PERSONAL VIEW

Year : 2010  |  Volume : 23  |  Issue : 2  |  Page : 515

In the News! An Opinion Feelings about Students' Emotions

J van Dalen
Associate Editor, Education for Health

Correspondence Address:
J van Dalen
Associate Editor, Education for Health

Source of Support: None, Conflict of Interest: None

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PMID: 20853247

An unfortunate incident occurred in one of my classes a few years ago.



I (some 55 years old at that time, grey haired and an experienced communication skills teacher) was teaching a group of ten first-year medical students, around eighteen years of age. At my school in the Netherlands, teachers for communication skills classes remain with their student groups for a whole year, and this was mid-year, around January. The students had recently met individually with their fourth simulated patient, and their consultations had been recorded. They had watched and commented on their own and each other’s performances, and they now sat together to clarify their feedback and try out alternative approaches to their initial communication styles which were based principally on their unschooled intuitions. The atmosphere in the group was benevolent and constructive, and the students were eager to learn. The case played by the simulated patients was that of an elderly gentleman who assumed he had broken his ankle, although he could still walk a few steps. Based on his own understanding of needed care, he insisted on getting an X-ray to know for sure if his ankle was or was not broken (“You cannot see through it, doctor”). According to the ‘Ottawa-rules’ for appropriate X-rays for ankle injuries, the students had learned in their tutorial groups that walking a few steps reduced the likelihood that an X-ray would find anything broken and therefore made the X-ray less necessary.



Suddenly and unexpectedly, a student in our group started to cry. She felt sad and guilty because she had given in to her simulated patient’s demand and had ‘given him’ an X-ray, although she knew that that was really not necessary. The group addressed the student’s feelings of sadness and guilt. The group admirably used their ‘reflection of emotion’ skills, and the issue was adequately dealt with.



However, the incident has remained with me since then. Medical educators are strong believers of constructivist and experiential learning, especially in the field of communication skills. Students have been communicating their entire lives, starting well before they entered medical school. Transferring this experience to a professional medical setting helps them integrate the factual, intellectual aspect of what to tell to a patient and the emotional aspect of how to tell it. The fact that in this instance this approach triggered a healthy and bright eighteen year old student to feel so sad and guilty that she cried made me realize that maybe we, the organisers of the course, overshot the point a bit. That is not what we intended. I may have been playing with hotter fire than I realized over the years.



This incident has helped me to better appreciate the intensity of experiential learning. I have since been more careful to not assume that all students can always deal with the stress that can arise from this type of teaching.





Two thoughtful pieces appeared in today’s Academic Medicine relevant to this point^1-2. Julie Scott Taylor, author of the first piece, is an associate professor of family medicine at Brown University, Providence Rhode Island, USA. She described a didactic intervention she ventured with a group of medical students whom she knew well and had a good relationship with. She conveyed to the students some bad news about their course, and then later revealed that the news was not real. The students’ initial reaction to the bad news was used as an ‘actualiser’ to help the students empathise with patients’ reaction to bad news about their health.



The session was handled well, and Dr Taylor describes prerequisites that should be in place when doing this; or, in the words of her director of curriculum affairs: ‘to get away with this’. Her prerequisites are: the students’ emotions can and should be used to illustrate the patient’s perspective; this format is most effective in a context of a pre-existing, positive relationship; it should take into account the learning styles of individual students; and the students’ emotions that are elicited should be relevant for the topic of training (in this case ‘breaking bad news to patients’).



On the next page in the same issue, Michael Elnicki of the Section of General Internal Medicine of the University of Pittsburg, Pennsylvania, USA pleads for educators to be cautious with teaching formats like the one described, intended to elicit emotions with students in attempt to increase empathy with patients. He asks educators to check: 1. whether the assumption that this format helps students learning fits with prior educational research; 2. whether the experience from this particular training session with this teacher is generalisable to other situations and teachers; 3. whether stress at the right level is good; and 4. what greater lessons they want to teach beyond the content of a lecture.



Dr Elnicki addresses these issues one by one. He indicates that the format described may reduce the required comfort of the learning environment, both physically and psychologically. The described training-format is probably highly dependent on the relationship between the teacher, the teaching material and the students. Further, research shows that mistreating medical students can have profoundly negative consequences. One of the greater lessons we want to teach is that we would never provide false information to our patients, and one of the ways to get that message across is to not give false information to our students.



Dr Elnicki’s final call is that “as instructors we are seldom aware of individual students’ levels and who is ‘on the edge’. These learners should be considered cherished assets. As educators we need to nurture learners and demonstrate that it is possible to pass through the crucible of medical training without compromising one’s humanity and integrity.”



Two pages only from Drs. Elnicki and Taylor, and such wise words. I recommend reading them and discussing them with our colleagues.

Jan van Dalen

Associate Editor, Education for Health

References



1. Taylor JS. Learning with emotion: a powerful and effective pedagogical technique. Academic Medicine. 2010; 85(7):1110. Available from: http://journals.lww.com/academicmedicine/Fulltext/2010/07000/Learning_With_Emotion__A_Powerful_and_Effective.8.aspx



2. Elnicki M. Learning with emotion: which emotions and learning what? Academic Medicine. 2010; 85(7):1111. Available from: http://journals.lww.com/academicmedicine/Fulltext/2010/07000/Learning_With_Emotion__Which_Emotions_and_Learning.9.aspx