When I analyse clinical communication I offer critique, I show additional contexts, ambiguities or assumptions behind what clinicians or patients say. In consequence, one of the most frequent questions (trainee) clinicians ask me me is how to say things right. This post is another explanation why there is no ‘golden mean’ of communication.
The problem touches one of the crucial characteristics of language/discourse. Whatever can be said can be said differently. Language offers just about an infinite number of options of saying things. But every language use entails decisions as to which aspects of extralinguistic reality to include and how to do it. No text, spoken or written, therefore, represents reality in a neutral or objective way; language is always ‘loaded’. Our choice is only which way we want it ‘loaded’. This means that there cannot be ‘the right way’ to communicate, there can only be the way which, here and now, reflects our assumptions, values, beliefs, sensitivities and allows us to attain our communicative goals.
And here we come to the main point of this blog post. Whenever I’m asked about what should be said, I’m, in fact, asked about the foundation of a procedure. And there are none and there cannot be any communicative procedures. Communicating with me is inevitably here and now, we cooperate as we jointly create out conversation. You cannot prepare the ‘right’ question (or some other message), be it because you simply cannot know whether I will feel like talking to you.
Let me put it a different way. Every time a clinician asks me about ‘the right way’ to communicate, they assume that I, the patient, have nothing to do in clinical communication. The ‘right way’ assumes that there is a simple way in which to get me either to talk or to be happy with what you say. It’s a view of communication in which what is said simply pushes buttons. Communication is something that happens between the sly doctor and the nitwit of a patient who simply reacts to the brilliance of the clinician’s words.
But then when you just stop to think about it. Just because you say
I love you.
doesn’t really mean that the addressee of such a confession will inevitably say
I love you, too.
Obvious? Of course it’s obvious. In the same way, just because you ask me:
Do you love me?
doesn’t mean that I will respond
(because it’s soooo closed a question) and not, for example:
Why would you ask such a question?
Of course, I do, I love you so much I cannot even express it in words.
I wish the answer were as simple as the question.
Or a zillion other responses. And so, why would we assume that all this somehow stops in a doctor’s surgery? There is none and there will never be a communication procedure!
But what always surprises me in the questions about ‘the right way’ is that what I say about communication, the context, negotiation, meaning making and whatever else is not exactly new or earth-shattering. So why do the questions still come?
I am pretty certain those who ask such questions are simply concerned about the quality of communication. The problem is that order to ask such them, you must assume that clinical communication is not between two persons, but it is between two roles. And so, it’s not Mary and Dariusz who are talking to each other, but it’s a doctor and a patient. The moment you perceive your communication in institutional terms, you can also ask about an institutional communication procedure. Yes, a procedure which is ‘patient-centred, but not ‘Dariusz-centred’. And myself, I don’t really care for ‘patient-centred’, because it doesn’t focus on me. It focuses of the social role.
In the process, we come to a paradox, I think. The more you want to communicate well with your ‘patients’, the more you distance yourself from them. Because the more you focus on the patient, the more you lose sight of me. And just like all others, I’m not your average patient.
But I want to make one final point. Talking about doctor-patient communication and not about John-Dariusz communication makes things considerably easier for the doctor. This is because we don’t really focus on how John or Mary communicate with me. You might prefer to think about ‘the doctor’, but I actually prefer thinking about ‘John, my doctor’. You know, the person I will see tomorrow and next moth. Moreover, as a patient, I really don’t care that much about doctors and how they communicate. I care much more about how my doctor communicates with me.
The focus on doctor-patient communication in medicine allows you to avoid speaking about how you, Dr Paul, gets on with communicating with me, Dariusz. That, needless to say, doesn’t stop you from routinely noting, recording or commenting about how I communicate with you, inevitably, of course, making me responsible for the quality of communication between us.
Currently, I go through clinical notes, made both by psychiatrists and psychologists. Most have comments on communication and it is always the patient who communicates badly. They talk too much, or too little, or answer in monosyllables, or speak without asking. Basically, if there is something wrong the communicating psychiatric patient can do, you will find ample ‘evidence’ for it in the notes. In contrast, what I find completely absent, like: zilch, is comments on the clinician’s communicative skills.
I am yet to find clinical notes in which the clinician writes something like:
- I asked two questions in one and the patient had no idea how to answer.
- I asked a question with an unwarranted assumption.
- I was patronising.
- I pathologised perfectly normal behaviour.
- I never allowed Mark to speak.
- I interrupted every single answer the patient tried to give.
Believe me, I could continue with the list for quite some time.