I'm carrying out a study which addresses a current, real-world topic in medical education from the analytic perspective of sociolinguistics.
Postgraduate medical assessments now involve an important and well-established focus on effective interaction with patients, and this is often formally assessed as part of various clinical examinations. Through simulated consultations with role-played patients, doctors can be observed in action, enabling examiners to assess not only clinical knowledge, but crucially how that knowledge is deployed and communicated with a patient in a spoken context. However, the pass rates in many of these exams, particularly higher failure rates for those who have done their initial medical training overseas, have led to concerns that linguistic and cultural factors may play a role in doctors' poorer performance in consultations.
Building on a Knowledge Transfer Partnerships study, conducted at King's College London from 2011-2013 under Professor Celia Roberts (PI) and Professor Kamila Hawthorne, this ESRC 'Future Research Leaders' grant enables me to further research these simulated consultations, with a view to better understanding what is happening at an interactional level. A close linguistic analysis is made of video data from simulated patient surgeries, including an analysis of non-verbal features of communication, in addressing where communicative differences or difficulties might be occurring. This has implications for further understanding contemporary clinical examinations and the training and preparation postgraduate doctors can undertake.
I am currently looking at the use of simulation in two key settings:
- General Practice
- Emergency Medicine
Performance features in clinical skills assessment: Linguistic and
cultural factors in the Membership of the Royal College of General Practitioners examinatio
This research looks at performance in clinical skills assessment from a linguistic and cultural perspective, with a view to understanding why there are such differential pass rates and giving suggestions on how this issue can be tackled. The book, available for download here, is both a research report and a guide to the sociolinguistic methodology used. While the findings are based on a research project in partnership with the Royal College of General Practitioners, they are applicable to many other medical settings where standardised examinations of simulated consultations are used. More widely, this research addresses a central paradox in institutional life – how to balance validity in assessments and be fair to a diverse group of candidates in an increasingly diverse society, while maintaining reliability with standardised and universal marking criteria.
It has been widely acknowledged that candidates from overseas fair less well in such examinations. A close look at the interactions which make up these simulated consultations shows that there are complex and subtle differences between passing and failing candidates which cannot be explained simply as ‘language’ and ‘cultural’ differences and put in a box separate from issues of fairness. These structured examinations, unintentionally, contribute to the weight of the assessment on overseas candidates, particularly in how interpersonal effectiveness is judged both explicitly and implicitly.
The research has identified a range of successful candidate strategies which form the basis of a set of e-learning materials, created at the University of Notitngham to be published by the RCGP. It also suggests that aspects of the exam, notably the more subjective features of interpersonal skills, are not best assessed in highly structured exams. This area needs to be better defined, using a new analytic language, to debate how and where it could be most effectively and fairly assessed.
Project report (free to download in PDF format) by King’s College London with the University of Nottingham, also available as a hard copy from the University's online store (£15 each, including postage)
Simulated scenarios are frequently used for training and assessment in emergency medicine, usually involving team interactions, around either a patient-mannequin or a role-player. The aim of studying simulations in this setting is to identify features of successful communication, building on the methodology and findings of the General Practice project, outlined above. Two related, real-world problems can directly be addressed by using analytic methods form linguistics:
1. How are power relations manifested between members of the clinical team?
This is an issue for medical teams with very real consequences. For example the Elaine Bromiley case (Bromiley, 2008) centred around the failure of care due to communication difficulties between ad hoc team members. Two nurses, who knew a tracheotomy needed to be performed, were unwilling to speak up because of the perceived seniority of a surgeon in the team. Such events illustrate that technical skills alone are not sufficient in ensuring patient safety. Building on work by Bezemer et al (2011) on operating theatre teams, a key new research question that can be answered by linguistics is: How are power relationships achieved interactionally in emergency scenarios within ad hoc teams?
2. What experience can be usefully gained from simulating clinical scenarios?
Much of the literature on medical role-play makes the case for their being as authentic as possible. However, evidence from linguistics suggests simulated interactions necessarily demonstrate differences to ‘real-life’, particularly in the audience-design of utterances for an overhearing 3rd party (Seale et al, 2007; Roberts, Atkins and Hawthorne, forthcoming 2014). What evidence is there of audience design in the QMC simulations? Since the team simulations are unlikely to be ‘authentic’, what is it participants gain from the interactions that is helpful?
Data-collection for this part of the study has recently commenced at Nottingham. A range of simulations are being filmed, particularly those focusing on trauma scenarios and team communication skills.
Conferences and lectures
24th November, 2014
Sarah Atkins delivers a talk on the practicalities of making liniguistics truly ‘applied’:
Title: Applying linguistics in healthcare
Université de Lausanne, Switzeralnd
Authors: Sarah Atkins and Celia Roberts
11th November, 2014
Sarah Atkins delivers a workshop:
Title: ‘Model behaviour’: Rethinking communication skills in the ‘real' simulation
Annual Conference for the Association for Simulated Practice in Healthcare
Authors: Dr Sarah Atkins, Dr Frank Coffey, Dr Stephen Timmons, Dr Bryn Baxendale, Professor Svenja Adolphs (University of Nottingham) and Dr Keiko Tsuchiya (Tokai University, Tokyo
12th November, 2014
Sarah Atkins delivers a short communication on:
Title: Assessing our Assessments: A sociolinguistic investigation into communicative issues in simulated consultationsAnnual Conference for the Association for Simulated Practice in Healthcare
Author: Sarah Atkins
11th November, 2013
Sarah Atkins delivers a lecture:
Title: ‘Performing’ professional talk in the UK general practice licensing exam
ECLS Applied Linguistics Research Seminar Series, University of Newcastle
Authors: Celia Roberts and Sarah Atkins
25th September 2014
Workshop delivered to GP Trainers
Sarah Atkins and Celia Roberts
‘Insiders’ Guide to the Clincial Skills Assessment’
Subregional GP Trainers Day, Coventry
10th September 2014
Workshop delivered to GP Associates in Training
Sarah Atkins and Kamila Hawthorne
‘The Insiders’ Guide to the MRCGP Clinical Skills Assessment’, GP Trainees Day, Cardiff VTS registrars, Cardiff University