Monday, September 25, 2023

Technology applied to communication skills training without feedback is like fencing in the dark

The Comment piece this week is by Prof Peter Gillen, associate professor of surgery at the Department of Surgical Affairs, RCSI

A recent article (Guardian, June 21) by Ranjana Srivastava, an Australian oncologist and author, reignited the long-running debate about the merits of online training for the acquisition of communication skills. In her article Dr Srivastava lauds the merits of Artificial Intelligence (AI) (what isn’t it being lauded for recently?) as a provider of ‘what to say’ when breaking bad news and demonstrating empathy. As a practicing oncologist she ponders the thorny question of ‘how am I doing?’ with her approach to patients receiving bad news.

Prof Peter Gillen

She does so against a backdrop, no doubt, of a busy clinical load and the almost inevitable human toll that this produces over a clinical lifetime. After all, it is well known that empathy levels are at their highest as a final-year medical student and then life and work get in the way, which see a steady decline in empathy levels over the coming years.

It was perhaps no surprise then that one of the main findings of the recent National Maternity Survey was that women felt a distinct lack of empathy from medical personnel (another main finding was a lack of shared decision-making – not altogether unrelated to empathy levels itself). Other results from the National Patient Experience surveys continue to tell stories of bad news being delivered in a less than empathic manners, with conversations occurring sometimes in totally inappropriate settings – which may leave patients feeling overwhelmed and unable to face future challenges.

Clearly medics do not set out to cause such upset and intend to demonstrate empathy, but repeatedly, it would appear, fall short – either from lack of knowledge, experience, communication skills-training, or a combination of the above.

Dr. Srivastava talks of her experience of enlisting AI help to see if her communication skills could be improved. She honestly confesses to wondering when she last spoke some of the empathic statements proffered by AI in her own busy work-life.

The statements in themselves have undoubted merit. AI gets it right in the words and phrases chosen. It’s quick, reliable, and consistent in its offerings. It can be accessed easily on a smart device before an upcoming patient encounter to deliver ‘bad news’. Recent evidence suggests it may even be superior to medics in online question forums as reported in Jama Intern Med 2023; 183(6): 589-596.

Therein lies the problem, as well as the solution. Knowing the ‘right’ words to say is a definite help. We only have to read patient comments in our own surveys to realise the effect that using the ‘wrong’ words can have. But words and phrases by themselves are not sufficient.

The crux of communication skills training is simply that – training. The training is not dissimilar in respects to an actor on a stage. Delivering lines in the proper order is one thing, but delivering them in the context of high emotional drama is what distinguishes good from great actors. Continuing the analogy, it’s interesting that all such performances often require multiple ‘takes’ – with directorial input of vital importance. Even naturally gifted actors frequently wax lyrical about the merits of certain directors, and how they have been improved by directorial feedback.

Ranjana comments on how she would love feedback herself on her own performance at such times of highly emotional situations, like breaking bad news. As medics we are very poor at providing such feedback for colleagues. The idea of consultants, for example, submitting themselves to critical analysis in patient encounters is perhaps the holy grail of communication skills-training – and just as elusive, most likely!

That is not to suggest we simply abandon the quest. The benefits of such interventions are numerous. Renewed interest in communication benefits, adoption of new skills, and a boost to resilience when such skills prove effective are just a few to begin with.

This brings us back to AI. Granted having stock phrases for empathy is useful, but like our actor friends – a script is only as good as its delivery. Additionally, the delivery can be greatly improved by directorial input (read supportive feedback for communication skills training). Technology may be a double-edged sword, but applied to communication skills training without feedback, it’s akin to fencing in the dark.

As medics we may not always cure or even control symptoms, but we can always comfort. It’s possible to be better – even without AI.

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