Rotations make youdizzyHolmboe ES, Ginsburg S, Bernabeo E. The

rotational approach to medical educa-

tion: time to confront our assumptions?

Med Educ 2011;45:69–80.

If 2010 is to be remembered inmedical education circles for anyspecific aspect, it will be as thecentenary of Abraham Flexner’sseminal report on North Americanmedical education.1 Never in thisfield have so many editorials,conference keynotes and reportsto government been launched onthe back of the same historicaldocument. It is fortunate thatFlexner’s report is insightful,direct and nicely written.

Flexner rightly took a stick tothe multitude of private medicalschools that were offering poorlystructured, low-quality coursesacross the continent. Theconsequence, however, has been atendency to have students marchthrough serried ranks ofstructured rotations, blinkered tolearning opportunities occurringslightly to the side. This require-ment to spend time in a widevariety of rotations is enshrinedin course accreditation standardsand – although allowing students

to observe a number of careeroptions – it does risk reducingcourses to a series of sentences tobe served.

In this article, Holmboe et al.have challenged us to confrontour assumptions about this lock-step model of learning. At theother end of the spectrum from‘time-served’ medical education isan outcomes-based approach thatallows the student to move ononce they have achieved thenecessary competencies. Rota-tions become less a requirementof the course and more anopportunity to build on specificknowledge and skills that arelacking. It is the transitionsbetween and within rotations thatare the specific focus of thispaper, which summarises the keyassumptions about frequentclinical rotations as:

• allowing greater diversity andbreadth of exposure, withmore learning opportunitiesand the chance to focus on asubspecialty;

• preparing learners to adapt andcope with the multitude ofvarying practice styles, expec-

tations and stresses they willencounter during their careers;

• promoting greater indepen-dence by forcing learners toadapt and learn on their own.

The major problems identifiedby these assumptions also fall intothree areas: sociological, learningtheory, and quality and patientsafety. Sociological problems arisewhen learners are rapidly shuntedaround before they can socialiseto the learning environment anddecode the hidden curriculum.Patients (and staff) don’t reallymatter as people to the learner,who is just passing through.

Medical education is presentedas being out of step with broadereducational theories because ofits reluctance to consider thesocio-cultural aspects of learning,especially within clinical teams. Itis easier to rely on ‘dwell time’ as aproxy for competence rather thanusing that time to actively coach,assess, role-model and mentor alearner towards expertise.

And, finally, Holmboe et al.draw attention to the risks topatients of having clinical

Sociologicalproblems arisewhen learnersare rapidlyshunted aroundbefore they cansocialise to thelearningenvironment

Digest

� Blackwell Publishing Ltd 2011. THE CLINICAL TEACHER 2011; 8: 67–70 67

learners being only transientlypart of the ‘microsystem’ that isthe clinical workplace, and thusisolated from the qualityimprovement systems that rely ongood communication and cyclesof review. Their article proposes

that Flexner would be displeasedby the ‘rotational dance’ in whichtrainees are engaged, and headvocates strongly for reforms tothe system to allow competency-based training, educational con-tinuity and improved quality.

REFERENCE

1. Flexner A. Medical Education in the

United States and Canada: a Report to

the Carnegie Foundation for the

Advancement of Teaching. New York:

Carnegie Foundation for the Advance-

ment of Teaching; 1910.

Meaning what you saySalmon P, Young B. Creativity in clinical

communication: from communication

skills to skilled communication. Med Educ

2011;45:In press.

Communication skills trainingis well-embedded within medicalcurricula. It seems to be a self-evident truth: students need to betrained in the distinct skills ofinterpersonal communication inorder to assemble them intocomprehensive clinical communi-cation competencies for use inthe workplace.

Dr Peter Salmon and Dr BridgetYoung (psychologists from theUniversity of Liverpool, in the UK)both have extensive experience inclinical communication training.Their paper in this month’s issue ofMedical Education presents thesomewhat provocative propositionthat clinical communication can-not be taught and assessed asdiscrete skills, but rather as aholistic and creative process. Thismust come as a relief to clinicianswho have felt uncomfortableabout the complexities of clinicalcommunication being reduced to aseries of check-box micro skills,taught in the same step-by-stepfashion as the skills of informationgathering through history andexamination. Is it really possibleto treat something as organic asclinical communication as if itwere a ritualistic dance?

In the evaluation of commu-nication skills (for studentassessment or research purposes),this ‘atomisation’ of complexbehaviours into actions that canbe observed and coded misses

much of the creativity of success-ful communication. The authorsgive examples of experiencedpractitioners intuitively ‘depart-ing from the rules’ in order to get abetter outcome for patients. Theskilled clinician makes a lightningjudgement about the needs oftheir particular patient at thatparticular moment, and presentsinformation in the most appropri-ate way. Their example of a sur-geon telling a cancer patient thather prognosis lay ‘in the hands ofGod’ is particularly compelling.The creative nature of clinicalcommunication is presented asmeaning that there are no rigidrules for effective communicationwith every patient in everycontext.

Salmon and Young takeparticular exception to the use ofthe word ‘skills’ to describecommunication tasks. Whereas aneye surgeon has a set of skills toimplant a lens in a certain way or

a pilot has the skill to land aplane in a thunderstorm, thecommunicating clinician is deal-ing with a situation in which thepatient’s response is far less pre-dictable than that of an isolatedorgan or a plummeting plane. Thepatient’s experience of theclinician’s communication isentirely subjective, influenced bytheir personal and social con-texts. The authors also decry thefocus on linking communicationskills with specific outcomes,given that employing the sameskill can achieve extremelyvariable results in differentpatients. So, too, a skill that isused without sincerity rings hol-low in the patient’s ears. Mypersonal belief is that studentsshould be disciplined for parrot-ing the phrase ‘I can see thatmust be difficult for you...’ with-out meaning it.

The paper comes to theconclusion that a reductionist

Clinicalcommunication

cannot betaught andassessed as

discrete skills,but rather as a

holistic andcreative process

68 � Blackwell Publishing Ltd 2011. THE CLINICAL TEACHER 2011; 8: 67–70