Stop reinventing the wheel

About 10 years ago, when I started my interest in things psychiatric and psychological, I participated in a seminar in psychiatry for final (sixth) year students of medicine in Poland. What I heard frightened me. This feeling came back a few days ago.

Let me tell you the story of the class. It was attended by, if memory serves, about 10 students who were asked by the convenor, a consultant psychiatrist, to do two things. First, they were to diagnose a patient, second to find out whether there was a psychotic component in the diagnosis. The patient was a young woman (about 25) who was attending a day-care clinic of a psychiatric hospital. She came into the room smiling, the consultant introduced her and thanked her for agreeing to participate in the class, after which he asked the students to take over.

And so, the nightmare started. The students asked a barrage of questions, all started with ‘Do you have X?’, all of which were answered with a brief ‘No.’ As the questions progressed, the students were getting visibly annoyed and exasperated. They just could not catch a break. From fairly widely cast questions, they were moving to increasingly narrow ones, probably not realising that a chance of hitting it with a question like ‘Do you go to church on foot at 8.45 on March, 24?’ is really quite remote. Their exasperation was not helped by the fact that it was quite a hot summer day and the patient’s expression suggested she was bored out of her skull.

After about 45 minutes, I decided to do something before we all passed out in the heat and asked a question like ‘So, what did you come to see us about?’ (‘Z czym Pani do nas przyszła?’). The woman looked at me with so much relief. Probably hoping that the more cooperative she would be, the quicker she would be able to get the hell out, she offered an extremely helpful narrative.

I asked another question, which I forget today, something about her views on what’s happening, to which she also responded more than helpfully. The exchange lasted about 5 minutes, after which I declared to the consultant that I had the answers to his questions. With a sigh of relief, he went out of his way to thank the patient, who was only too happy to leave.

I’m not certain who was more bewildered, the students or I. They looked at me with disbelief, this man, who proclaims to be a linguist, was able to offer a ‘diagnosis’ within 5 five minutes, they were after 5.5 years of medical school! I was looking at them trying to process the fact that not a single one in the group had the bright idea that instead of asking ‘Do you have X?’, you could ask ‘What do you have?’. I actually asked them about it and they said, somewhat sulkingly, that no one had taught them, that they were taught differential diagnosis etc., etc.. I wasn’t convinced, I must admit, I think, students on a fairly elite course in medicine should be able to have such brilliant ideas.

Still, I explained the situation to myself by telling myself that students in Poland (at the time at least) were not taught, not even made aware of, issues of clinical communication. Not like, I thought, the brilliant doctors in the English-speaking West. Fair enough, isn’t it?

Except now I am going to reveal the reason why I am writing this post. I’m writing it because I was pinged on Twitter and pointed in the direction of this article. 10 years on, a doctor, in a major medical journal, is discovering that you can actually ask ‘What do you have?’!!  Even better, he is still telling his colleagues that leading questions are a problem. Gosh!! I mean, do you really still need to share the wonders of the insight that no, you really don’t have access to the patient perspective? And no, saying ‘I understand’ is not a linguistic problem.

I could actually offer some further advice. It might be surprising, but do you realise that it’s a good idea to say ‘Hello’ when you meet your patient? Have you discovered the amazing phrase ‘Thank you’? I really don’t know what kind of baseline we’re talking about. Are we talking kindergarten level, or do we already go to the primary school? For example, when I mock advice that doctors should maintain eye contact, maybe we are actually talking kindergarten stuff and I should get used to it.

But the author of the article goes further. He discovers, wait for it, words! It’s amazing in its own right, but that’s not all, he discovers that words are understood in context. The depth of this discovery threw me down onto my knees, as I was thinking: linguistics is finished.

I wanted to finish here, but I thought there was one more thing to say. I want to stress that, despite appearances, this post is not about the wonders of open questions and the hell of closed ones.  In other words, I’m not trying to make the point that had the students been told of the difference between open and closed questions, all would have been hunky-dory. That’s not the issue at all. The issue, rather, is that the medical students were not able to think about what the goal of their questions was and how to get there. And they kept repeating the same strategy. The same, I’m afraid, is used by the author of the article. He now decided that there are some ‘bad’ things and there are some ‘good’ things. Go, practise!

And my point, somewhat yawningly, is that things with communication are way more complicated and there will never be simple rules of the ‘If you say this, X will happen’ kind. You see, even with the silly ‘Do you have X’ questions, the students could have said: ‘OK, tell me more’ (yes, it’s awkward, but possible). Moreover, people, especially in a clinical situation, are fairly unlikely to simply respond with a monosyllable. Yet, for one reason or another, the patient didn’t feel like saying: ‘No, but….’.  Finally, the students could have simply shut up and ‘pressure’ the patient with silence (silence after a while can get very uncomfortable). In other words, there are plenty of ways in which you can achieve a patient’s story, and the so-called open questions are by far not the only one. Moreover, a closed question can be followed by a ‘Yes and…’ response, the fact which is yet to be processed by the clinical disciplines.

But I want to end with a sigh. Over the years, I have read some really excellent accounts of clinical communication from medics. They are not a dime a dozen, still they are not so rare you can’t find them.  And while I haven’t got much hope that linguistics will go marching into medicine with advice, analysis and all the rest of it, I would hope that medicine should at least acknowledge and celebrate its own success. So, please, stop reinventing the wheel. It’s tiresome.


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