Continuity of care versus speed of access.

improving and that communication is best learnt through observation in clinical situations. If the role models that medical students and junior doctors are observing are poor communicators how do we expect these learners to improve? I agree that observation and reflection is an important part of the experiential learning process, as is practising skills. But we know that in clinical situation learners vary rarely receive feedback to help them reflect and improve. Therefore communication needs to be introduced before the students first talk to real patients (theoretical knowledge plus work with simulated patients) and followed up by observation with debriefing so that they can begin to distinguish the good from the poor. The other problem is that senior medical students and junior doctors rarely discuss management plans with patients; when the latter do they are rarely observed and they learn this important process through trial and error, as well as the memory of how their senior colleagues have performed. The apprenticeship model is all well and good if the tutor is all of the following: a fine communicator, an excellent clinician and a good teacher. Modern experiential communication skills training does not degrade what is profound in medical practice. It must be continued into clinical settings and refined with practice. Dr Fitzpatrick writes that doctor-patient communication relies on ‘establishing a degree of empathy and trust’, yet he has previously disparaged the concept of the ‘expert patient’ and the idea of the ‘meeting between experts’ that is an important part of the doctor-patient relationship. However, this may also have been written in his role as devil’s advocate.