Improving communication with patients: learning by doing.

“Learning by doing” has been the mantra of clinical education since the days of Osler. Simulation (for example, in laparoscopy or in enhancing communication skills) is a relatively recent teaching innovation. It allows for a controlled setting andminimizationof patient risk anddiscomfort. Thehope for any formof simulation is that itwill be an effective pedagogic tool, avaluableadjunct toexperiencewithrealpatients.1Teaching physicians the skills to communicatewellwith patients at the end of life is a worthy goal, because it is profoundly beneficial to patients when done correctly.2,3 In this issueof JAMA, Curtis andcolleagues4describe their use of a 4-day simulation-based workshop using standardizedpatients to improve the end-of-life communication skills of 178 internal medicine trainees and 33 nurse practitioner or registered nurse trainees, compared with a control group of 198 internal medicine traineesand36nursepractitioneror registerednurse trainees. In an attempt to answer the question ofwhether this previously validated workshop method5 makes a difference to patients and others in the real world, the authors included a 10-month follow-up period during which participants were evaluated by actual patients and families as well as by supervising faculty; the goal was to determine how well participantsperformed in thedomainsof communicationand inproviding end-of-life care. Even though the workshop was associated with improved skills among theparticipants (as evaluatedby the standardized patients), the authors were unable to show that it helped in subsequent interactionswith real patients.After adjustment, comparing the interventionwith control, therewas nosignificantdifference in thequalityof communicationscore forpatients (difference,0.4points [95%CI,−0.1 to0.9];P = .15) or families (difference, 0.1 [95% CI, −0.8 to 1.0]; P = .81) and no difference in quality of end-of-life care score for patients (difference, 0.3 [95% CI, −0.3 to 0.8]; P = .34) or families (difference, 0.1 [95%CI, −0.7 to 0.8]; P = .88). Indeed, patients of the trainees in the intervention group were actually found to have significantly increased depression scores. There are many possible reasons for the unexpected results. Patients and families are not formally trained to evaluate communicationskills.Additionally, theacquisitionof skills was tested over the course of a 10-month period following workshop participation and not immediately following specific end-of-life discussions. It is possible that the improvement inparticipants’ skillswasnot enough tomake ameasurable difference to patients; conversely, it is possible that trainees did not recall training and so were not able to apply the communication skills. The finding of increased depression scores in patients of trainees in the intervention group is intriguing. The phenomenon was more common with the patients of interns than with patients of more senior trainees. Perhaps in the world of a busy intern, with many tasks competing for time and attention, and with work-hour restrictions, it is a challenge to reproduce what was learned in the setting of a controlled workshop. Accordingly, one conclusion from the study might be that end-of-life conversations should be left to more senior physicians. Ericsson’s idea of deliberate practice,6 in which motivated trainees emphasize specific learning objectives, receive timely and relevant feedback, self-reflect, andengage in focused repetition, can be applied well in a simulated controlled environment.7 But even with the best learning methods, simulation has inherent limitations: for example, hightech mannequins with audio recordings are not a perfect substitute for real patients when teaching cardiac examination skills.8 The study by Curtis et al4 raises the question of whether standardized patients can convincingly display and express feelings they are not really feeling. Can trainees in simulation experience empathy, knowing they are hearing a standardized patient script? If the trainee learns to speak and act in a manner that represents empathy, is that the same as beingtrulyempathetic?9Nonverbal communication (bodyposture, facial expression, and gestures) can be intentional, but it is just as often nonintentional and registered by others at a conscious or subconscious level. For the trainee to “act” the partmight not only be insufficient, itmight seem insincere to a real patient.10 Ultimately, there isprobablynoperfect substitute for trainees’ engaging in the deliberate practice of reevaluating themselves, raising the bar to learn more advanced skill sets, and receiving constant feedback from patients and supervisors. This may require both simulation and longitudinal experiences with real patients, for whom the complexity, nuances, and unique challenges of communication are preserved. The study by Curtis et al4 should make educators reflect onhowwell traineesaredoingwith theskills imparted to them. For example, everymedical school teaches some version of a physical diagnosis course in the first and second years. There usually is a substantial investment in standardized patients, not to mention faculty, space, and money. An end-of-course test affirms the acquisitionof knowledge, if not skill. Butwhat does it all mean in the real world of patient care? Patients and Related article page 2271 Opinion