The night Bernard Shaw taught us a lessonBMJ 2006; 333 doi: https://doi.org/10.1136/bmj.39062.728900.55 (Published 21 December 2006) Cite this as: BMJ 2006;333:1338
All rapid responses
Thank you Michael O’Donnell for reinvigorating interest about
dialogue in the relationship between doctors and patients. More than
anything else the article illustrates the value of the arts to clinical
practice, a relationship increasingly emphasised in progressive medical
schools but still, sadly, a foreign concept in much daily clinical
practice. The distinction between medicine and art becomes blurred when
we remember that all our words describing things ‘technical’ arise from
the Greek word for art.
Annie Cushing and colleagues do current medical education a service
by reminding Michael O’Donnell how the best teaching has advanced
considerably from the days when some of us were students. I guess that
we’re stuck with the term communication skills’ for the time being but, as
Harold Cook points out in the accompanying editorial, the ability
underlying so much of our judgement is emotional intelligence which
implies that we need to recognise our own emotions and those of others in
order to respond more sensitively.
Like Annie Cushing, and for the same reasons, I use role-play, in my own
case, as a technique in workshops to help consultants learn the skills
necessary for appraisal and mentoring but I am starting to wonder whether
the distinction between role play and acting or performance may be less
distinct than I thought. I, too, emphasise that role-play differs from
acting by requiring that we speak and act as we would do ourselves if we
were in the scenarios (based on real life) used. Given that ‘Method’
acting requires a similar mind set we might not be dealing with such
All seem agreed that clinicians need high level skills in dialogue;
initially I suspect we do need to learn some basic mechanics but can
quickly move on to the more subtle use of language and behaviour that
demonstrate genuineness and other qualities mentioned. The challenge is to
make this teaching and learning more widely available. The development of
all skill is a function of motivation, practice and feedback with some
expert coaching as a catalyst. This all takes time and money but I can’t
remember any politicians promising that communication skills would be
delivered by the next election. Perhaps it’s just easier to use a stop
watch to time the trolley-wait and call that the useful target.
Competing interests: No competing interests
Letter to BMJ
Michael O’Donnell (2006) makes some important points about the danger
of an over-mechanistic approach to communication skills education and the
elusive nature of personality in the interaction with patients.
The key features of genuineness, respect, warmth, concern and empathy
have long been emphasised in the literature on communication (Simpson et
al 1991, Silverman, Kurtz et al. 2005) and medical education should aim to
foster these qualities. However, it is not sufficient to just say that
some people are naturally good communicators and others are not. Those
involved in the curriculum have a responsibility to help all students
develop competency in communication, which is what patients want
(McWhinney 1989; Kurtz, Silverman et al. 1998; Cohen-Cole and Bird 2000).
Making the ‘invisible’ explicit helps reflection and self-awareness
with opportunities to develop skills needed for a professional role.
Otherwise, communication can remain a mysterious quality that some just
Role-playing enables particular situations and challenges to be set
up and students to learn how they might deal with these and to gain
feedback on their interactions. This methodology allows students to be
‘themselves’ in a roleplay potentially creating an honest and personal
learning experience as opposed to playing ‘another’ as an actor would in
a play. Students appreciate these experiential opportunities if they are
offered by tutors who themselves demonstrate genuineness, respect, warmth,
concern and empathy.
Simulation is just that, and things are never the same in real life.
However, a laboratory type of learning situation allows for
experimentation, practice and reflection with techniques and strategies
that can be usefully drawn upon in real life encounters. Indeed, it could
be argued that simulation provides the ideal environment to allow students
to develop and practice cultural competence and flexibility in their
encounters with patients. Students do report that they have used
particular skills and phrases to help them when talking to patients. They
are able to consciously consider the effects that doctors’ communication
has on patients and to think about options.
However, the particular problem that arises is the assessment of
skills in the context of artificial situations and judged by a third
party. Deconstructing communication into its component skills and then
marking these is a dilemma we face in the name of standardisation. This
holds for much of the climate of assessment and appraisal we now find
ourselves in both in education and at work.
Whilst we might want to unpick some of the behaviours in teaching
settings and discuss constructively what they reveal about underlying
feelings and attitudes, this process is much more suspect when we come to
We need to find ways of supporting personal qualities and also
helping people learn what helps them to communicate effectively in their
professional role. Expectations of the doctor-patient relationship are
also changing and the danger of the charismatic personality is a potential
for perpetuating the paternalistic relationship. We shouldn’t throw out
the methods we have but perhaps need to be more honest about the strengths
and limitations of any approaches we use. After all, George Bernard Shaw
famously considered all professions as ‘conspiracies against the laity’
(Shaw 1946) and we must therefore aim to deconstruct some of the
Cohen-Cole, S. A. and J. Bird (2000). The medical interview : the
three-function approach. St. Louis, Mo. ; London, Mosby.
Kurtz, S. M., J. D. Silverman, et al. (1998). Teaching and learning
communication skills in medicine. Abingdon, Radcliffe Medical.
McWhinney, I. (1989). The need for transformed clinical method. In
Communicating with medical patients. Newbury Park, CA, Sage Publications.
O'Donnell, M. (2006). "The night Bernard Shaw taught us a lesson."
BMJ 333(7582): 1338-40.
Shaw, B. (1946). The Doctor's Dilemma. London, Penguin.
Silverman, J. D., S. M. Kurtz, et al. (2005). Skills for
communicating with patients. Oxford, Radcliffe Pub.
Simpson M, Buckman R, Stewart M, Maguire P, Lipkin M, Noack D and
Till J (1991) Doctor-patient communication: The Toronto consensus
statement. BMJ 303:1385-7
Dr Annie Cushing, Reader Clinical Communication Skills, Barts and The
London, Queen Mary’s School of Medicine & Dentistry, University of
Ms Jo Brown Senior Lecturer Clinical Communication Skills, St Georges
Medical School, University of London
Dr Dason Evans, Lecturer Medical Education and Sexual Health, Barts and
The London, Queen Mary’s School of Medicine & Dentistry, University of
Competing interests: No competing interests