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We read with interest the article by Barth et al. [1] entitled “Consequences of insecurity in emergency telephone consultations: an experimental study in medical students”, which is published in Swiss Medical Weekly. The authors have presented a simple yet fascinating study on the behaviour and performance of medical students during emergency telephone conversations and also on their level of insecurity during such consultations [1]. The authors draw some important conclusions from their results; however other conclusions could also be drawn. Principally there is the issue of the exact relationship between the reduced performance and the insecurity. Was the insecurity causing the poor performance? Or did the students’ realisation that their knowledge level was sub-optimal cause the insecurity? It is difficult to tell from the data presented. In fact it is possible that both phenomena were occurring simultaneously. Insecurity might have contributed to poor performance which at the same time was contributing to insecurity. The authors concentrate on tackling the poor performance with suggestions of more education in emergency telephone consultations. Certainly the strategy of taking on the more tangible of the two potential problems is likely to be a wise one. However the issue remains of what, if anything, to do with the problem of insecurity – if that was (in some students at least) the overarching problem. Reflection is now commonly encouraged in medical education and it could well have a role to play here. Reflection can happen after the event – as it did here – when the students reflected on and articulated their level of insecurity. However reflection may also occur “in action” – during a consultation or procedure. Could the students be taught to reflect on their level of insecurity during the conversation and to consider the effect that this level might be having on their behaviour? This strategy might well be worthwhile and could be usefully combined with strategies to rectify knowledge or communication skill deficits. In fact efforts to separate cognitive and non-cognitive needs in medical education may be futile – they are highly likely to be deeply interrelated. If this is the case, then only integrated educational interventions will result in improvement.

Letter to the editor concerning: "Consequences of insecurity in emergency telephone consultations: an experimental study in medical students"