A few days ago, Lancet Psychiatry published my essay: Language and psychiatry. The article seems to be quite popular. At the time of writing this, it was tweeted 426 times, which takes my breath away, to be honest. One of the points I make in the article is that clinical communication should be seen in terms of communication goals. In this post I want to elaborate on this.
My first point is fairly obvious from a linguistic (and not only) point of view. Communication is a goal-oriented activity. We communicate in order to achieve goals. Here is what I wrote in the article:
When we say something to somebody, we want to achieve something. When we promise, inform, request, warn, or ask questions, we want to achieve commitment, knowledge, compliance, or get information, respectively. Moreover, we might also want to get our addressees to laugh, to get angry, to go on a date, or to think we are knowledgeable. We might also want to pass time, as we chat with a complete stranger stuck on a long-haul flight.
Communicatively, the clinical encounter (I hope, I’m dangerously getting close to being obvious) is a very complex encounter. Both the clinician and the patient have a number of goals both socially and institutionally imposed (like ‘taking history’), as well as a number that might result from individual contexts. I sometimes wonder how aware people who teach ‘communication skills’ are of this.
Now, in a number of previous posts, I criticised current communication training in medicine (well, at least as far as I am aware of it). What dominates is an approach suggesting that medics should acquire certain skills which should be used by them in the clinical context. There are many of such skills and here is a sample:
- 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.
- be uncomplicated
- Be specific
- Use some repetition
- Prepare patient for deliberation
- Facilitate understanding
- Overcome barriers
- Engage in partnership building
- Facilitate patient expression of emotional consequences of illness
As can be seen, those skills vary from quite basic ‘use some repetition’, through fairly complex ‘avoiding jargon’ and just about idiotically difficult ‘tailor your language to your patients’ understanding and information needs’, all the way to completely meaningless ‘overcome barriers’. Similarly meaningless is, for example, ‘expressing empathy’. For the life of me, I have no idea what it means and what this skill involves or consists of (I will come back to it).
More generally, I am yet to find an account of clinical communication skills which takes into account levels of linguistic system or communication interaction at which the so-called skills operate, or, indeed, of social complexity which is underpinned by the ‘skills’. They simply tend to be constructed as token instructions which are deemed desirable.
You can add skills often mentioned in psychology. Psychologists are taught, for example, to:
- ask open-ended questions.
But my main problem with such communication skills is not that they don’t make some sense. They do. Some. It does make sense, for example, to paraphrase what your patient says (though it makes no sense to teach people to ask ‘open-ended questions’). But what doesn’t make sense is to make them a goal of communication training. It makes no sense at all to paraphrase because paraphrasing is good. And yet, surprisingly, this is what, occasionally, clinicians do say. Something like:
I paraphrased because I was told to paraphrase.
Communication skills are constructed as if they were just great and the point is just to use them. I think such an approach is nonsense. I would imagine, for example, that most of us (medics and patients) would agree that avoiding jargon is desirable and medics should avoid jargon. And yet, as I argued before, in some contexts I actually prefer ‘medical language’, as it is less stigmatising in my view.
My preference, even if it is only mine, a singular idiosyncrasy (which I don’t believe for one second, incidentally), throws away the communication skill as it is presented. No, you shouldn’t teach clinicians to ‘avoid jargon’, because there are moments when they shouldn’t!
A number of years ago, I saw an ophthalmologist. I have a long history of strabismus and I know everything I want to know about it. During the visit, the doctor was telling me quite a lot of things, probably a bit too slowly. After she finished, I got up, still carrying my university ID card which sported ‘Dr’ in front of my name. The medic noticed it and said, with some exasperation:
Why did I bother explaining all this?
To which I said:
I have no idea.
The repeated avoidance of any medical language was as patronising, as it was irritating, as was the assumption that I needed her explanations, that I needed knowledge, that…. The point, however, is that the doctor was probably following the advice she received: she avoided jargon, what she said was veeery clear, very uncomplicated – it only alienated me. I was leaving the surgery irritated, hoping I would never have to see that doctor again. Except that she did everything by the book. That’s what she was trained to say!
And she was trained to say it because clinical communication is taught the wrong way round. And I suggest that it is more useful to start with what you, a clinician, want to achieve with your words when talking to a patient, here and now. Instead of learning the ‘communication skills’, consider your goals and how you want to achieve them.
On the most basic level, this is fairly easy and obvious. If you want to find out, you ask a question. If you want to tell me something, you make a statement. Easy, isn’t it? In fact, it’s not. Consider:
- Does it hurt?
- It hurts, doesn’t it?
- Would you tell me if it hurts, please?
- Can I ask you if it hurts?
- Gosh, it must hurt!
Here you have six questions which ask the same question, except that they do it in different ways. You see, even the most basic of communicative goals, obtaining information (let’s call it that, please), is actually way more complex than it would appear. For example, the first question is very matter-of-fact, the last statement-as-question is quite empathetic. Incidentally, I use these questions precisely because they are closed and still can be empathetic. I do it, because I so wish that one of the legacies of this blog is that clinical disciplines would stop telling trainees to ask only open-ended questions. It makes no sense, it’s counterproductive, and just plain silly.
Now, I have no idea what communication skills are covered by the various questions, I do understand, however, that my communicative goal can be served by a number of different utterances/questions. And I suggest that instead of telling clinicians ‘Ask a question’, it’s more useful to ask ‘How do you find out about…?’
Of course, decisions about how to communicate are far more complex when your goal is not conventionally associated with a linguistic form or communication act. So, let’s go back to empathy. I think that there is no such communication skill as ‘expressing empathy’. I have written before that empathy is not linked to any linguistic form, it is not possible to say how to be empathetic. In fact, I think it is much more useful to think of empathy as a communicative goal. Something like: I want to show you I empathise, I’m with you, I understand your suffering. And the question that I must answer is how I achieve that.
There is, of course, no simple, easy, obvious answer to such a question. Indeed, this is perhaps why the issue of empathy is so elusive – and perhaps it is time to stop banging on about the skill of empathy. There is no point. There is no such thing. It’s done here and now, between me and you and no one can tell you how to achieve ‘empathy’ with me.
And so, yes, I advocate a bit of a communication revolution. I think that instead of telling clinicians that they can speak in a particular way, I suggest that they think of what they want to achieve when they speak. And consider what can get them there. What I am saying has some advantages.
First, it gets rid of the notion that there are acontextual ways of speaking, that you can make up any communication rule which will hold true in any context, with any person. There are no such rules and any communication skill is subject to contextual validation or invalidation.
Second, the moment you think about the goals you want to achieve, I hope you also think about the situation in which you are. I hope you understand that ‘being empathetic’ doesn’t apply to every single consultation you have with every single patient. And no, there cannot possibly be any list of communicative goals. Any such list would make absolutely no sense.
Third, understanding communication in terms of goals also helps understand what your patient says. It helps understand that patients are not books which are opened by your wonderful (and open-ended) questions. We, patients, also have our multiple goals. No, you will not be privy to them, but understanding that I might want to, for example, avoid being embarrassed might help you understand what and why I am telling you.
There you are. Something never to consider.