Think, doctor!

Today I want to write about a brief fragment of an exchange between a patient and a doctor:

  • Patient: I feel like I’m choking & it’s really scaring me.
  • Doctor: So, what would you like to have come out of this consultation?

I find this exchange extraordinary; it’s very bad, but also it’s fascinating. It’s bad because the doctor spectacularly fails to show any empathy, it’s fascinating because the doctor is actually following the rules of engagement.

Let’s start with what’s wrong with the exchange. Linguistically, the patient starts with self-reference (“I feel”, “I’m choking”), but the construction is quite interesting. The complaint bit of the utterance is put in the subordinate clause of “I feel”. Linguistically, there is no evidence, but socially, it might be that the utterance is meant to be cautious. The speaker might prefer to focus on what s/he feels rather than on ‘real choking’.

This interpretation is supported by the fact that at the end of the utterance, the patient shifts self-reference from linguistic subject/agent to object/patient. In other words, the patient is not saying s/he is scared, but rather, that the ‘it’ scares her/him. Again, there is no linguistic evidence to offer an interpretation of why this happens. Socially, however, it might be that admitting that s/he is scared is too face-threatening (Goffman, later Brown and Levinson’s term; sort of ‘undermining’) and making the ‘it’ responsible for scaring the patient is easier. There are probably other interpretations.

I already suggested that what the patient said can be seen as a complaint. This is what s/he comes to see the doctor about. Indeed, the self-reference, the negativity of what is referred to leave little doubt that this is the issue, the point of the discussion.

The doctor, it seems, has a number of avenues. Considerably more could be said here, but s/he can focus on any (or all) of three elements – feeling (“I feel”), choking (“I’m choking”) or ‘it/scaring’ (“it’s scaring me”). In other words, the patient opens the space (Holdcroft’s conversational demand) to talk about any or all of these three things. Yet, the doctor ignores what the patient has said and asks about the patient’s expectation of the consultation. Linguistically, what the doctor says does not refer to what the patient said, it’s as if s/he were evading the issue (evasion, as I suggested many years ago, is linguistic). Yes, the doctor also focuses on the patient, but in ‘normal’ circumstances, it is probably quite difficult to imagine the doctor’s utterance to change the topic so completely that the patient would not feature in it at all.

Communicatively, the complaint is not received, so to say. It’s not acknowledged or validated or taken up (Conversation Analysts would probably have a much better idea of what a response to a complaint is). Rather, the doctor shifts the conversation to the more general level of the consultation as a whole.

So, that’s a linguistic account of what happened. But let me now take a look at the institutional account. You see, as the doctor heard the complaint, s/he…., yes, you guessed it, ICEd the patient! ICE – ideas, concerns, expectations and the doctor did the patient a deal – the doctor skipped straight to expectations.

Obviously, I have no access to what the doctor wanted, thought, felt etc., yet, it is not beyond the realm of reason to suggest that s/he simply wanted to get the ICE questions over with. The doctor tried to be a good and diligent doctor and follow the rules of clinical communication and, more importantly, rules of patient-centred medicine. So, as any good patient-centred medic, s/he enquired about the expectations of the patient, so the consultation could go in the direction the patient wanted. Moreover, given the nature of the complaint, the doctor might also have expected that the ‘complaint’ is so serious  that if s/he didn’t ask the question straight away, s/he would not have had the chance to do it. So, s/he (idiotically) interrupted the patient in telling her/his story and asked the question.

Is this what happened? I don’t know. But assuming that the doctor didn’t want to cause the patient more pain and distress and s/he is not an idiot, such an interpretation is reasonable, perhaps even likely, but I don’t want to push it. It all results in complete communicative and social (and probably medical) failure.

Now, I’m writing this post not only to show that the doctor missed an opportunity either to shut up or to use their empathy, if s/he has any. My ulterior motive in writing this post is to take another swing at the so-called communication skills. You see, as I have written before, the way communication skills are presented and, presumably taught, are those acontextual rules which must be followed and applied regardless of the situation in which the doctor finds themselves in. And so, doctors are told to ask about ideas, concerns, expectations, so they ask about ideas, concerns and expectations. Stupid? Yes. But the rules, not the doctors.

Here I start repeating myself. The whole problem with clinical communication, the difficulty it poses, is that it is unpredictable. And communication skills will either be so general that they are useless, or they will be useless because they will try to impose a frame on something which cannot be predicted. So, yes, you can offer advice (it’s real) such as:

Communicate with honesty,

but it’s meaningless. Does it really mean you can only tell the truth, the whole truth and nothing but the truth in all circumstances? Surely, it can’t, for if we, including medics, couldn’t lie, our lives would become unbearable! Alternatively, if you tell doctors they must ask about ideas etc. at the beginning of the conversation, you will have exchanges such as the one this post is above.

Is there a solution? No, there isn’t. There will never be clear and simple rules of communicating which medics will be able implement. And as much as I know that talking about reflection etc. is just boring, what you can do is reflect on how you communicate. Nothing else. Because what works with me, might/will not work with the patient coming in after me. On the other hand, the dreadful mistake you make with me, might/will work wonders with the next patient. Go figure.

So, a linguist’s advice on language and communication is, paradoxically: Think, doctor!


  1. Out of many annoying exchanges – the psychiatrist who started off saying ‘well I expect you’d like me to provide a magic solution.’ Well actually that would be very nice, but by that opening statement you have now made it quite clear that you think I am an idiot and that you have no respect for me……

    1. Dariusz Galasinski

      I agree with this comment. Of course, it slightly depends on the context (was it a joke, for example, said while laughing), but transcripts of psychiatric interviews I have are full of utterances which suggest lack of any thought. Why on earth whould you say a thing like that?

  2. Having had a similar experience, I cannot imagine who would appreciate being spoken to in this formulaic manner. Perhaps there is such a person? In fact, my distinct impression was that this question is used specially for someone perceived to have a spurious complaint which did not fit an easy solution. Perhaps there was an ulterior motive to the complaint? Or was s/he just ‘one of those patients’ who is set on a referral or who has been naughty and consulted ‘dr google’ in advance? By asking this question early I wondered whether the doc was trying to out manoeuvre me by tricking me into giving my ‘real’ motivation.

    1. Dariusz Galasinski

      That’s a very interesting comment, Caroline! And your account of what happened is very different from mine. But you’re right. Such a shift of topic might well be interpreted as an attempt not to engage, to test the veracity of the patient. As we don’t know the context, any such interpretation is speculative. I do know, however, that the patient was taken aback by the medic’s comment.

      When I was asked the ICE questions, I assumed that the GP was simply following a script. Indeed, I challenged him and he admitted that it was now the ‘new thing’ he had to do. This has obviously informed what I wrote.

      Obviously, our interpretations might be complementary, the doctor might use the institutional script (as I suggested) in order to achieve goals for which the script was not designed (as you suggested).

  3. Communication rules and narrative competence are two different things. The former is akin to painting by numbers, the latter more like seriously, painstakingly and sensitively engaging with the work as it is co-created.

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