Reply to the Letter to the Editor of K. Walsh


Regina Ahrens, Jürgen Barth, Mireille Schaufelberger

We very much appreciate the comments of Kieran Walsh [1] on the relationship between reduced performance and the insecurity of medical students in simulated emergency telephone consultations (ETCs). In our study [2], the second most frequent reason cited by students for feeling insecure was a low level of knowledge about the necessary questions to ask, suggesting that insecurity and poor performance were associated with this lack of knowledge. It was this finding that led us to recommend better education on emergency telephone consultations, as well as training on what questions to ask.

There is indeed, as Walsh points out, the possibility that a feeling of insecurity about the ETC itself may have prevented the students from using their knowledge to perform well. Interestingly, little is known about the factors that improve or hinder the transition from knowledge into performance as exemplified by Miller’s pyramid of competence [3]. It is unclear whether insecurity is one of the factors that hinder such a transition. In our study, the reason most frequently cited by medical students for their insecurity was lack of clinical knowledge and experience. This insecurity could indeed have led to difficulties in applying existing knowledge. Training on strategies to deal with this was our second recommendation.

We agree with Walsh that training in emergency telephone consultations should be accompanied by reflective activity including how to deal with insecurity. In our practical course, reflection is done at the end of each simulated consultation, when students discuss their emergency telephone call with the simulated patient and are asked to state how they felt during it [5]. This reflective component could have a stronger focus on any feelings of insecurity, as well as feedback from clinicians or communication experts about phases with unclear communication. Recorded consultations could also be used by students to help them reflect on any feeling of insecurity during the ETC [5]: a “think aloud” approach, or asking students to note and comment on times that they felt insecure. Reflection during the consultation itself could be taught by immediate interruption of the consultation by either student or tutor as soon as any insecurity is perceived, allowing them to discuss it.

We agree that, to produce an improvement in ETCs, training needs to address both knowledge and how to handle feelings of insecurity. Further investigation to disentangle the relationship between these two components would be worthwhile.


1 Walsh K. Letter to the editor concerning: "Consequences of insecurity in emergency telephone consultations: an experimental study in medical students". Swiss Med Wkly. 2014;144:w13993.

2 Barth J, Ahrens R, Schaufelberger M. Consequences of insecurity in emergency telephone consultations: an experimental study in medical students. Swiss Med Wkly. 2014;144:w13919.

3 Miller GE. The assessment of clinical skills/competence/performance. Acad Med. 1990;65(9):63–7.

4 Schaufelberger M, Harris M, Frey P. Emergency telephone consultations: a new course for medical students. Clin Teach. 2012;9(6):373–5.

5 Hulsman RL, Harmsen AB, Fabriek M. Reflective teaching of medical communication skills with DiViDU: Assessing the level of student reflection on recorded consultations with simulated patients. Patient Educ Couns. 2009;74(2):142–9.