Metadiscourse in Simulation: Reflexivity of/as Communication Skills Learning

Abstract

Phenomenon: I examine simulation-based communication skills training as a practice of metadiscourse (or talk about talk) on three levels: (1) the conceptualization of communication as a skill; (2) the use of simulation-based approaches for teaching and assessing communication skills; and (3) the purposes of communication-skills training, specifically as it relates to outcomes of skilled communication. Within each, I explicate the following tensions: (1) communication as an individual skill vs. communication as a distributed dynamic; (2) communication as a process of information exchange vs. communication as mutual accountability; (3) communication for institutional outcomes vs. communication for multiple purposes. Approach: I use discourse-analytic approaches to reflexively analyze communication-skills training practices. My data are from a communication-skills practice exam for third-year medical students with simulated patients. The purpose of my analysis is to illustrate the metadiscursive tensions as they occur via (1) question-and-answer sequences; (2) repairs; and (3) orientations to institutional protocols. Findings: Through my analysis, I analyze the affordances and constraints of metadiscursive tensions. (1) Communication as an individual skill affords concrete and systematic frameworks for teaching and assessment, while communication as a distributed dynamic emphasizes the joint nature of talk and patient-centeredness. Additionally, simulation is a distinct genre of communication, specifically in how simulated patients communicate differently than actual patients, which can limit their utility for individual assessment. (2) Communication skills and communication-skills teaching embody the paradigm of cause and effect, which is in tension with communication as a process of mutual accountability. Conceptualizing communication skills and communication-skills learning as interventions in the possession of knowledge/skills affords claims of effectiveness but at the risk of essentializing students and patients as data points. (3) The institutional purposes of communication-skills training are often associated with positive outcomes for patients and providers but such findings often oversimplify the multifunctionality of talk, namely who we show ourselves to be through communication. Insights: To draw on the affordances of metadiscursive practices, I suggest incorporating video-based reflexive dialogues as addendums to simulation-based learning sessions. In video-based reflexive dialogues, medical students and simulated patients watch their simulated consultations together and discuss mutual goals, what communication strategies worked toward those goals, and what else talk accomplished. Retooling communication-skills teaching and learning to promote reflexivity as a “meta-skill” provides learners and practitioners the resources to reflect on and act in unison with patients toward mutual goals of health and well-being.