Contributions to the Australian Communicating for Safety standard

Recently I contributed as a Subject Matter Expert on communication at the Australian Commission on Safety and Quality in Health Care. It was great to see how the standards draw on a wide range of expertise.

Here are some of the comments and papers that I raised in the discussions:

Healthcare in asymmetrical. This is not a bad thing - it's how we allow for people to provide care to us. This is found in how we have conversations in healthcare. However, that functional asymmetry can become dysfunctional and so it is the responsibility of those within the system to avoid that. This idea of functional asymmetry comes from this paper and I discuss this responsibility here.

Personalised feedback is the only type of training that has sufficient evidence for improvement of communication. While other forms of training can help set the foundations for analysing communication in order to give and apply feedback, if there is no such coaching, there is a limit to improvement. This comes from this Cochrane review.

I raised that there was insufficient use of evidence and an over-reliance on vibes and myths in current feedback and training. This is partly because the complexity of communication is not sufficiently appreciated and so engaging with relevant expertise is not done. We discuss that here.

This included challenging the assumption that face-to-face conversation was inherently better. I have previously posted about some of the myths and like to direct people to Elizabeth Stokoe's posts.

The basics of communication are often overlooked, so I paraphrased Jonathan Silverman, co-author of the Calgary-Cambridge Guide, who said that we need to learn how to drive the Ford Focus before we learn to drive the Ferrari. Part of the issue here is that there are so much incorrect information about how conversations actually unfold that the basics aren't always well taught even if they are included. Here's a paper describing a curriculum that includes some of the science of conversation.

Standards are not about prescribing how to do things, but there still is a reductionism when choosing what to include. I raised the importance of have a transparent and frequently reviewed process of standardisation for organisations implementing systems. This comment is explained in my paper on objectivity and complexity, which is based on my plenary talk at ICCH2024.

What I didn't end up raising, was that a team of experts identified core considerations in healthcare communication specifically relevant to those in Australia & Aotearoa New Zealand.

Opening questions: telling patients what you know

Have you ever prefaced a story with “did I tell you about …”? We do this kind of prefacing to avoid telling the other person something they already know.

This norm is present in everyday conversations as well as institutional ones. Personally, I say this a lot, particularly if I am explaining a concept or a project to someone and I’m not sure if I’ve talked to them about a particular concept before.

Establishing how much someone already knows about a story you have or about your health can be complicated, particularly if that other person has notes on you and you have no idea if they’ve read them or not.

Take the case of a woman who was admitted to hospital with a postoperative infection. She had also developed deep vein thrombosis after the surgery but before the infection. This was being treated with anticoagulants and both problems were treated in the same hospital, with a period of time at home between the two issues.

She recounts how a doctor came into her room, introducing himself and saying: “I’ve had a look at your notes …”

This doctor was coming in to cannulate for intravenous antibiotics. As she had already told the admitting team that she was on anticoagulants, she assumed the information about this was in her notes. Given that the doctor had said that he read the notes and didn’t ask about medications, she didn’t raise it.

Then, when attempting to cannulate, she bled much more than anticipated, to the doctor’s surprise. In response to his surprise, she asked if he knew she was on anticoagulants, and he did not.

There are multiple factors that could have led to this issue, such as whether the information had been placed in the notes or if the system made such information accessible. In terms of communication, though, the patient made the assumption that the information was known, so in the absence of additional prompting, did not re-tell it.

Often when we think of consultations and knowledge, we focus on the knowledge and expertise that the doctor brings. The patient also brings the knowledge of their condition and, at the start of a consultation and particularly at the start of a therapeutic relationship, will be in a much greater “knowledge-plus” (K+) position about their presenting problem and how it affects them than the doctor. This requires the doctor, who is in a “knowledge-minus” (K-) position, to ask questions. These are usually in the form of an opening question to elicit a patient narrative or problem presentation and then in history-taking questions.

The design of a doctor’s question reveals their epistemic stance, that is, how much information they either assume or know about the patient and their presenting problem. This can be in the opening question design. For example, “how can I help?” tells the patient that the doctor is not making an assumption or has no prior knowledge as to why the patient is there. Whereas, “you’re here to check your blood results?” clearly demonstrates some prior knowledge as to the reason for the visit. This can also happen in history taking, where the doctor will use assumptions based on aspects such as the patient’s age as well as information from previous visits, clinical notes, and referrals to design their questions in a way that demonstrates differing levels of prior knowledge.

The norm of not telling someone something they already know can have consequences in health care, where a question’s epistemic stance may seem at odds with how much information the clinician likely has.

Consider the impact of the referral letter on a doctor–patient consultation. Ordinarily, in a general practice consultation, the doctor does not know why the patient is attending. It may be they suspect that it is a follow-up from a recent injury or a routine appointment for chronic illness management, but the patient is able to raise different concerns and can do so without worrying whether the doctor already knows why they are there. The doctor asking an opening question like “how can I help?” makes sense as the patient knows that the doctor does not know why they are there.

In a referred consultation, however, the doctor is given a letter ostensibly for that purpose. The patient may or may not have access to that letter and any other information provided to the specialist doctor. Even if they do, they don’t know if the doctor has read it. As such, the patient is at risk of breaching the norm that you do not tell someone something they already know.

Specialists address this problem by frequently designing their opening questions differently as compared with general practitioners. They often acknowledge the additional information they have regarding the patient and request the patient to present their problem, for example, “I’ve got a letter here from Dr Smith but I want to hear from you what’s going on”.

This is called a referral recognition sequence and it mitigates the risk of the patient assuming that the specialist has more information than they really do, which would affect their problem presentation. When a referral recognition sequence does not happen, the patient might respond to an opening question such as “what’s brought you in today?” with a “I want to get my hip fixed”. This does not provide sufficient information about the problem and requires the doctor to further pursue a problem presentation.

This can create issues, particularly in settings where a patient may be unsure whether they should be providing a problem presentation at all and important clinical information may be missed.

This was the case for the woman I mentioned earlier, who assumed the doctor not only had access to the notes but had also read them. This was further reiterated by the doctor opening their interaction with “I’ve had a look at your notes …”, meaning that she would be more likely to breach the conversational norm of telling someone something they already knew, given he told her he knew things about her from his notes.

Addressing the patient’s assumption that you know something by being clear that you have some knowledge, but would like to hear it in the patient’s own words, can help patients know how much information to share with you.

Originally published on MJA Insight+ https://insightplus.mja.com.au/2022/14/opening-questions-telling-patients-what-you-know/ 19 April 2022

“Fit and healthy”: reconciling its meaning to patients

Quite a few of my friends exercise regularly and eat a balanced diet. One of these gym-going friends recently went to have a COVID-19 test and during the pre-test screening was asked whether she was fit and healthy, to which she answered “yes”. The next question was whether she was on any medication, to which she responded with information about her intravenous immunosuppressant infusion schedule. This response prompted the nurse to cross out my friend’s initial “yes” response to being fit and healthy.

By crossing out the “yes”, the nurse demonstrated her understanding of the phrase “fit and healthy” – that it referred to other diseases and illnesses. My friend, on the other hand, who exercises regularly, eats well, looks after her mental and physical health proactively, and has multiple sclerosis understood the question in reference to how she perceives herself.

While we could spend time discussing the conceptualisations of “health”, we can also look at what this means for communication in practice. When we teach doctors, we often say to avoid jargon, which is important given the low availability of understandable health information in Australia.

However, miscommunication is not just about medical terminology; commonly used medical terms as well as lay terms, like “fit and healthy”, can also be understood differently by patients compared with clinicians.

Take the attempt to simplify cardiovascular risk into the term “heart age”. On the surface, this seems like a clear solution; however, it reduces credibility of the information provided and does not improve engagement in behavioural change. The word “cancer” is another example, when used to refer to low risk conditions it can result in an increased desire for unnecessary invasive treatments.

The ambiguity of lay terms in clinical settings can also cause problems between clinicians, with varying understandings of the same words. While words, such as “fit and healthy”, can provide insight into a patient’s life outside the disease for which they are receiving treatment, the differences in understanding of what these words refer to and, in the medical setting, their general ambiguity, mean that information is not explored further.

Research methods that focus on how communication works in real life give insight into health literacy in practice. In conversation, we can identify whether someone has understood us by how they respond to what we have said. And when someone has shown they did not understand in the way we intended, we can adjust what we have said. This, in conversation analysis, is called “repair” and is necessary for mutual understanding.

This is an important concept when we look at health literacy in practice. We are constantly making decisions about how much the people we speak to know when we’re talking to them, such as when we ask them questions. Clinicians make choices about what level of health literacy the patient might have, which helps design an explanation. Listening to the patient response can give information about whether they pitched it accurately.

When providing one-to-one feedback to a doctor a few years ago, we noticed that the doctor often used medical jargon, even commenting to one patient that what they were explaining was “kind of technical”. In the recordings following training, which included advice on using less technical language and providing explanations when medical terminology was used, we observed that patients responded with more indications that they were following along with what the doctor was explaining.

More explicit approaches to assessing patient understanding come with their own challenges. Teach-back, usually a question formulated to elicit the patient’s explanation of what has been explained to them, is often advised as an approach to assess patient understanding; however, there is recent evidence that in practice explicit teach-back requests are met with more minimal responses in comparison with other approaches. By using a conversation analytic approach, the authors identified more effective ways of determining patient understanding. This included implicit teach-back questions, where doctors asked for information from third parties, and “experience questions”, which were questions that enquired after the patient’s experience so far.

It is impossible, and ill-advised, to suggest there is one right way to formulate a question or an explanation. You will continue to make choices for the patient in front of you and attentively listening to their responses will help you assess whether you need to make adjustments for your next turn at talk.

When we look at written information, considering the audience as well as the purpose is essential to assist patient understanding. In the context of survey questions, considering how their formulation affects the response is important. If the information required by the question about being “fit and healthy” is necessary for clinical decision making, then the question needs to be redesigned so that it is clearly understood in the same way by those asking and those responding. If it is not, then maybe it does not need to be asked.

Originally published on MJA Insight+ https://insightplus.mja.com.au/2021/45/fit-and-healthy-reconciling-its-meaning-to-patients/ 29 November 2021

Asking the right question for the patient in front of you

Earlier this year I was in hospital for urgent surgery after it was found I had an ectopic pregnancy. While waiting in the anaesthetic bay at around 10 pm, the anaesthetist came in to ask me what I assume are all the usual preoperative questions. The nurse had already asked a few and now the doctor was asking those again as well as more. The anaesthetist asked me “do you have any heart problems?” to which I answered “no”.

The anaesthetist was later surprised, and concerned, when during the operation the cardiac monitor showed frequent ventricular ectopic beats.

On my way back to the ward after midnight, a nurse mentioned to me, in my post-anaesthetic haze, that I would need to see a cardiologist. The next day the anaesthetist called me to tell me his concern at what the electrocardiogram had shown, given I had no heart problems. To which I sheepishly replied that I do in fact have a heart problem if one considers benign ectopic beats a problem.

I’d know about this for 4 years at least. So why didn’t I mention it? It would be easy to dismiss it. Perhaps I was emotional and distracted given the reason for the surgery. Maybe it was because of the late hour of the surgery and I was too tired to remember. But when I look back on it, I can see an interactional reason.

To understand medical questioning, we must look at the multiple factors that influence how those questions are designed. As a clinician, you probably don’t even realise you’re making this multitude of small decisions all throughout the consultation. Not just what information you need, but the decisions you make in terms of how you will ask it.

Questions have preferences – both grammatical and social. I’ve previously mentioned the influence grammatical preference can have on patient response. You can see that the question I was asked, “do you have any heart problems,” is more likely to receive a “no” response because of the word “any”. Beyond this grammatical preference, Heritage and Clayman describe both congruent and cross-cutting social preferences that influence question design in medicine.

Question design in medical consultations — that is, how you ask a question — is guided by three key principles: optimisation, problem attentiveness, and recipient design.

Optimisation refers to how questions can be designed to assume a favourable health or social response from a patient. In “do you have any heart problems,” no is the preferred answer because the favourable health response is that I do not ,and there was no reason to necessarily believe that there was a “problem”.

Problem attentiveness refers to the moments when optimisation is not appropriate, usually in regard to the presenting concerns or knowledge of another existing health concern. If I’d been seeing a cardiologist for palpitations, on the other hand, and they’d asked “do you have any heart problems?” I might think it odd because that would be why I am there.

Recipient design refers to asking a question with the addressee or recipient’s circumstances in mind. This is a more general principle that guides conversation. Perhaps if I had been older or male, the recipient design principle would have prompted the anaesthetist to ask it in a different way based on the assumptions related to that demographic information.

These principles might seem unnecessarily technical, but they provide insight into why you design questions in particular ways, why a patient might answer with a “no” to you but with information about a problem to another clinician, and why sometimes it can seem tricky to ask a question when these principles are cross-cutting.

“Do you have any heart problems” is not inherently wrong, it just didn’t work for me. With the “any” as well as the use of the word “problem” when the ectopic beats had previously been considered not a problem, I was not prompted to disclose relevant information – it didn’t even cross my mind. What could have the anaesthetist asked me? If the question had been “have you seen your GP or a cardiologist about your heart?”, I would have been more likely to say “yes”.

Originally published on MJA Insight+ https://insightplus.mja.com.au/2021/40/asking-the-right-question-for-the-patient-in-front-of-you/ 25 October 2021

Influence of treatment expectations on talking with patients

I have experienced chronic pain all of my adult life. As part of my current management plan, I am prescribed pain medication.

There is a lot of stigma attached to medication management of chronic pain, so I often find it difficult to bring it up, even though my regular GP developed the management plan with me and is invariably the one who prescribes it. My concerns about raising it are based on how I feel I will be perceived and on the assumptions that I know could be made about my expectations for treatment.

Doctors use all sorts of heuristics to make decisions and some of these can lead to incorrect assumptions about what patients want and expect. Patients bring their own assumptions too, just like my assumption above that I will be perceived negatively or that there will be resistance, so I design the way I talk to avoid that as much as possible. These assumptions influence, and are influenced by, how doctors and patients communicate with each other.

As these assumptions are evident in consultations, they can be examined through close analysis of recordings. In consultations with surgeons, for example, we can see that patients and surgeons orient to surgery as being the default treatment recommendation. This is not to say that surgery is the preferred option in all or even most cases, but that recommendations for non-surgical management require more interactional work. Recommendations for surgery tend to be presented early and in a straightforward way while recommendations for treatment options other than surgery are delayed and include more justification about why surgery is not the recommended treatment. The assumption is that a patient seeing a surgeon is possibly expecting for surgery to be the recommended treatment option and that surgeons design their recommendations for something other than surgery to counter potential resistance against a non-surgical recommendation.

Similarly, there is an assumption that parents of children sick with upper respiratory symptoms expect antibiotics. While it might feel like that as a clinician, and there would be variation between cultures and medical systems, there is some evidence that tells a different story. Doctors’ perception of parent expectation for antibiotics can be influenced by how a parent presents the child’s illness. If the parent presents a candidate diagnosis, such as “I think my child has tonsilitis”, a doctor is five times more likely to assume that the parent is wanting a prescription. Yet, in this study, this did not match with parent-reported expectations, with other reasons for parents presenting candidate diagnosis, such as legitimacy in seeking care.

Doctors are generally adept at gaining acceptance of treatment recommendations from patients through persuasion, although being responsive to resistance is not the only strategy that can be used. Just as in the surgical consultations described above, there is extra interactional work that doctors do to reduce resistance to treatment recommendations.

By providing a positive action, such as resting and drinking fluids, before telling the patient that antibiotics aren’t suitable, there is higher likelihood of acceptance of the recommendation not to prescribe antibiotics. This can be pre-empted even earlier in the consultation than the treatment recommendation. In response to the problem presentation, doctors can foreshadow the likelihood that the illness is viral to manage patient expectations.

These kinds of strategies to manage interactional resistance may be taught explicitly. During a project where I was observing handovers at an emergency department to develop training material, I watched a senior doctor coach an intern on how to more successfully transfer a patient to a larger hospital.

Many of these strategies would also be developed by the clinician over time through trial and error, with repeated consultations acting as a wind tunnel to find what communication practices result in a smoother consultation.

Using the evidence from the antibiotic prescribing research mentioned above, a training module has been developed as another way to support doctors to more strategically use interactional means to reduce resistance to non-antibiotic treatment recommendations.

Adding in an extra level of expertise through detailed analyses of clinical practice and development of related training can further support doctors to improve consultations in a more systematic and evidence-based way, including how to better understand their own assumptions of patient expectations and how to manage patient resistance to treatment recommendations in a person-centred way.

Originally published on MJA Insight+ https://insightplus.mja.com.au/2021/36/talking-about-treatment-expectations-with-patients/ 27 September 2021

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.

“To gain an understanding of what goes wrong we must first understand what actually goes on in doctor-patient consultations.”

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.

“‘Patient agency’ … refers to a patient’s ability to participate in a consultation and associated decision-making about their care.”

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?

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?

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:

1. Increasing interdisciplinary efforts to bring together organisational scholarship and linguistics in research and teaching.

2. Steering away from communication training as skill development, focusing on raising language awareness and the development of analytical skills.

3. 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.