When, and how, to talk about weight with patients
During my undergraduate degree I was acutely unwell with a bad cold. I needed a medical certificate to get an extension on an assessment that was due so I could recover through rest. I couldn’t get into my regular GP, so I went to one nearer the campus.
As I was a new patient, the doctor wanted to take a slightly broader history, which made sense to start with as that gave her some more contextual information. But I was surprised when she decided to explore something in more detail: “Let’s talk about your weight”.
Part of that surprise was because at the start I had explained that this was a one-off visit to the clinic and that I’d follow up with my regular doctor if I had ongoing symptoms. It was also because it really seemed out of the blue for a consultation about a cold.
I didn’t think about this incident much until just last year when a friend of mine went to see a GP about a lump in her breast. She decided it would be worth seeing someone that had a good reputation specifically in this aspect of women’s health. It was her second ever visit to this doctor and the first for this concern.
After a very brief examination, the doctor declared: “I’m not concerned about your breast, but you are very overweight”. This was followed by my friend being put on an extremely restrictive diet so that she could lose weight quickly, without so much as a discussion as to her general medical history or lifestyle or mental health.
In news that is unlikely to surprise you, neither of us lost much weight after these encounters. It is also not an uncommon experience for overweight people, and particularly women, to have our weight be front and centre in consultations. The fatness can often be the first problem source considered for symptoms, which can result in missed diagnoses along with a reluctance to seek further care in environments where fat patients can be treated with less respect, resulting in lower trust.
Health behaviour change strategies such as motivational interviewing are being more frequently recommended as a good approach to all sorts of lifestyle concerns. These kinds of patient-centred strategies have reasonable outcomes within study environments, but how does talking about weight work in the wild? In practice, talking about weight is hard for a variety of reasons, including difficulties in even broaching the topic and the awkwardness of such conversation.
When considering raising weight, some research has shown that one of the more effective strategies is to ensure it is linked to the patient’s presenting problem. Rather than raising weight as an additional concern, highlighting the clinical relevance of weight opportunistically can allow for more positively received brief interventions.
This needs to be done carefully because there is some evidence that it may be met with resistance, particularly if the link was not clear to the patient. This may be due to the larger social issues at play – the ongoing issues of stigma and moral accountability for weight can make starting conversations difficult. If weight is raised in ways that are not sensitive to these issues, it may delegitimise the patient’s request for medical attention.
No matter the approach used, listening to the patient’s response is crucial. Recent research into referrals to weight management services in the UK showed that simple affirmative responses from patients, such as a “yes” or “yeah”, are often interpreted as positive uptake by the GP. But, in reality, these were not associated with engagement with the service. Instead, patients who gave more enthusiastic affirmative responses, such as “oh yes” or “lovely”, were more likely to take up the suggestion.
Equally, when a patient seems resistant, pursuit of positive uptake is not helpful. Resistance is not something that needs to be overcome. Instead, it can be a window into the personal and social barriers for the patient in taking on lifestyle advice and offers an opportunity for the doctor to modify that advice rather than simply repeating it.
These studies have found that providing positive advice and foregrounding general principles of being healthy regardless of weight were more likely to get uptake from a patient. The mixed evidence on how to do this highlights that more research is needed to identify the more effective approaches in different clinical and cultural contexts. For now, carefully listening to how patients respond while checking for your own possible bias toward fat patients and their concerns will make these conversations easier.
Special thanks to A/Prof Maria Stubbe and Dr Charlotte Albury who provided advice on this article. All errors remain my own.
Originally published on MJA Insight+ https://insightplus.mja.com.au/2021/33/when-and-how-to-talk-about-weight-with-patients/ 6 September 2021
Managing multiple patient concerns in a GP consultation
One of my favourite studies to share with doctors is what’s commonly known as the “some/any” study. In this randomised control trial, participating primary care doctors were trained to ask the patient about their additional concerns after they had presented their first concern (presenting complaint or problem). Before the consultation, the patients were asked to list the concerns they were planning to talk to the doctor about that day. The doctors were randomly allocated into one of two groups. One group asked, “Is there anything else you want to address in the visit today?” and the other asked, “Is there something else you want to address in the visit today?”
It’s just one word, so you might not think it would make a difference. But it really did. What was already known from interactional research was that “any” is more likely to get a no response, while “some” is more like to get a yes. When the analysis was conducted, the authors found that for patients with multiple concerns and who were asked “anything else”, 53.1% raised another concern. For those who were asked “something else”, it was 90.3%. One word can really make a difference.
In my experience as an educator, doctors really like this study because it is a seemingly simple change that can make a big difference. And, if I’m being cynical, there is a higher value placed on quantitative research. But focusing on one word might distract from the problem being addressed: patients’ unmet concerns.
I’m the kind of patient that comes in with a list when I see my GP. I save a few things up and then go, and I’m not alone. I’m also the kind of patient that whips out my list at the start of the consultation, pre-empting the upfront agenda setting that can help doctors manage a consultation. Upfront agenda setting is when the doctor and patient establish what concerns will be discussed near the start of the consultation. It helps plan the structure of the consultation and results in fewer surprise topics being raised later in the visit. And because it assists in time management, upfront agenda setting does not make the consultation longer.
My own research has focused on surgeon consultations where multiple concerns might be less expected for patients compared with primary care. That said, in ongoing work looking at general practice consultations, we have not come across upfront agenda setting much either, even when it turns out patients do have multiple concerns that they pursue without prompting.
This is reflected in research that found that agenda setting, upfront or later, occurs infrequently. If a doctor solicits additional concerns early in the visit, patients are more likely to respond with additional concerns than if it were later in the visit. Equally, if the patient raises their own additional concerns, earlier is also better as it’s more likely to get addressed by the doctor.
Upfront agenda setting works, so why doesn’t it happen more often?
My research involves recording and analysing real consultations and I’ve noticed that doctors have their own habits and styles. This is good as it means communication is authentic and reflective of their own characteristics. However, it might make new habit-forming more difficult. Communication is part of all medical programs in Australia; however, without a specific review on content or a national curriculum for communication, it is unclear whether the particular skill of upfront agenda setting is taught. Perhaps the doctors I have recorded were not taught upfront agenda setting at medical school and those that have may have incorporated it into their consultation style.
There’s good interactional research that supports introducing upfront agenda setting into the consultation. Beyond including it in medical training, this could be taught to practising doctors through recording consultations and reviewing them to help identify their own practices and how they might incorporate such a change in their own approach to consultations. Just like any new skill, communication skills can be taught and learnt, and practice is what facilitates improvement. If you do try it, just don’t forget that one word can really make a difference.
Originally published on MJA Insight+ https://insightplus.mja.com.au/2021/28/managing-multiple-patient-concerns-in-a-gp-consultation/ 2 August 2021
Communicating legitimacy: acknowledging the right to be sick
Medical schools and colleges agree that communication is important to clinical practice. Sometimes it is seen as essential for patient satisfaction or rapport building, which are important, but this is a limited view as to how communication can directly affect patient care.
As a linguist and conversation analyst, I have spent the past 15 years exploring the intricacies of doctor–patient communication – how the structures of interaction influence patient participation in one of the central parts of health care provision. As a person, I have spent the past 20 years living with illness. My drive and desire to understand what goes on in clinical consultations comes from too many experiences of what goes wrong.
Some of my struggle as someone with chronic illness has been trying to be taken seriously, especially when I was younger. With lower back pain as a 17-year-old, I was told it was just because I was still growing. As a 25-year-old, I was told it was because I wasn’t trying hard enough to get better. It was not generally talked about as a serious problem until more recently when I’ve reached an age where pain might be more expected.
Much has been written on this topic in recent years, particularly about women and minority genders when experiencing pain. This is exacerbated for people of colour.
When I teach about being taken seriously, I draw on Parsons’ sick role. In the 1950s, Talcott Parsons wrote about the social rights and obligations of people when they’re sick. While there have been critiques of this theory, particularly in considering acute versus chronic illness, we can still see both patients and doctors orienting to these rights and obligations in the way they interact in consultations.
The rights of being sick, to paraphrase Heritage and Clayman, involve an individual’s exemption from normal activities and freedom from personal responsibility while the obligations are that the individual strives to get better and that they seek appropriate help to do so. If a patient’s legitimacy for seeking care is called into question, it can threaten their role as being sick and thus their ability to claim these rights. In everyday life, these rights are seen in the provision of medical certificates for sick leave, for example. Sometimes a problem is clearly legitimate without explanation, such as an acute and obvious injury. Other times, this legitimacy is less clear and so is talked about with the patient demonstrating that they consider their problem is “doctorable”.
Patients strive for legitimacy in consultations, saying things such as “I’ve rested and taken cold and flu tablets, but I can’t shake this cough”, which shows they’ve tried to get better on their own and now need expert help. Or they might say “my wife sent me”, which implicates an external source of legitimacy. For those with referrals, they have that legitimacy built in, with an expert providing external support for the validity of pursuing care. This has its own implications within referred consultations, where the treating doctor needs to work with both the patient’s concerns and the referring doctor’s expertise in having referred the patient.
As a doctor, you can reinforce the patient’s legitimacy in seeing you. When I was pregnant with my first child, I had a placenta at the front, which means I couldn’t feel many kicks. The second time I went to the hospital to check the baby near the end of the pregnancy, the obstetrician said to me “everything is fine, but I am glad you came; if you can’t feel kicks again, please come up”. This ensured that I felt that I had requested care legitimately and that I would come again. When experiencing some strange autoimmune symptoms, an immunologist said words to the effect of “just because we don’t have a diagnosis, doesn’t mean these symptoms aren’t real, so let’s work to manage them”. These words allowed me to know that my concerns were being taken seriously and that I could trust her to help me, rather than looking elsewhere.
Why are these kinds of statements important? They address the sick role: if a patient’s concerns are dismissed, it implies that they are misusing the sick role, that they should not have sought care in the first place. This can cause people to distrust medical care, which may, in turn, create more problems. Providing legitimacy through talk can go a long way to making patients feel heard, that they are being taken seriously and that their concerns are reasonable and deserving of care. Legitimising the patient experience in turn assists in a smoother conversation, a better relationship, and very likely improved adherence to treatment.
Originally published on MJA Insight+ https://insightplus.mja.com.au/2021/24/communicating-legitimacy-acknowledging-the-right-to-be-sick/ 5 July 2021
Compassion in healthcare interactions
Compassion, like rapport and respect, are the outcome of an interaction. This is sometimes referred to as “relational work” in interaction.
Research on real social interactions, such as those that use conversation analysis, show how empathy and compassion are achieved.
There is a growing interest in compassion and empathy in this kind of research on healthcare interactions. This paper, for example, shows that “effective empathic validations must (a) demonstrate shared understanding and (b) support the patient’s position.” Poorly timed or expressed empathy can lead to patient rejection, while well-crafted empathic responses are more likely to be accepted.
“Rather than a rush through, personalized care must at times enact a slowdown to honor the integrity of patients’ emotions.” Beach (2022, p220)
Empathy and compassion do not need to be a standalone moment in the interaction. It can be achieved while conducting biomedical work, such as demonstrating an understanding of the patient’s perspective while also conveying a biomedical perspective in the same turn. Empathy and compassion can be used to agree with a patient’s concerns and experiences. But empathy does not equal agreement. Clinicians can be empathetic without agreeing with a patient’s perspective.
Compassion is achieved through interaction. This means that improving compassion needs to focus on evidence as to how this is done in the wild.
More research is needed to identify whether there are compassionate conversational practices that can lead to improved patient experiences and outcomes. Similarly, we need research into the external factors that may reduce compassion, such as organisational and professional cultures. This will produce greater evidence to support teaching the how of empathy and compassion to healthcare providers. In the meantime, we need: continued advocacy for person-centred care, integratation of the research that is available into teaching, and support for clinicians to engage with the complexity of conversation so that they can develop skills in responsiveness to support suitable empathic responses and to recover if empathic responses ‘misfire’.
Patient agency: connecting the dots in my research
As I transition from full-time academia to my own adventures in business, it’s given me pause to reflect on the story of my research. I have always tried to pursue research projects that I have felt would be important, impactful, or interesting. Preferably all three.
I started researching communication in healthcare due to personal interest. As a young person with what had become chronic pain, I had experienced what might be called “bad” communication. These experiences occurred at the same time as when I studying linguistics in my undergraduate degree. I’d fallen in love with a course I took on Conversation Analysis — it was so fascinating and opened up a whole way of looking at the world.
Instead of assuming doctors are bad communicators, I wanted to understand how doctors and patients get things done through conversation. Starting with surgeons, I began by examining how consultations happened — how did surgeons and patients get from the first greeting to the end of the conversation.
This led to an exploration of patient agency and, in reflecting on the story of my research, I realise this is a thread that has continued through my research as well as my teaching and advocacy. It has been important to me to describe how patients are not passive recipients in healthcare. How they contribute to the consultation in ways that are active yet with consideration of the expected socio-cultural norms of communication when seeing the doctor.
Agency has remained a core component of my research even as I’ve researched other clinical professions and had different focal topics. In researching telehealth for specialists and surgeons and then for general practitioners, we found ways in which patients manage to initiate additional contributions to the consultation and how conversational (rather than transactional) approaches by GPs can facilitate additional patient contributions.
Patients can exert agency and clinicians can be proactive in supporting agency within the consultation through their conversational choices.
This has extended to my research on teaching communication in healthcare. We have demonstrated how in simulated interactions actors-as-patients do not communicate in the same way that actual patients do and that sometimes clinicians need individualised feedback to identify the ways in which they may inadvertently be hindering patient agency.
Consideration of how patient agency is collaboratively achieved has informed my teaching, with inclusion of conversation analytic conceptualisations of agency into communication curricula. In reflecting on current approaches to teaching and assessing healthcare communication, I have also identified the potential harms to patient agency to which such simplified approaches may contribute.
Agency has also constituted a key component in position papers and opinion pieces, including an Australia and Aotearoa New Zealand collaborative conversation starter in which we argue for tailored communication that supports active patient participation. And I argue that the responsibility for supporting patient agency rests with the clinician.
When I tell people what I research and teach, I am often confronted with stories of when consultations have not been a positive or productive experience. This can stymie patient attempts to exert agency. These stories motivate me to continue public-facing communication through social media and industry publications.
“patients have interactional means through which they can assume agency”
As I continue on my journey in supporting clinicians, students, and organisations to improve communication, patient agency and how it is achieved and how it can be better centred in consultations, will remain central to my work.
Is communication an art or a science?
The craft of communication.
Actually, I think it’s a craft.
We’re probably familiar with arguments around communication being an “art” and also that there is a growing appreciation of the role of evidence in understanding communication both abstractly and in practice. I argue that instead of contrasting “art” to “science”, we focus on the “craft” of communication. This is particularly relevant when considering teaching and assessing communication for specific professions, where learning through doing with individualised feedback is more likely to improve a learner’s communication skills.
A “craft” involves skills that “can only be learnt and employed in [a specific] occupational setting” and that are “refined through experience”.
By using the term “craft”, we can move away from the false dichotomy of art versus science in referring to communication and engage with the reality of conversation that incorporates and applies both in iterative, participant-managed ways. In doing so, we are resisting the notion that communication is either wholly subjective or objective. We can then more accurately reflect how we implicitly and explicitly improve how we communicate.
In analysing question design across a series of institutional phone calls, Heritage and Clayman use an analogy of a wind tunnel to describe how we learn and modify our conversational conduct through our experiences, finding paths of less resistance in the ways we choose to design each turn at talk.
“As in the design of a car, the aerodynamics of this question has gone through a wind tunnel of testing by repeated use. This judicious, cautious, even bureaucratic question design is the kind of design that develops in contexts where officials have to do interactionally delicate things on a repetitive basis.” Heritage and Clayman 2010, p.46
This is our implicit education in the craft of communication. In referring to coffee tasters, Liberman notes that “they say that by applying their knowledge and craft, they can repair nearly any difficulty”. That is, the skill of a craft is being able to use knowledge and experience to manage challenges in situ, as they unfold. This, too, is the goal of learning communication. The skill is in the responsiveness to each moment and knowing what each interactional choice is most likely to be understood as doing.
References
Gilligan, C., Powell, M., Lynagh, M. C., Ward, B. M., Lonsdale, C., Harvey, P., James, E. L., Rich, D., Dewi, S. P., Nepal, S., & Silverman, J. (2021). Interventions for improving medical students’ interpersonal communication in medical consultations. Cochrane Database of Systematic Reviews, 2021(2), Article CD012418. https://doi.org/10.1002/14651858.CD012418.pub2
Heritage, J., & Clayman, S. (2010). Talk in Action: Interactions, Identities, and Institutions. Wiley-Blackwell.
Liberman, K., 2022. Tasting Coffee: An Inquiry Into Objectivity. State University of New York Press.
Lynch, J.M., van Driel, M., Meredith, P., et al., 2022. The Craft of Generalism: Clinical skills and attitudes for whole person care. J Eval Clin Pract., 28(6), pp.1187–1194. https://doi.org/10.1111/jep.13624.
Travers, M., 2020. Craft skills and legal rules: how Australian magistrates make bail decisions. In: B. Dupret, J. Colemans & M. Travers, eds. Legal Rules in Practice: In the Midst of Law’s Life. 1st ed. Routledge. https://doi.org/10.4324/9781003046776.
White, S.J., 2025. Complexity and objectivity in teaching interprofessional healthcare communication. Patient Education and Counseling, 131, p.108558. https://doi.org/10.1016/j.pec.2024.108558
Communication in healthcare— a soft skill?
Communication skills are core competencies. Being an effective communicator requires knowledge about communication, as well as reflection and analysis skills.
Spoiler: there is nothing soft about communication
“Patients dying daily due to poor ‘soft skills’ among Australian surgeons, experts warn”
Working in within University schools for health and biomedical sciences as well as for business, I have found that the conceptualisation of communication as a “soft skill” is common across research and teaching. This has often bothered me. As a conversation analyst, my job is to analyse how people get things done through interaction. “Things” include all parts of social life — ordering coffee, chatting with friends, and, of course, all the interaction needed for work.
This work is done collaboratively. It isn’t “message sent and message received”. We co-create a shared understanding. We build relationships through interaction. While “soft skills” as term may not be intended to minimise such skills, they can often been side-lined or taken less seriously as compared to “hard skills” or “technical skills”. Interpersonal communication is central to doing our jobs and, given that this often requires specialised approaches for different jobs (e.g. negotiation, discussing difficult news, etc), it can be seen as a “technical skill” too.
In exploring this idea of shifting from “soft skills” to “core skills” or “critical skills”, I came across a paper by Erica Darcis who provides the following recommendations for improving communication education in management training:
Increasing interdisciplinary efforts to bring together organisational scholarship and linguistics in research and teaching.
Steering away from communication training as skill development, focusing on raising language awareness and the development of analytical skills.
Using linguistic and discourse awareness as a basis for self-reflexive, responsible management practice.
These recommendations are echoed in healthcare communication literature, with a systematic review demonstrating that personalised feedback is the most reliable way of improving medical student communication skills. Such feedback relies on all three of the above recommendations.
Effective communication should be integrated as a core clinical skill. How else do you find out why someone has come to see you or whether the treatment you’re recommending considers their preferences and concerns?
Building relationships and communicating effectively with patients are not soft skills — they are clinical skills. As Dr Ben Bravery commented in his reflections on humanity in medical school:
“I thought the things that mattered weren’t being rewarded”
Communication training is often front loaded in healthcare degrees, leaving plenty of time to unlearn it when the pressures of placements and then practice combined with its “soft” status mean that it’s given less importance. This is reflected in the lack of resourcing and investment in education and research on communication, even though there are systemic, scientific ways of observing, understanding, and improving communication skills.
Communication is a core skill in healthcare. Not a soft one.