Language and Clinical Communication

This Bright Babylon

John Skelton, Dominic Greenyer

• Publisher: CRC Press
• Year: 2017
• Print ISBN: 9781846191251
• eBook ISBN: 9781315343112
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

The search for a set of skills which can be identified and taught as 'good clinical communication' has been of considerable value in persuading decision makers at medical schools and other bodies that communication matters. These days, very large numbers of medical schools use what are essentially skills-based models, such as the extraordinarily thorough Calgary-Cambridge approach. However, I believe that the emphasis on communication' as simply a set of skills, such as eye contact, open questions and so on, has badly skewed the development of the discipline. The teaching of "communication skills" in fact strikes me as a very small part of what I do, not a very difficult part for the majority of students, and - whisper it - one which is often pretty dull...In "Language and Clinical Communication", John Skelton critically considers the theory behind this complex field. His wide-ranging approach reflects on the recent developments within the medical humanities and reflects on his controversial stance; questioning the relevance of skill-based teaching in the clinical arena in an accessible, easy to read manner. You will find Skelton's light-hearted and open-minded attitude to the topic unquestionably illuminating.

CHAPTER 1

Introduction

[Teaching involves] hinting, suggesting, urging, coaxing, encouraging, guiding, pointing out, conversing, instructing, informing, narrating, lecturing, demonstrating, exercising, testing, examining, criticizing, correcting, tutoring, drilling and so on - everything, indeed, which does not belie the engagement to impart an understanding. And learning may be looking, listening, overhearing, reading, receiving suggestions, submitting to guidance, committing to memory, asking questions, discussing, experimenting, practising, taking notes, recording, re-expressing and so on - anything which does not belie the engagement to think and to understand.

Michael Oakeshott¹

Surface, depth and other oppositions

This is a book about clinical communication and clinical education. It is a book, I'm tempted to say, in which problems are posed which are not so very unfamiliar. My point in undertaking it is to elucidate the issues from a different perspective, and in consequence to offer people ways of thinking and reflecting on them which may not have occurred. And I have a further ambition, which is to confirm that what constitutes 'good communication' is so uncertain, context-dependent and subjective that any context-free generalisations we come up with are likely to be banal. From which I think it follows that those of us who are involved in the discipline should embrace a degree of wise subjectivity.

My starting point is with 'surface' and 'depth', with the way what we apparently say is not what we apparently mean, and the way in which the things we do in professional life do and do not mirror the way we are underneath. It is similarly about the extent to which the data that we collect measure and fail to measure what we need to have information about. The book is also partly concerned with other well-established sets of educational oppositions. It draws on notions which are standard in linguistics since Chomsky² about the difference between how we 'perform' on particular occasions, and what this says about our underlying 'competence' - and it is about the distinction between 'training' and 'education.'

Rethans et al.³ describe the performance/competence distinction which, although it was originally concerned specifically with language, is often extended to other areas. Thus, they claim, we should differentiate between 'what a doctor actually does in daily practice (performance) and what he or she is capable of doing (competence).' For example, I have what is called 'native-speaker competence' in English, but if I'm tired, or talking too quickly, or inattentive for some reason, I will make mistakes in the actual 'performance.' So this morning as I came to work I got stuck behind a bus: 'boody blus', I muttered. A spoonerism like this is a simple, common type of performance slip, and you can deduce nothing much about my underlying competence in the English language from such things in isolation. Competence is what I can do, whereas performance is what I actually do on specific occasions.

A word of warning, however. Within medical education the distinction is seldom consistently maintained, and the terms have come to be used in a variety of less theoretically exact ways. Epstein's review article,⁴ drawing on an earlier study,⁵ says for example:

[Competence is] the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individuals and communities being served.

'Performance', on the other hand, is 'what [the doctor] does habitually when not observed.' And 'all clinicians may perform at a lower level of competence when they are tired, distracted, or annoyed.' In precise Chomskyean terms, this ought simply to read 'all clinicians perform less well when they are tired, distracted or annoyed.' Strictly, the doctors' level of competence remains the same. Similarly, in the above quotation, the doctor may indeed 'habitually' perform at a similar level, but neither the question of habit nor the lack of observation is integral to the original use of the terms.

I have laboured this point not to make a criticism, but to draw attention to the way in which terms developed within one academic community can get picked up by another, and then develop a life of their own. Thus neither Rethans et al. nor Epstein cite Chomsky as a source - Chomsky's own inspiration here, it is generally acknowledged, being the great Swiss linguist, de Saussure.⁶ These are aspects of the workings of a 'discourse community', which I discuss in Chapter 3.

At any rate, I shall try to follow Chomsky's usage although, particularly in Chapter 7,1 use the word 'performance' in the actor's sense as well.

'Surface' and 'depth' is also a Chomskyean distinction, but I shall use it loosely to distinguish between what we perceive - for example, when we observe communication happening - and what we cannot perceive. The precise meanings of these terms have in any case shifted somewhat over the years within linguistics (and the key phrase 'deep structure' - which has a highly technical meaning - in fact pre-dates Chomsky, as Crystal⁷ points out).

The training/education distinction is compactly and lucidly described by Playdon and Goodsman:⁸

We identify training as a learning process which deals with known outcomes. It is exemplified in the production line and production management, and its central concern is that the same product should be produced identically each time. So it deals in repetitive skills and uniform performances which are expressed as standards or criteria which must be followed exactly. Medicine deals with some areas where uniformity of this kind is desirable - for example, taking blood. But, clearly, these protocols are not the whole of medicine.

For that we must turn to education. Education is a learning process which deals with unknown outcomes, with circumstances which require a complex synthesis of knowledge, skills, and experience to solve problems which are often one-off problems. There are no simple answers to ethically based questions such as 'Should this 3-year-old child have a bone marrow transplant?' Education, on the other hand, refers its questions and actions to principles and values, rather than merely standards and criteria.

Surface and depth, performance and competence, training and education - to which one might add such pairings as rote learning and deep learning, skills and abilities - all of these oppositions catch elements of the most basic of all educational playthings, namely the relationship between appearance and what lies beneath it. And it is the consequences of these issues which are explored in what follows. As a result, I hope, this book will appear as an invitation to think less superficially about what clinical communication is, about what kind of teaching it involves, and about how it can be conceptualised.

I discuss what might be called a form of 'reductionism', but this is a word I dislike. Largely I am wary of it because it has irredeemably negative connotations and is impossible to use fairly. And in fact the thrust of my overall argument -hence the reference to Henry James's ambiguous jewel in the title - is not that 'reductionism is wrong' in some imprecisely general sense, but that it is very hard to tell when splitting concepts into their component parts is a good idea and when it is not. Actually I would want to argue that the real problem we have in clinical communication is simply that we are insufficiently aware of the difficulty. We may split at the right time, we may do it at the wrong time, but we don't discuss it, and because we don't discuss it, we don't appreciate the implications of our choices. And - this being the point at which I admit exasperation - although we often need to atomise, we should not be seduced into a belief that because the result looks in some vague way more scientific it is actually better, or offers more precision, or that the whole is precisely the sum of the splintered parts we are left with. We should, in other words, not ask the sets of often clumsy behavioural categories our energetic atomisation leaves us with to carry more weight than they will bear.

Partly too 'reductionism' is a word that is often misused, as Pinker⁹ points out. And, as it is, there are quite enough technical terms in the relevant area of education which are floating around with no very secure moorings. So I have tried to avoid it - sometimes, you may feel, at the expense of unnecessary circumlocution.

A basic argument

My argument is, I think, fairly straightforward.

The search for a set of skills which can be identified and taught as 'good clinical communication' has been of considerable value in persuading decision makers at medical schools and other bodies that communication matters. These days, very large numbers of medical schools use what are essentially skills-based models, such as the extraordinarily thorough Calgary-Cambridge¹⁰ approach. However, I believe that the emphasis on 'communication' as simply a set of skills, such as eye contact, open questions and so on, has badly skewed the development of the discipline. The teaching of 'communication skills' in fact strikes me as a very small part of what I do, not a very difficult part for the majority of students, and - whisper it - one which is often pretty dull.

Yet there is, in the literature and in the persistent use of the label itself, an emphasis on communication as a set of surface skills. The reasons for this are clear enough. First, 'skills' are generally (although not invariably) conceived of as elements of perceptible behaviour. We can see eye contact, we can hear open questions, and we know - or think we know - how such skills can be defined. And, being perceptible, these skills are amenable to empirical research. Secondly - a point not usually made, but not contentious - part of the definition of communication is that it is perceptible. It may not actually be perceived (I may not hear you over the traffic noise), but it is perceptible, in the sense that it is capable of being perceived. It therefore, prima facie, lends itself perfectly to the kind of research paradigms that are familiar in the sciences.

However, the action of communication on the hearer, to put the case at its simplest - and most extreme - is not the same as the action of a drug on a patient. Nor can 'poor communication' be identified with the objective ease of (many) clinical conditions. In the end, good communication fulfils a set of aims which are abstract and not susceptible to simple definitions. It is perverse to ask 'What is "empathy"?' and expect an answer of the kind one gets to the question 'What is "pneumonia"?'

The difficulty is compounded by societal and educational demands for transparency. For example, research ought to tell us what is the case. Curriculum design ought to make clear selections from research about what should be taught. Students should be clear that the transparently stated curriculum outcomes are what will be tested. So for all these elements of the educational endeavour, we talk of perceptible behaviours. And this is a very good thing, in many ways. Indeed, we mirror it in classroom practice, talking not of 'empathy' in the abstract, but giving students opportunities to practise it - for example, in a simulation. And if we are ever asked 'What is "empathy"?', we can therefore reply 'Well, you remember when you said "Oh dear", and leaned towards your patient? That was being empathic' That was empathy in action - that was doing empathy. And, we might feel with a certain glow of satisfaction, that is exactly what good feedback is like - evidence based.

Put like this, what we have is an inductive ('bottom-up') syllabus in action. The so-called 'traditional' syllabus works deductively (it is 'top down'). It begins with the assertion of grand principles ('The main symptoms of X are ...') and invites learners to observe them in practice subsequently. The inductive syllabus invites learners to reach their own generalisations from a string of particular examples. 'So', we might say to our student, 'here are not one but a dozen examples of the abstract term "empathy." Now is it clear what empathy is?'

This is an excellent way of proceeding. Abstract terms need to be demonstrated. Within medical education, this kind of approach is entirely consonant with the general principles of problem-based learning. Incidentally, one of the driving forces in this kind of approach, as in a substantial amount of education over the last half century and beyond, has been language teaching. Some of the principles are well elucidated in Julian Dakin's early classic.¹¹ (Dakin was a precocious talent who died tragically young.) They don't, however, sit very easily with the desire to keep things at the level of absolute transparency, as I shall argue. Dakin's general approach to teaching and learning is usually described as 'mentalist.' And in that term, which drives a great deal of the learning endeavour into the mind, where it can no longer be perceived, lie the seeds of the problem.

Things, in other words, are not simple. To speak of transparency, to teach and test and research and set goals and all the rest of it as clearly as possible, is to risk impoverishment of the discipline - or, as some might phrase it, to turn a potential for education into an occasion for training, with this latter term carrying all kinds of negative connotations, at worst of unthinking rote learning.

The danger is well illustrated in aspects of the current debate about 'professionalism', which is a contemporary growth area in medical education, and one which overlaps with communication in a number of ways. This is an attempt, at its most basic level, to respond to the problem that there are people capable of passing examinations of clinical knowledge and understanding, and capable of mastering clinical skills, who nevertheless ought not to be doctors. Much of the work from the USA on this topic is directly or indirectly motivated by 'Project Professionalism',¹² and the central debates are well set out in Stern ...

Table of contents

• Cover Page
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Preface
• About the author
• Dedication
• 1 Introduction
• 2 The ambiguous inheritance
• 3 Language, rhetoric and the discourse community
• 4 Two ways of looking at ambiguity
• 5 An old debate
• 6 Remediation and referrals
• 7 The commissar and the connoisseur
• 8 Conclusion
• Appendix
• Index