Abstract
Role play. Does that word bring you out in a cold sweat? I am afraid that it is unavoidable during your time as an Associate-in-Training (AiT) and beyond, it is even incorporated into ‘trainer's training’! What is it about role play that strikes initial terror in many but, if done well, can give you a deeper appreciation of your communication skills?
Rehearsals
Some people are naturally good communicators. Even if you are blessed with such skills, watching an empathic, efficient 10 minute consultation from an experienced GP can leave you feeling very inferior. All the components of the consultation require developing complex skills that, all trainers will say, need rehearsal.
At the start of my training, I often found trying to elicit a patient's agenda awkward. As Roger Neighbour says in The Inner Consultation, ‘Like a small child who has just learned how to tie a shoelace, we are “all thumbs”’. You want to ask ‘why are you really here … what makes you tick?’ It took time to get the right phrase and the way I do it is probably different to the way you do it—it is all individual.
What do patients do in the waiting room to help themselves communicate their needs? They often rehearse their ‘opening gambit’ and plan what they are going to say. It makes sense, therefore, for us to try out ways of phrasing questions too. One trainer described rehearsing consultation skills to me as filling a toolkit. Having a range of prepared skills allows you to adapt to different challenges.
Role play done well can give you a safe stage where you can try out new skills. You can perfect what you do well and have those things you do less well brought to your attention constructively. Often you are then given space to work on these areas.
Role players or robots
Many vocational training schemes employ professional role players to deliver workshops during GP training. These role players, and those who work during the Clinical Skills Assessment (CSA), are often resting actors who have been trained to respond as patients do during simulated consultations.
For the CSA, role players are primed for their case for hours prior to the start of the exam (as we all traipse across Croydon). They will do that case for the entire sitting and be with the same examiner throughout. It is about as close to a real patient as we are going to get in an exam, but be prepared for your style changing to fit the situation. There is an unavoidable element of performance and exam technique. You do not have the visual and natural verbal cues you get from real patients so it will feel artificial. If you are aware of that, you can acknowledge it and then move past it. Pay attention to the age and background information that you get on the case sheet because the actor recruited may not share the same age, body mass index (BMI) or physical signs!
Working with role players can feel like you are in some kind of complex dance where the correct phrase or question will unlock another chunk of information. The role players in the CSA make it clear when you have ‘pushed the right button’ and will also give you lots of obvious cues if you are missing the point. It is a shame that ‘real’ patients do not make their agenda that obvious!
Vocational training means building up real-time hard evidence of our abilities during day-to-day practice. It is a shame we have an exit exam as some competent people simply have a ‘bad day’ and do not get through. However imperfect, it is superior to many other postgraduate exit exams. In contrast to the assessments our hospital colleagues have to do, the CSA is more realistic, better resourced and more carefully quality controlled. It is a challenging exam and rightly so as passing it awards you membership of the Royal College of General Practitioners (RCGP).
Role-playing doctors
There is much debate about how to prepare for the CSA. There are many books on the market, which are not written or supported by the RCGP, and are designed to be used within peer study groups. Study groups with your friends can highlight learning needs and help you rehearse phrases and skills in a familiar environment. A word of warning though; doctors make terrible patients during role play. Peers are either too harsh or give information easily, like presenting a history on a ward round. Rope in willing non-medic friends and family for a more realistic feel—most of my family loved it! This is particularly useful when giving explanations as you will soon find out if you use too much medical jargon.
The most useful way of perfecting your skills, in my opinion, is within practice. Make the most of seeing patients and reflecting on consultations by yourself, by videoing them and by asking your trainer to sit in during surgery. There are many CSA courses out there, some of which give an opportunity to work with role players and to rehearse the exam.
General tips from my recent experience of the CSA are in Box 1.
So good luck! Work on your consultation skills never ends; it is definitely an art form. Feel proud that you will soon be joining The Big Time among the ranks of the only generalists left.
CSA tips
Listen very carefully to the opening statement. It has been carefully rehearsed and scripted and contains useful information. Perhaps try and echo it as your first move. Always elicit ideas, concerns and expectations (‘ICE’). Sorry if that seems obvious but it is amazing what you forget when you are stressed. You will not get a blank face from a role player like you do sometimes with ‘real patients’. Put the case into a psychosocial context like you would for a consultation observational tool. Once you have asked a few open questions, done ‘ICE’ and put the case into a psychosocial context-STOP. Do not keep searching for a hidden agenda that is not there; time is precious. If you want to examine someone, explain what you are going to do and why—this is good practice in real life. Then go ahead. If you do not need to, the examiner will be quick to stop you. Be prepared to examine a model of a body part. Make sure you spend no less than 4 minutes on the last part of the consultation. Remember you have to fit in a patient-centred explanation, share management options and safety net. This is the last skill we learn as registrars and is worth really concentrating on during ST3. Practice giving explanations and only give yourself a few minutes—it is very hard! Remember the obvious. Get enough sleep, food and exercise in the weeks leading up the exam. Take all that you need, arrive in good time and try and relax into it. Take in a glass of water as you are going to be doing a lot of talking! Most importantly, plan something exciting for after you finish. Put it to one side while you wait for your results and get on with your life.