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From their starting point – the view that many doctors lack ‘democratic’ and empathic attitudes and behaviour – Bleakley and Marshall1 launch a challenging critique of how medical curricula prepare students for clinical relationships.

Their warning that a technical approach to communication cannot, alone, do justice to the reality of clinical relationships is important. Bleakley and Marshall1 focus on empathy, which has been subject to much investigation with a technical focus on linking empathy to specific behaviours.2 For example, in a recent study, cancer patients who watched videos of doctors breaking bad news saw the doctor who sat down to deliver this information as more compassionate than one who stood.3 Even if standing and sitting have meaning that is independent of the context in which they occur (i.e. so that sitting or standing in an examination cubicle can mean the same, respectively, as they do in a spacious office), the value of such a finding is questionable. In order to support its practical application to education, the study would need to show that doctors who have been told or taught to sit are thought to be more empathic than doctors who choose to stand, which seems unlikely. Technical sophistication – the paper’s title3 tells us that this was a randomised controlled trial, the acme of research design – should not be allowed to hide the fact that human qualities such as compassion and empathy are not easily illuminated by the standard technological research paradigm.2 Similarly, these qualities are inherently challenging to teach. Patients seek ‘authentic’ compassion and caring, but pre-specifying training objectives to include behaviours that indicate compassion is hard to reconcile with authenticity.4

Clinical relationships are complex in a further way that compounds the challenge for educators. Bleakley and Marshall1 describe the goal of ensuring practitioners are ‘democratic’ in enabling patients to participate. Of course, democracy in this context cannot mean ‘one person: one vote’ and thus what counts as participation is not straightforward. Calls for ‘patient-centred’ practice or for the establishing of ‘partnerships’ with patients are unhelpful when they neglect the fundamental asymmetries of doctor–patient relationships.5 Doctors have clinical knowledge that patients and other members of the team do not. Similarly, patients need to feel that their doctors know them, care for them and value them, whereas doctors need to maintain the emotional distance that preserves clinical objectivity. Asymmetry also arises from attachment processes elicited in patients who, feeling vulnerable in the face of illness, see doctors as ‘attachment figures’.6,7 That is, asymmetry is not just an aspect of the institutionalised power and role of medicine, but arises from the deeply rooted psychological processes that illness triggers. So being ‘democratic’ in the context of the asymmetry of clinical relationships means somehow transcending the tensions between participation and authority, or caring and objectivity. The corresponding challenge for educators is to formulate clinical relationships in a way that encompasses these asymmetries and helps doctors to manage these tensions.

Asymmetry of authority has often been described as ‘paternalism’. Curiously, this term is usually applied with a pejorative overtone. It certainly evokes sexism, but it also points to the continuity between clinical and parental relationships. It is axiomatic in psychoanalytic theory and developmental psychology that childhood experiences shape how we approach caring relationships later in life. Adults who recall abuse in childhood find it harder to form relationships with their practitioners when they seek care for cancer, and the effects of abuse on attachment styles help to explain this.8 So we have to consider clinical relationships, at least in certain situations, as having some resemblance to parental care. From this perspective, Salander et al.9 have shown how clinical relationships in contexts in which patients face mortal illness can be understood using Winnicott’s10 ideas of play. Just as a child thinks of her doll as a real person in one moment and casts it aside as inanimate the next, patients ‘play’ with different, and apparently contradictory, ways of seeing the world. Thus a patient who presents as hopeless and resigned to early death on one occasion can, on another, disregard his illness and describe plans for a long future. From this perspective, the doctor’s task is not to correct the patient’s apparent ‘denial’, but to provide what Winnicott10 described as ‘holding’ while the patient plays with different versions of reality.

Bleakley and Marshall1 take the metaphor of play an important step further by proposing it as a way of facilitating understanding of the relationship of the educator to the student. This is their radical pedagogic alternative to the current technological emphasis on behavioural skills training. Instead of pre-specifying behavioural learning outcomes, a pedagogy based on play would emphasise the learner’s own discovery. Correspondingly, it would complicate and enrich the way in which we see the educator’s role. Instead of being a trainer, directing learning to predefined ends, the educator becomes a guardian of the ‘potential space’, to use Winnicott’s term,11 within which students can learn about clinical relationships. The teacher ‘holds’ the learner by being attentive, reliable and tolerant. This approach puts learners’ creativity in the face of ambiguous demands at the centre of education.11

As Bleakley and Marshall1 argue, immersing learners in medical humanities, as ‘playful’ rather than ‘prescriptive’ disciplines, might foster creativity in the face of the inherent ambiguity of clinical relationships. However, for a pedagogy to be valuable, it must have more than a single expression in the curriculum. We need to explore the possible implications elsewhere in communication teaching of seeing the student’s role as exploring and the teacher’s as ‘holding’. Might the prescriptive ways in which some current approaches are specified be seen to stifle the potential for students to relish communication as an exciting and challenging subject? How can teachers model their role with students on Winnicott’s10 depiction of the psychotherapist as playful rather than authoritarian?

Play will, inevitably, prove to be limited as a metaphor for education in relationships. For one thing, it says little about teachers’ obligations to ensure that students are equipped to be competent and safe doctors. Herein, perhaps, lies the most important point of Bleakley and Marshall’s article.1 It shows the value of educationists and researchers themselves being ‘playful’ rather than prescriptive in the theories and disciplines that they apply to the perplexing and exciting field that is clinical communication and clinical relationships.

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