Paternalising distress

Here is the tweet by the BMJ in which they show a new infographic on communicating with patients in distress. I find the content of the infographic quite objectionable. This post is about why this is so.

Let me start with a general reflection. Whenever I read  about communication skills in medicine, I am disappointed. Time and again, I see communication skills and examples in communication described and recommended outside of any social/communicative context. Clinicians are taught communication as if it were about pushing buttons. As long as they remember how to do it right, communication will simply happen. Needless to say, this is a breath-taking oversimplification and whenever I am asked to talk to clinicians about communication, this is the one thing I ask them to take away from what I say. Communication is a negotiation not an imposition. Unfortunately, the ‘model’ of communication rendered in the infographic is similar to the one I have just described above. The clinician is represented as the one in charge of communication and its channels, while the patient is reduced to being a passive receiver of what they’re told.

The first stage of the ‘distress communication’ is inviting the patient to disclose distress and priorities. It’s worth saying that inviting suggests the possibility of declining. Yet, this possibility seems moot, as the second stage is about acknowledging distress. And here you have the problem. It’s a model in which the patient cannot not speak, well, disclose. Your words open me like a book you will read in the 15 minutes you give me.

It really never ceases to amaze me that medicine seems to think that your ‘invitation’ will set me off on the journey of disclosures. Of course, talking about the most intimate, distressing, troubling, shameful things I experience will simply happen on your say-so.  I mean, we really must live in different universes, if you think that I will share anything with you just because you say something. Please try to get real.

But something else happens in the first two stages of talking to a distressed patient. While the first stage is about distress and priorities, in the second stage the distress disappears. The question the clinician is supposed to ask is about my….concerns and then only priorities. So, where has the distress gone? Let me put if differently – is there still an opportunity to simply talk? You know, like talk. Psychology tells us that just telling a story of my distress can be therapeutic, your listening to me can be therapeutic, so is there a chance you will simply listen to me? As I tell you a story, however incoherent? Can I simply talk?  For the model suggests that there is no such chance. Distress vanishes quickly, and you will be asking me about my priorities, and my conceptualisations? And, stupidly, I thought we were about to talk about my distress…No?

But the first two stages have another interesting dimension. They firmly show who is in charge. After the inviting (regardless of whether the patient wants to be invited) and acknowledging (after all, I so will open), you then ‘set the agenda’. And I have a question. Do I have a say in setting the agenda? You know, with ‘patient centred’ and all this nonsense, I should, shouldn’t I? Well, not in the world of the BMJ. The medic sets the agenda and that’s the end of that.

But notice the question, the medic is encouraged to ask:

I’d like to learn more about your concerns and develop next steps to start addressing them.

The medic-centeredness is complete. For even the question in which you are supposed to ask me about how I feel is about you and what you want. And, to be honest, I don’t give a flying flamingo about what you ‘would like to learn’. That’s your problem and, for pity’s sake, is there any chance you could stop talking about yourself and start talking about me?  Could I perhaps have an opportunity to ‘start addressing’ or is it also about you?

I am not going even to dignify the reduction of my potential distress, suffering, fear and shame to ‘my concerns’ with any significant discussion. Really? All that I feel can just be reduced to ‘my concerns”. Bloody hell, you really have no idea, do you?

The third stage, after you established the agenda, told me what you want, is about putting me in my place even more firmly. For I could not possibly do anything without you, so you must help me. And I appreciate your help no end. I am this little, half-witted patient, who cannot possibly think for myself. But thank goodness, you are there for me.

And have you noticed what the medic is encouraged to say:

By focusing on one concern today, this helps you avoid feeling overwhelmed and be better able to make a plan you feel confident you can try.

I couldn’t be more patronising even if I wanted to. The certainty with which the medic is supposed to talk is awesome. You really do know what will help me, don’t you? What can I do? Well, I can’t make my own plans, I need to be helped, and the only thing I can do is to try the plan. Even if you wanted to undermine me some more, you probably couldn’t.

However, what happens, if, you know, on the off-chance, I still feel overwhelmed? Well, tough shit, innit? I have only myself to blame. After all, the doctor has motivated and empowered me. When I read it, I just started laughing. I hope that you will have noticed that once again, I have nothing to do with the motivation and empowerment. It’s all the doctor’s gift and doing.

And when you tell me that you believe in me, I will be soooo happy. I can’t even hope for so much kindness from you. Alas, I am not entire certain whether telling me that you will ask me how it went is a promise, a warning or a threat, but there you are. It’s all about you, after all.

But I am so delighted you end by focusing on me. It’s so kind of you. Perhaps you could re-consider the fact that the only thing you say about me is about me failing, but I guess, I should be delighted you actually noticed me. Because it’s not entirely about you after all….Gosh, you are so good to me.

Let me finish with the creation of commonality at the end of stage 4 (let’s review…’). Interestingly, it vanishes as quickly as it appears. After all the paternalism, after all the agency bestowed on the doctor, the end of Stage 4 is about what the patient chose. I chose one priority (not that I had any choice), I made a plan. Yes, at the end of the day, it’s all on me, isn’t it? Even though you set the agenda, you told me what to do, the bottom line is that you wash your hands off it all. If I don’t succeed, you make it very clear, I will be to blame. Thank you, doctor.

And so, we come to the end. No, I have no idea what the authors of the infographic thought. I think that how it is written is quite telling. It’s an embodiment of paternalistic medicine which pretends to be something very different. Don’t be fooled.

Perhaps, I should stop here.


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