A recent piece of advice on clinical communication is about sitting. In order to communicate more effectively, the clinician should sit down. In this post, I want to comment on it and on why clinicians seem unable to get to the heart of the matter.
Let me start with a story. Last year, I was in hospital. Here is the full account of my stay there in which, incidentally, I did write about sitting down. This is because the first thing that struck me during my stay was that everybody was standing. As I was forced to lie in bed, people who came to talk to me inevitably stood towering over me. The situation in which I was made to lie in bed and either a nurse or a medic was standing above me, made me feel like a child. The standing created a spatial perspective in which I became a child having to look right up to speak to the powerful adult. I hated it.
I commented on it and heard that it was all about hygiene. Siting on my bed would transfer bad bacteria onto it and I wouldn’t want it, would I? I pointed out that that I had seen visitors sit on beds and nobody seemed to care. Surely, I continued, visitors do not miraculously bring less bacteria to the hospital than the doctors. On that, I heard it was what it was – the usual dismissal of a challenge to a routine. Only one doctor sat down to speak to me and it was a very different conversation.
When I came across the abovementioned blogpost, I thought hope was at hand. Alas, I was disappointed. This is because, I think, the article misses the point.
The two authors identify problems with standing. Apart from what I said above, they say that a conversation in which the doctor is standing may seem hurried (and there is research to support the claim) and direct eye contact could more difficult. And so, they suggest that doctors should sit down. They even suggest a slogan, let’s “commit to sit”.
Unfortunately, I think such advice (let alone the slogan) misses the point. In fact, the moment you make any all-or-nothing rule about clinical communication, you miss the point entirely. Yes, sitting down is important, but would I like every single nurse or doctor to sit down? Of course, I would not! There are conversations, conversations, and conversations and all with different people. And only in the case of the third kind, would I like the consultant to sit down. And just as with (fatuous) advice urging doctors to lean forward (here you can read about it), let’s not start a new rule of sitting down. Sometimes, it’s impractical, sometimes, there is genuinely no time, sometimes a million other reasons. And in my mind’s eye, I can already see medics for whom sitting down, which they will celebrate no end, will be more important than the conversation itself. And in their self-appraisal they will tick all the appropriate ‘sitting down’ options.
When I read advice like that on sitting down, time and again, I think that as much as it sometimes makes sense (as I said, sitting down can be helpful), I keep wishing for suggestions that cannot be so easily overturned in context. No, sitting down doesn’t always make sense, neither does leaning forward or shaking hands with every patient coming in.
So, is there advice which you can give for all contexts? Surprisingly, yes, there is. And the advice is, hold on to your seats, is to be respectful! And I keep wondering why hardly anyone talks about it in reference to clinical communication. You hear about jargon all the time, all kinds of medical language are invented, all sorts of words are banned and pushed down clinicians’ throats, and, in contrast, I would suggest that the best advice is to be respectful. I think that it’s a matter of respect to sit down when you tell your patients significant information about their health. It’s a matter of respect to sit down when you discuss their treatment options. Such conversation shouldn’t be done in passing. On the other hand, there will be plenty of exchanges that you can have on the hoof.
So, why not talk about respect? Well, I think it’s because ‘we’ want to assume that respect is a given. Doctors like to be liked, we like to like our doctors. And saying that doctors are crap is not much liked. Indeed, when about a year ago patients started using the hashtag #DoctorsAreDickheads (here is my post about it), quite a lot of doctors objected and took offense. After all, we so should not generalise all that negativity that you can read under the hashtag. It’s worth adding, however, that when you say that doctors are great, generalisations, as if by magic, somehow become OK. And all of a sudden, all doctors are great and those who are not great are the rare rotten apples. Go figure.
And yet, I feel disrespected by doctors I see “all the time”. Patronising is the daily staple, looking at the screen when I talk is another, assuming that I cannot possibly understand phrases such as myocardial infarction is very frequent. You could add quite a few other examples, and this is just to do with communication. How about stretching comfortably in the armchair while I am perched sideways on the dinky chair….
And so, perhaps instead of urging medics to sit down, or to maintain eye contact, or not to use jargon, you could just say: show respect when you communicate. Use your bloody judgement. And if you continually get it wrong, perhaps you shouldn’t be a doctor? Just saying.
So, if you really want to have a slogan, how about ‘let’s commit to respect’? How’s that?