Examinations
A discourse analysis study of ‘good’ and ‘poor’
communication in an OSCE: a proposed new framework
for teaching students
Celia Roberts,1 Val Wass,2 Roger Jones,2 Srikant Sarangi3 & Annie Gillett1
Background There is still a great deal to be learnt about
teaching and assessing undergraduate communication
skills, particularly as formal teaching in this area
expands. One approach is to use the summative
assessments of these skills in formative ways. Discourse
analysis of data collected from final year examinations
sheds light on the grounds for assessing students as
‘good’ or ‘poor’ communicators. This approach can
feed into the teaching ⁄ learning of communication skills
in the undergraduate curriculum.
Setting A final year UK medical school objective
structured clinical examination (OSCE).
Methods Four scenarios, designed to assess communi-
cation skills in challenging contexts, were included in
the OSCE. Video recordings of all interactions at these
stations were screened. A sample covering a range of
good, average and poor performances were transcribed
and analysed. Discourse analysis methods were used to
identify ‘key components of communicative style’.
Introduction
Despite the vast literature on communication between
patients and health care professionals, effective consul-
tations are still difficult to achieve. Poor communica-
tion is often associated with poor clinical performance.1
The quality of communication in doctor–patient inter-
actions may be damaged by several factors. These may
be related to the constraints imposed by the clinical
environment such as lack of privacy and time. They may
also impact on its content – history taking, risk
1
Department of Education and Professional Studies, King’s College
London, UK
2
Guy’s, King’s and St Thomas’ School of Medicine, London, UK
3
Health Communication Research Centre, Cardiff University, Wales,
UK
Correspondence: Celia Roberts, Department of Education and
Professional Studies, King’s College London, Franklin Wilkins
Annexe, Waterloo Bridge Road, London SE1 9NN, UK. Tel.: 00
44 207 848 3122; E-mail: celiaroberts@lineone.net
192  Blackwell Publishing Ltd ME D I C AL ED U C AT I ON 2003;37:192–201
Findings Analysis revealed important differences in
communicative styles between candidates who scored
highly and those who did poorly. These related to:
empathetic versus ‘retractive’ styles of communicating;
the importance of thematically staging a consultation,
and the impact of values and assumptions on the
outcome of a consultation.
Conclusion Detailed discourse analysis sheds light on
patterns of communicative style and provides an
analytic language for students to raise awareness of
their own communication. This challenges standard
approaches to teaching communication and shows the
value of using summative assessments in formative
ways.
Keywords Education, medical undergraduate ⁄ *stand-
ards; *communication; educational measurement;
curriculum; clinical competence; England.
Medical Education 2003;37:192–201
communication, explanation, etc. – because of, for
example, linguistic and semantic difficulties, a know-
ledge gap or a mismatch between the values and
assumptions of the patient and doctor.2,3 These factors
are routinely treated as discrete components of skill and
knowledge which do not take into account the context
of the interaction.
The need to enhance doctors’ communication skills
is widely recognised. In the UK, the General Medical
Council (GMC) has emphasised the importance of
teaching and assessing communication skills in the
undergraduate medical curriculum4 and the ‘concor-
dance’ model of doctor–patient communication in
medicines prescribing has been promoted by the Royal
Pharmaceutical Society.5 Communication skills teach-
ing is at the core of much generalist training in the
USA6 and of medical curricula in Canada.7
Progress has been made in teaching communication
skills ) by moving from role-modelling to explicit
training8 ) and in their assessment ) by moving from
‘Good’ and ‘poor’ communication in an OSCE: a proposed new framework
Key learning points
Video recordings of OSCEs can be used as
formative tools for improving communication
skills.
Discourse analysis of these recordings sheds light
on the details of candidates’ ‘communicative
styles’ and helps to explain their relatively high or
low grades.
This communicative style depends on how candi-
dates design their questions and responses, how
they stage the themes of the consultation and on
the values and ideologies they bring to it.
Detailed maps of OSCE consultations give
students a new analytic language for monitoring
their own and others’ communication skills.
the long case to methods such as the objective struc-
tured clinical examination (OSCE).9,10 However, there
is much more we need to understand about appropriate
teaching techniques and assessment methods.11 For
example, students’ performance in OSCE communica-
tion stations is assessed on a checklist of criteria, such
as ‘establishes rapport’ and ‘uses closed and open
questions appropriately’.12,13 Yet the details of what
makes students good or bad communicators are not
necessarily obvious. A more fine-grained understanding
of the attributes of good and poor medical communi-
cation is needed to improve communications teaching
and the validity of its assessment. Why not, therefore,
look at OSCE performance itself to try and unravel
these questions? Spencer reminds us of ‘the tremen-
dous gold mine of data that systematic, progressive
OSCE-type examinations offer to the researcher’.14
In order to use assessment as a formative (as well as a
summative) tool and to mine the gold that lies hidden
in OSCEs, a research approach is needed that will slow
down the whole process and fix our gaze on each
1. Cancer: an older white woman is advised to have a bronchcoscopy because of possible tumour recurrence, although she denies the
possibility that the cancer may have returned
2. Sexually transmitted disease : a young Muslim women has had unprotected sex and is concerned that she might have caught
something. She also feels very upset about what has happened.
3. Alcohol: a Chinese businessman has come for the results of liver function tests. The results indicate he may be drinking too much.
4. Drugs: a young Afro-Caribbean man is seeking a methadone prescription because he says he has lost the one recently given to him at
the drug rehabilitation centre.
Figure 1 The four OSCE communication stations.
 Blackwell Publishing Ltd M ED I C A L E D UC A T I O N 2003;37:192–201
• C Roberts et al. 193
interactional episode and how it came to be produced,
so that the talk of consultations can be analysed in
detail. For this reason we have taken a discourse
analytic approach,14,15 in which video recordings of
consultations are transcribed and the language and
interactional features of the consultations are analysed
in depth. Aspects of communicative style are identified
across the recorded data to provide both evidence and
understanding of how broad categories such as ‘estab-
lishes rapport’ are achieved, or not.
Method
Final year OSCEs
Our research was set in the final examinations on the
Guy’s and St Thomas’ campus of the now merged
Guy’s, Kings and St Thomas’ medical school (GKT)
in June 1999. These examinations involved a
24-station OSCE. This included several communi-
cation stations, each of 7 minutes duration, using
standardised simulated patients. The OSCE ran over
2 days.
We designed four OSCE scenarios to present partic-
ular challenges to final year students and to reflect a
multicultural student and patient population. The
scenarios are detailed in Fig. 1. Two stations were
included each day. Each station was marked by one
examiner, who was experienced in assessing communi-
cation skills, used a checklist of criteria and gave a
global rating, and by the role player, who also awarded
a global rating. The project was approved by the
relevant local research ethics committees, and informed
consent was obtained from all students.
Data collection and screening
Sequential audio-visual recordings were made of all
students taking these stations on the successive days. A
total of 179 students took the OSCE and all agreed to
be video-recorded. In all, 358 recordings were made,
194 ‘Good’ and ‘poor’ communication in an OSCE: a proposed new framework
but 49 were rejected for technical reasons. This
generated a database of 309 7-minute video interac-
tions (86Æ3% of the total). A total of 28 consultations
were fully transcribed (just under 10%). These inclu-
ded consultations by the 12 candidates who were
judged to have failed at least one of the specially
designed OSCE scenarios, together with equal numbers
of top-rated and middle-ranking encounters.
The 309 video-recorded consultations were all
viewed and notes made of each interaction to identify
emergent patterns in the data, such as particularly
awkward or responsive moments, formulaic responses
and styles of presentation based on the assumptions
brought along to the encounter. These viewing notes
formed the basis for identifying the components of
communicative style and were used to select the 28
consultations for transcription. The screening of a
relatively large database produced patterns that were
confirmed in the detail of the transcribed data as well as
disconfirming evidence, which led to the reinterpreta-
tion of some aspects of the detailed transcriptions. In
this way, larger data sets and micro-analysis of inter-
actional moments support each other.
Discourse analysis
Discourse analysis looks at the ways in which speakers
design the content of each turn at talk, at how
interactions are sequenced and managed and also at
speakers’ choices in terms of vocabulary, grammar,
intonation and rhetoric. These detailed features con-
tribute to our understanding of how social relations are
managed in talk: how the patient and doctor establish
relations of relative equality, how together, for example,
they may use various face-saving strategies and take
account of the other’s relative knowledge and emotional
state. The emphasis here is on talk rather than non-
verbal communication, as the physical setting of the
OSCE and some of the inevitable institutional con-
straints make it difficult to assess aspects such as body
movement and gaze.
The approach used here, interactional sociolinguis-
tics, draws on ethnography and conversation analysis
to look at how individuals differ in the ways in which
they interact with and understand one another.14)16
Understanding presupposes a level of conversational
involvement in which both sides share ways of
interpreting what the other has said. However, there
is also an emotional dimension to involvement, which
connects it to rapport and affiliation, and this aspect
presupposes a level of understanding. Thus, involve-
ment and understanding go hand in hand.17 Individ-
ual differences between speakers, which affect how
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• C Roberts et al.
relatively involved or detached they appear, are based
on styles of communicating. These have developed as
a result of longterm exposure to networks of relation-
ships in the home, school and community, so that a
particular communicative style is the product of
social ⁄ cultural experiences: ‘‘‘style’’ is not something
extra, added on like frosting on a cake. … style refers
to all the ways speakers encode meaning in language
and convey how they intend their talk to be under-
stood.’18 Communicative style therefore relates to talk
and interaction at all levels, from the most fleeting
intonation pattern to the wider assumptions about
how, for example, to relate to patients. These wider
assumptions are part of the ideological values and
principles about professional identity and how to
conduct oneself in interaction that are brought along
to any encounter and which appear as evidence in the
data.
Interactional sociolinguistics, in common with most
forms of discourse analysis, uses naturally occurring
examples of talk. The OSCE interactions are, on one
level, examples of authentic talk in that they represent
actual occurrences within a vital examination. At
another level, they are strictly timed role-plays,
institutionally based synthetic encounters, and this
puts constraints on both candidates and actor-
patients. Both are working from scripts ) the actor
is given a set of symptoms and an identity, while the
candidate has a set of medical scripts to work from )
but each interaction is subtly (or, in some cases,
radically) different, depending on how each partici-
pant interprets and responds to the other. The
interactions are further complicated by the fact that
the ‘patients’ are also assessors and often voice
feelings and attitudes that are either kept hidden or
managed in more indirect ways in real consultations.
These vocal actor-patients tend to trigger more
formulaic responses from weaker candidates, who
have been trained in rapport words but cannot achieve
rapport work. This is an example of how the
institutional constraints of the OSCE can magnify
differences between weak and poor candidates. How-
ever, it also serves to contrast these scenarios with
real patient)doctor communication, and, as such, it
could be used to argue against research on synthetic
consultations. However, while OSCEs are used to
assess students’ communication skills and while they
continue to be treated as an adequate way of doing
so, there is a case for analysing the interactional
details which account for relative success or failure in
them. Moreover, gaining understanding of what
makes for a successful OSCE result is worthwhile
from the students’ point of view.
‘Good’ and ‘poor’ communication in an OSCE: a proposed new framework • C Roberts et al. 195

poor communicators. A summary of the classification

Findings
Detailed analysis of the communicative content of these
four key scenarios showed them to be extraordinarily
complex, and there is clear evidence that the commu-
nication skills of a small but significant minority of
students were inadequate. A larger group, who per-
formed at a pass level, still found many aspects of the
consultation difficult to perform well.
The OSCE students tended to display an overall
communicative style in which their management of
social relations was relatively sensitive or not. This
communicative style accounted for the very different
interactional climates created by strong and weak
candidates and this in turn depended on the kinds of
features identified by Tannen.17,18 Students were either
relatively empathetic, authoritative and persuasive,
organically building a joint problem-solving framework
with the patient, or they were relatively ‘retractive’ (our
term), using questions and responses that served to
distance them from the patient.
Analysis of the transcriptions led to observations on
differences in communicative style between good and
1.Empathetic questions and responses:
* Attentive responding
* Joint problem solving
* Contextualising and face saving
2. Retractive questions and responses:
* Inappropriate responding
* Schema driven progression and patient labelling
* Storage failure
* Insensitivity to patients’ levels of understanding
3. Thematic staging
4. Values and assumptions
Figure 2 Components of communicative style.
of the components of communicative style is shown in
Fig. 2. Although it is possible to rate a particularly good
or weak candidate as having an overall empathetic or
retractive style, this rating is based on the cumulative
effect of many often small and subtle features, which, in
the specific context where they occur, lead to relatively
more involvement or detachment (see the analysis
below).
Empathetic and retractive styles
Two examples from the sexually transmitted diseases
scenario illustrate the empathetic and retractive ele-
ments that contributed to candidates’ communicative
styles. Rather than demonstrating an average candi-
date, we have used two highly contrasting examples of
good and bad performance in order to show
the differences between empathetic and retractive
communication clearly. Middle-ranking students
tended to show both types of features rather than
the stark contrasts illustrated here. The particular
ways in which these two candidates designed their
questions and responses accounted for much of the
overall effect of, on the one hand, solidarity and
persuasiveness in the strong candidate, and, on the
other, distancing and lack of mutuality in the weaker
candidate. In these examples we provide extracts of
the transcribed recordings; the transcription conven-
tions used are shown in Fig. 3.
Empathetic styles are categorised in three ways. The
first of these is ‘attentive responding’.
Example 1: Attentive responding (lines 52)63)
The patient has explained that she has slept with a man.
She is worried she may have caught something and she
‘feels so dirty’. After asking her what kind of sex she has
had, the candidate continues:
can: so (.) what’s been happening since then have you
had any problems in yourself have you had any prob-
lems going to the toilet or anything like that

can: candidate
act: actor-patient
(.) short pause
(( nods etc. )) non-verbal communication
…….. section of the transcription omitted
= word =
= word = overlapping speech i.e. two speakers speaking at the same time
Figure 3 Transcription conventions; e.g. can: did the partner you had sex = with did he have =
simplified version based on Gumperz J & act: = yeah =
Berenz N22. ‘erm’ sound used to fill a pause at the beginning or in the course of an utterance

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196 ‘Good’ and ‘poor’ communication in an OSCE: a proposed new framework
act: no
can: ok have you erm (.) had any discharge from
down below
act: ((shakes head, whispers:)) (no)
can: so it’s just really that you’re worried that
something’s happened
act: ((nods))
can: ok (.) I’m going to ask you about a bit more
about what (.) went on ok erm (.) what actually
happened that that day when it all happened
Here the candidate attends to the patient’s increas-
ingly minimal responses, the last of which is
co-ordinated with head movement and with a lowering
of volume, and to her earlier expression of self-disgust
in order to arrest the medical agenda and pay attention
to the patient’s feelings. The candidate does this by
reformulating the patient’s indirect messages of anxiety
into an explicit question: ‘So it’s just really that you’re
worried that something’s happened?’ The candidate
then shifts to eliciting the patient’s narrative rather than
following her own medical agenda.
The second empathetic strategy is ‘joint-problem
solving’. This includes strategies for involving the
patient in explanations and reassurances and in aligning
the candidate with the patient.
Example 2: Joint problem solving ( lines 22)28)
Near the beginning of the consultation, the candidate
reassures the patient:
can: right ok well let me tell you first of all that (.)
whatever we talk about in here is completely confi-
dential ok (.) you don’t have to worry about anything
like that
act: all right
can: erm I’m going to ask you some questions about
what went on if that’s all right and erm (.) you know
we can see if we can work something out together
Here the candidate explicitly sets the tone of the
consultation as one where, together, they can solve the
problem, using the pronoun ‘we’ to suggest inclusive-
ness. Both her second and third pauses give the patient
an opportunity to respond, but when the latter does not
take up her turn, the candidate upgrades her reassur-
ance: ‘You don’t have to worry’ and her inclusiveness,
from checking agreement to: ‘We can work something
out’.
The third type of empathetic strategy concerns
‘contextualising and face-saving’.
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• C Roberts et al.
Example 3: Contextualising and face-saving ( lines 61)65)
In the previous example, the candidate sets the context
for the next phase of the consultation when she says:
‘I’m going to ask you some questions’. She contextu-
alises her questions again a little later on, as we can see
by looking again at the first example:
can: ok (.) I’m going to ask you about a bit more
about what (.) went on ok erm (.) what actually
happened that day when it all happened
act: er it was like a party
can: right
She sets the context (‘I’m going to ask you …’) and
then is careful to refer back to the incident in a general
way which will not cause embarrassment or loss of face
to the patient. As before, when the patient does not take
a turn at the second pause, the candidate makes her
contribution more explicit, asking: ‘What actually
happened?’ This contextualising helps the patient to
distance herself from the present emotional trauma.
The event is now seen as belonging to the past, thereby
making it easier to narrate. She can talk more openly to
the candidate, which, in turn, helps to bring them
interactionally closer together. Thus, in just two small
extracts, a number of empathetic moves are clustered
together.
Retractive styles are categorised in four ways. The
first of these is defined as ‘inappropriate responding’
and includes minimal responses, inappropriate mood
and formulaic or trained empathy.
Example 4: Inappropriate responding ( lines 23)24)
act: erm (.) I just (.) ((breath out)) (.) just (.) feel
really terrible about it
can: ok (.) erm (2Æ0) did you use protection at all
Here the candidate’s ‘OK’ does not acknowledge the
patient’s talk or the hesitation and outbreath which
reinforce her words. He simply gives a minimal
response and then moves on to a new topic after a
pause of 2 seconds. This ‘OK’ can be contrasted with
the ‘OKs’ in example 1, which both confirm the
patient’s response. In example 4, the patient makes an
evaluative comment about her emotional state. An
‘OK’ after such an expression of affect shows no
recognition of this state.
The second type of retractive strategy is defined as
‘schema-driven progression and patient labelling’,
where the candidate drives through the medical agenda
and often labels the candidate as ‘a worrier’, ‘not telling
the truth’, ‘an alcoholic’ and so on.
‘Good’ and ‘poor’ communication in an OSCE: a proposed new framework
Example 5: Schema-driven progression and patient labelling
(lines 56)65)
can: any rashes or
act: no don’t think so
can: discharge (.) have you yourself had any
discharges at all
act: no
can: any erm (.) irritation down there
act: no
can: any pain when you’re passing water
act: no
can: erm (.) any blood in your urine
act: no
Here the medical agenda is driven through and,
as this happens, the consultation becomes interrog-
atory, with the patient giving minimal and categor-
ical responses that do not allow for any negotiation
of meaning. This is in marked contrast to example 1.
The third and fourth types of retractive style concern
problems of understanding, sometimes when the can-
didate has failed to take in what the patient is saying
and at others concerning the use of medical jargon.
Examples 6 and 7 illustrate this, the first demonstrating
what we term ‘storage failure’ and the second providing
an example of insensitivity to the patient’s levels of
understanding.
Example 6: Storage failure (lines 18)22)
act: no it’s complete one it’s my first time yeah (.)
because I come from a traditional muslim culture
can: right
act: er we don’t have boyfriends in our culture
can: right
(56 seconds later)
can: right erm (.) have you ever ha- been pregnant at
all
act: no
Here the candidate fails to take in the fact that the
patient has never had sex before and carries on with his
checklist of questions, which includes a question about
pregnancy. His failure to remember the earlier infor-
mation may well be reinforced by the schema-driven
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• C Roberts et al. 197
medical checklist concerning pregnancy and so on,
which he takes the patient through.
Example 7: Insensitivity to patient levels of understanding
(lines 46)54)
can: right ok (1Æ0) erm (6Æ0) did (.) this patient have
any er overt signs of any sexual disease did he have
any rashes at all or
act: sorry
can: did the (.) did the partner that you had sex ¼
with did he have ¼
act: ¼ yeah ¼
can: any (.) sort of signs of (.) sexually transmitted
diseases
act: ((shakes head))
The candidate’s initial question confuses the patient
in a number of ways, including by the slip of the tongue
where he talks about ‘patient’ instead of ‘partner’.
However, the problems of understanding are due
largely to the medical register in which the question is
expressed and to the assumption that the patient would
know what the symptoms of sexually transmitted
diseases are like. Such jargon will distance the candi-
date from the patient. In addition, in his attempt to
repair the error, in assuming too much medical know-
ledge, the candidate shifts down to give a specific
example (‘any rashes’) without showing through words
or intonation that he is doing so. His attempt at
clarification when the patient fails to understand is no
more helpful because he is still using medical jargon. As
well as these distancing elements of his style, the long
pauses and repairs seem to produce a degree of
interactional discomfort in the patient, as evidenced
by her minimal responses and, finally, only a head
shake.
It is worth stressing that no single question or
response is necessarily empathetic or retractive. An
empathetic move such as ‘responsive listening’, which
often depends on making inferences from the patient’s
remarks, may, in another context, be treated as high
inferencing and produce the negative labelling of a
patient. For example, a question such as: ‘You’re not
worried about …’ may be an attentive response to a
patient’s narrative or may make the patient feel they are
being labelled as ‘a worrier’, in which case it may not be
perceived as empathetic at all. Similarly, one candi-
date’s reassuring moves, which contribute to an overall
high grade, may appear as set responses, or what we call
198 ‘Good’ and ‘poor’ communication in an OSCE: a proposed new framework
‘trained empathy’, in another candidate. The success,
or not, of a particular remark or question by the
candidate depends on its location in the whole inter-
action and the kind of climate which their communi-
cative style has already established.
If we contrast the high-rated candidate (examples
1–3) with the candidate who failed (examples 4–7), it is
clear that the overall empathetic or retractive climate
results from a layering of good or bad aspects of
communicative style. The weak candidate is interroga-
tory, focuses narrowly on the medical agenda, does not
use more personal authority to reassure, assumes the
patient is concerned about risks or has had abnormal sex
and is responsible for several misunderstandings. In
addition, his overall staging of the consultation means
that towards the end, when he does try to show some
empathy, this comes across in a formulaic or trained
way. This staging of themes represents a further
component of communicative style.
Thematic staging
The global impression of the candidates and the quality
of their communicative style did not depend only upon
empathetic or retractive questioning and responding.
The issue of how questions and responses were posi-
tioned or sequenced in the consultation to cover
particular themes was also significant when the whole
interaction was examined. In other words, how the
different themes of the consultation were staged affected
its overall emotional climate and helped to define the
candidate’s communicative style.
Each interaction had a key moment or crux (or, in
most cases, a number of cruces) around which much of
the interaction was organised, such as the moment
when the Chinese businessman asked, ‘Am I an
alcoholic?’; the drug addict asked for a repeat meth-
adone prescription; the young muslim woman con-
veyed her feelings of self-disgust, or the bad news was
broken to the cancer patient. How candidates built up
to, realised and followed up these crucial moments
affected the whole climate of the interaction and the
success or otherwise of its outcome. This thematic
element contributed to the relatively empathetic or
retractive style of the whole encounter, as well as
progressing the medical agenda.
In attempting to account for the overall impact of the
role-played encounters, the analysis has to integrate the
local, turn-by-turn empathetic and retractive moments
with the staging of the whole encounter. In an adapta-
tion of the sociolinguistic idea of mapping conversa-
tions,19 interactional maps were made of the 28
transcribed scenarios. This mapping gives an immediate
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• C Roberts et al.
visual impression of difference. It also connects a
typology of the whole with specific examples from the
transcripts. Figure 4 shows two contrasting maps of the
cancer scenario, again one of a high-rated and one of a
low-rated candidate.
Here, an older white woman resists advice to have a
bronchoscopy to assess whether her cancer has
returned.
The good candidate gradually and sensitively took
the patient through the consequences of not having a
bronchoscopy. She staged her case for this further
investigation so that each time the patient rejected her
advice, she still had some persuasive resources to bring
to the consultation. Examples 8 and 9 are extracted
from the maps in Fig. 4 to highlight their differences.
Example 8: Good thematic staging
The strong candidate sequenced her case for the patient
having a bronchoscopy as follows:
1 we need to exclude the worst;
2 we need to investigate in more detail;
3 we would like to do a bronchoscopy;
4 we want to exclude the possibility of a tumour;
5 you had a tumour before, and
6 there is the possibility of a recurrence of the tumour.
By contrast, the weak candidate staged the argument
differently. He introduced the fact that the patient had
cancer of the kidney much earlier on in the consultation
and then had no strong reasons left with which to
persuade the patient as the consultation continued.
Example 9: Poor thematic staging
The weak candidate sequenced his case for the patient
having a bronchoscopy as follows:
1 we need to do more investigations;
2 the possible recurrence of the tumour;
3 the possible recurrence of the tumour;
4 it would be better to have the bronchoscopy, and
5 do you have any other worries?
Whereas the strong candidate built up to the most
persuasive argument, the weak candidate brought in the
worst case scenario early on (at line 90, 60 lines before the
strong candidate). This produced a confrontational
response from the patient. The consultation then tailed
off as the candidate ran out of persuasive resources, with
some general exhortations that ‘it would be better’, and
an elicitation about any other worries (as if the possibility
of a return of the cancer was not bad enough!).
These contrastive examples show that candidates not
only need to design their questions and responses
sensitively, but need to be aware of the overall staging
‘Good’ and ‘poor’ communication in an OSCE: a proposed new framework • C Roberts et al. 199

Cand. B
Cand. A
Thematic Retractive Thematic Empathetic
Empathetic
1-10 1-6
Establish identity Establish identity
E1/20
R1/12 7-19
11-34 Negotiating purpose
E3/36 Eliciting
feeling?
worried?
R3/23 20-48
E3/41 Eliciting
What complaining
35-50 about?
E3/48 Result giving
R3/49
49-52
E1/62 51-70 Result giving
Stating intention (treatment)
R1/54
E2/63 53-55
CRUX – 1
Stating intention
(exclude worst)
E2/69 CRUX– 2
R1/63 CRUX - 1
(investigate)
CRUX – 3
E3/69
(bronchoscopy) 55-106
R1/66
Negotiating commitment
E1/79 E2/80
R3/78 CRUX – 2
E3/91 (kidney recurrence-repeated)
70 -131 CRUX – 3 E2/100
Negotiating commitment (bronchoscopy)
E3/116
R1/85 R2/85-93
CRUX – 4
E3/121 (exclude tumour) 107-111
Explaining
E3/132 132-149
Eliciting
112-169
E3/166 R1/113 Negotiating commitmen
t
CRUX – 5
(tumour before)
E2/188 169-174
150-200 Eliciting: other worries; cough
E2/192 Negotiating commitment
CRUX- 6 R1/183
175-182
(tumour recurrence)
Offering treatment
E3/194
(antibiotics)

Figure 4 Contrasting maps of the cancer patient scenario: one of a high-rated and one of a low-rated candidate. E1–3 refer to the
three empathetic styles (see examples 1–3). R1–4 refer to the three retractive styles (see examples 4–7). The number after each of
these codes refers to the line number in the transcription.

of an encounter, particularly where persuasion, nego-
tiation or reassurance are the focus of the consultation.
This awareness may be brought to the encounter by
either type of candidate, but the candidate with a highly
rated communicative style stages the themes in a
responsive way, designing the progress of the consul-
tation to fit the particular local interactional context
produced by the patient.
Values and assumptions
A final element in the candidate’s overall communica-
tive style related to the assumptions they brought along
to the encounter. These concerned beliefs, values and
ideologies about their relationships with patients,
together with more deeply held views about social
issues related to alcohol, sex and drugs. Candidates’
ideologies concerning medical expertise, patient-cen-
tredness and authority underpinned their communica-
tive style.14,16 At a general level, candidates tended to
present themselves on a spectrum from a position of
personal authority and conviction on the one hand to,
on the other, one that relied on the authority of medical
evidence and procedures. A balance between the two
seemed the most successful.
Similarly, the candidates managed the notion of
patient-centredness in different ways. There was a
contrast between stronger candidates, who were sensi-
tive to patients’ levels of knowledge and understanding
and did not label candidates as ‘being worried’ or
‘heavy drinkers’, and weaker candidates, who tended to
use set or trained elicitations such as ‘How do you feel
about that?’ too early in the consultation and ⁄ or who
labelled patients in the way they designed their elicita-

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200 ‘Good’ and ‘poor’ communication in an OSCE: a proposed new framework
tions and responses (see above ‘patient labelling’ as a
retractive strategy). When these assumptions about the
patient were made explicit (e.g. ‘We cannot force you to
take the test’), they were often retractive rather than
empathetic.
There was also some evidence among weaker candi-
dates that their own moral assumptions influenced the
design and staging of questions. The most obvious of
these was a gendered ideology about normal sex.
Several male candidates responded as if the young
Muslim woman’s feelings of disgust and dirt were the
result of abnormal sex. Thus, for example, when the
actor-patient expressed these feelings and admitted, ‘It
was a massive mistake’, some of the male candidates
immediately asked, ‘What kind of sex … ?’ instead of
attending to her feelings. The weak candidate illustra-
ted above displayed these assumptions. In data example
4, he seemed to assume that she felt terrible because she
had put herself physically at risk, whereas throughout
the consultation these negative feelings were clearly
related to the act of sex itself and the patient’s
emotional response to what she had done.
Discussion
This research approach, using interactional sociolin-
guistics, provides new insights into the fine grain of
communication in medical encounters. Whilst high-
lighting some of the complexity of the use of language,
it also enables us to work towards a taxonomy of
communicative style. We are particularly struck by the
way in which strong candidates stage their consulta-
tions, and design their turns in context-sensitive ways,
tuning in to the particular moment. This ability to tune
in is hard to teach and, certainly, trying to improve
communication skills with standard phrases and
‘trained empathy’ appears, from the evidence of our
data, likely to be counter-productive.
Although we are confident that we have identified
key components of weak and strong communicators,
and are working towards a new taxonomy to accom-
modate these, we recognise that much further work
needs to be done. We need, for example, to undertake
further discourse analysis to establish to what extent we
can map the features of communicative style that we
have identified so far onto other scenarios. We are also
aware that several of the aspects of empathetic and
retractive styles illustrated here are widely recognised in
the communication skills literature. Where our analysis
differs, however, is in its attempt to look at good and
poor communicators in the local context of specific
interactions, to link specific styles of questions and
responses to the overall staging of the consultation and
 Blackwell Publishing Ltd ME D I C AL ED U C AT I ON 2003;37:192–201
• C Roberts et al.
to the ideological underpinnings of individuals’ styles.
We have used the device of interactional maps, which
can be readily compared and contrasted, to shed light
on the differences in communicative style between
strong and weak candidates.
We also need to assess the value of this form of
analysis and classification in a teaching context.
Recently, preliminary evaluations of the objective struc-
tured video examination (OSVE) have focused on
specific cognitive aspects of communication skills and
their assessment, including students’ recognition and
understanding of the consequences of various commu-
nication skills.20 Our collection of video-recorded
interactions and the associated analysis could take the
OSVE one step further. The taxonomy of communica-
tive style used with examples taken from this OSCE data
can develop students’ analytical skills and provide them
with a new analytic language. This approach should be
generalisable across consultations, while, at the same
time, alerting students to the fine tuning of particular
responses to individual interactions.21 An approach to
analysing communication which accounts for the
success of the whole and is sensitive to the local context
of interaction is also transferable to naturally occurring
consultations. Although the detailed examples may not
be relevant, the method, incorporating the analytic
components and the interactional maps, should also
prove useful in analysing real patient–health profes-
sional communication.
Contributors
Complete and detailed transcriptions of the scenarios
referred to in the text are available from Celia Roberts.
Celia Roberts collected and analysed the data and was
the lead writer. Val Waas designed the study and was a
co-author. Roger Jones contributed to the design of the
study and was a co-author. Srikant Sarangi collected
the data, contributed to the analysis of the data and was
a co-author. Annie Gillett contributed to data collec-
tion and analysis.
Acknowledgements
We thank Stevo Durbaba for his invaluable technical
assistance and all the students who so kindly co-
operated with this study.
Funding
This study was supported by a grant from the King’s
Fund. We are also grateful to King’s College Teaching
Fund for a further grant, which enabled us to make a
‘Good’ and ‘poor’ communication in an OSCE: a proposed new framework • C Roberts et al. 201

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