Medical Teacher

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Utilizing theatrical tools in consultation training. A

way to facilitate students' reflection on action?

Anders Baerheim & Torild Jacobsen Alraek

To cite this article: Anders Baerheim & Torild Jacobsen Alraek (2005) Utilizing theatrical tools in
consultation training. A way to facilitate students' reflection on action?, Medical Teacher, 27:7,
652-654, DOI: 10.1080/01421590500046437

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Published online: 03 Jul 2009.

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Short communications

Medical Teacher, Vol. 27, No. 7, 2005, pp. 652–654

Utilizing theatrical tools in consultation training.

A way to facilitate students’ reflection on action?

ANDERS BAERHEIM & TORILD JACOBSEN ALRAEK

Section of General Practice, Department of Public Health and Primary Health Care,
University of Bergen, Norway

SUMMARY The aim was to give the individual student a group- path using just occasional glimpses of the terrain to feed info
based opportunity to reflect on possible consultation strategies as the to the feed-forward system.
consultation was evolving. An actress acted as patient in the Rough terrain used as a metaphor may indeed be valid for
consultation training for a group of 30 students. The consultation difficult consultations. By letting the students reflect on
was stopped at each critical incidence, and time-out given to allow actions to adopt between periods of being in action, we hoped
the students to reflect on possible continuation strategies, and then in this project to facilitate their training of consultative feed-
to carry out one of them. The project was evaluated adopting a forward systems. That is, not only training specific consulta-
pragmatic version of the reflective practitioner research strategy as tion skills, but also learning to anticipate likely short-term
developed by Taylor. The evaluation was based on tutor and outcomes of possible strategies adopted at any point of the
actress’s field notes, students’ written free text evaluation and consultation.
students’ evaluation through two focus groups. The qualitative In the present study, we aimed to describe the actor’s and
analysis resulted in the three categories: the fiction created, tutor’s reflections during the learning sessions, and the
temporality manipulated, and students’ learning through students’ evaluation of it.
reflection. Implications for students’ learning process are discussed.
We conclude that our way of creating fiction and manipulating
temporality in the consultation training was paralleled by most The learning sessions
students’ report on substantial learning feed-forward abilities from
The project was developed early in spring 2003. It was used
reflection on action.
as part of a consultation course for final year medical students
at the Medical School, the University of Bergen, Norway.
Students at this medical school are subjected to three courses
Introduction with a total of 63 hours consultation training through their
six year study. Specific aims have been set for each of the
Training medical students in consultation techniques has three courses.
become an essential part of the medical curriculum One of the main problems with curriculum-defined
world-wide. Actors are being used for training and assessing aims is that we never know how many of the students are
consultation skills of medical students or doctors (Hazelkorn really in a position to benefit from the aims defined. In a
& Robins, 1996; Glassman et al., 2000). Usually, students or recent controlled study applying an established educational
trainees run the consultation or sections thereof with the model, students exposed to the intervention scored 5%
actor as the patient, and then get feedback, or are evaluated higher (on a 0–100 scale) for communication skills compared
afterwards (Smith et al., 2002). to a non-exposed control group (Yedidia et al., 2003).
The problem is that feedback is always given A substantial proportion of the exposed students must
retrospectively. A consultation, however short, is a complex then after the course have scored fairly equally to unexposed
performance. For the student to gain full benefit from the students, having not in any measurable way benefited
feedback given to them, it is essential for them to be able to from the teaching.
recall the total situation being addressed. In most training We therefore decided that the present project should allow
situations and for most students this is not the case. each student to develop her consultation style from the skill
We have aimed to stimulate the students’ feed-forward level presently mastered. To achieve this, we aimed to create
abilities. The concept of feed-forward is used in gait studies training conditions as stimulating as possible for the students,
(Patla, 1998). In this context, feedback is the information our explicitly stating that we expected them to work from their
motor system receives when the foot hits the ground. In a individual starting points, modifying their personal consulta-
rough terrain this information is insufficient for planning the tion style.
next step. The concept of feed-forward implies that we
manage walking by letting our senses, mainly the eyes, feed
Correspondence: Anders Baerheim, Section for General Practice, Kalfarveien
the motor system information on the forward properties of 31, N-5018 Bergen, Norway. Tel: þ47 55 58 61 40; fax: þ47 55 58 61 30;
the ground. When trained, we manage to negotiate a rough email: [email protected]

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In large groups, we let the students take frequent time- Manipulating temporality. Most students appreciated the
outs at any point in the consultation process, in order to frequent time-outs. Time-outs gave them the opportunity
reflect on the process from this point onwards with her peers to rethink the situation and reflect on possible next steps,
and the tutor. He/she or another student might then go on alone or in discussion with others. Moreover, many
with the consultation from the break point, or an earlier one, students appreciated being counselled as they progressed,
choosing a strategy for further action, elaborated during the instead of merely getting feedback at the end of the training
reflection process. session.

At time-out you can have a breather, take a step back and

look at what you have been doing.
Evaluation A few stated that the time-outs made it all too abstract:
they lost the feeling of continuity and became disinterested.
The sessions were evaluated adopting a pragmatic version of
the reflective practitioner research strategy as described by Don’t chop up all the consultations. I’d rather watch one
Taylor (Taylor, 1996). We decided on three unrelated data as a whole.
sources for the project:

The tutor and actress’s reflections during the sessions put Learning through reflection. Students stated that they had
down in field notes. gained greater insight into their personal consultation style

The students’ written free-text evaluation of the course. and how it might be improved. They learned from seeing the

A semi-structured group interview of students after each consultation evolve step by step over time, from repeatedly
session. discussing ‘what next’, being challenged on possible
outcomes of their proposals, and by experiencing how their
The resulting texts from the two last sources were
personal consultation style worked.
transcribed when necessary, and analysed together, using the
phenomenological method described by Giorgi and modified To try and fail in safe surroundings.
by Malterud (Malterud, 2001). Citations are given as
illustrations of categories found. Actress (TJA) and teacher Some students also gained a better insight into how the
(AB) analysed data independently and condensed the patient was thinking and feeling during this session than in
categories presented from the combined results. other forms for teaching or clinical work.

I was inspired to be a better and more human doctor.

Results No right answers. Many students appreciated that there was

no absolutely right choice at any one moment. They learned
The tutor’s and actress’s reflections during the sessions from seeing different approaches carried out by fellow
During the teaching sessions, the students concentrated students with different personal styles, and from seeing how
fully on the consultation techniques used, becoming both the direction and development of the consultation depended
intellectually and emotionally involved. For example, when on choices made and actions carried out.
we declared at the beginning of the session on breaking bad The consultation may take many directions depending on
news that blood samples from the patient showed lymphatic what you do.
leukaemia, one student cried spontaneously: ‘‘Oh no, didn’t
she have enough to cope with!’’ Not all agreed.
At this point, the actress introduced the concept of fiction. There wasn’t much advice from you experts. When asked,
This concept stems from the grand old man of theatre, you just threw the ball back.
Constantin Stanislavsky (1863–1938). He relates fiction to
the magical as if (Stanislavsky, 1973). In the theatre, fiction
means the scenic context and performance created by the Discussion
actors, making the audience experience it as if it was real. The Our results indicate that our pedagogical strategies resulted
students’ reactions indicated that they reflected and reacted in intensive individual learning of consultation strategies,
within the context as if it was real. Some students stated that even in fairly large groups.
the context was more real than reality. According to theatre science, the actors create fiction in
co-work with the audience. By inviting the students to reflect
on possible ways forward in the consultation, we conse-
Students’ free-text evaluations and group interviews quently also invited them to participate actively in the creative
process of further development both of the consultation and
Believable fiction. The students reported that the sessions
the fiction. This is a learning-intensive situation often used in
felt very realistic. They experienced emotional situations with
drama (Taylor, 1996).
first-hand intensity, which they had never experienced
We took time-outs at critical incidences and started the
elsewhere in their medical study, even in actual clinical
verbal reflection among the students. Time-outs are periods
work with patients.
for reflection outside the time of the fiction, which

Something happened! temporarily has been stopped. As can be seen from our

More realistic than with a real patient! results, the majority of the students attributed much of the

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learning potential of the project to the time-outs and the Acknowledgement

ensuing peer-based reflection.
We want to thank our medical students at the University of
We also manipulated temporality by creating the oppor-
Bergen for their thorough evaluation, and Angela Rowe for
tunity for the students of rewinding the consultation. This
linguistic support.
was used when one student had tried out a strategy, and
another wanted to test an alternative. As may be seen from
the students’ evaluation, many stated they learned a lot from
observing how different actions and consultation styles Conflict of interests
resulted in widely different outcomes.
None.
The concept of reflection-in-action dates from Schön in
1983 (Schön, 1983). Reflection among students as a learning
tool is most often positioned between longer periods of
exposure to relevant stimuli, as in role-play or by a video of a Ethical approval
consultation (Smith et al., 2002; Ang, 2002). By putting the
We did not find it necessary as no personal integrity was
reflection process frequently and repeatedly within the
violated.
training session, we aimed at working as close as possible to
the individual learning process in each student, thereby
stimulating the individual reflection process, training their
feed-forward abilities. Notes on contributors
Results of qualitative analysis are always subjected to ANDERS BAERHEIM, is professor in General Practice at the Section of
the preconceptions of the researchers. We developed the General Practice, Department of Public Health and Primary Health Care,
learning strategies used in the early planning phase of the University of Bergen.
project. However, as the planning and implementation of TORILD JACOBSEN ALRAEK, is educated as an actress, and has worked on
the project went on, we gradually acquired a further stage for 20 years. During the last few years she has completed a Master of
understanding on how concepts from theatre science, as Arts in drama at the University College of Bergen. She is affiliated to the
fiction and manipulated temporality, could be used in the Section of General Practice, Department of Public Health and Primary
Health Care, University of Bergen, Norway.
planning and for giving us increased understanding of
what we were doing. At analysis, we were not at all
surprised that we ended up with the same categories in
the results. Consequently, the categories must be regarded References
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