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The drama of the consultation

One of my former registrars demonstrated a superb level of clinical knowledge, but some patients after seeing him would then ask for an appointment with me in order to check whether the treatment prescribed or management plan advocated was indeed correct. Invariably I discovered that his advice was excellent, but some of the patients clearly had problems believing the strategies that he offered. Watching him consult and replaying videos of his patient interactions revealed his weakness lay in a lack of confidence with which he delivered otherwise excellent clinical information, and an inability to detect subtle cues of dissatisfaction from the patient. My registrar needed coaching on how to project confidence, which in turn allowed the clinical information to be received as authoritative by the patient, and on how to detect the cues of whether an interchange had been successful before the patient left the room. I’m glad to say that he rapidly adapted his communication style, but I couldn’t help wondering what might have happened if he had been exposed to techniques taught at drama school. When doctor and patient meet, the stage is already set. At the time appointed by front of house staff, both protagonists adopt their expected roles against a backdrop of props, lighting and scenery set up by a team behind the scenes. The subsequent interaction unfolds with the awareness of a predetermined structure that is accepted as script. Interpreting the familiar process of the consultation with insights taken from the dramatic is neither new nor demeaning. Indeed, the use of actors and role-play in the training of medical students and postgraduate doctors has become commonplace.1–4 Is there not, however, a risk of teaching students how to recognise a particular scenario and then simply reproduce information and a response which may or may not match the expectations of the patient and the demands of the situation? This could leave professionals with the belief that they have fully addressed the problem when in fact the patient may view the outcome as inadequate and inflexible. Larson and Yao5 compare what they consider to be the fake emotional display generated by participants in role-play with the internal changes that result from ‘empathetic imagination’. The former is characterised by the use of appropriate expressions and tones of voice, contrasted with what they claim is the unique response of doctors in clinical situations when they feel genuine internal emotions. These experiences are referred to as ‘superficial’ and ‘deep’ respectively. Traditional consultation training may rely on the adoption of learned roles copied from actors, an internal pre-prepared script and a standardised patient reaction anticipated from training sessions. This technique may appear to follow the patient’s agenda but can actually remain very doctor centred. Case and Brauner6 suggest using instead an imagination-based approach – encouraging the doctor to ‘think with the other’ because they ‘think as the other’. This capacity to experience parallel emotions that reflect those of the patient, described by Persaud7 as similar to an actor getting into a researched role, is claimed to be more effective for the patient and much less stressful for the doctor. If this is the case, we may learn not only from the example of actors but also from similarities between the art of medical communication and the craft of acting. Through studying dramatic technique we may enhance the discovery of the ‘deep’ level of empathy in which we aim to ‘think as the other’. Standard methods of acting pioneered by Stanislawski8 and taught at drama school involve the actor tapping into their personal memories and using it as a source of genuine emotions. Stanislawski wrote about the subconscious adjustments that occur automatically in any successful communication dependent on the registering and correct interpretation of cues from those around us.8 This idea will immediately resonate with any experienced practitioner or educator familiar with detecting subliminal changes in paraverbals and body language. Such a desirable trait is not always natural or easily acquired even by good trainees, as witnessed with my former registrar. We should think of the consultation itself to be a form of drama. In doing so, we do not denigrate the clinical domain by including the concept of ‘play acting’. It is true that practitioners may risk being misunderstood as only feigning interest in their patients, with the professional interchange perceived as lacking integrity, and a subsequent loss of trust necessary for a successful consultation. But we already risk this interpretation through teaching skills that are inordinately dependent on role-play, encouraging trainees