Reflective Practice in Medicine and Multi-Professional Healthcare

John Launer

• Publisher: CRC Press
• Year: 2022
• ISBN:
  9781000542875
• Edition: 1
• Topic: Médecine
• Subtopic: Théorie, pratique et référence de la médecine

This unique book presents in a single collection around 50 essays by Dr Launer on reflective practice in medicine, including examples specific to medical education and multiprofessional healthcare. Based on existing contributions to the literature by Dr Launer, the book brings them together in updated form for the first time as a themed collection with an introduction linking the different topics addressed. Coverage includes communication skills, supervision, teamwork and organisational health. In a time of unprecedented demand on healthcare services, educators and practitioners, Dr Launer offers invaluable guidance to a broad audience including community-based GPs, practice nurses and nurse practitioners, pharmacists, physician assistants and paramedics, secondary care staff including consultants and registrars across all specialties, communications skills educators, counsellors and mental health professionals, and health service managers and administrators.

PART 1 Learning to Communicate

LEARNING TO COMMUNICATE Conversations Inviting Change

DOI: 10.1201/9781003158479-2

Why don’t doctors pursue lifelong learning in their communication skills just as they do with their scientific and technical skills? Good medical communicators have fewer complaints in their careers and cost their employers and insurers less in negligence claims (Tamblyn et al., 2007). Doctors who communicate well are better at putting patients at their ease. They are more likely to be given the right information, to make the right diagnosis, and to recommend the most appropriate treatment, which patients are then more likely to take (Groopman, 2007). They will be able to cope with the large proportion of cases where people want to discuss their lives as well as their bodies. There is in fact an inextricable link between good communication and simply being a good doctor. The lack of any requirement for working doctors to keep improving their communication skills, as they have to do with their other skills, isn’t just surprising. It’s alarming.

At present, most training in communication skills takes place in undergraduate medical schools. This is paradoxical. It means that students are exposed to this training when they are seeing very few patients, and have no direct responsibility for any of them. They may acquire some basic skills to use in their later careers. However, it may be several years before they can try these out in the real world, where attempts at good communication have to compete with a tremendous number of other pressures. These include heavy workload, the hierarchy of the medical team, and the need to make quick decisions. It is rather like learning to ride a powerful motorcycle along quiet village roads and then being asked to navigate at speed around Hyde Park Corner in central London, without ever having a chance of further training, observation, or assessment.

There are a few examples of specialities that encourage training in communications skills beyond medical qualification. Trainee GPs usually examine video recordings of some of their consultations with their trainers, but this stops as soon as they complete their training. Some established GPs—although only a tiny number in the United Kingdom—belong to Balint groups, where the emotional aspects of consultations are scrutinised (Salinsky & Sackin, 2000). Psychiatrists may spend time talking to each other in detail about their consultations. However, even in these contexts, the emphasis is often on general issues of doctor-patient communication, rather than on what exactly the doctor said, and what effect this had on the patient. The vast majority of doctors in most specialities never once sit down to consider systematically the words and phrases they use when conversing with patients, or the tone and manner in which they deliver them. I suspect that many patients would be astonished to discover this.

Doctors and their patients may in fact have far lower expectations regarding good communication than they should have. There is an interesting contrast here between medical doctors and psychological therapists or counsellors. Most people in those professions regard conversations as therapeutic in their own right. They approach each consultation with the assumption that the acts of talking and listening will bring about change as a matter of course. They give priority to the teaching and learning of communication skills not simply because it will lead to better treatment, but because it will actually be better treatment. Therapists learn precise micro-skills that make the conversational skills of many doctors seem crude by comparison. Their training enables them to pick up words, hesitations, nuances of tone, or gestures of hands and body, and to be able to follow these through with sensitive questions or, if appropriate, with silence.

There is clearly a difference between medicine and psychological therapy. However, there is absolutely no reason why medical consultations should not be therapeutic in the same way. There is also no reason why the psychological effects of a good consultation should not go alongside the effects brought about in other ways, such as a careful physical examination or the right pharmaceutical treatment. Indeed, one of the markers of an effective consultation may be the doctor’s ability to bring about an improvement both as a result of the consultation and through the conduct of the consultation itself.

Communication is a two-way process, so it makes more sense to think in terms of the doctors actually needing ‘interactional’ skills—and not only for the consultation. They are essential in a wide range of other situations, including conversations with colleagues and in teams. Doctors with good consulting skills are generally good at helping their colleagues and juniors as well, through attentive listening and thoughtful questioning. They are better at promoting open communication in their teams and networks. A culture of good conversations is likely to lead to better systemic function within the workplace generally, and hence to greater patient safety and quality of care.

I have been personally involved in running trainings in interactional skills for over two decades now, and have seen the demand from working doctors expand hugely. When we started in the mid-1990s, we only taught a dozen or so GPs each year (Launer & Lindsey, 1997). Our workshops and courses then became available to all GPs in London who were trainers or carried out appraisals—several thousand in all (Launer & Halpern, 2006). We then extended our teaching to hospital doctors as well, followed by other health and social care professions (Launer, 2018). Our courses draw on the ideas and skills used by therapists, especially those who see families and children. We teach mainly through the medium of peer supervision (Launer, 2003). We ask doctors to talk to each other about difficult cases they have seen. We coach them on how to listen with attentiveness and to pose questions in a way that is both supportive and challenging. The technical term for our approach is ‘interventive interviewing’ (Tomm, 1998) but we prefer the friendlier term ‘Conversations Inviting Change’ (2021).

We base much of our training on narrative-based medicine, which teaches that everyone—doctors and patients alike—has a need to tell stories in order to make sense of their experience and the world around them (Greenhalgh & Hurwitz, 1998). Sometimes these stories can become ‘stuck’, but if we question people sensitively they will generally find a way of telling the story in a different way, and then see the problem in a different way too. Encouraging patients to develop a new and more hopeful story about themselves can be as much a part of healing as any physical treatment. This is especially true in cases of chronic illness and disability (Mattingly, 1998), in ‘grey area’ conditions like chronic fatigue and fibromyalgia, and with somatisation (Morriss & Gask, 2002). It also holds true with doctors who may be feeling hopeless or inadequate with some of their cases.

All conversations, whether with patients or colleagues, can be therapeutic. Collectively, good conversations can transform a working culture from one that is technocratic, impersonal, and potentially dangerous, to one that is both kinder and safer. We need to persuade doctors everywhere that the lifelong development of interactional skills is a core professional need.

References

• Conversations Inviting Change. Available: www.conversationsinvitingchange.com/ (accessed 1 January 2021).
• Greenhalgh T, Hurwitz B. Narrative Based Medicine: Dialogue and Discourse in Clinical Practice. London: BMJ Books, 1998.
• Groopman J. How Doctors Think. New York: Houghton Mifflin, 2007.
• Launer J. A Narrative Based Approach to Primary Care Supervision. In: Burton J, Launer J, eds. Supervision and Support in Primary Care. Oxford: Radcliffe, 2003.
• Launer J. Narrative-Based Practice for Health and Social Care: Conversations Inviting Change. Abingdon: Routledge, 2018.
• Launer J, Halpern H. Reflective Practice and Clinical Supervision: An Approach to Promoting Clinical Supervision Among General Practitioners. Work Based Learn Prim Care 2006;4:69–72.
• Launer J, Lindsey J. Training for Systemic General Practice: A New Approach from the Tavistock Clinic. Br J Gen Pract 1997;47:453–456.
• Mattingly C. Healing Dramas and Clinical Plots: The Narrative Structure of Experience. Cambridge: Cambridge University Press, 1998.
• Morriss R, Gask L. Treatment of Patients With Somatized Mental Disorder: Effects of Reattribution Training on Outcomes Under the Direct Control of the Family Doctor. Psychosomatics 2002:43:394–399.
• Salinsky J, Sackin P, eds. What are You Feeling Doctor? Identifying and Avoiding Defensive Patterns in the Consultation. Oxford: Radcliffe, 2000.
• Tamblyn R, Abrahamowicz M, Dauphinee D, Wenghofer E, Jacques A, Klass D, Smee S, Blackmore, D, Winslade N, Girar, N, Du Berger R, Bartman I, Buckeridge D, Hanley J. Physician Scores on a National Clinical Skills Examination as Predictors of Complaints to Medical Regulatory Authorities. JAMA 2007;298:993–1001.
• Tomm K. Interventive Interviewing: Part III. Intending to Ask Lineal, Circular, Strategic, or Reflexive Questions? Fam Process 1988:27;1–15.

LEARNING TO COMMUNICATE The Three-Second Consultation

DOI: 10.1201/9781003158479-3

There are many different models of the medical consultation and for teaching the skills to conduct it well. Most doctors nowadays will have learned one or more of these at medical school or later. The models largely depend on the idea that every consultation has, or should have, a regular pattern involving certain standard sections, each of these lasting several minutes. They generally propose what one might call a ‘symphonic’ structure to the consultation. They see conversations between doctors and patients as meetings that need some kind of pre-determined shape. They regard the doctor as the conductor of the symphony, if not the sole composer.

Thus, for example, one very influential model proposes that every consultation should consist of five parts: initiating the session, gathering information, examination, explanation and planning, and closing the session (Kurtz & Silverman, 1996). Another popular authority on the consultation suggests that doctors should follow a routine of ‘connecting, summarising, handing over, safety netting and housekeeping’ (Neighbour, 1987). Other leading teachers offer a variety of names for different parts of the consultation and some models are more ornate than others, but broadly speaking they all share two assumptions: the consultation needs to have a standard structure, and the doctor needs to be in control of it.

In some ways, all these consultation models are quite enlightened and patient-centred. They are certainly an advance on the traditional ‘clerking’ of patients involving a ritual series of questions followed by a full physical examination. They also challenge the idea that patients are simply there to report their symptoms, shut up, and then listen to what their doctors have to say. Yet in other ways the models are problematical. They close off the possibility that each consultation might have infinite possibilities of improvisation. They ignore the principle that true dialogue means both parties play an equal part in its direction: the best conversations, whether social or professional, are unconstrained by any prior expectations of where they ‘ought’ to go. In linguistic terms, the current models are based on a naïve assumption: that the only reason we converse is to state facts, rather than to explore meaning, stake out positions, form relationships, or try to evoke a particular response.

One approach that challenges this assumption is based on narrative medicine (Launer, 2009). This approach entirely rejects the idea of having a prior set of guidelines for the consultation. Instead, it works on the principle that doctor and patient are co-authors in constructing an agreed story about what has happened, what its significance is, and what if anything needs to be done. At the heart of this model is the idea that humans are innately story-telling creatures: we need conversations with others in order to develop these stories. This view of the medical encounter is radical, but we can take it even further. What would happen if we looked at the medical consultation as a fluid encounter, where the final story is determined by the ebb and flow of every single utterance or action made by doctor and patient, and as a result of the interplay between them?

To explore this idea, I recently studied a video recording of some consultations, together with two colleagues. As we started to observe the first consultation, we found ourselves drawn into some tiny details of the doctor’s behaviour: the way she welcomed the patient into the room, and then allowed him a moment’s silence to compose himself. We replayed the opening section again and again, discussing how well she had set the scene for the encounter. We looked at each of the details of movement, gesture, and facial expression. In fact, we spent over an hour reviewing the first three seconds of the recording—and we hadn’t even reached the doctor’s first question. While we did so, we conceived an entirely new idea for analysing and teaching communication skills. It was to see the doctor’s task as managing a series of three-second moments. The first job is to get the initial three seconds of the consultation right, and then the next three seconds, and so on through the whole conversation.

Once we had come up with this core idea, we began to elaborate on...