Communication, explanation and understanding

Submitted by tonyplant on April 17, 2006 - 15:02.

Judges in the US are attending a programme of classes to educate them in the science and medicine that underlies the detection, diagnosis, treatment and prognosis of disease. The programme is intended to help in the ajudication of medical malpractice cases.

In addition to acquiring a scientific knowledge base, judges said they learned that understanding physician-patient communication is key to interpreting complex medical cases.

Ohio trial Judge Lee Sinclair said he was particularly enlightened by a mock exercise in which a newly diagnosed cancer patient evaluated treatment options with several doctors, including a surgeon and an oncologist.

When the judges got together to discuss the conversation, “what you realized was everyone in the room heard things in a different way,” Sinclair said. “Often what you hear in medical malpractice cases is the physician saying he explained it to the patient and the patient saying it never happened.”

The insights are especially valuable in helping judges eliminate potentially frivolous lawsuits or find alternate ways to resolve legal disputes without going to trial, said Marvin J. Garvis, a Maryland federal judge.

I found this exercise interesting for a number of reasons. How many times have we heard someone say, "But I told you that", or "You never told me about that". Sometimes, we have been told information but the stress or shock of the circumstances under which we were told means that we don't remember. Sometimes, we retain fragments of the information, rather than its context.

This communication gap is one of the reasons why some carers' groups advise people to record medical consultations or social services advice seesions, so that they can play it back several times and extract all of the information. However, a number of medical or social services personnel do not agree to the recording of the consultations, which leaves the option of taking notes at a time when you need to be listening.

Malcolm Gladwell has posted a review of Charles Tilly's book, Why?. Why? explores the manner in which we claim, establish, negotiate, repair, rework, or disengage with others through the reasons we give. Tilly looks at the style and content of our everyday social interactions: he invites us to reconsider everything from the way we talk to children, partners and colleagues to the way we argue about politics.

Tilly illustrates different types of reason giving. For example, he suggests that an air traffic controller might explain the near miss of two aircraft in several different ways, depending upon the intended audience and setting:

• at a cocktail party, he might shrug it off by saying "This happens all the time," or offer a chatty, colloquial rendition of what transpired
• for a colleague at work, he might offer a longer, more technical explanation, and for a formal report for his division head he might provide an exhaustive, detailed account.

Tilly identifies the four different categories of reasons:

• Conventions: "I'm sorry I spilled my coffee; I'm such a klutz."
• Narratives: "My friend betrayed me because she was jealous of my sister."
• Technical cause-effect accounts: "A short circuit in the ignition system caused the engine rotors to fail."
• Codes, procedures or occupational jargon: "We can't turn over the records. We're bound by statute 369."

The greatest interest lies in how and why we use each of these categories, and what it says about our relationship/attitude to the person to whom we are giving these reasons.

Tilly says that the husband who uses a story to explain his unhappiness to his wife—“Ever since I got my new job, I feel like I’ve just been so busy that I haven’t had time for us”—is attempting to salvage the relationship. However, if he resorts to the cliche, “It’s not you—it’s me.” then he has defaulted to a convention. In this case the wife realises that it’s not the content of what he said that matters. Use of a convention signals a shift from the kind of reason-giving that underpins commitment to the kind that communicates disengagement. Marriages thrive when people trade stories. They die when conventions are used to communicate significant issues.

As a side issue, I am fascinated by the way people talk to themselves, and the explanations that we give ourselves to explain what is happening in our lives. Cognitive-behavioural therapy (CBT) is concerned with our distorted thinking about events. Some of this distorted thinking involves reasoning to ourselves in conventions: "I'm always clumsy", "I'll never be successful", "My life isn't worth living". CBT techniques tend to include disputation. Disputation means that people examine a statement and see whether or not it fits into the overall story of their lives. For example, "OK, I am occasionally clumsy when I'm nervous. The rest of the time, I'm fine. I never burn myself when cooking and I rarely cut myself during food preparation - so, I can't be that clumsy". Talking to ourselves in stories can be more respectful than dismissing ourselves with conventions.

A good communicator recognises the need to shift categories. A doctor understands illness with the technical language of anatomy, physiology and biochemistry, but she might explain it to a patient, who knows nothing of medical science, by using a mix of conventions and stories.

Gladwell summarises the switching of categories in this way:

Tilly argues that we make two common errors when it comes to understanding reasons. The first is to assume that some kinds of reasons are always better than others—that there is a hierarchy of reasons, with conventions (the least sophisticated) at the bottom and technical accounts at the top. That’s wrong, Tilly says: each type of reason has its own role.

Tilly’s second point flows from the first, and it’s that the reasons people give aren’t a function of their character—that is, there aren’t people who always favor technical accounts and people who always favor stories. Rather, reasons arise out of situations and roles...

Effective reason-giving, then, involves matching the kind of reason we give to the particular role that we happen to be playing at the time a reason is necessary.

Carers receive a lot of conventions and technical explanations: sometimes, these are appropriate. They don't always hear a story-telling understanding of their situation from others: this can contribute to the perception that they are not listened to, or that their contributions are not valued. A lot of the present rhetoric about social care packages involves conventions. We hear comparatively few stories about initiatives that are aimed at easing the financial, physical and emotional burdens of caregivers. Maybe that says something significant about the attitude of these decision-makers to carers. Maybe that is why Carers UK questions whether carers' human rights are being overlooked.

Copyright 2006, Tony Plant Happystance Project

gladwell | explanation | communication | cognitive behavioural therapy | charles tilly | CBT