Let’s just talk. You and I

I guess this blogpost is another rant. I simply don’t understand why medics are taught ‘phrases that ‘we’ found useful’.

Let me start by repeating what I said a number of times. Whenever I object to documents which make suggestions how to speak, I inevitably hear that I simply don’t know what I am talking about. No one makes any suggestions, the examples are just for the heck of it. And so, when I read the ‘Check list of key skills, which you can find on the Health Foundations website, I found it strangely refreshing. At least they are open – yes, they want the trainees to learn phrases. When you speak to your patient, you can recall phrase 1, 13 and 56 and Bob’s your uncle. You will do SDM in no time at all to the satisfaction of yourself and your patient. What can go wrong?

Well, before I tell you what can go wrong, let me tell you that I actually do mean it. I prefer the honesty of telling people that there are phrases that are helpful, instead of pretending that they are only examples which are to be ignored. This is because such an openness allows an honest discussion about the approach. But that’s where the sugar runs out, and my rant starts.

My rant can be summarised as follows: just about everything is wrong with such an approach and here are what I think are the most important reasons.

1. I find it really scary that a fairly reflexive medic must be taught specific phrases for use when s/he talks to a patient. Yes, it’s good to practice communication, but surely a well-educated and thinking doctor is capable of understanding what is conducive to building their relationship with their patient and what is not. I actually hope that as much as they can take a decision which pills to give me, they are capable of deciding what to say without a cheat sheet. If not, I guess, I must reassess what I think about their capacity to reflect.

2. I have no evidence for it, but I tend to think that asking doctors to memorise phrases will lead to formulaic, stilted, unhelpful communication in which the physician will be looking for the moment to place the phrase, so to say. This is the point I tend to make with regard to ICE questions, they must be asked, so they are asked regardless of what they patient is saying and how distressed s/he might be (I made this point explicitly here).

The mechanism is simple, I think. If good communication means using certain phrases, then medics will try to use the phrases, regardless of whether it makes sense or not!

3. Here comes the main issue – the context. The phrases suggested in the checklist are abstracted away from any interaction context in which they must be said. Problem? Yes, a big one, as one phrase might fit into a conversation with X, but not with Y. Consider the first of the phrases in the checklist (I’m taking the first one, so that I can show that I was not looking for the phrase that is easy for me to argue against):

Now that we have agreed on the problem, we can talk together about what to do next”

Consider two things. First is the use of the pronoun ‘we’. I dislike ‘we’, it can be very manipulative and in the process imposing. Many times I have objected to doctors using the pronoun in reference to themselves and me, saying that there is no ‘we’, it’s you and me and that doesn’t necessarily mean ‘us’. The pronoun suggests that there is a rapport, a common goal and understanding. Please, medics, if you read it, ask yourselves how many times can you actually honestly say that you achieve it with your patients. I can tell you that, while it varies, of course, I’d say I achieve a ‘weness’ with a doctor very rarely. And it’s probably rarer that that.

Needless to say, I do accept that it happens, perhaps it happens more often than I think, still, if it doesn’t always happen, please don’t patronise me with your ‘we’. It’s you and me.

The second point is the phrase ‘we can talk together’. I’d like to ask you this: Can I say this? It’s a simple question. Can I say:

We can talk together about what to do next.

I can’t, can I? It’s for you to open the space for this talk, it’s for you to open the channel of communication. The phrase is only about your communication rights and absence of mine. But then ask yourselves how shared is the shared decision making, if you actually give me permission to engage in it. Tough one, innit?

I know what you’re thinking. The first phrase is just unlucky. Take the second phrase:

There is more than one way to deal with this problem and the evidence shows that some treatments suit some people more than others

Why tell me this timeless truth, instead of telling me there are ways in which to deal with my problem. Or even better, in which I can deal with my problem? Or perhaps you and I can deal with my problem? There is no answer to the question which is the best option, there cannot be, but please don’t tell me that I should learn your phrase rather than those I just wrote.

Call me an optimist, but I would really like to hope that, as competent language users, even medics will stop a moment to think about which one to choose. And they will not be reciting the phrase the HF found useful.

Teaching medics, and other people for that matter, how to communicate is tough and there’s no way round the problem. I’m afraid that as well intentioned as the course is, teaching individual phrases will never lead to the kind of communication and care that the Health Foundation aims for. In fact, I would suggest that it is likely to have the opposite effect. Moreover, I personally will always prefer a doctor who muddles her/his way through, but shows me they care, instead of one who perfectly recites the perfectly timed phrases using the perfectly pitched voice. It’s probably because I prefer speaking to a human being.


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