Attachment styles and clinical communication performance in trainee doctors
Introduction
Effective health-care requires practitioners to understand biological, psychosocial and cultural factors of relevance for each patient [1]. Successful provider-patient communication is crucial for the identification of such factors, and has been associated with improved health outcomes [2], [3], [4], [5]. With a shift in medical practice towards advocating and emphasising patients’ views, concerns and emotions, patient-centred communication skills have become an important aspect of the medical education curriculum [6], [7]. It is expected that through a combination of teaching and clinical experience, medical students will improve and develop their communication skills throughout training [8]. Trainee doctors are commonly assessed through Objective Structured Clinical Examinations (OSCEs) which provides a systematic method for testing specific clinical and communication skills [7], [9]. OSCEs often involve an encounter with a ‘simulated patient’ (an actor trained to play the part of the patient) and scenarios target different skills including communication with patients. Simulated patients (SPs) are used widely in medical education for teaching and assessment purposes, and provide a standardized method for assessing students’ skills [10], [11]. Using SPs within OSCEs is viewed as a useful method of assessing medical students’ communication skills within a clinical consultation [9], [12]. Reliable and valid measures have been developed to assess clinical communication during these types of exams e.g. Liverpool Communication Skills Assessment Scale (LCSAS) [13], [14].
The role of attachment processes in provider-patient relationships has been suggested by a number of researchers [16], [17], [18], [19]. Attachment theory posits that an early child-caregiver relationship leads to internal working models which will continue to influence relationships in adult life [20], [21], [22], [23]. Within the general population, attachment security provides a foundation for care-oriented feelings and care-giving behaviours, whereas attachment insecurity can interfere with care towards others and provides a theoretical explanation for why some adults experience difficulty in forming interpersonal relationships and avoid intimacy [24], [25]. Attachment status can be conceptualised as two dimensions: Anxiety/dependency (horizontal axis) and Avoidance of intimacy (vertical axis) [26], [27], [28]. Attachment anxiety is characterised by fear of rejection, unwarranted need for approval and distress if support is not available from close partners. Attachment avoidance is indicated by fears of intimacy and dependence on others, self-reliance and non-disclosure.
Attachment theory is becoming increasingly recognised as relevant to provider-patient relationships and interaction styles, however, the focus has principally been on patients’ attachment style [30], [31]. It is argued that when threatened by illness, patients can view doctors as an attachment figure and their working models of attachment relationships influences how they communicate during medical consultations. Recently the influence of the doctor’s own attachment style has been considered within this interaction. It has been hypothesised that practitioners with positive working models of relationships will have the necessary internal resources to respond to patients’ emotional needs. Whereas those who have less positive models of relationships will find managing interactions with patients, particularly those that are emotionally charged, more challenging [32], [33].
Research findings concerning health providers suggest provider attachment style can affect responses to patients’ emotional/psychological distress, with securely-attached mental-health case managers better able to attend and respond to patient [34]. Attachment avoidance has been associated with difficulties making psychological inferences about patients’ behaviour in psychiatric setting, and higher attachment anxiety is significantly related to lower levels of therapeutic alliance [35]. Elsewhere it has been shown that GPs’ interpersonal models affects whether they are likely to propose somatic interventions for patients presenting with medically unexplained symptoms [36]. It has been asserted that securely-attached doctors can respond most flexibly to client needs and trainee doctors should learn about their own attachment styles, to better understand how their relationship experiences may influence their clinical capabilities [37]. Hence, doctors’ attachment style might have important bearing on communication within doctor-patient relationships.
The attachment paradigm may be particularly important to explore within health professionals who are still training: It has been found that dimensions of attachment (avoidance and anxiety) of trainee counsellors was associated with their level of emotional empathy and it is argued that training programmes should focus on the personal development of students [38]. During the phase of training, there is evidence that attachment styles can develop which makes this an ideal opportunity to intervene [39]. Hence it is important to understand further the relationship between attachment and trainee doctors’ interactions with patients.
A systematic review of the literature tentatively suggested evidence for a relationship between medical provider attachment status and communication [40] identified only one published study that had explored doctors during their training [41] which was replicated more recently (Cherry et al. [42]). Both focused on formative communication assessments in students very early in their training and found only tentative evidence for a relationship [42]. Both these studies focused solely on communication skills. To date, no study has investigated whether attachment style influences trainee doctors’ performance on clinical skills, nor on their performance in qualifying assessments. The main prediction was that securely-attached medical students would perform better than those with insecure attachment styles, and specifically medical students with lower attachment anxiety and/or lower attachment avoidance scores will have higher communication and clinical performance OSCE scores.
Section snippets
Participants
The study was conducted at a large UK medical school. At this institute, students are assessed in a final summative OSCE on their competency across clinical and communication domains at the end of their 4th year of undergraduate study. This marks the end of their undergraduate studies. All students registered for this qualifying examination were invited to take part in the study, which was approved by a University Research Ethics committee.
Procedure
The entire cohort (n = 291) was informed about the
Participant characteristics
Two hundred and ninety-one students were examined in the summative OSCE, of which 190 (65.3%) consented and completed the questionnaires, of which 123 were female (64.7%) and 67 male (35.3%). There were no gender differences between non-participants and participants (X2 = 1.59, df = 1, p = 0.21). The mean age of non-participants (24.27 years) was higher than participants (22.93 years); however despite the statistical difference the mean difference (1.3 years) between the two groups was small (t = 2.73,
Discussion
This is the first study to consider whether trainee doctors’ attachment styles are related to their clinical communication performance within a qualifying examination. The results support the research hypotheses. There were significant relationships between attachment styles and participants’ communication with simulated patients based on objective OSCE measures. In general, attachment avoidance had a greater influence on forms of communication identified in this investigation than attachment
Author contributions
SP and IF conceived of the study and oversaw data collection. IF acts as guarantor for the study. RM collated the data and led the analysis and initial drafting of the manuscript. All authors were involved in revisions to the paper and approved the final version.
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