Just talk

Whenever I’m asked about communication skills, I’m torn. I support efforts to make clinical communication better, more useful for me, the patient. But then the linguist inside me raises his (ugly?) discourse analytic head. And so, here is my second post on communication skills.

I understand that professions such as medics, psychologists or nurses, which rely heavily on communication in their daily activities, must have a way in which to talk to each other about communication. I see talking about communication skills as showing concern about with how you communicate with me and I applaud it. The problem is that I think ‘communication skills’ are acontextual instructions which, apart from telling clinicians what’s good and what’s bad, are not particularly useful. I tend to fail when I see a communication skill and start wondering what exactly a medic is supposed to say. Put differently, how do you actually know that the medic has actually mastered the skill?

In the last post I briefly talked about one of the most commonly mentioned communication skills. A healthcare professional should ‘tailor their language’ to their patients’ understanding. And for me, a linguist, it’s just about meaningless. While I accept that after years of caring for me, you might (and I do stress ‘might’) get a sense of what I understand or not, how do you do it during  the first visit, or the second, or the third….?

And that’s just for starters. Which aspects of your language do you focus on? Vocabulary? Yes, it’s very easy to speak about medical vocabulary, but even this is not exactly easy and clear-cut (medical language has its important uses). I also don’t think that the question of how you decide whether you should or should not use medical language has an easy answer.

What about other vocabulary, though? Some doctors are fairly educated and might have vocabulary which is not accessible to their patients. What do you do? Do you weed out all your four-syllable words? In fact, it also works the other way around. I am sometimes fairly surprised how limited clinicians’ vocabulary is. But what about grammar? Should you start speaking in simple clauses, nothing fancy, no compound sentences? Should you use the singular instead of plural? Should you emulate the accent? Incidentally, the last question is not as off-the-wall as you might imagine. Especially at the beginning of my life in the UK, it was the doctors’ accents that I struggled with most. Needless to say, I have never ever been asked whether I understand the doctor and, indeed, at times I didn’t.

There are, of course, no answers to such questions. The problem is that, as usual, ‘it all depends’. But when you have 10 minutes to speak to me, there are so many more things to worry about. So, please, let’s not talk about ‘tailoring’ the language, but let’s just go for a simple ‘Do you understand?’. Also because, to be honest, I would prefer, if you didn’t speak my language.

After all this, I would like to have a look at the article pointed out to me by Jennifer McAnuff. It focuses on learning outcomes for communication skills and, so, if I understand it well, some of the 205 learning outcomes also contain communication skills which are to be acquired by clinicians. Here is a sample:

  • Communicate with honesty.
  • Demonstrate genuine apology as required.
  • Acknowledge communication partner’s feelings.
  • Express a willingness to help.
  • Use intonation to modify verbal delivery.
  • Allow communication partner to complete full statements without interruption.

Great, aren’t they? Who would disagree with all this? Unfortunately, I’m sorry to say, they are meaningless.

Let’s consider them in turn. What does ‘communicating with honesty’ mean? Do you have a special voice? Do you use special words? Or do you pledge honesty before the patient, oh, pardon me, the communication partner, sits down? You see, the problem is that there are no linguistic markers of honesty and a lie looks exactly like a truthful statement. That’s the whole point of it!

What’s the difference between a ‘genuine apology’ and regular one? And, please, just don’t tell me it’s all in the eyes! But, moreover, how do you ‘demonstrate apology’? Does it, for example, involve simply apologising? Or is it demonstrating engagement with the apology procedure?  I also genuinely don’t know how to acknowledge someone’s feeling. Do I make a face? Do I say something? If so, like what?  But more crucially, I am not entirely certain I am after your acknowledgement of my feelings. Well, sometimes I might be, sometimes I might not and such a general and unqualified rule seems to me counteruseful.

And then we come to the intonation rule. This is just utter nonsense. Are there really doctors who can speak without intonation? I mean, even Lt. Cmdr. Data was able to use intonation, even the Terminator!  In other words, how do you NOT use intonation?  Yes, I suppose letting me finish is a good idea, but is it really an all-or-nothing rule? Are we really saying you should never interrupt, like never ever? That would also be nonsense.

But there are instructions which are not ambivalent to the point of meaninglessness. The active listening instruction is different:

Demonstrate verbal cues of active listening, such as:

  1. back tracking
  2. reflecting communication partner’s story
  3. mirroring language
  4. using words of encouragement
  5. verbally acknowledging
  6. paraphrasing to indicate health professionals’ understanding
  7. interrupting minimally

It does make some sense. I assume that ‘back tracking’ refers to phatic expressions such as ‘uh-uh’ or gestures such as nodding. And that’s, I guess, sensible advice, just as long as you use your common sense and don’t just attack me with your uh-uhing.

It goes a bit downwards from there. I thought reflecting the story was about paraphrasing – it clearly is not and I am at a loss. What does it mean? Personally, I’m also not a great fan of paraphrasing, as it might suggest that I am talking gibberish and the clinician simply corrects what I said. But perhaps that’s me. I have no idea what mirroring language is (and which part of it). And please, don’t ever use ‘words of encouragement’ on me – I’ll just ask you whether you learnt them by attending a course on being patronising. I guess, I shall live in ignorance where minimal interrupting ends and regular one begins.

You could, of course, challenge me and say that it might be only me, so it doesn’t matter. Well, I think it’s very unlikely I am the only one who doesn’t want to be encouraged, and even if I am, the strength of the rule should be weakened.

There is a reservation to be made here, though. I don’t know what was said in the actual guides or instructions and how nuanced the training is. Judging by the article I commented on in the previous post, I am not exactly hopeful, but I don’t know. What I see in the article are only representations of the outcomes from various other documents. Yet, they still give us insight into how communication skills are seen. The instructions are universal and acontextual and, if taken at face value, make little sense. They are procedures which, incidentally, make even less sense in an individual interaction between Mary, the clinician and John, the patient.  That’s precisely clinical communication is so difficult.

But I don’t want to dismiss them. The authors have a point, I think. As much as I believe that there is little point in seeing those instructions in terms of skills to master, I also think that at least some of them (perhaps most of them) convey important values which should underpin clinical relationships and communication. So, as much as I still think it’s better to teach you to use verbs and understand that there is no point in getting hung up on the open-closed questions distinction, I still think you should keep creating the rules and the ‘communication skills. I think, it’s important to say aloud what matters in a clinical encounter. But if you really want to teach medics how to communicate better, you might want to consider asking linguists.

There is one more point I want to make, though. Over the years, I have heard or read transcripts of many interviews. Some, probably most, were dreadful, they had nothing to do with the values rendered by the communication skills instructions discussed in the paper. Very few were excellent in the sense that you could genuinely hear rapport, empathy, relationship. But, quite amazingly, I guess, they had also little to do with the instructions. Well, the instructions were negotiated to the point of obliteration. There was ineffable quality about those interviews achieved by waiting for a few minutes for the patient to start, by a warmness of voice, but also by a well-placed and, yes, sometimes curt interruption. This is probably because they had a foundation which was not of following communication procedures, but understanding that sometimes you just must speak not like a doctor, but like a human being. You know, you can just talk.

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