Effect of ethnicity on performance in a final objective structured clinical examination: qualitative and quantitative study
BMJ 2003; 326 doi: https://doi.org/10.1136/bmj.326.7393.800 (Published 12 April 2003) Cite this as: BMJ 2003;326:800Data supplement
Differences in communicative style
Students with lower grades usually had a more medicalised style of consulting in which the disease agenda was driven through. A few male students from ethnic minorities tended to show a rather extreme form of this style and this, combined with other, more subtle, differences in style, contributed to their low grades. The following example is from a student taking a sexual history from a young Muslim woman (station 18, day 1), who received the lowest grade given by any simulated patient and who was failed by the examiner:
1. Student: Right erm let me just ask you some (.) er questions about (.) er the
2. encounter with this gentleman (..) erm (1.5) is he a regular partner or ...
3. Simulated patient: No it’s complete one—it’s my first time [yeah] (.) because I
4. come from a traditional Muslim culture.
5. Student: Right.
6. Simulated patient: Er we don’t have boyfriends in our culture.
7. Student: Right.
8. Simulated patient: Erm (..) I just (..) ((breath out)) (..) just (.) feel really terrible
9. about it.
10. Student: Okay (.) erm (2.0) did you use protection at all?
11. Simulated patient: No (..) it happened really quickly.
12. Student: You didn’t use any form of contraception?
13. Simulated patient: ((shakes head))
- Student: Okay and e- what type of erm (..) sex did you have was it er
- penetrative (.) vaginal sex
16. Simulated patient: [I just had] sexual intercourse.
17. Student: You had full sexual intercourse.
18. Simulated patient: ((nods))
19. Student: Right (..) did you have any (1.0) anal intercourse or oral (.) sex
20. Simulated patient: No.
21. Student: Right okay erm (5.5) can I just ask you a few (.) other questions. When
22. was your last period?
23. Simulated patient: Er it started yesterday.
24. Student: It started yesterday (.) right and have you had a cervical smear before
25. at all?
26. Simulated patient: No.
27. Student: Right erm (.) have you ever ha- been pregnant at all?
28. Simulated patient: No.
29. Student: Right okay (1.0) erm (6.0) did (.) this patient have any er overt signs of
30. any sexual disease did he have any rashes at all or ...
31. Simulated patient: Sorry?
32. Student: Did the (.) did the partner that you had sex = with did he have =
33. Simulated patient: = yeah =
34. Student: Any (.) sort of signs of (.) sexually transmitted diseases?
35. Simulated patient: ((shakes head))
36. Student: Any rashes or ...
37. Simulated patient: No don’t think so.
38. Student: Discharge (.) have you yourself had any discharges at all?
39. Simulated patient: No.
40. Student: Any erm (.) irritation down there?
41. Simulated patient: No.
42. Student: Any pain when you’re passing water?
43. Simulated patient: No.
44. Student: Erm (..) any blood in your urine?
45. Simulated patient: No.
46. Student: Erm (.) has your urine been offensive at all?
47. Simulated patient: What do you mean?
48. Student: Has it been smelly at all?
49. Simulated patient: No.
50. Student: Erm (.) and (..) do you have this (.) increase (.) do you have an increased
51. need to (.) go (.) to the (.) loo.
52. Simulated patient: No.
53. Student: Okay = =
54. Simulated patient: = = It’s the same.
Both the simulated patient and the examiner gave this student a low grade for several reasons. Firstly, he staged these opening moments of the encounter from a perspective of physical medicine despite the patient, at lines 8-9, explaining that she felt "really terrible about it." The student acknowledged this only with "okay" and then proceeded to ask her about protection and the type of sex she had. This led to a protracted linear phase, lines 19-54, in which the patient gave no more than minimal responses. These interrogatory sequences show the student going through a mental checklist rather than responding to the patient’s expressed needs and seeing the associations between her statements and her likely orientation to sexual activity.
The student’s ideological positioning is also likely to have distanced him from the simulated patient. He derived his authority from his technical questioning and information on tests and test procedures rather than drawing on a more personal authority. In doing so, he categorised himself as a technical or medical person rather than as a social being relating to another. This meant that, for example, questions about whether the patient had safe sex took precedence over responses to her feelings. And, his questioning of what type of sex, lines 8-18, so close to her negative feelings, suggests that he was working with a schema that these sort of feelings must be associated with abnormal sex.
This ideological positioning affected the turn by turn design of elicitation and responses. So, for example, from line 24 onwards the atudent asked a series of slot filling questions, "have you had any ...?" which closes down the possibility of a more descriptive conversational mode of interaction. These questions also involve the atudent in a phase of rapid shifting of topics which, combined with the slip of the tongue at line 29, may have contributed to the patient’s failure to understand him at line 31. Similarly, this checklist mode tends to override any careful listening by the student, who twice in this phase of the consultation, at lines 19 and 27, indicated that he had failed to pick up on information the patient had given him.
Finally, there are several performance factors that relate to the student’s fluency, clarity, understandings and misunderstandings, and voice quality that contributed to his low grade. These included a long pause at line 29, the slip immediately after, and his false pitching of medical register, for example, his difficulty in gauging the patient’s medical knowledge, "overt signs of sexual disease" (lines 29-30). These performance factors, in combination with the design of elicitation and responses, feed into the assumptions that the student brings to the interaction, which themselves help to determine the turn by turn level.
The data here shows the uncomfortable moments, lost opportunities, inefficient use of time, and trained empathy characteristic of the student’s communicative style in simulated consultations. Students need not only technical competence in English but also to be at ease with their means of communication so that they can use it flexibly in responding to patients’ need.
"White" communicative style
A "white" communicative style is used by many students but is particularly evident in intercultural consultations where it may either create difficulties in understanding or simply be rated less highly by simulated patients from ethnic minorities. The following two examples are both of white male students. The first one, on the alcohol station, received nearly full marks from the examiner but a middle ranking mark from the simulated patient, a Chinese businessman who was asked to simulate a patient with limited English (station 8, day 2). The following is an extract from near the beginning:
Transcript 1
1. Student: I’ve got the test results here in front of me.
2. Simulated patient: mm.
3. Student: ((clears throat)) (1.0) And there are a couple of abnormalities on them.
4. Simulated patient: mm
5. Student: Erm but I’d like to know a little bit more about you.
6. Simulated patient: mm = =
- Student: = = Because erm it’s important that when we get any blood result that
8. we
9. Simulated patient: mm
10. Student: Look at the whole patient = and we =
11. Simulated patient: = mm = mm
12. Student: erm (.) Put everything in context so we can make best sense of it.
This is quite typical of the interaction in that this student did a great deal of context setting (or framing) (lines 5-12) and moved gradually towards the crucial question asked by the simulated patient: "Am I an alcoholic?" The examiner rated the quality of his talk very highly, but the simulated patient, both within the consultation and in the mark he gave afterwards, was somewhat less happy. This may have been because of the student’s communicative style: a great deal of framing, leaving things open, delaying advice on specific treatment, and going for the whole person, for patient understanding and commitment. He was offering talk, explaining how he wanted to conduct the consultation but the simulated patient wanted action—in this case, specific treatment. The difficulty with a style that relies on using more talk and talk about talk to try to be more patient centred is that patients who speak limited English may not understand the words or the purpose of such style.
The second interaction shows a similar pattern (station 18, day 1). The student was given quite a good mark by the examiner but a rather mediocre one by the simulated patient (again the young Muslim woman of south Asian background who had had unprotected sex). This extract is from nearly a third of the way through the consultation:
Transcript 2
1. Student: Okay well (1.5) well th- the first thing to say is that from from (..) from
2. our point of view we can do some tests and find out if you have got anything.
3. Simulated patient: Yeah.
4. Student: And (..) er obviously it’s better to use protection in these situations (..) 5. but y- I mean (..) being honest about it y- you (.) there’s a high chance that you
6. won’t actually have caught any any disease from him.
7. Simulated patient: Ri = ght =
8. Student: = And = wha- what’s (.) what’s worrying me slightly more is (.) is the
9. fact that you feel so bad about what you’ve done (2.0) er is there anyone you can
10. talk to about this at home, friends?
The student took on a personally authoritative role, engaging with the simulated patient’s feelings and giving her a lot of general reassurance (lines 4-6, 8-10). She, on the other hand, asked about the tests on several occasions and commented afterwards that he was a difficult student to mark. Again, the examiner rated the quality of his talk highly, whereas the patient wanted action—in this case, tests. So, in both examples, the "white" authoritative, reassuring performance, where there is quite a lot of talk about talk (for example, "being honest about it," "it’s important that ¼ we look at the whole patient") was rated highly by the examiners but was may be rather less patient centred as far as the simulated patients from ethnic minorities were concerned. This suggests that even where there were no obvious cultural and linguistic differences displayed by simulated patients from ethnic minorities, there may be subtle differences in style and expectations. The traditionally good student may need to adapt his or her style if there are cues from patients that they have rather different expectations.
Transcription code
erm, er hesitation sounds
(.) short pause
- timed pause in seconds
= word(s) = overlapping speech
[words] unclear speech
((breaths out)) non-verbal phenomenon
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