Whenever I read about clinical communication, I see two assumptions made of my talking with the doctor. One is that communication is good, desirable and the patient simply wants to share their problem. The other is that communication is triggered by the clinician’s (whether a doctor or psychologist) skill and technique.
I have already written about the first of the assumptions before. I pleaded for my, the patient’s, right not to talk. Today, I want to write about the other, the assumption that all you need to do is ask the (right) question. Indeed, as I was recently explaining advantages and disadvantages of various opening questions, I forgot to mention one thing. I forgot to ask:
What if the patient does not want to answer?
and I am yet to find an answer to such a question in communication guides. From the (nonsensical) distinction between open and closed questions, to much more sophisticated typologies of questions, all of them assume that I will want to answer (first assumption mentioned above), as long as you ask the right question (second assumption).
The latter assumption boils down to the idea that communication is just a mechanistic process and the question is a switch starting it. Obviously, it’s not. However, perhaps it’s worth repeating again that your question, doctor, is only the beginning, a beginning which opens space which is far from defined and there is no way of predicting what kind of end that opening will bring.
I asked the above question because I think it highlights an important problem. It signals the moment when ‘we’ stop thinking about the communication process and start thinking about patients. And I was reminded of a blog post by Jonathon Tomlinson, who writes:
I’ve recently been doing work with old and young GPs about our favourite patients. For young doctors, favourite patients are friendly, cooperative, honest, and grateful. They present with symptoms that lead to a diagnosis and a cure or failing that, a good death. Gratification is quick. Dreaded patients are the opposite of all these things. I asked four experienced GP trainers in Lambeth each to describe one their favourite patients to a room full of trainees. The patients they described were hard to form relationships with, took time and hard work to get to know, were argumentative, dishonest, chaotic and disruptive, unwilling partners in care.
The answers Jonathon received are indicative of the conceptual model of communication implied in communication guides. Communication is good, the patient needs (and, in fact, wants) to communicate and good questions start communication. It’s so simple that if something goes wrong and the patient does not want to answer and the communication breaks down, then the patient, obviously, is “argumentative, dishonest, chaotic and disruptive, unwilling”.
Moreover, I think more often than not, this is how I would be described by doctors I see. I am argumentative, challenging, disruptive, as I, for example, point out the I am far too intelligent not to notice the ICE questions, the strategies of placating me, or the obnoxious certainty of doctor’s pronouncements. Inevitably, the doctor gets irritated, I probably get labelled. If I were a psychiatric patient, I would probably get a new symptom. As I tend not to express eternal ‘trust and gratitude for effective medical treatment’ (a quote from Hamilton and Roper’s article), I probably lack insight.
Justyna Ziółkowska’s yet-to-be published research confirms it. When interviewed, psychiatrists labelled patients who did not communicate in an expected manner, uncooperative, lacking insight or non-compliant. Communication doesn’t even have to break down, as long as it is not what the doctor expected, ‘we’ apparently do not stop to think about communication, but about the patient. Even if it is done with respect (a study quoted by JT), the patient still becomes ‘challenging’, as if there was a clear and objective category in which to put them into.
Yes, yes, I am one of them. It’s because I hate being treated as a dim-witted oaf who must listen in awe and wonder to the doctor, who decides to use this strategy or that strategy, but forgets to have a conversation with me. And more and more, I want to cut the linguistic branch I sit on and stop teaching people about how to ask a wonderful question. I prefer to say – imagine you speak to a person you have just met or you already know. In other words, let’s not pretend that on entering a doctor’s surgery, principles of social interaction get suspended and instead of talking, we must engage in doctor-patient communication.
There is more, though. As we focus on communication, how about also focusing on the clinician? On the doctor or the psychologist, who seem to lose the ability to communicate as they progress through university. With every passing month, they are taught to speak ‘like a doctor’ or ‘like a psychologist’, emulating the golden standard of medicine or psychology. This standard is then topped up with the (nonsensical) ‘open question rule’, which is to guarantee communicative success, as if there were not context in which one talks. Only after some years of practice and experience, do (some) clinicians shed this burden of stilted communication ‘as a doctor’, and replace it with communication as John or Mary, who also happens to be a doctor.