The unbearable simplicity of clinical consultation

When I read titles such as “What Are We Really Talking About?” I start wondering. The ‘really’ is so out of place. So, when this title appeared in my Twitter timeline I rushed to see what I ‘really’ have missed in clinical communication. Here is what I found out and why I suggest that the adverb ‘really’ be used with much more caution.

The authors

propose an organizing framework of seven specific consultation types, which apply broadly across disciplines: ideal, obligatory, procedural, S.O.S., confirmatory, inappropriate, and curbside.

Let me offer a brief account of a couple of types of consultation, just to offer the flavour of the argument. The ideal consultation is about “a clinically significant illness that undoubtedly falls within the expertise of the consultant expertise”.  This is when a medic doesn’t know something and asks for advice. The obligatory consults are when “some hospitals have policies which require consultation for certain conditions”. The SOS consults happen when “Patients are admitted with many comorbidities and undifferentiated acute medical illnesses. In such scenarios, it may not be possible to ask a narrowly defined question. Instead, the primary team requests that the consultant essentially co-manage the patient.”

Is that all fair enough? Well, no. This is because the authors explicitly say that they are interested in communication and they describe the consultations as communicative events. The problem is that what they describe are medical events which the authors try to shoehorn into communication categories.

Before I offer some comment, let me just say that calling a consultation ideal is really not ideal. Why put a value judgement? Who says it’s ideal? Are the other types less than ideal? I am fairly certain you can label it in a less value-laden way. All that just for starters, though.

The ‘ideal consultation’ is basically asking for advice. The clinical doesn’t know, they ask someone who knows for help. Indeed, they offer an example:

I have a patient with suspected lupus cerebritis, would you please recommend appropriate management?

Easy. Except, what happens when you ask about something which is not “a clinically significant illness that undoubtedly falls within the expertise of the consultant expertise”? Is that not possible in medicine? I’d suggest that such a communicative situation is not outside the realm of what’s possible. Interestingly, even though such a scenario falls outside the ‘ideal consultation’ (and cannot be found in any other type), it clearly is within the scope of the communicative situation described in the ideal consult. In other words, the clinician still asks for advice; only the object of advice has changed. Needless to say, I don’t want to speak to the medical soundness of distinguishing between advice about ‘clinically significant illness’ and something else, however, communicatively, the distinction makes little sense.

Indeed, it would seem to me that, communicatively, the ideal consultations are similar to the SOS consultations. Medically, they might not be, they do describe similar communicative scenarios. I also hope it is fairly obvious that ‘obligatory consultations’ have nothing to do with communication. Rather, they are communicative events which result from requirements of policy. Indeed, I am not particularly surprised that they authors offer no particular question or type of communicative move to exemplify them.

I could go on. All of the types of consults described in the article suffer from such problems. And they do, because the article is not at all about communication. It is about medicine and communication is piggybacked on arguments about how medicine is (or should be) organised. But that’s only half of the problem.

The other half is that the article makes to assumptions. First, it assumes that medical categories can be easily mapped onto communicative categories. It is about medicine that is imposed onto communication. The underpinning idea is that if you understand medicine, you will understand clinical communication. In other words, we identify types of consultations, therefore we identify ways in which people (here: clinicians) will communicate.

Alas, I have bad news. Communication doesn’t work like that. Like not at all. And while it may well be important for medics to understand the types of consultation, this understanding will not contribute at all to understanding how clinicians communicate.

The second problem is that time and again, in medicine clinical communication is constructed as largely uncomplicated, easily divided into categories. Consultation A will result in communication A, all you need to do is to identify the former, which will necessarily lead to identifying the latter, and then, hey, presto, we’ll teach clinicians how to communicate in consultation A. And Bob, the great communicator, is your uncle! Unfortunately, that’s the other piece of bad news, communication, doesn’t work like that either. In fact, communication is anything but.

It would really be much better for medicine to stop assuming, very simplistically, that people communicate in these simple word-packages which have easily identifiable and predictable functions that can be implanted in a given situation. It is precisely the foundation of these endless communication skills guides, driving me round the bend, which offer simple (and simplistic) advice what to say. Again – communication is anything but.

Communication is messy, quite unpredictable, highly contextual. What can easily be said to one patient, can be offensive to another (for example, how many patients object to the word ‘squint’ just like I do?!). The fact that you mean something when saying A, doesn’t mean at all that when I say it, I will mean the same thing. In fact, it is quite likely that I won’t. To make things worse, clinical communication is often cross-cultural, cross-generational, cross-class, often having to overcome significant linguistic limitations. Furthermore, our stories are not only told in the local context, they are also said in a variety of social, cultural, psychological contexts, sometimes extremely complex, especially in medical contexts. It’s worth stressing that the same applies to communication in other medical settings, for example, in medic-to-medic consultations.

So, when the authors say at the end of their article:

It is important to recognize that perhaps the fundamental communication piece is not “What’s the question?” but “What’s the consult type?”

I can only say, no, don’t go there. This is too unbearably simplistic.

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