I was following tweets from the #encounteringpain conference and once again I encountered a line with which Rita Charon, the creator of ‘narrative medicine’, suggests consultations could be started. She says:

Tell me what you think I should know about your situation.

And, again, I said I didn’t like it. So perhaps it’s time to explain why.

Let me start with the positives, at least on the face of it. The utterance is probably designed to open communicative space, to give up the Foucauldian medical gaze with which the clinician sees the disease.  Except that, I would argue, it doesn’t do it at all. I’m afraid, the utterance, if anything, reinforces the power imbalance, together with the epistemic injustice of clinical encounters. This is because the clinician is at the very centre of what the patient is asked to do.

There is a reservation to be made here. I have absolutely no doubt that the sentence is meant to be helpful. The insight I offer is that of a linguist, outside any clinical context. And it should be seen as such. I do not wish to undermine any clinical practice which might be useful to patients, with complete disregard to what I am about to say.

Let’s consider first, what exactly the patient is asked to say. Well, s/he is asked to say what

(the clinician) should know.

The sentence is actually quite complicated and I shall not bore anyone with parsing it. Let me just say that what is to be said is determined by the clinician’s perspective. Or, to put it more nicely, it is the clinician that is the measure of things. The patient cannot tell the doctor about her/his experiences, pains, worries, anxieties. Well, they can, but only if they ‘think’, this is what the doctor should know.

And before you say ask: so what, let me quote from an interview with a patient who was asked to tell the interviewer about her conversation with a doctor

 You know I do make the cardinal mistake and with tenacity. Namely, I do try to say the most, in order to make a diagnosis easier for the doctor. And then I think that I talk too unnecessarily, too much and off the topic. Or that the doctor looks at me with a distance, like at a hysterical broad who is so self-centred and is completely unable to control herself and tells what needs to be told and particularly what doesn’t. Without thinking. And has become verbose, and that it is unnecessary.

(you can read more about it in my article on ethnography and discourse analysis)

And here you have the heart of the problem. The patient describes how she starts thinking about what the doctor ‘should know’. And she castigates herself for simply talking too much, after all it is not her perspective that matters, it is the doctor’s. And the abovementioned opening sentence does exactly that – it reinforces the perspective of the doctor and elides that of the patient. It prevents the patient from ‘babbling’, from saying to much, from being verbose. The patient will be succinct and to the point, after all they are supposed to say only what they think the doctor should know.

But there is more. How am I supposed to know what you, the doctor, should know? I am not a doctor, so why do you ask me to try to second-guess what you should know. You give me a task I cannot possibly fulfil, in such a way condemning me either to frustration, or fast and intensive facework (in Goffman’s sense) or some other communicative activities I cannot now think of.

Furthermore, why is the patient asked to say what they ‘think’ the doctor should know. Why shift what is potentially an emotional, distressing, worrying experience into the realm of rational thought? In other words, can I tell you what I feel you should know? Or perhaps, can I tell you what I feel? Now, there’s the thought.

As you ask me to consider what I am going to say rationally, you also ask me to tell you about ‘my situation’.  I start wondering what on earth you want me to say. Would you like to hear about my dying grandmother my mother is taking care of to the detriment of her health? I can also tell you about my mortgage and car payments! Please, do not patronise me with the ambivalence of ‘my situation’, because at the end of the day, I know and you know, I am not going to even start telling you anything about ‘my situation’. Not only have you got no time to listen to me, you can do zilch about it, and I have not come to you for a chat, but with a pain in my stomach. So, let’s get real here and focus on what’s relevant, without communication which is more about you than it is about me.

Sorry, what a rant….I don’t know if I think you should know that, but I just wanted to get it off my chest….

I often discuss how to start conversations with students and trainees. I tell them that the point is to open up space for their patient to talk. Ideally, we could say, the beginning of a conversation could be something like: “I am listening.”. In Polish you can actually say it (“Słucham”), in English it is more difficult. But it’s about opening the channel of communication and giving me the communicative rights to tell you what I want. Yes, those rights are yours to give, but once I have them, I could focus on me. This is how I become the measure of things.

But can I really be the measure of things? I can already hear clinicians shouting: “Of course! We are listening.”  And then reality begins biting. My GP has 5 minutes for me (or is it 10?). So, let’s not pretend that I can talk about ‘my situation’. Let’s use the 10 minutes to talk about ‘symptoms’.

And we come to a conclusion that the most idiotic of sentences: “What are your symptoms?” might in fact be the most useful given the political economy of healthcare.

Sigh.