Power and docsplaining

A week or so ago, I read a piece on docsplaining. The term, as John Launer writes, refers to doctors’ explanations which are unwanted, unnecessary or patronising for the benefit of us who made the fatal error of not getting a medical degree.  I agree with the points made by the author, but I think it’s worth taking the argument a bit further.

Before I do, I would like to offer one of my favourite examples of docsplaining. Quite few years ago, I was invited to do a presentation at a meeting of the local chapter of the Polish Psychiatric Association. I accepted and decided share recently-published paper on the Beck Depression Inventory, a very popular questionnaire in gauging depression intensity.

As the paper is very critical of the BDI, I expected a fierce discussion and I was right. As I was trying to hold my own, one of the shrinks stood up and said that I had got the whole thing wrong. There is no point in talking about questionnaires, after all, the BDI is not one. It’s an inventory, as the name suggests, and I should discuss it as such. Questionnaires should be compared with questionnaires, inventories with inventories.

I became speechless for a good while. Many options went through my mind, mostly from fairly unparliamentary to very unparliamentary, but eventually, I decided to thank for the comment and not dignify it with an answer. However, to my utter amazement, despite that his comment was patronising nonsense, the psychiatric audience seemed delighted with it and my lack of engagement with it. He got me, he showed me where my place was; a linguist will not be telling psychiatry what to do or what not to do (an attitude I have seen throughout the time I’ve been interested in things psychiatric and psychological).

Now, I am assuming that the audience understood that the distinction between an inventory and a questionnaire is bogus, so the question that I’ve been asking myself ever since was why the shrink said it and, more importantly, why his colleagues in the audience liked it.

And here we come to John Launer’s article. He writes:

Across all specialities, belittling patient experience and expertise appears to be the rule, whether this relates to patients doing their own researches, asking questions, or even describing their own pain (‘I’m sure it isn’t as bad as you think’ was one example). Doctors like to keep control of the narrative, and they use docsplaining to disqualify alternative versions. We seem to have acquired an institutionalised addiction to docsplaining, and we now have our work cut out trying to monitor and treat it.

Yes, the comment was about disqualifying my account (probably, also me), yes, more generally, I think docsplaining is about controlling the narrative, whether clinical or, in my example, academic.

I would, however, like to offer some more. You see, I’m not certain doctors have acquired an addiction to docsplaining, rather, I think that you have been trained to have it, while at the same time, the power relations between us (i.e. doctors and non-doctors) have reinforced you in speaking to us, particularly in clinical settings, in such a way. You can afford speaking to us in such a way, as we can do precious little about it (especially in psychiatry), and every time you say such things this state of affairs is reinforced. You remain more and more powerful, I become more and more powerless. The fact that you don’t do it consciously, intentionally, makes no difference, the upshot is the same.

The question that I would like medicine to ask itself is where docsplaining comes from. After all, it didn’t just appear out of thin air, it wasn’t a spell cast on the medical profession, was it?

Some time ago, I wrote about my hospital experience and being an ‘interesting patient’ for students to practice their communication skills on (here is the link). One of the students was given the task of interviewing me. After asking a question, he never even looked at me. He was looking around, checking the walls and the windows. After a couple of minutes, I stopped and said: For pity’s sake, man, can you at least pretend that you’re interested? And I proceeded to tell him that looking at the walls and the windows is not the way to talk to a patient. The students’ tutor didn’t react, even though I think she should have stopped the student. He was very disrespectful and patronising. And yet, after my second rant, she simply walked off, without a ‘thank you’.

If this is how you train medical students, no wonder, you continue despairing about clinical communication and about doctors’ empathy. Indeed, if this is how you train students, no wonder, you will find docsplaining. If a 5th-year student can already blank me after asking a question, is it really surprising that ‘real’ doctors do it? Is it really surprising that you see docsplaining, if this is what students do and see?

Moreover, I think it is fair to assume that the student wanted to pass, perhaps even do well, when conducting his interview. After all, it was formal training and the student’s performance, so I was told by the instructor, would be assessed. So, either he was a very bad student who had no bloody idea how to talk to a patient, or he thought that his behaviour was acceptable. I tend to think that the latter is a more likely option.

And so, as much as I agree with Dr Launer, I think he underestimates the role of the profession in inculcating such communicative practices into medical trainees, while at the same time offering too little reflection on the power doctors hold and wield.

Now, Launer makes a link to a BMJ blog on the infamous Twitter hashtag #doctorsaredickheads. The lead to the blog says:

Mean spirited insults close off the necessary wisdom, communication, and relationships so necessary in complex healthcare.

The closing paragraph says:

There is an assumption that doctors should just tolerate these insults, but what is less well understood is the profound and harmful nature of rudeness. Mean spirited insults close off the necessary wisdom, communication, and relationships so necessary in complex healthcare. We should all get more comfortable with life’s hardest sentence: “I don’t know.” Nobody gains by leveling harsh accusations at fallible humans, regardless of their proximity or salary. Doctors are not dickheads, we are just heads, and, like our patients, these heads are connected to hearts.

Lovely, innit? My heart goes out to your hearts and bleeds with you… Well, almost. Because I would really find the paragraph somewhat more palatable if you at least tried to understand the anger and the pain behind the unpleasant hashtag, as it was called (here is my blog about it). I would also like to see such impassioned pleas for clinical communication without patronising, gaslighting, blanking, shaming etc. etc. Somehow, however, the impassioned blog concerns their highnesses’ egos being injured because patients called them dickheads. Oh, please, give me a break.

So, in order for me to be even mildly sorry for you, I would need to see a blog in which the lead is, to borrow from your blog:

Docsplaining closes off the necessary wisdom, communication, and relationships so necessary in complex healthcare.

But I will not be holding my breath, as I suspect that John Launer will not be followed by dozens of colleagues denouncing how medics communicate.

So, what about docsplaining? I welcome the article, it’s necessary, but in my view, it doesn’t go far enough. I think, there are fairly clear sources of such communicative practices. And the solution is not so much identifying docsplaining, it’s more about reflecting on and changing how you train doctors and how you see yourselves as doctors. When you get this right, your docsplaining will take care of itself.

1 Comment
  1. A very interesting position on the positions of power. My thoughts? Deeper observation of the health and social care scene however reveals some current marginalisation of the medical authority, and the coming to the fore of the ‘patient voice’. Much has been achieved over the years e.g. the ‘Montgomery judgement ‘ which despite the personal trauma to the family and all involved, stamped an indelible mark on how medics ought to behave. That said it is what happens in practice which is the proof of the pudding. Another perspective coming on stream is that of ‘cultural safety’. Originally crafted in New Zealand nursing competence has extended to be applied to how organisations conduct themselves. It concurs with Sherry Arnsteins ‘ladder’ which moves the patient working within the same power structures as the clinician. Finally when power is taken or being taken, the fear of the ‘unconfident’ may cause some not so nice behaviours. Sadly we do see this and prevents us all from moving forward.

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