In thinking about my question – about what I wasn’t taught (or maybe didn’t learn) in medical school – I’ve been trying to come up with a way of summarising the themes and chanced upon a book about life skills needed for the 21st Century. I thought it encapsulated the needs of the modern doctor in training nicely. Whilst modern curricula do address some of these issues they certainly don’t give them enough prominence.

Trilling and Fadel describe in their book 21st Century Skills: Learning for Life in Our Times, 7 C’s that constitute the 21st Century skill-set when combined with the tradiational 3 R’s (reading, writing & arithmetic). The 7 C’s are:

Critical thinking and problem solving
Communications, information, and media literacy
Collaboration, teamwork, and leadership
Creativity and innovation
Computing and ICT literacy
Career and learning self-reliance
Cross-cultural understanding

Looking through the 7 C’s one can see the importance of each of these skills for a doctor working in a health system dominated by team-based healthcare, electronic connectivity, mHealth, social media, and patient empowerment. These skills also subserve the doctors of the future as more and more digital natives or Millennials pursue non-traditional, portfolio-style careers. Practising doctors and medical students can evaluate themselves against these 7 C’s.

As I was going though medical school and especially when I was doing speciality training as a medical oncologist there was a growing trend to teaching communication skills. Generally this focused on communicating with patients and in particular this focused on breaking bad news. Although this was useful and now it is something that I pride myself on doing well it wasn’t really enough to address my communication needs.

Doctors need to be able to communicate with patients but also with their colleagues including other doctors, nursing and allied health professionals, junior staff and students. Although rough frameworks are taught in communication skills training what isn’t taught is how any of these interactions requires dramatic skill and the ability to improvise.

An example I use is from a tutorial I run with medical students about malignant spinal cord compression. As we work through the case I get the students to pretend that they are the doctor in the emergency department in the middle of the night who has to call the radiologist, the neurosurgical fellow and the radiation oncologist about the patient. Any doctor who has worked in an ED on an overtime shift can tell you of the joys of having to make these calls and ‘sell’ the case to another doctor. The job of the junior doctor is to do stuff for other peope and to get people to do stuff for you. This process continues on through one’s career as you move from making your case to one other doctor to groups of doctors in multi-disciplinary meetings.

When dealing with patients the communication skills we are dealth with at medical school really only covers the basics. I like to think of it as jazz. There are a set of chords and melodic themes to work with but then you have to adapt to the occasion. In any given clinic the doctor might move from needing to break bad news to the patient he or she has known for years and whom there is an established rapport to the totally new patient whom one has to assess in a matter of minutes and then play one’s spiel to the tempo of the occasion. Discussing end-of-life with somebody who you met 15 minutes earlier requires a lot of improvisation and a great deal of practice: one size doesn’t fit all.

Now I guess you can argue it is hard to teach these skills and that some are more naturally gifted than others. Well that it true but I think one can learn. The first step is to realise that you can’t simply say the same things in the same way to every person. The worst communicators I’ve met follow the same pattern every time.

For me the most important components of learning to improv in medical communication are:
– actually know what you are talking about – it is hard to be an expert if you aren’t actually an expert
– if you don’t know what you are talking about then admit it openly
– establish what the patient and their family expect from the consultation
– find out what people know first – sometimes I ask if they just want to ask questions or would they like me to do the talking
– start with the most simple explanations and then make them more complex as needed
– use non-medical analogies to help people understand
– compare and contrast – for example – when I explain chemotherapy I explain what happens with and what happens without treatment
– practice a lot and remember what works
– be repetititive so you are thorough but don’t follow a strict script
– when there are treatment options offer clear choices that are genuinely different and don’t offer too many
– recap and check understanding

One particular way to improve communication improv skills is to explain the same concept to different audiences, expert and non-expert, – this way you learn to move the explanations along the complexity spectrum. With the experts you have to use the right jargon – with the non-experts you can’t.

It seems, as time goes on, there is less time for junior doctors to watch senior doctors explain things to patients and also less time for senior doctors to watch junior doctors make explanations. In the era of mHealth this needs to change. Medical schools need to move beyond the limited communication skills currently taught and train star performers.