Viewpoint: power and communication: why simulation training ought to be complemented by experiential and humanist learning

The simulation game: an analysis of interactions between students and simulated patients

CONTEXT

Institutional interactions are often asymmetrical in that the professional has more control over the conversation. It is difficult to say who the professional is in simulated consultations between simulated patients (SPs) and medical students because these feature a real (educational) institutional context and a simulated (medical) institutional context. This study describes this asymmetry and makes educational recommendations based on the description.

METHODS

One hundred assessed conversations between SPs and Year 3 students were transcribed and analysed using discourse analysis (DA). We aimed to find linguistic patterns in predefined parts of the conversations (questions, topic initiations, openings, closings) that might suggest conversational dominance.

RESULTS

The SP is conversationally more dominant, despite performing the role of the patient, in that he or she asks more direct questions, is more likely to initiate topics, is more likely not to follow topic changes by students, and closes the consultation. The student is likely to follow topics initiated by the SP and to seek permission to pre-close the consultation.

CONCLUSIONS

The apparently greater dominance of the SP indicates that the simulated consultation differs from the doctor-patient consultation in certain key aspects. It is in that sense unrealistic. We argue, however, that 'realism' ought not to be a goal of simulated consultation and that what matters is that such consultations are sufficiently realistic for their educational purpose. We discuss the educational implications that follow from this.

A simulation-based curriculum to address relational crises in medicine

INTRODUCTION

Preparing health care professionals for challenging communication tasks such as delivering bad news to patients and families is an area where a need for improved teaching has been identified.

OBJECTIVES

We developed a simulation-based curriculum to enhance the skills of health care professionals, with an emphasis on the communication of difficult or bad news, which we termed relational crises.

METHODS

Our approach was based on a review of existing simulation-based curricula, with the addition of unique features, including a learner-focused needs assessment to shape curriculum development, use of 360-degree evaluations, and provision of written feedback. Development and implementation of our curriculum occurred in 3 phases. Phase I involved a multidisciplinary needs assessment, creation of a clinical scenario based on needs assessment results, and training of standardized patients. In Phase II we implemented the curriculum with 36 pediatric and internal medicine-pediatrics residents, 20 nurses, and 1 chaplain. Phase III consisted of the provision of written feedback for learners, created from the 360-degree evaluations compiled from participants, observers, faculty, and standardized patients.

RESULTS

Participants felt the scenarios were realistic (average rating of 4.7 on a 5-point Likert scale) and improved their practice and preparedness for these situations (average rating, 4.75/5 and 4.18/5, respectively). Our curriculum produced a statistically significant change in participants' pre- and postcurriculum self-reported perceptions of skill (2.42/5 vs. 3.23/5, respectively, P < .001) and level of preparedness (2.91/5 vs. 3.72/5, respectively, P < .001).

DISCUSSION

A simulation-based curriculum using standardized patients, learner-identified needs, 360-degree evaluations, and written feedback demonstrated a statistically significant change in participants' self-perceived skills and preparedness for communicating difficult news in pediatrics.

The moral aesthetics of simulated suffering in standardized patient performances

Standardized patient (SP) performances are staged clinical encounters between health-professional students and people who specialize in role-playing the part of patients. Such performances have in recent years become increasingly central to the teaching and assessment of clinical skills in U.S. medical schools. SP performances are valued for being both "real" (in that they involve interaction with a real person, unlike written examinations) and "not real" (in that the SP does not actually suffer from the condition portrayed, unlike an actual patient). This article considers how people involved in creating SP performances reconcile a moral commitment to avoid suffering (to keep it "not real"), with an aesthetic commitment to realistically portray it (to keep it "real"). The term "moral aesthetic" is proposed, to indicate a sensibility that combines ideas about what is morally right with ideas about what is aesthetically compelling. Drawing on ethnographic research among SPs and SP program staff and medical faculty who work closely with them, this article argues that their work of creating "realism" in simulated clinical encounters encompasses multiple different (and sometimes conflicting) understandings and practices of realism, informed by three different moral aesthetics: (1) a moral aesthetic of induction, in which an accurate portrayal with a well-documented provenance serves to introduce experientially distant forms of suffering; (2) a moral aesthetic of inoculation, in which the authenticity and emotional impact of a performance are meant to inoculate students against the impact of future encounters with suffering; (3) a moral aesthetic of presence, generating forms of voice and care that are born out of the embodied presence of suffering individuals in a clinical space. All are premised on the assumption that risk and suffering can be banished from SP performances. This article suggests, however, that SP performances necessarily raise the same difficult, important, fundamentally ethical questions that are always involved in learning from and on human beings who are capable of suffering, and who need and deserve recognition and respect as well as care.

[Evaluation of the clinical course Psychosomatics and Psychotherapy employing standardized patients]

OBJECTIVE

Since the Winter Term 2008/2009 the Medical School of the University of Muenster, Germany, has used standardized patients in the clinical course Psychosomatic Medicine and Psychotherapy with fourth-year undergraduate students performing bio-psycho-social anamnesis on these standardized patients. We wanted to evaluate the influence of the course on the empathy of the students.

METHODS

A total of 107 students participated in the standardized patient program during the Winter Term 2009/2010, with 90 (84.1 %) completing the Jefferson Scale of Physician Empathy before and after the course. In addition, we conducted a standard evaluation of the medical faculty.

RESULTS

The pre-post comparison revealed a significant increase in empathy (d = 0.331, p = .001). The standard evaluation yielded a high satisfaction among the course participants, though several students did assess the course critically.

CONCLUSION

The implementation of a standardized patient program in psychosomatics and psychotherapy proved to be of value, since it increased empathy of the students and received a positive evaluation. To prevent the students from being humiliated, it is of particular importance to implement a gentle and tactful feedback.

Learning to cure, but learning to care?

Utilizing interviews with students and a key administrator, analyses of academic schedules, and observations of courses, labs, and small groups, this study examines if and how elements of the explicit preclinical curriculum may have deleterious effects on medical students' humanitarian attributes, namely empathy. Findings from this case-study of a medical school in the United States suggest that the lack of frequent formal testing in the psycho-social aspects of patient care during the preclinical years, as well as a general reduction in curriculum hours devoted to teaching the social aspects of medicine, may serve as mechanisms behind the diminution of medical students' levels of empathy and other positive attributes as found by previous research. Following the basic tenets of the Testing Effect and the assumption that assessment drives learning, it is argued that a feasible way to maintain and potentially cultivate these traits among medical students, without saturating an overwhelmed medical curriculum, would be to install periodic, formally graded exams into preclinical curriculums that evaluate empathy and the psycho-social aspects of care.

Creativity in clinical communication: from communication skills to skilled communication

Medical Education 2011: 45: 217-226 Objectives  The view that training in communication skills produces skilled communication is sometimes criticised by those who argue that communication is individual and intuitive. We therefore examine the validity of the concept of communication as a skill and identify alternative principles to underpin future development of this field. Methods  We critically examine research evidence about the nature of clinical communication, and draw from theory and evidence concerning education and evaluation, particularly in creative disciplines. Results  Skilled communication cannot be fully described using the concept of communication skills. Attempts to do so risk constraining and distorting pedagogical development in communication. Current education practice often masks the difficulties with the concept by introducing subjectivity into the definition and assessment of skills. As all clinical situations differ to some extent, clinical communication is inherently creative. Because it is rarely possible to attribute specific effects to specific elements of communication, communication needs to be taught and evaluated holistically. Conclusions  For communication teaching to be pedagogically and clinically valid in supporting the inherent creativity of clinical communication, it will need to draw from education theory and practice that have been developed in explicitly creative disciplines.

What can people approaching death teach us about how to care?

OBJECTIVE

This study sought to hear what patients approaching death had to say about doctor-patient interactions and care in order that doctors can learn how to demonstrate care more effectively so that each patient feels cared for as an individual.

METHODS

In semi-structured interviews, 13 people dying of cancer shared their experiences and perspectives on care within the patient-doctor relationship.

RESULTS

Participants' recollections of experiences with doctors showed that genuine demonstration of care begins with doctors seeking common ground with the patient as a fellow human being and individual. The psychological and physical suffering that results from allowing stereotypical assumptions and behaviours to shape doctor-patient interaction was clear.

CONCLUSION

The consequences of allowing the stereotypes and power of the primary context in which patients and doctors interact challenge the process of building a caring doctor-patient relationship. Caring doctors overcame this by exploring and carefully attending to the individual characteristics and needs of patients as people first and foremost.

PRACTICE IMPLICATIONS

To demonstrate genuine care doctors must learn to recognise and question the social expectations and inherent assumptions of medical contexts and roles of patient and doctor and allow unique characteristics of patient and context to guide their interactions.

Mind the gap: Learners' perspectives on what they learn in communication compared to how they and others behave in the real world

OBJECTIVE

To explore the lack of the learners' voice at previous international conferences on communication in healthcare.

METHODS

A group of medical students and recently qualified junior doctors were invited to give the learner's perspective on how communication skills are taught and how they are implemented in 'real life', at a 90min symposium at the EACH International Conference on Communication in Healthcare, 4th September 2008, Oslo.

RESULTS

We attempt to bridge the gap between learning communication skills formally in the medical classroom and actually implementing these in the real world between doctors and patients from a learners' perspective. In making this transition we highlight obvious weaknesses and potential pitfalls, whilst also drawing attention to the successful strategies used in our respective medical schools. Four key areas are discussed: (1) using simulated patients, (2) learning in the clinical setting, (3) barriers to utilizing communication skills, (4) future directions. We have drawn upon the learning experiences from both undergraduate and postgraduate environments in the UK, the USA and Norway.

CONCLUSION

Our experiences differed between universities from the same country, which widened across continents. The differences between how we behave in the classroom and how we are with real patients when unobserved have been highlighted; and we have attempted to explain why trainees sometimes modify their behavior in medical assessments with standardized patients for examinations as opposed to how we would perform on wards or in general practice. The teaching of communication skills will continue to develop over the forthcoming years.

PRACTICE IMPLICATIONS

Integrating communication skills into medical school curricula is essential. Identifying enthusiastic doctors who are effective communicators and have the initiative to help develop this is vital. It may be beneficial to train simulated patients to react to students in a variety of different ways to reflect the diversity of true patient responses. In addition, having a better understanding of the multidisciplinary roles and rapidly developing technology would facilitate not only communication between health professionals but would also help optimize patient care.

[Role playing as an essential element of simulation procedures in medicine]

Role playing is an important element of virtually all simulation-based procedures. An improved understanding for methodological aspects facilitates its goal-oriented use in education and training, research and examinations. In the present paper we describe how different forms of role play are used in different simulation-based procedures. We describe a plausibility study from skills labs demonstrating that the introduction of role-playing can increase perceived realism. Finally we derive practical suggestions for the conduction of role plays in medical simulation.

The reality of role-play: interruptions and amount of talk in simulated consultations

CONTEXT

The language and structure of doctor-patient consultations have been widely researched. Although simulated patients (SPs) are much used in communication skills teaching, the language of the simulated consultation has not received much attention.

OBJECTIVES

This study aimed to resolve the following questions. How are interruptions and numbers of words distributed in simulated consultations? Do they correlate with set variables (e.g. gender, scenario) or outcome variables (e.g. grade)?

METHODS

A total of 100 videotaped assessed consultations between SPs and Year 3 medical students were transcribed. Words by each participant were counted, and interruptions were coded and counted. Amount of talk and interruptions were chosen because they are potential markers of conversational dominance.

RESULTS

We found that SPs talk (55% versus 45% for students) and interrupt (74% versus 26% for students) significantly more than medical students. The scenario is significantly associated with the number of words and interruptions. Multivariable testing shows that female SPs are associated with more words. The number of words is significantly and positively associated with examination grade. The number of student interruptions is significantly and positively associated with grade.

CONCLUSIONS

Because the simulated consultation takes place in an institutional setting, the SP may have institutional power over the student. This may explain how findings from these role-play interactions differ from actual doctor-patient consultations. This suggests that simulated consultations are educational devices rather than exact representations of doctor-patient interactions. The authors hope this paper will contribute to a discussion about the nature of role-play in medical education.

Virtual reality skills training for health care professionals in alcohol screening and brief intervention

BACKGROUND

Educating physicians and other health care professionals about the identification and treatment of patients who drink more than recommended limits is an ongoing challenge.

METHODS

An educational randomized controlled trial was conducted to test the ability of a stand-alone training simulation to improve the clinical skills of health care professionals in alcohol screening and intervention. The "virtual reality simulation" combined video, voice recognition, and nonbranching logic to create an interactive environment that allowed trainees to encounter complex social cues and realistic interpersonal exchanges. The simulation included 707 questions and statements and 1207 simulated patient responses.

RESULTS

A sample of 102 health care professionals (10 physicians; 30 physician assistants or nurse practitioners; 36 medical students; 26 pharmacy, physican assistant, or nurse practitioner students) were randomly assigned to a no training group (n = 51) or a computer-based virtual reality intervention (n = 51). Professionals in both groups had similar pretest standardized patient alcohol screening skill scores: 53.2 (experimental) vs 54.4 (controls), 52.2 vs 53.7 alcohol brief intervention skills, and 42.9 vs 43.5 alcohol referral skills. After repeated practice with the simulation there were significant increases in the scores of the experimental group at 6 months after randomization compared with the control group for the screening (67.7 vs 58.1; P < .001) and brief intervention (58.3 vs 51.6; P < .04) scenarios.

CONCLUSIONS

The technology tested in this trial is the first virtual reality simulation to demonstrate an increase in the alcohol screening and brief intervention skills of health care professionals.

Difficult conversations: improving communication skills and relational abilities in health care

BACKGROUND

Communication skills and relational abilities are essential core competencies that are associated with improved health outcomes, better patient adherence, fewer malpractice claims, and enhanced satisfaction with care. Yet, corresponding educational opportunities are sorely underrepresented and undervalued.

OBJECTIVE

To evaluate the impact of an interdisciplinary experiential learning paradigm to improve communication skills and relational abilities of pediatric critical care practitioners.

DESIGN

Prepost design, including baseline, immediate follow-up, and 5-month self-report questionnaires.

SETTING

Tertiary care pediatric hospital, Children's Hospital Boston.

PARTICIPANTS

One hundred six interdisciplinary clinicians with a range of experience levels and clinical specialties.

MEASUREMENTS

Participants rated their sense of preparation, communication and relational skills, confidence, and anxiety. Open-ended questions asked participants about lessons learned, aspects of the training they found most helpful, and suggestions to improve the training.

MAIN RESULTS

When questions were posed in a yes/no format, participants were nearly unanimous (93% to 98%) that the training had improved their sense of preparation, communication skills, and confidence immediately after and 5 months posttraining. Ninety percent of participants reported improvements in establishing relationships immediately after the training and 84% reported improvements 5 months posttraining. Eighty-two percent reported reduced anxiety immediately after training and 74% experienced reduced anxiety 5 months posttraining. On Likert items, 70% estimated their preparation had improved; 40% to 70% reported improvements in communication skills, confidence and anxiety, and 15% in relationship skills. Four qualitative themes emerged: identifying one's existing competence; integrating new communication skills and relational abilities; appreciating interdisciplinary collaboration; and valuing the learning itself.

CONCLUSIONS

A 1-day experiential learning paradigm focused on communication skills and relational abilities was highly valued, clinically useful, and logistically feasible. Participants reported better preparation, improved communication and relational skills, greater confidence, and reduced anxiety. Participants deepened their understanding of family perspectives, recognized valuable existing competencies, and strengthened their commitment to interdisciplinary teamwork.

Dependence and caring in clinical communication: the relevance of attachment and other theories

OBJECTIVE

Clinical relationships are usually asymmetric, being defined by patients' dependence and practitioners' care. Our aims are to: (i) identify literature that can contribute to theory for researching and teaching clinical communication from this perspective; (ii) highlight where theoretical development is needed; and (iii) test the utility of the emerging theory by identifying whether it leads to implications for educational practice.

METHODS

Selective and critical review of research concerned with dependence and caring in clinical and non-clinical relationships.

RESULTS

Attachment theory helps to understand patients' need to seek safety in relationships with expert and authoritative practitioners but is of limited help in understanding practitioners' caring. Different theories that formulate practitioners' care as altruistic, rewarded by personal connection or as a contract indicate the potential importance of practitioners' emotions, values and sense of role in understanding their clinical communication.

CONCLUSION

Extending the theoretical grounding of clinical communication can accommodate patients' dependence and practitioners' caring without return to medical paternalism.

PRACTICE IMPLICATIONS

A broader theoretical base will help educators to address the inherent subjectivity of clinical relationships, and researchers to distinguish scientific questions about how patients and clinicians are from normative questions about how they should be.

Expanding clinical empathy: an activist perspective

BACKGROUND

Discussions of empathy in health care offer important ways of enabling communication and interpersonal connection that are therapeutic for the patient and satisfying for the physician. While the best of these discussions offer valuable insights into the patient-physician relationship, many of them lack an action component for alleviating the patient's suffering and emphasize the physician's experience of empathy rather than the patient's experience of illness.

METHODS

By examining educational methods, such as reflective writing exercises and the study of literary texts, and by analyzing theoretical approaches to empathy and suggestions for clinical practice, this article considers how to mindfully keep the focus on what the patient is going through.

CONCLUSION

Clinical empathy can be improved by strategies that address (1) the patient's authority in providing first-person accounts of illness and disability, (2) expanding the concept of empathy to include an action component geared toward relieving patients' suffering, and (3) the potential value of extending empathy to include the social context of illness.

Applications of simulation technology in psychiatric mental health nursing education

The purpose of this paper is to review the use of simulation in education across the health professionals, to describe the development and implementation of innovative simulation techniques for an undergraduate psychiatric mental-health nursing course, and to identify lessons learned and future directions for successful simulation experiences in psychiatric nursing.

Can simulations measure empathy? Considerations on how to assess behavioral empathy via simulations

Standardized patient simulations have been used as an assessment tool, providing teachers an opportunity to observe learner clinical and communication skills while eliminating the fear of harm to patients. Yet the vices and virtues of these simulations in measuring clinical and communication skills have been deliberated. Based on our standardized patient examination experience, we believe standardized patient simulations can be used to assess certain forms of learners' empathic behaviors. We advocate that, in properly designed and conducted simulations, the scores and feedback comments from standardized patients to learners regarding their empathic behaviors can identify learners with important deficiencies. We conclude our discussion by recommending that reflective practice, challenging cases, decision moments, and raters training to provide feedback can supplement and enrich the use of standardized patient simulations in evaluating empathy.

Rituals of verification: the role of simulation in developing and evaluating empathic communication

The use of simulation and standardized patients in medical education is firmly established. In this "point-counterpoint" format we debate not their important function but the extent to which they are used to establish "evidence" for trainees' empathic communication skills beyond their surface manifestations. We also question such issues as the power dynamics implicit in simulation when patients are not really worried or dependent but rather students who are under the evaluative surveillance gaze, often relying on formulaic and superficial behaviors associated with good communication. We offer educative experiences in narrative domains as opportunities to develop the habits of thinking and authentic feeling often absent in evaluative-based simulations.

The integrative care conference: an innovative model for teaching at the heart of communication in medicine

BACKGROUND

By focusing on the biomedical aspects of a disease, physicians often dismiss the emotional effect that patients have on them and the stories that provide meaning to the patients' experience with illness. This approach often leads to strained relationships, medical errors, and dehumanized health care.

DESCRIPTION

We describe the Integrative Care Conference, an interdisciplinary format for teaching enhanced communication between residents and their patients.

EVALUATION

Three findings emerged: (a) The gap between what the resident knows about the patient and what is relevant to the patient's health care is wide. (b) Despite this gap, patients express great appreciation for their physician. (c) After learning about their patients' life and relationships, residents developed more humanistic approaches to their patient that reshaped treatment.

CONCLUSIONS

The Integrative Care Conference provides a powerful format for teaching patient-physician communication.

Walking a mile in their patients' shoes: empathy and othering in medical students' education

One of the major tasks of medical educators is to help maintain and increase trainee empathy for patients. Yet research suggests that during the course of medical training, empathy in medical students and residents decreases. Various exercises and more comprehensive paradigms have been introduced to promote empathy and other humanistic values, but with inadequate success. This paper argues that the potential for medical education to promote empathy is not easy for two reasons: a) Medical students and residents have complex and mostly unresolved emotional responses to the universal human vulnerability to illness, disability, decay, and ultimately death that they must confront in the process of rendering patient care b) Modernist assumptions about the capacity to protect, control, and restore run deep in institutional cultures of mainstream biomedicine and can create barriers to empathic relationships. In the absence of appropriate discourses about how to emotionally manage distressing aspects of the human condition, it is likely that trainees will resort to coping mechanisms that result in distance and detachment. This paper suggests the need for an epistemological paradigm that helps trainees develop a tolerance for imperfection in self and others; and acceptance of shared emotional vulnerability and suffering while simultaneously honoring the existence of difference. Reducing the sense of anxiety and threat that are now reinforced by the dominant medical discourse in the presence of illness will enable trainees to learn to emotionally contain the suffering of their patients and themselves, thus providing a psychologically sound foundation for the development of true empathy.

Psychiatric education and simulation: a review of the literature

OBJECTIVES

Simulation methodologies are integral to health professional education at all levels of training and across all disciplines. This article reviews the literature on simulation in psychiatric education and explores recent innovations and emerging ethical considerations related to teaching and evaluation.

METHOD

The authors searched the MEDLINE, ERIC, and PsycINFO databases from 1986 to 2006 using multiple search terms. A detailed manual search was conducted of Academic Psychiatry, Academic Medicine, and Medical Education. Literature indirectly relevant to the search parameter was also included.

RESULTS

Of the more than 5000 articles retrieved from the literature on simulation and health professional education, 72 articles and books used the terms simulation and standardized patients or role play and psychiatry education. Of the more than 900 articles on objective structured clinical examinations (OSCE), 24 articles related specifically to psychiatry OSCEs.

CONCLUSIONS

Live simulation is used in teaching, assessment, and research at all levels of training in psychiatric education. Simulated and standardized patients are useful and appropriate for teaching and assessment and are well accepted at both undergraduate and post-graduate level. There is also an important place for role play. Further research is needed regarding the implications of different simulation technologies in psychiatry.

Difficult conversations in health care: cultivating relational learning to address the hidden curriculum

The authors describe the philosophy and pedagogical approach of an innovative educational program, grounded in principles of relational learning and designed to improve the preparedness of health care professionals for engaging in challenging conversations with patients and families. The Program to Enhance Relational and Communication Skills (PERCS) is a project of The Institute for Professionalism and Ethical Practice at Children's Hospital Boston, developed in collaboration with Education Development Center, Inc. The one-day workshop is interdisciplinary in its structure, includes practitioners with varying levels of professional experience, uses trained actors to portray patients and family members, and involves learners in improvised case scenarios. The program responds to several developments in contemporary health care: medical education reform, changing definitions of professional competence, and calls for greater attention to qualities of compassion, trust, and respect in practitioners' relationships with patients and families. The program's pedagogy responds to these developments by creating a safe climate for relational learning, by enacting emotionally challenging and ethically salient case scenarios, and by integrating patient and family perspectives in novel and substantive ways. By creating a curriculum and learning environment that explicitly embraces the moral experience of learners, the program's developers aim to exert a countercultural influence on the dehumanizing effects of the hidden curriculum.

Interpersonal skill in medicine: the essential partner of verbal communication

Medical educators have promoted skillful communication as a means for doctors to develop positive relationships with their patients. In practice, communication tends to be defined primarily as what doctors say, with less attention to how, when, and to whom they say it. These latter elements of communication, which often carry the emotional content of the discourse, are usually referred to as interpersonal skills. Although recognized as important by some educators, interpersonal skills have received much less attention than task-oriented, verbal aspects. Moreover, the field lacks a common language and conceptualization for discussing them. This paper offers a framework for describing interpersonal skills and understanding their relationship to verbal communication and describes an interpersonal skill-set comprised of Understanding, Empathy, and Relational Versatility.

Patients' experiences and perceptions of medical student candidates sitting a finals examination

BACKGROUND

The Final Professional Examination for medical students at Leicester Medical School involves the use of real patients, and senior clinicians assess students over a series of consultations with these patients. What the patients themselves think of the students is not known.

AIMS

This qualitative study identifies the perceptions and opinions which patients who have been used in this examination have of the student candidates, and whether these may be used to enhance the training of medical students.

METHOD

Patients who had participated in a number of examination diets were interviewed in either a group interview or individually. The interviews were loosely structured in order to discover the experiences that these patients had and how they interpreted them. Data was analysed inductively using the constant comparative method.

RESULTS

The large majority of views of patients fell into the following categories: observations on student conduct during the examination (both in terms of affective and professional behaviours), demographic characteristics of students and views on student performance.

CONCLUSIONS

Based on the results of this study, educational recommendations are made which might improve student performance in the examination and lead to greater patient satisfaction with the 'end product' of the medical school, namely the graduating student. These include the incorporation of students' observation of infection control measures within the assessment schedule, and more direct preparation of students in handling uncertainty and their anxieties within the consultation.

Medical education and the maintenance of incompetence

We think of medical education as a process that moves novices from a state of incompetence to one of competence. This paper explores the idea that education may, at times, actually lead to incompetence as a result of over-emphasizing particular discourses that construct what competence is. This paper explores four discourses each with its own terminology and core conceptualizations of competence; each of which creates different roles for students and teachers. No one discourse is ideal and all drive teaching and assessment in particular ways. Sometimes these forms of teaching or assessment may inadvertently foster incompetence. In this paper I argue that, as with medical treatments, medical educators must pay more attention to the side-effects of the discourses that shape medical education.