Communicating power, skilfully

I avoid speaking about communication skills. This is because I am sceptical about them. I find these well-meant positive rules for communication too general and acontextual. And yet, this is a post about them.

A few days ago Jennifer McAnuff asked me what I thought about an article about learning outcomes for communication skills. Before writing a response here, I wanted to look around for what medics write about communication skills nowadays. I immediately came across a piece on the BMJ website, offering Top tips for effective communication. I was quite struck by it and decided to write about it, before offering comment on the learning outcomes article.

On the face of it, the top tips are great. Clear language, NVC, negotiating an agenda, establishing dialogue – it all makes perfect sense and it’s very difficult to disagree with such prescriptions for communication. And I actually agree with them. But as I was scanning the article, I was taken aback by one of the tips:

Apologise when mistakes occur.

Oh, for pity’s sake, I thought, really?! I mean, really?!

Mistakes occur?! Just all of a sudden they appear out of thin air? And when one appears, then you apologise? Oh, no, you don’t. How about heeding your own advice and using clear language? Mistakes don’t just occur, people make mistakes. So whose mistakes do you have in mind? Or let me put it differently, is it really so important to hide behind language and not say that doctors should apologise for their mistakes? Is it really so important not to say that, yes, doctors make mistakes?

After this I decided to read the top tips a bit more carefully and was quite surprised with what I found. In a nutshell, despite the surface, the communication skills which are offered are all about doing something to the patient, these are skills  in exercising communicative power. Let me make the point on a couple of examples, starting with the all-important “Empathise and listen” advice. It says:

Your relationship with the patient is vitally important. It facilitates therapeutic space in which patients can express their concerns and receive support and advice. Empathy is the ability to understand what another person is experiencing and to communicate that understanding to the person. As the patient begins to relate his or her story, it is necessary to silence our own internal talk, including the diagnostic reasoning process, which can interfere with our ability to listen.

Have you noticed that this advice actually does not say: “Listen”? Yes, that’s right, the advice to listen doesn’t actually ask the doctor to listen. It only says that the reasoning process interferes with your ‘ability to listen’. And I almost felt sorry for you, doctors, as you must silence your internal talk…I mean, please, all such effort on my account.

The tip consists of four sentences, three of which are descriptions of general ‘truths’, and on the fourth one offers advice. But the advice is not to listen, but to ‘silence’. Moreover, in contrast to other tips (not all), the advice is not in the form of a verb in the imperative form (like ‘determine’ or ‘avoid’ from the first tips), but in the form of a general rule. So, it says:

It is necessary….

and doesn’t ask, instruct, advise the medic to do anything. Why?

OK. So let’s have a look at those tips which very unambiguously tell the doctor to do something. Here are all of them:

  • Avoid jargon and tailor your language to your patients’ understanding and information needs.
  • Ask patients what they need from the consultation, and explain what can be covered.
  • Determine whether your patient agrees with the diagnosis and management plan.
  • Tailor your approach to the individual patient.

And my question is – do I have a say in all this? Where am I? As you avoid the jargon (whether I like it or not) and explain to me what I can get, while determining whether I agree with you, where is the bloody dialogue you encourage us to have? These verbs only show activity on the part of the doctor who, with her/his Superman’s vision, determines things. These are communication skills for speaking unto me, not talking with me, discussing with me. Even asking me what I need is followed by your explaining what I can actually need. Presumably, in case I need too much.

Of course, there is much more to be said about such advice. For example, what’s the basis on which the doctor is to ‘tailor their language’. Such advice is extremely difficult to follow, if it is not to be based on social stereotypes, such as that if I wear a tie, my language must be more sophisticated than the language of a person in tracksuit bottoms.  How you ‘tailor the language’  in a 10-mnute consultation encounter is really beyond my capacity to understand reality.

Anyway, the above advice constructs one-sided communication in which the doctor, after deciding who I am and what I need, will just continue speaking. There is no space for me in all this. I can only answer questions, while the doctor will then, so good of them, remember to silence their processes. Isn’t it also really ironic that establishing dialogue consists only of asking the patient whether they agree with the medic? I can only wonder what happens if I actually disagree. After all, we wouldn’t want to have that, would we?

The last of the top tips says:

Recognition and explicit acknowledgment of the emotional content in your patient’s story is particularly important in establishing rapport. Doctors often respond to emotional cues by offering premature reassurance, explaining away distress as normal, attending to physical aspects only, switching the topic, or “jollying” patients along.

Thank you for the words of wisdom about acknowledgement and for saying that some doctors are crap. Great stuff. Do I need to do anything, though?

Now, I understand the argument that, after all, ‘we all’ know what the authors meant. Of course, we do. And yet, it seems to me that it is significant that only in some cases they are very forceful in their advice, while in others, they only imply advice. Why? Is it by accident? I doubt it; I’d imagine a text like this is revised, edited, until both the authors and editors are happy with it. One could, therefore, suggest that the difference in language has a different source. It might, for example, offer insight into priorities in communication skills. The important ones are marked with a clear instruction.

But it might also reflect considerable ambiguities in the skills.  For while it is relatively easy to ask the patient whether they agree, it is not so easy to ‘explicitly acknowledge the emotional content’. In other words, I really would not know what exactly is asked of me. Yes, I know that ‘tailoring language’ is ridiculously difficult, still it’s one of the explicit instructions. Perhaps I’m missing something.

And here we come to why I really don’t like speaking of communication skills. I simply don’t know what they mean. And I prefer talking about skills such as using verbs. But I shall explore it all in some more detail in the next post.

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