Benefit to womb from a view

November 8, 2002

'And this is a picture of your ovaries.' Geoff Watts examines the radical methods being used to teach trainee doctors good bedside manners.

When doctors have finished examining the nooks and crannies of a woman's reproductive organs, they don't usually treat her to a videotaped replay featuring edited highlights of this most intimate exploration. Nor do students practising their suturing skills expect to find themselves working on fake skin attached to a living human - who squeals if they wield the needle and thread without due care.

Both are examples of how British medical schools are trying to improve communication in medicine and both have been entered for the prestigious BUPA medical communication award.

Every medical curriculum now has its communication skills module and the teaching of craft skills has also changed with developments in materials technology fostering the creation of plastic and silicone models that look and feel like real flesh.

What occurred to staff working at Imperial College School of Medicine is that doctors are increasingly having to combine communication and craft skills as more procedures are conducted on patients who are conscious and want to know what is happening. Many students, however, find it hard to combine the two. "When they're doing one they stop doing the other," says Roger Kneebone, a communications lecturer at the school.

The solution for Kneebone and colleague Debra Nestel was to combine the inanimate and the living into one unit. Kneebone began with a model used for teaching the insertion of a catheter into the penis. Despite being life-size and anatomically correct, it comprises just a 30cm-long section of the hip region of the trunk, which is difficult to relate to as a patient. To overcome this, Kneebone, with the help of colleagues, cobbled together a combination of human and model (the joins being hidden by blankets) and was amazed by how convincing it was.

"I went up to this chap just to try it out. I introduced myself saying 'Hello, Mr So-and-so, I've come to put a tube into your bladder,' and pressed the model's abdomen. He said 'Ow!' I immediately responded, 'Oh, I'm so sorry, I didn't mean to hurt you'. Even though I'd just set this whole thing up, my instinctive reaction was to treat him as I would a real patient."

To practise closing an upper arm wound, fake patients have a standard slab of simulated skin wrapped around their own arm. Their upper body, from the shoulder downwards, is then covered with a surgical drape. A small window allows the student to see just the portion of "skin" with the wound to be repaired. "Students often forget altogether that it isn't a patient," says Jane Kidd, another lecturer in communication at Imperial.

Teaching staff watch from the next room via a TV link. The actor-patients are drilled in how to respond to what's being done, as well as engaging the student in conversation. "If the student forgets to put in local anaesthetic, as they sometimes do," says Kidd, "the patients know to start flinching or yelling."

More ambitiously, the Imperial group has moved on to endoscopy simulators. Students insert and manipulate endoscopes, long flexible viewing tubes, into a computerised simulator. What the user sees on the screen is a convincing simulation of the part of the body being probed. A fake patient lies on a table beside the equipment, and blankets are strategically applied. To add a final touch of reality, the fake patients are connected to the machine with earpieces and can respond to any clumsy movements with a moan.

Communication is also the core element of an innovative approach to chronic pelvic pain being explored in the obstetrics and gynaecology department at the University of Sheffield. Pain of this kind is common, distressing, difficult to manage and subjective.

Our beliefs about the causes and nature of our pain can alter its severity. So, too, can the mental images that we conjure up, says William Ledger, professor of obstetrics at Sheffield. One woman, who was later diagnosed with endometriosis, told him the pain was "like a porcupine with spines that come out at certain times of the month". But the actual patch of diseased tissue was smaller than the head of a drawing pin.

Ledger reasoned that false mental images could be damaging. He wondered if showing women a video recording of their internal organs might help by allowing them to see that they were healthy - or, if they weren't, how the problem had been treated. The project was set up with the psychology department to ensure it was sensitively handled.

A pilot study was run with 16 women who had agreed to laparoscopy, a key-hole surgical technique for examining the abdominal organs. A few weeks before the operation each woman was interviewed about her perception of her pelvic pain. At the follow-up consultation a month after the laparoscopy the women were re-interviewed, then shown the video. The final interview took place a month later. The edited highlights exclude everything but the internal organs themselves, recorded before and after treatment.

The changes reported by the women were positive and impressive. Their imagery of their bodies was more realistic, their feelings of distress were reduced and their pain diminished dramatically.

Although Ledger thinks the improvements were a consequence of the video images, he can't yet be sure. Anyone taking part in a research project gets more attention - and this by itself can be therapeutic. Hence his intention of carrying out a random trial in which half of an identically treated group of women will see their video, and half won't. Seeing, he hopes, really will aid believing.

The winner of the 2002 BUPA Foundation communication award will be announced on November 14.

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