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I read the discussion paper on communication skills by Professor Skelton with interest.1 Having been involved in the teaching of communication skills to medical students and GP registrars for some years I feel that the paper raised interesting issues about the subject and its future. Traditionally the model of medical expertise used to design teaching (and assessments) considered the three domains of knowledge, skills and attitudes. A fourth domain of problem-solving skills was later added. In this model, communication and consultation teachers use a skills-based approach to facilitate learning. We tend to speak of consultation skills, often forgetting the important aspects of knowing what to do (knowledge) and the manner in which to do it (attitude) as well as how to do it (skill). The domains are not independent and more recently educationalists are thinking in terms of roles or competences. For successful completion of a task or role, different aspects of medical competence have to be integrated.2 Thus, as Skelton concludes, we also need to think outside the narrow limits of ‘skills' and consider our trainees’ professional attitudes as well.
To some extent this is happening within medical schools which include modules called ‘Personal and Professional Development’ or similar. These courses integrate learning about communication/ consultation with other aspects of professional competence, such as interprofessional teamwork, reflective practice and management. However, the integration is not always successful as timetables listing ‘communications skills’ and ‘working in teams’ suggest.
Laurence Olivier, on the set of the film ‘Marathon Man’ is reported to have advised his co-star, and exponent of method acting, Dustin Hoffman ‘to just act’ rather than try to immerse himself totally in character. Acting may thus be seen to be reduced to technical skills. Is communication solely a set of skills or should we expect more? Or to put the question another way: are underlying attitudes important if observed behaviour with patients and peers is acceptable? We know that attitudes may be inferred from behaviour but correlation between observed behaviour and attitudes is not always high.3 If we learn the techniques of ‘patient-centred’ consulting and demonstrating empathy without really liking patients or agreeing with patient partnership is this a problem? If our assessments rate such behaviour highly and assessment drives learning, perhaps we do not need to soul-search too much. Or do we?