Great communicators lean forward?

I had not heard about patient-centred communication till a few days ago. My initial reaction was one of astonishment. I just about understand patient-centred care (though with some difficulty), but patient-centred communication seemed a bit strange, to be honest. Can there be communication which is not ‘patient-centred’ in a doctor’s surgery? I decided to investigate.

A quick search yielded a narrative review. The authors say that patient-centred communication is agreed to be:

  • eliciting and understanding patient perspectives (concerns, ideas, expectations, needs, feelings, and functioning),
  • understanding the patient within his or her unique psychosocial and cultural contexts
  • reaching a shared understanding of patient problems and the treatments that are concordant with patient values.

Great? Well, kind of, as the first of the points reminds me being ICEd, but at the end of the day, can I really say that these principles are a problem? Not really, it’s nice rhetoric. Yes, in my view, it’s rhetoric and not much more.

As a linguist, I tend to be interested in how exactly it will be achieved. And this has two aspects. First it’s about the possibility of an understanding platform, second, it’s about what is said. While I am fairly regularly ICEd (though certainly not by all doctors), I am yet to see a medic who is even remotely interested in what I have to say. They simply pay lip service to the rhetoric.

However, to a considerable extent, I wouldn’t be interested in what I have to say, either. For example, my perspective and expectation with regard to my CFS is that it go away, except it won’t, so there is really not much to talk about. Yes, you could say I should get real and change my perspective, except that I am not interested in changing it. So, with all the respect I can muster, you can go to hell.

And this is my first problem with the wonders of ‘patient-centred communication’. All these lovely ideas assume that I actually want to be understood, that my perspective is negotiable.  Moreover, the doctor just needs to reach out and, hey, presto, there I am, ready to share understandings. This is quite irritating, I must admit. But it’s more than irritating when I read the following in an editorial on patient-centred communication. The author writes:

Patient-centred care requires physicians and other healthcare providers to have the communication skills to elicit patients’ true wishes and to recognise and respond to both their needs and their emotional concerns. As much as any technical skill, communication is a sophisticated procedure—one that needs to be taught and honed throughout one’s career.

How patronising can you get? I mean, do I have any role in your eliciting? Or do your skills simply ‘elicit my true wishes’ whether I like it or not? Could you possibly consider (just for once) that I might not wish to tell you something and all your eliciting will come to nothing? Is there any chance at all for some humility?

Before I go to the nitty-gritty of patient-centred communication, let me just deal with one more thing (from the narrative review). Successful communication is (among others) to

  • be uncomplicated
  • be specific
  • use some repetition

Really? Things are just uncomplicated and so, you will  simply be uncomplicated? And if you don’t repeat, I will not understand? I’d better not comment.

Some time ago, I wrote about communication skills. I argued that they are means of exercising power through communication. Interestingly, nothing changed in this respect also when you talk about patient-centred communication. Here is a communication skills table from the narrative review, the best practice – if you do it, you just can’t be more patient-centred. Also here, however, no one noticed, it seems, that this whole communication caboodle is only about the medic and their power. Have a look at those phrases:

  • Prepare patient for deliberation
  • Facilitate understanding
  • Overcome barriers
  • Engage in partnership building
  • Facilitate patient expression of emotional consequences of illness

And my absolute favourite:

  • Elicit patient’s full set of concerns

As this blog is politely academic, I will not tell you what I think about this. Let me just suggest that directing the medic to elicit my ‘full set of concerns’ is, I’m sorry to say, idiotic. How will you ever know that you have the full set, if I might not know it myself? But what is crucial in these directions is that they construct communication as actions which the doctor performs on me, their passive object. Even partnership building is something that only the medic does. Yes, even the bloody partnership is constructed in paternalistic terms, with no respect for me and my wishes. It’s like a gift bestowed on me which I, obviously, must receive with gratitude. Gosh, what privilege!

Let me show you more. In the monograph Patient-centred communication in cancer care, the authors encourage:

  • Helping a patient share power by offering him or her meaningful involvement in choices relating to his or her health

And I just despair. Why is it all is in your gift? Why is it for you to ‘offer me involvement’? There is no sharing power here – you allow me to do things. And I’m really uninterested.

But then the authors offer examples of patient-centred clinician behaviours and under non-verbal, they list the following:

  • Maintaining eye contact
  • Forward lean to indicate attentiveness
  • Nodding to indicate understanding
  • Absence of distracting movements (e.g., fidgeting)

You see, this is normal conversation. Little children tend to maintain eye contact and nod when they understand. So, why would you give such advice to adults who, admittedly, were high achievers at school and are fairly well educated and probably fairly intelligent? Surely, they mastered the art of talking to another person, no?

And then it struck me. It seems that medics need to be reminded that when talking to a patient, they actually talk to a person and they need to do it in a civil way. You know, that looking at the computer screen when the patient is telling you about what hurts them is not exactly nice. But then, and that’s really ironic, if you need to remind medics of all that, how patient-centred is the care they provide? What transpires in the process is that the advice is actually about pretend play. Doctors are told to act. I can almost see a little note on the desk in front of the medic:

  • Lean forward, stupid.

And when a patient happens to complain, this will be the greatest defence: But I leaned forward. Or, damn, I forgot to lean forward again.

I could even offer a new slogan for medical education:

Great communicators lean forward.

But if you wish to cover your face with your palm, I will understand.


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