I recently attended a seminar organised by the Centre for Medical Education. Professor Alan Bleakley gave a thought-provoking presentation on “Communication matters: doctors must learn with, from and about patients.” I knew this seminar was going to be interesting but I am even more pleased I went because the talk was developed around 3 main points that I am developing in my literature review: Communication, Democracy and Complexity.
I arrived a few minutes late and the fist slide I saw was describing this concept: “the purpose of medical education is to improve patients’ care”. In order to benefit patients, doctors need to communicate effectively with them, “listen to them closely and give them their rightful place—at the heart of medical practice.”(1)
This may look like something straight forward but in reality there are a lot of issues around it and this concept has stimulated a flow of thoughts which I am still in the process of connecting in a meaningful way. This is what I am trying to do with this post but, I must say, these thoughts will have a very personal, perhaps very tangled, thread.
Communication is one of the keys of good medical practice. Poor communication (doctor-patient, inter-team) can lead to medical errors and iatrogenic deaths, this is why it is so important that particular attention is given to it, starting from the early years of undergraduate medical education.
Prof Bleakley explained that students are often exposed to “bad examples” of doctor-patient communication. “The patient has to learn the doctor’s language, obey the doctor’s lead, follow the doctor’s advice and even work out how to negotiate his or her way around the doctor’s world.”(1) Medical students are spectators of this unbalanced dynamics and can luckily pick these habits. Why does this happens? Language for Pierre Bourdieu is not only used for communication but also as a mechanism of power. Every person uses a peculiar language which is strictly influenced by his/her position or status in the society. In this way everyone “makes clear” to others if and in what extent he/she is in the condition to “have the last word” for example or even to be interrupted or not in the discourse (sorry for the twisted thought!). This is exactly what happens sometimes in a doctor-patient and student-teacher dialogue – and in many other situations.
Bleakley said that first of all medical education needs to become more democratic, both in the communication process and in action. Moreover students need to learn how to face the culture of change, complexity and uncertainty in which they will practice as doctors in the future.
What can we do about this in undergraduate medical education? How could we facilitate, or even teach, if possible at all, good communication, complexity and understanding?
Two of my favourite thinkers, John Dewey and Edgar Morin, come to my mind when talking about these subjects.
Dewey has pointed the democratic society as the most suitable environment for the development of personal qualities and skills. An educative environment should be a place where dialogue and critical thinking are constantly practised and where communication and listening skills are developed alongside with personal constitutive skills and energies. These are fundamental because within democracy every single subject needs to collaborate for a common end, and at the same time everyone needs to be ready to face change, be accustomed and open to it, acknowledging the dynamic character of democracy.
And dynamism, change, transformation are definitely intrinsic aspects of today’s social environment. If Dewey has seen in democracy both a “place” where education is exploited and, at the same time, the “product” of a (democratic) education; Morin has put it within a list of seven facets of essential knowledge that should be covered in education for the future, along with principles of pertinent knowledge, mutual understanding, detecting error and dealing with uncertainty.
“We have to learn how to confront uncertainty because we live in a changing epoch where our values are ambivalent and everything is interconnected. This is why the education for/ in the future must review the uncertainties connected with knowledge. […] Learning is indeed an uncertain adventure which in itself permanently entails the risk of illusion and error.” (2) He then adds that “learning is navigation on a sea of uncertainties dotted with islets of certainties”. I particularly like this metaphor because it reminds of online learning. A journey that can take you to many little islands carrying information but also allow connections with people with whom you share knowledge and dialogue. This can sometimes bring communication and understanding issues, especially when dialogue happens in an online environment.
Now, if we consider learning as a “navigation on a sea of uncertainties”, it means that the learning process itself and the environment where it evolves is actually the place where students should be “trained” in coping with change, complexity and uncertainty.
Morin defines complexity in terms of an “extreme quantity of interactions and interferences between a very large number of units” (3). Social Media in this sense is definitely a paradigm of complexity. Now the question is: could SM be considered as a “playground” where students can experience interactions with different people, cultures and backgrounds, communicate with professionals in higher positions, patients, doctors, peers, etc… This also becomes a tool for reflection. In fact, according to Morin, the understanding of complexity of social interactions and of the human being itself comes through introspection, which should also improve empathy.It also requires communication, discussion, exchange of opinions rather than ” damning and excommunicating” (3). In short, a democratic principle, which naturally entails a social interaction component, is needed to understand others, but it all starts from an introspective work of self-reflection. Obstacles to understanding come principally from egocentrism, inability to self-criticise, preconceived ideas, wrong assumptions, ethnocentrism.
Can we learn how to cope with complexity by experiencing it directly inside the complex SM environment? Can we practice (teach?) democracy and acceptance in an environment where (ideally) democratic principles of dialogue should be intrinsic, but are often neglected? In Twitter for example, I saw many good examples of dialogue but also situations where the 140 characters were used as a substitute of pottery shards to ostracize someone, who only shared their opinion openly through a tweet.
There is no need to say how vital the role that medical humanities play in this; communication skills are taught in the curriculum and it is extremely important to facilitate students in recognising the sociological implications in every social interaction: with peers, teachers, patients… both face to face and online. During my Master’s I was introduced to basic counselling skills, the meaning and importance of being assertive and listen actively; I enjoyed reflecting on gender and power issues, group dynamics, inter-cultural communication issues, how assumptions can lead hour behaviour and thinking. This kind of self-reflection is a good starting point for recognising unbalanced power situations and try to overcome them, both in language and in action.
(1) Bleakley A, Bligh J, Browne J. Medical Education for the Future: Identity, Power and Location. New York: Springer, 2011
(2) Morin E. Seven Complex Lessons in Education for the Future.UNESCO, 1999.
(3) Morin, E. On complexity. New Jersey: Hampton Press, 2008