Is there anyone out there who has had a completely satisfactory relationship with their doctor? Have there been times when you went for a routine consultation in reasonably good spirits and emerged some 10 or 15 minutes later feeling patronised or intimidated, confused or frightened - or maybe all of these? If this has happened, the chances are that this is the result of poor communication on the part of the doctor, and your feelings at the end of the consultation would probably genuinely shock and upset your doctor if you were to turn at the door and express your exact state of mind. But a patient who already feels intimidated is unlikely to take this step, and so the cycle of ignorance continues.
Attending a doctor, while it has long been seen in this country as something akin to a consultation with the local oracle, is a service, and the medical profession is increasingly aware of the need to provide a good service. For this reason, communications skills are now a standard part of medical students' training. The Royal College of Surgeons in Ireland pioneered clinical communication some 12 years ago.
"This was the only medical school which was looking at students holistically," says Ciaran O'Boyle, professor of psychology. His colleague, Prof Bill Shannon, comments: "We felt that doctors involving patients in consultations could start back in medical schools."
So the college started a series of roleplaying workshops in which students worked with each other, alternately taking the role of the patients. Predictably, more time was spent in collective mirth at fellow-students' acting abilities than concentrating on the needs of the "patient". But the college still felt the communications exercise was worthwhile, if they could find a different way of going about it.
They did this in two main ways: by bringing in professional actors and drama students to work with the students as simulated patients; and also, through associations like the Irish Cancer Society, by inviting ex-patients to come and talk to students about their experience of illnesses such as breast cancer. The communications module is now a mandatory part of student exams.
In the fourth year, for instance, students must make a six-minute video when they have a consultation with a simulated patient, who is played by an actor. The student doesn't know in advance why the "patient" is coming to the surgery, as happens in reality. These videos are then played back the same day and commented on, in the presence of a few of their fellow-students, tutor Bill Shannon, and the "patient" who then gives feedback while still in character. The emphasis is on positive, constructive feedback from all.
On this particular morning, a group of fourth-year med students - Khalid Ali Huessein from Kuwait, Morten Smedsrud from Norway, and Molly Lindhart, Claire Magauran and Kirk Williams, all from the US - are waiting to watch the re-run of the videos they made earlier in the morning. Actor Jimmy Hill has been working with Huessein, Magauran, and Williams, in the role of a patient who has profound and recurrent indigestion, and works as a long-distance lorry driver.
Huessein is the first to see himself on camera. "When you say indigestion, what do you mean?" he asks Hill early on, which Shannon later praises, saying that it's important that both patient and doctor have the same definition of a condition.
When it's Magauran's turn, she uses a diagram to illustrate an endoscope, which is a possible option for the patient to investigate if there is bacteria present in the stomach causing pain. "You sound kind of disturbed by the endoscope," Magauran says, picking up straight away on Hill's wince and defensive body language. She suggests he try a change in diet first and then return for another consultation.
"I was wondering if it was something more than heartburn," Hill says. "Something more?" comes back the response. "What's worrying you?" Afterwards, Hill says that he felt "totally reassured," and that Magauran had "sold" him the endoscope test, on the basis that he would know the results very soon. Shannon tells the students how valuable the use of diagrams can be, and that patients often ask to take them away with them.
When Williams is questioning Hill, he brings up the possibility of a heart-related condition. Hill is immediately suspicious. "What's wrong with my heart, doctor?" he insists. Williams responds by saying, "It's nothing," and changes the subject by asking how his children are.
When he explains about the endoscope, he says it will have to go down "the oesophagus". "What's that?" "The gullet." "Oh, the food-pipe!" Hill says, finally understanding. Later, he says he had felt alarmed when the heart issue had come up, and had felt there was something sinister in the sudden change of subject. However, Williams's impression (and that of the other students) was that he had successfully got off the subject. Surprised, they mull on this collectively for a while.
THE second scenario of the morning is a 29-year-old mother of four, now on the Pill, who has had a headache for three days, and is played by actress Una MacNulty. MacNulty is worried her headache has sinister origins. "Most headaches are caused by stress," Molly Lindhart tells her, "especially with a lot of small children. They're rarely caused by anything too serious."
She prescribes painkillers and suggests leaving the children somewhere one morning a week for a break. Afterwards, Lindhart says she feels she gave the patient a lot of reassurance. MacNulty confesses that what she was really worried about was that the Pill was causing her headaches, which wasn't picked up by the doctor.
She mentions her Pill worries to Morten Smedsrud, though, and wonders if "clots" are causing the headaches. "I don't think so," he says, and suggests she come off the Pill. "I don't want any more children, and condoms were no good last time." "I could refer you to a gynaecologist for a sterilisation," Smedsrud says briskly. MacNulty looks positively dazed. At the end of the consultation, he asks if there is anything else. "What about the headache, doctor?" she reminds him timidly. "Oh yes, the headache!" he exclaims in an unconsciously comic moment, which has his fellow students laughing out loud.
Later, Shannon makes the point to everyone that the doctor should always make sure couples discuss contraceptive issues together. "But you'll learn all this later," he reassures them.
After all the videos have been played, the students relax and discuss the merits of the whole project. "It is an artificial situation," says Huessein. "It's really hard when you know you're being videoed," Magauran says. "It's really hard to concentrate, but it's great to hear `patient' feedback at the end. You never usually get to hear that. And you never get to see yourself in action either." They all agree that developing listening skills is very important - and very difficult.
Williams is still thinking about his misreading of his patient's unease. "I would just have walked away and not thought any more about it, because I assumed I had reassured him. It will definitely make me more watchful next time."
They all praise the actors, whose improvised performances are crucial to the project. One or two of them wonder if Jimmy Hill really does suffer from chronic indigestion, so convincing was his performance. Then Kirk Williams gives a big grin. "One thing's sure," he says, "those people would be able to get a sick cert from a doctor any day!"
