Emotions, and their recognition in those we communicate with make it possible to behave flexibly in different situation as we regulate our social interactions[1
]. One interaction where emotions are frequently shown by participants is the doctor-patient consultation. In his article 'Emotions revealed: recognising facial expressions' Paul Ekman states that recognising facial expressions, including the less obvious facial micro-expressions of patients may be useful to a doctor in their interactions [2
]. Being able to perceive facial expressions accurately may aid in interpreting how much pain a patient is experiencing. In one study which interviewed Certified Nursing Assistants in an American care home one method the nursing assistants used to gauge the pain level in cognitively impaired residents was their facial expressions[3
]. A further use would be to pick up clues to the patients emotional state. Archinard studied the behavioural responses of a doctor when interviewing patients who had attempted suicide[4
]. Although the doctor appeared to pick up on facial expression cues from the patients to distinguish between those who would re-attempt suicide, as they behaved differently towards such patients; they were unable to use this information consciously to assign those patients as being at risk of re-attempting suicide. That is, although the doctor could discriminate and behave differently towards individuals who would repeatedly attempt suicide and those would not repeat, this information was not, or could not, be utilised when clinical decisions were made.
Emotional cues may be verbal or non-verbal[5
]. Levinson et al found that responding to emotions expressed verbally by patients may result in shorter consultations[6
], but the same study found that physicians responded positively to patients' verbal emotional cues in only 38% of surgery cases and 21% of primary care cases. Similar results were noted in oncologists in response to verbal cues from cancer patients, where only 28% of emotional cues were responded to appropriately[7
]. Another study noted that cues were most likely to be missed by doctors if they did not directly state the emotional impact on the patient[8
]. If a verbal message is ambiguous non-verbal behaviour, such as facial expression may elucidate what is meant[8
There is mounting literature to suggest that a patient-centred model of care, whereby physicians address patients' emotional concerns and
biomedical conditions should be adopted[10
] and that such a positive interaction between doctors and patient is important for patient outcomes[11
]. It is difficult to address emotional concerns if these are not recognised by doctors. Therefore the recognition of emotions in patients, using verbal or non-verbal cues is one of the important skills which can aid doctors in creating patient centred communications. Difficulties in communicating with patients have been shown in several studies to relate to complaints against doctors. For example, in a longitudinal study, Tamblyn et al. [12
] reported that nearly one in five physicians had a retained complaint filed with the medical authorities in the first 2 to 12 years of practice, and physicians who scored in the lowest quartile of their Clinical Skills Exam (CSE) were at significantly greater risk of complaints than those in higher quartiles. Communication was one component of the CSE that was an important predictor of future complaints to the medical authorities.
One question this pilot study therefore wanted to ask was whether one reason for poor communication was due to an inability to recognise facial expressions. This was done by investigating whether there was a difference in the ability of medical students identified as good or poor communicators to perceive facial micro-expressions. Micro-expressions are brief (lasting up to 0.2 seconds) partial expressions which are less obvious than a full (or cardinal) facial expression[2
]. The hypothesis tested was that individuals classified as good communicators would perceive facial micro-expressions more accurately than those classified as poor communicators. If this were indeed the case then this would provide us with one area that we could help such students in their clinical communication training.
Most medical schools currently incorporate an aspect of clinical communication training into their curriculum[12
]. Training has been shown to be effective at improving the communicatory abilities of medical students, and these benefits can persist[13
]. The training can employ a variety of methods including opportunities to practice particular skills with other students, or actors portraying the role of patients[15
]. A 1989 paper by Lavelle[16
] describes a course for medical students in 'The objective methods of clinical practice' a component of which was training in the recognition of full, cardinal, emotional facial expressions. Although no data is presented the author reports that 'Students' capacity to read single emotions remains much the same, but their ability to read multiple emotions improves dramatically'. In that study the students performance in the recognition of single full emotional facial expressions was maximal prior to training, whereas the recognition of multiple expressions was not and therefore training had an impact. A further question this pilot study wanted to investigate was whether skills such as recognition of facial micro-expressions could be taught explicitly to medical students.
Both research questions will be investigated by the use of the Micro-Expression Training Tool (METT) developed by Paul Ekman http://www.mettonline.com
. The METT has been used previously to investigate the ability to perceive micro-expressions in a group of student participants[17
] but there are currently no published studies investigating it's use in Health professionals.