’ knowledge (recognising pat-terns of previously encounteredcases), while using their formaltraining to analyse the case fromboth a clinical and biomedicalpoint of view. As novices,students have little experienceon which to rely, and so have touse their basic biomedicalknowledge to explain clinicalpresentations.

Much of modern medical edu-cation is built around usingproblem-based learning cases tohelp students integrate theirknowledge networks for moreeffective diagnostic reasoning.Using real patients (rather thanpaper-based cases) helps studentsto be better engaged with thereasoning process, while alsoposing the risk that the studentwill be too seduced by thereal-life problem-solving taskto bother with cementingtheir pathophysiologicalknowledge. Being able to solve apatient’s clinical problem is

one thing; being able to explainhow the problem occurred isanother.

The research questions in thispaper relate to understandingmore about how biomedical andclinical knowledge is addressedwhen a real patient’s case is underconsideration by preclinicalstudents, and whether clinicallytrained tutors dominate thesediscussions. Three groups ofsenior pre-clinical studentsundertaking problem-based learn-ing cycles with 29 real patientswere selected. The cycles involvedthe groups preparing for theirpatient encounters in one sessionand then reporting back on theirexperiences afterwards. Tutorswere responsible in the first phasefor helping students to elaborateon the patients’ problems beforethe encounter, and then todiscuss them in depth afterwards,

forming connections betweentheir biomedical and clinicalknowledge.

The groups were observedand their discussions were codedinto ‘patient information’, ‘for-mal clinical knowledge’, ‘bio-medical knowledge’, ‘informalclinical knowledge’, ‘proceduralinformation’ and ‘other informa-tion’. The results indicate that –after presenting the cases theyhad seen – the students spent asubstantial proportion of theirtime exploring the biomedicalknowledge underpinning theclinical presentations, and thatthe tutors did not dominatethese discussions (although theywere more dominant during thepreparation phase of the cycle,albeit in a facilitative ratherthan a didactic style). Studentsused their biomedical knowledgeto explain the underlying

Using realpatients inproblem-basedlearning iseffective inmakingconnectionsbetweenbiomedical andclinicalknowledge

� Blackwell Publishing Ltd 2011. THE CLINICAL TEACHER 2011; 8: 67–70 69