Who listens?

Not long ago, I was involved in a discussion about the LISTEN project, developed in the NHS. It’s advertised as developed by service users, carers and clinicians. I think the idea is great – it is certainly desirable, probably also necessary, to remind clinicians to listen. Unfortunately, the poster, which is created as a reminder, is not very good at all.

Time and again, when I see posters trying to put across a message about clinical communication succinctly, I tend to be disappointed. On their surfaces, the posters/messages seem to convey a helpful message, but when you stop to consider it, it becomes much more unhelpful and, oftentimes, you wish it hadn’t been offered. What transpires is more of the same paternalistic medicine, asymmetrical relationships, and agency endowed only to clinicians with patients reduced to being objects of their actions.

And so, let’s consider the poster of the LISTEN project.

Listen poster for download

It makes sense to assume that the poster is directed at clinicians who are told to listen. But who speaks, you might ask. I hoped it would be the patients, rendered here as service users.

A reservation here. I honestly don’t understand this obstinate use of phrases like ‘service user’. I haven’t come across a single piece of research that suggests that most people who receive treatment want to be called ‘service users’. There is research, however, that people want to be called patients. It really beats me why continue to avoid ‘patient’ and shove ‘service user’ down the patients’ throat. What’s wrong with being a patient?!

Alas, the author of the poster is hidden. Can it be the patient, though? It can, but if it were, the patient would not refer to themselves in the 3rd person. I would never, for example, tell the doctor to ‘inform Dariusz’. Rather, I’d say: ‘inform me’. Similarly, why would patients say: ‘inform the service user’? So, who speaks? God? The NHS? The management? We don’t know, what we do know, however, is that patients as ever, are spoken about. Patients have no voice.

And indeed, the entire poster represents the patient as without a voice. The patient doesn’t speak, they can only listen. Consider for example:

  • Listen and validate concerns
  • Inform the service user
  • Be clear
  • Encourage responsibility
  • Evaluate what has been agreed

These, and a couple of others, are all communicative actions on the part of the clinician. The patient is never represented as doing anything, let alone saying something. It’s done so doggedly that possible patients’ activities such as understanding (under S) or agreeing (under T) are deleted.  Instead of constructing a relationship, the poster says:

  • Shared understanding achieved
  • Evaluate what has been agreed

Achieved how, where, between whom? All that is left out. Who agreed what? That is also left out. For the author of LISTEN, it is better to talk about impersonal understanding and things being agreed, rather than represent the patient as understanding and agreeing. And you could, for example, write something like:

  • Make sure you understand me.
  • If you’re not sure you understand me, ask me questions.
  • By listening, you will understand better what I have to say.

There are many other possibilities in which a poster like this represents both parties, the clinician and the patient, as communicating on a par. And yet, it’s extraordinary that the patient is altogether removed from the poster. The only time the patient is referred to:

  • Inform the service user

it is as an object of the healthcare professional’s informing. And there can hardly be a more unidirectional act of communication than informing. It is ironic, isn’t it, that the poster which purports to tell the clinician to listen represents them as speaking and it is the patient who is represented as listening. It is so consistent that the clinician in the poster has nothing to listen to – patients are not represented as speaking at all!

The poster about listening is not about listening at all. If anything, it is about reinforcing the drastically asymmetrical relationship between the clinician and the patient. It doesn’t serve listening; it only serves legitimising the doctor who has the power to validate my concerns (do they really need validating?) and tell me how it is.

Let me end with a more general point. Every day, my Twitter timeline contains tweets announcing that language matters or asking to make sure that we speak right. The poster I am taking apart has, I assume, only words which are allowed. And yet, it is utterly unhelpful. It reinforces much of what is wrong with medicine. And so, instead of worrying about individual words, worry about how grammar works in the text. How are people represented in it, who does things, who is done to? Where are the verbs, in what form are they, where the adjectives? When you stop to think about them, you will see what kind of social reality appears in the text. And you can ask yourself whether you like what you see.

And then, you can design the LISTEN poster again.


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