On patient-centred communication

When I was writing one of my previous posts on patient-centred communication (PCC), I came across the idea of measuring it. I decided to check it out and here is what I found. Or shall I say: here is a brief story of my disappointment. 

One of the most frequently cited articles is a review by Epstein and colleagues. The article offers some insight into what is taken to be patient-centred communication and, I must admit, I was quite taken aback. The authors group the measures into two groups: observational and patient reports. The first are, obviously, doctors who assess other doctors.

For example, a paper suggested the following distinction:

Patient-centred talk. Sum of physician and patient questions about psychosocial issues; patient biomedical question-asking; all physician empathy, legitimation or partnership; all physician clarifying behaviour (asking the patient’s opinion, checking understanding)

Doctor-centered talk. Sum of physician biomedical question-asking and information-giving; all GP ‘directive’ statement; all patient biomedical information-giving

And to be honest, I don’t know where to start, it’s such a mishmash of hotchpotch. Let me suggest a few problems:

  • Why are directive statements are not ‘patient-centred’? It would seem to me that if a medic says to me: you must take this medication twice a day, hardly anything can be more ‘patient-centred’. But that’s me.
  • How do you establish empathy? Surely, empathy is in the eye of the beholder and there cannot possibly be any ‘golden standard’ of empathy.
  • Why is clarification ‘patient-centred’? Can’t the doctor clarify some biomedical stuff?
  • Why are biomedical questions from me ‘patient-centred’? Can’t I want to learn something?
  • Why is asking my opinions ‘patient-centred’? Surely, it depends on whether the opinions are taken on board. If they’re ignored, such questions are not patient-centred at all!!

The article and others I read are based on this mechanistic understanding of communication, ignoring the context in which it occurs. Yes, it’s only irritating and I cannot understand why it persists in today’s research.

So, I went to patient-report measures with some more hope, but they were even more bewildering. Why does patient satisfaction or a statement ‘I felt encouraged to ask questions’  suggest PCC is really incomprehensible. Just because you, medics, think that my greatest wish is your notion of PCC, it really doesn’t mean it is. (There is something ironic in it, isn’t it? Even studying PCC, what’s supposed to be really good for me, is all about the medics, their assumptions and, in the process, medical power).

In any case, as is usually the case with such studies, communication is taken to have only contents. Needless to say, I’m so used to the idea that in medicine linguistic form doesn’t matter that I haven’t even blinked. However, a recent study proclaims to be interested in ‘patient-centred statements’ and so, I started reading with some considerable interest. And indeed, patient centredness is defined as:

the RIAS-based ratio of patient-oriented and physician-oriented statements. This ratio was calculated as the ratio of the sum (frequency of occurrence) of defined RIAS categories, such as giving and asking for psychosocial or lifestyle information, in relation to the sum of physician-centred verbal behavior, which consists of requesting or giving biomedical information [57,58]. A score <1 indicates a conversation focused on biomedical issues, whereas a score >1 indicates an emphasis on patient-related content.

Right….It was not to be.  For, surely, even in medicine you must make a distinction between statements and questions, no? You know, statements are when you inform, questions are when you ask. So, if you want to focus on statements, how can you focus on questions? And the definition, which is about statements, very clearly makes a reference to questions. And statements are not questions and vice versa (though either can be used in the function of the other, but I really don’t want to overcomplicate stuff). Also, I never understand why medics keep talking about ‘verbal behaviour’. Communication is not ‘behaviour’, it is action, we do things when we talk. You know, like asking questions. But, again, it might be too complex.

In any case, that’s my first little suggestion that perhaps looking at how people talk, how they communicate, what linguistic form they use, might be a good idea. But I would like to suggest more and I’ll give three examples. First, I wanted to know what kind of statements are taken to be patient-centred and so I found a study which explicitly quotes such statements (granted I wasn’t looking long, but this is not easy to find). Here are three examples of PCC.

  1. Is there anything else you wanted to talk about? Is this what you were hoping to get out of today’s visit?
  2. What do you think is causing this cough?
  3. Would you rather try antibiotics or wait a few days to see if it goes away?

Are those questions (which are described as statements) all ‘patient-centred’? Of course, they’re not. Well, 1 is not at all, 2 is debatable, 3 is. But instead of boring you with linguistic accounts, I’ll  suggest possible answers to those questions:

  1. Yes there is. Yes it is.
  2. Cold weather.
  3. Yes I would rather wait.

And ask yourself the question whether the answers focus on the patient. They don’t, do they? Questions in 1 and 2 do not focus on me at all, and indeed, nor do my answers. Yes, question 2 will take an answer of “I walked without a scarf”, but the question still doesn’t ask me about me, but about something about which I think something. Only question 3 explicitly focuses on me and what I want. I do understand, of course,  that after “yes there is” I can happily continue speaking. My point is, however, that there is a difference between

Is there anything else you wanted to talk about?

and

Do you want to talk about anything else?

I do hope that the difference between the two questions is quite obvious. It is only the latter which focuses on me and not on the subject of conversation. Yes, you might still want to ask the former, but, please, stop saying it’s patient-centred. It’s not. It’s conversation-centred.

My second example, which is related, comes from my earlier discussion about the PTMFramework. I made the point that a question such as

What has happened to you?

doesn’t focus on the person, but on something outside them. Now, I accept that it might be intended as a prompt to get my story, my experience, but at least linguistically, it doesn’t. How it will be understood, I don’t know, but I do know that it’s better to be explicit about the goals of clinical communication. It makes things easier.

Now, my point so far has been that any discussion of patient-centred communication must take linguistic form into account. Focusing only on the contents of what is said impoverishes any analysis to the point that, in my view, the analysis becomes moot. Unless you understand that it makes a difference to ask ‘Is there…?’ as opposed to ‘Do you want to…?’, there is really not much point in continuing to discuss communication. You do what you will, live in your medical-communication bubble, happily testing your patient-centeredness to your heart’s delight. After all, we all have bills to pay and if those studies pay the bills, go study!

But my final point goes further. What keeps irritating me is the assumption that PCC is good, desirable, and the more of it, the better it is. I think it’s utter and complete nonsense. Here is why.

Below you will find a little snippet of an interaction between a psychiatrist and a patient:

  • Doctor: So, half a year after the child was born, you split up.
  • Patient: Is it relevant?

A textbook example of PCC, also linguistically focused on the patient, yet, the doctor’s question is challenged by the patient. Why? Hard to know, but the patient never answers the question. I’d suggest it’s because she perceives the doctor as taking liberties. Patient-centred communication for you.

Let me make this a more general point. I continually hear about too much medicine, overdiagnosis, over-everything, but I never hear about too much of PCC. Somehow, speaking about pain in life, asking about very personal stuff, with very little regard to whether I feel violated by such questions, is OK. Because it’s, drum roll, person-centred communication, shivers down the spine. So, as much as you will now think thrice about giving me antibiotics, let alone sticking a needle into me, you will not give another thought about sticking your question in me, which might actually be considerably more painful. But hey, who wouldn’t want to be centred upon, right?

My final example comes from another psychiatric interview on which I sat (the patient consented). A man, in his early twenties, hospitalised with a diagnosis of depression, was interviewed by the doctor in charge and her boss, a consultant (and me present). The patient was telling us about how he was feeling, and at some point said that all his experiences made him very helpless and weak, like a little chicken. I could see the shrink-in-charge’s eyes light up.

Do you think you are a chicken?

she asked, ready to uncover the psychotic component to his depression. When I heard the question, so bloody patient-centred, I might add, I thought I’d fall off the chair. What on earth (that’s a mild rendering of what I thought) are you thinking, I thought. For pity’s sake. It was clearly a metaphor, it was culturally appropriate. Indeed, the patient looked at the shrink with a pained expression. Is it not enough that I am here, he seemed to be communicating, do you really have to make me into an utter nutcase?

The question was a case of patient-centred communication. Or was it? It clearly focused on the patient and not on the delusion, didn’t it? Or not? Oh, I don’t know, and I soooo don’t care. I do know, however, that it should never have been asked. And I do wish that considerably more energy were spent on teaching physicians that they are not at liberty to ask me anything they want, just because they’re doctors.

Where does it leave us? Well, I’m really pleased that medicine is studying PCC. I mean, it’s important to have something to do, it’s important to be able to publish. You created this lovely straw man, so happy hunting. What could I, a patient, know?

If you did ask me, however, I’d say that I really don’t care whether you ask me questions about me-as-the-whole-person, I actually don’t know what it might be (this statement can be nuanced quite a lot). If you understand that ‘my symptoms’, for example, make it difficult for me to work, that’s really fine. My communication with you is really not about you saying something about me every other time you open your mouth. Because that’s not the bloody point of our communication!  My communication with you, doctor, should be useful. What it means exactly, we define every time I sit in front of you. And I really would rather you thought about it and not about ‘patient-centred statements’. How about giving it a try, hey?

 

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