Masters of communication

I do dislike instructions how to communicate. I think most of them miss the point of what it means to communicate. But today I would like to go beyond those points. I would also like to have a look at how the how-to-communicate guide constructs communication.

So, here is the link to an article which discusses communicating with palliative care patients nearing the end of life, their families and carers. The article fits in very well with similar kinds of communication guides. Communication is seen as a set of communication skills which are acontextual, unnegotiated, and to be completely honest, just nonsensical. Once again, the article talks about those ‘all-or-nothing’ rules which simply do not and cannot make sense. For example, the rule of using open-ended questions, about which I have written a number of times, is just silly. Are you really saying that you’re not allowed to ask the question:

Does it hurt?

in palliative care, just because it’s a closed question? It’s nonsense, nonsense, nonsense and if I could have just one impact onto clinical practice, I would choose getting clinicians and their teachers to give up this unhelpful distinction between open and closed questions, in which the former are the good ones, and the latter are the bad ones. It so completely doesn’t make sense…

And the same kind of argument can be made about other strategies that are suggested in the article. But I would like to look how they are written. But before I discuss the strategies, let me have a look at what the author writes about the aims of the discussions at hand. The author writes:

Consistent with the key skills that are fundamental to effective communication in any clinical encounter, the aims of such discussions include:

  • Eliciting the patient’s level of understanding, main problem(s) or concern(s) about their medicines (especially those that are anticipatory) and any impact (physical, emotional or social) that these are having on the patient;
  • Determining how much information the patient wishes to receive and providing this to ensure medicine optimisation;
  • Ascertaining whether the patient wishes more support to engage in medicine or EoL conversations with other family members or carers.

When I read it, I thought, is there anything else you would like to do to me? Yes, that’s exactly what I mean. Have a look at the initial verbs which are used in the three goals of the discussions with palliative patients. In this case pharmacists are to:

  • elicit
  • determine
  • ascertain

Bloody hell, I thought, can you also talk? You know, like talk, I don’t dare ask about listening. Or do you start with eliciting, then you do determining and you end with ascertaining? Note that even the patients’ wishes are actually (linguistically) mediated through what the pharmacist does. The patient cannot simply wish or express their wishes, oh no. It’s for the brave pharmacist to ascertain or determine!

Though I must admit that I particularly like the eliciting. You know, the patient just sits there, unaware and generally unintelligent, but, thank goodness we have the sly and shrewd pharmacist who will, in their unlimited intelligence, elicit stuff. It’s almost like Robin Hood stalking deer.

Problem? Yes, it’s a problem. Because this is how you see communication. For pharmacists communication is about them doing something to the patient who cannot be simply listened to. No, they need approval and authorisation from the pharmacist. And, incidentally, let’s be completely clear – it’s really not only pharmacists.

The problem, however, is more serious. Because this view of communication cascades down into communication strategies. Here are the first strategies mentioned in the article:

  • Using open-ended questions;
  • Soliciting agendas early in the interaction;
  • Asking permission to raise particular topics;
  • Using verbal and non-verbal expressions of empathy;
  • Using praise;
  • Using ‘wish’ statements;
  • Aligning with the hopes of patients, loved ones and carers through the use of ‘hope for the best’ phraseology.

Have you noticed that there there is no interaction at all? There is no talking, there is no negotiation, there is no listening. No, communication consists in the healthcare professional doing things. In particular, they use certain ‘language’, which, I must admit, I find mostly patronising. Why would you just say ‘using praise’? Do you also have this nagging impression that the strategies position the patients and families as children? Using praise? There is a good girl, you’re such a wonderful boy. But I’m probably exaggerating. Who wouldn’t want to be praised and hear ‘wish’ statements. No, I have no idea what they are.

I don’t even want to know what a non-verbal expression of empathy is. Do you have pictures?

Yes, yes, I have noticed the aligning ‘with the hopes’, but have you noticed that there is only one way in which to do it? You would be forgiven for wondering who actually needs to align with whom. If the pharmacist can only use ‘hope for the best phraseology’, then if you actually don’t want the syrup, then it’s tough. You align.

And yes, I have also noticed ‘asking permission to raise particular topics’. Very interesting. It seems there is this one area in which patients have a say. No, they still don’t listen, negotiate, talk, they just ask permission. May I? No. OK. Silence. May I? Yes. Thank you. I shall now solicit an agenda.

Do you occasionally have conversations? Are you capable of having a conversation? I started wondering where this comes from. The authors useful provide us with a source. Here is a link to NICE’s clinical guideline which is quoted in the paper. How do you communicate? Well, you ask (open the channel) and then you

“provide verbal and written information”.

I mean, do you, people, talk? Sometimes I wonder whether healthcare providers are actually human. You know, do you pee, fart, snore, swear and stuff yourselves with sweets? Like normal people. Or do you just hover half a metre over ground in an air of wonder for the rest of us to admire? Asking important questions and providing us, mere mortals, with information, obviously. And we will just lap it up in awe! How many people do you know who ‘provide information’ instead of just telling  others?

But, I’m afraid the worst is only to come. Below is a contrasting of two ‘communication behaviours’. To be honest, how a communication strategy becomes a communication behaviour within a few paragraphs is just beyond my capacity to understand, but there you are. Here you have it:

Communication behaviours that contribute to a patient’s sense of hope:

  • Being present and taking time to talk;
  • Giving information in a sensitive, compassionate manner;
  • Answering questions;
  • Being nice, friendly and polite.

Behaviours that have a negative influence on hope:

  • Giving information in a cold way;
  • Being mean or disrespectful;
  • Having conflicting information from professionals.

Awwwwwww. So nice….answering questions – kindness impersonated. And yet, have you noticed that even being nice, friendly and polite don’t have a recipient? It’s like you are supposed to be it, because we want you to be it. Communication is about you, you, and you. And never about me, the patient. You see, even the example of a seemingly helpful question:

Would it help if I put the tablets for each time and day in an easy to remember pack?

is really about you and not me. Have you considered who should decide whether the pack is easy to remember? Or do you already know and just will give it to me.  And if I don’t find it easy to remember, tough sh.., innit? And just a little snipe, please. I thought were not supposed to ask closed questions!


Communication is difficult. Communication in some circumstances can be very difficult. Healthcare professionals should get support to manage it. The problem is that communication guides do not offer helpful information. What they do offer, however, is insight into how communication is constructed by those who produce the guides. And it turns that communication is done unto people. Not with people. And so, perhaps, just perhaps, when you create your next communication guide, you start with considering what communication should be. That would be a really useful start.


  1. Thanks Dariusz (and apologies for my culturally insensitive spellchecker that systematically tries to remove the Z). If it’s text you’re mainly interested in, I hope you might look at some of the text of my book when it’s out and offer some reflections as a linguist in your blog. I don’t expect you to be uncritical but hope you’ll find some merit in some healthcare educators at least making the attempt to frame consultations in terms of dialogue and not interventions.

  2. Hi Darius. This is brilliant as always and full of important points every doctor should understand. But what I miss is an indication that there are ANY medical educators out there who accept all these problems and are trying as best they can to address them – and I know you know some of us. At the risk of immodesty (or, God forbid, inviting a dedicated rant of its own :-), please can I mention there is at least one model of interactional skills (I never use the term communication skills) that has the word conversations in its title, explicitly speaks of the co-constructed nature of consultations, and includes as a principle that any formulaic approach should be abandoned at once if the response indicates it is inappropriate or inauthentic. The book of the model is coming out in Spring, with acknowledgement of the part you have generously played yourself by giving input, particularly in relation to issues of power:

    1. Dariusz Galasinski

      John, thank you for your comment. I guess I should stress more that I tend to write only about text. Of course, there are educators (and doctors) who understand very well what I am ranting about and they actually put it in practice. To be honest, I even don’t care how successful they are. As a professional communicator, I know only too well how difficult it is not to make a mess of simple interactions. I do appreciate your acknowledgement! I look forward to reading the book.

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