Interview, Story, Conversation, or Poem?Reframing the Medical Consultation John Blair Corbett (bio) The issue of communication between healthcare provider and patient has long been considered problematical. The idea that a doctor should develop a reassuring bedside manner is first attested in the Oxford English Dictionary in 1869, and more recently a vigorous academic industry has arisen to teach novice doctors and nurses how to interact effectively and empathically with their patients and to assess their competences in this respect (for example, see Maguire; Lloyd and Bor; Li and Corbett). In 1995, Ong and colleagues set out an influential framework for effective communicative interventions; it takes into consideration many issues of various perspectives: background variables such as culture, doctor-patient relationship, and disease characteristics; "actual content of communication" such as communication behaviors and instrumental versus affective behaviors (903); and patient outcomes both short-term and intermediate, including satisfaction, compliance, and psychiatric morbidity. Such a framework informs the communication skills training materials produced by Celia Roberts and Becky Moss for King's College London, Doing the Lambeth Talk and Words in Action, which are both designed to support empathic and effective communication for healthcare providers whose patients inhabit a diverse, multicultural environment, present with a range of symptoms, and whose care, at times, requires astute negotiation. Roberts and her colleagues draw on the linguistic tradition of conversation analysis (CA) to indicate how, in real-life consultations, participants in interaction express humor, listen attentively, reassure, persuade, and negotiate action plans, bearing in mind that the discursive conventions followed by provider and patient are culturally relative and often idiosyncratic. While allowing for the utility of such materials, John Skelton raises the difficulty of generalizing from individual interactions, no matter how effective those interactions might be, and he points to the inherent subjectivity about what might be considered good practice in such interactions. He observes that even apparently uncontroversial advice like "make proper eye contact with the patient" begs all sorts of questions about who decides how much eye contact is proper, particularly when, in some cultures, [End Page 1] avoidance of eye contact can be understood as a gesture of respect towards someone in authority. Skelton reminds us that "something as context bound as a dialogue between two people is a fragile, momentary and personal thing, which resists interpretation" (48). Skelton argues, reasonably, any dialogue resists generalized, or decontextualized interpretation, and that the atomized constituents of doctor-patient interactions should not be packaged as a banal checklist of verbal and paralinguistic behaviors to be slavishly adhered to. Even so, he does acknowledge the value of trainees attending to the characteristic features of medical communication, drawing on the Social Science disciplines of sociolinguistics, conversational analysis, and pragmatics to illuminate how dialogue works. He is far from alone in doing so; for example, as noted earlier, Roberts and Moss use conversation analysis in their explorations of medical communication, and many other educators, such as Brian Brown, Paul Crawford, and Ronald Carter, appeal to both conversation analysis and philosophy in their discussion of the language of consultations. Brown, Crawford, and Carter, like Skelton, note the variable nature of individual interactions, though they follow Julian Barratt in identifying certain generalizable interactional styles exhibited by types of patients who presented at walk-in clinics, whom they characterize as "seekers," "clinical presenters," "confirmers," and "anticipators" (95–96). Barratt's study suggests that nurses adapt their interactional strategies to respond appropriately to these and other generalized styles. Thus, despite the context-bound nature of any dialogue, there is enough predictability in the healthcare encounter for Brown, Crawford, and Carter to affirm that "the fine-grained study of conversational encounters in health care yields information of potential importance to policymakers, educators and practitioners as well as clients themselves" (94). Alongside the Social Sciences, many works of Humanities have long provided medical educators with ways of approaching communication skills. For instance, Kieran Sweeney takes the metaphor of the Rubik's cube to suggest that any medical consultation is a six-sided construct (with each side representing a "forum"): the construction of a patient narrative, the dispensing of biomedical advice, disingenuousness about the rational nature of medical consulting, the rationing of medical resources...
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Sep 29, 2023
Pauline Madella 
Open Access
