- medicalisation
how human problems are increasingly framed within a medical framework. That is, problems are given a medical (rather than a social, cultural or educational) diagnosis and response.
Finally we describe the twenty-first century reality of high levels of healthcare complexity, and of the kinds of communication that it entrains. Central here is the increasingly complex character of healthcare institutions; fraught care trajectories; constantly changing medical, clinical, diagnostic and information technologies; rising levels of bureaucratic monitoring, intervention and regulation; and migrating professionals and patients on top of a rise in care consumers’ assertiveness and public participation in healthcare decision-making.
- complexity
a term used to describe situations that unfold in (seemingly) random or inexplicable ways. Complex situations do not resemble anything we are familiar with, and they do not allow us to act as we commonly do. They require new kinds of behaviours, new thinking and new solutions.
Healthcare communication in the present century cannot be understood without taking account of all these developments and factors, and the complexities they create for providers, policy-makers and consumers.
- healthcare communication
the exchange of knowledge, information, feelings and meanings that takes place in and around healthcare settings and services.
Introduction
To understand communication in health care, we need to look back to the time when medicine began to organise itself into formal institutions. Care had been institutionalised to a degree in religious settings throughout the ages. But the Renaissance saw a number of significant new developments, together creating a radical change in the care given to ill people. Among these developments, noteworthy are the rise of secular (non-religious, charitable) shelters for the unwell, and the beginning of scientific medicine thanks to a fusion of anatomical knowledge with pharmacological expertise.
Towards the end of the Middle Ages, European societies began to isolate people into separate spaces because they were considered to be ‘different’: they were orphans, paupers, invalids, the old, the blind, the deaf, beggars, the mad, prostitutes or criminals. These people were progressively sequestered in sick houses, prisons, and mad houses and the like. These ‘modern’ institutions all emerged around the beginning of the Enlightenment in the seventeenth and eighteenth centuries – the time when the practice of categorising and classifying phenomena came into full swing. Collectively, these new institutions marked the beginning of a Europe-wide response to managing the risk and spread of disease (notably leprosy, the plague and, later, syphilis), deviancy (particularly crime), and madness (individuals’ inability to conform to new and more intense public expectations).
- public expectations
the norms and values that we as citizens hold up as important. Whereas 50 years ago our public expectations with regard to receiving health care were quite modest, twenty-first century healthcare consumers place very high expectations on professionals and services.
As time went on, the sick house began to evolve from a place of social isolation into a place of rehabilitation, and then into a place where the diseased began to be subjected to innovative cures. These new cures were administered in places that Michel Foucault associates with the birth of the clinic (Foucault, 1973). The word ‘clinic’ derives from the Greek word kline meaning ‘bed’, and from the Latin clinicus, ‘a person who attends to a patient’. Foucault’s point was that the West was unique because there a new healthcare practice developed as the core of an entirely new institution: the hospital. This new institution had two defining features: it brought together people who were not well, and it was staffed with people who had developed and were actively developing new skills in deploying novel technologies on living bodies in ways never before attempted.
- birth of the clinic
Michel Foucault’s phrase for the emergence of a new medicine in the nineteenth century. This new medicine became possible thanks to ‘a new medical gaze’: a much more systematic and invasive way of subjecting the living human body to diagnosis and treatment than had been possible and acceptable previously.
The clinic was further unique in that the new cures practised there involved a novel collaboration among practitioners with different specialisations. First, from as early as the fourth century, there were those whose religious orientation inclined them to nurse the diseased and disadvantaged in dedicated wards attached to their monasteries (Miller, 1985). Second, there were the anatomists who descended from a long line of people who, for centuries, had done quite simple forms of surgery to gather knowledge about the human body from dissecting corpses. Then there were those who experimented with and dispensed drugs and potions, combining folklore and nascent science.
The fusion of these three specialisations proved revolutionary, producing what is now known as Western health care. It is important to remember here that this developmental trajectory has steered health care more and more towards detecting and treating pathological lesions, and away from dealing in holistic ways with the human body and its life circumstances. This trajectory defines to an important extent how modern medicine now positions its consumers: as people who are tolerant and willing to wait, or be (a) patient. From its inception, then, medical practice has tended to regard and treat patients as ‘inert anatomical creatures’, rather than as living and speaking persons (Armstrong, 2002).
Figure 2.1 The Anatomy Lesson, Anonymous Master, Bruges, 1679. As published in the Europeana database: Groeningemusuem Brugge © Lukas-Art in Flanders
At a result of a period of rapid scientific progress and successes in medicine over the last two centuries, what the patient had to say became increasingly immaterial to what the doctor did and knew. The patient’s voice became increasingly displaced by machine readings, test results and print-outs. What the doctor might want to communicate became increasingly defined by their technical knowledge about and clinical actions on the diseases of the body. This situation was further exacerbated with the rapid escalation in the number and power of technologies enabling clinical investigations into patients’ diseases.
Initially, these techniques were quite simple: inspection (scanning the body with the eye), palpation (laying on hands to identify abnormalities), percussion (to identify different densities of the lesion) and auscultation (listening to internal processes) (Armstrong, 2002). Soon, they became more technological: think of X-rays, pathology reports, and blood tests, all emerging during the late nineteenth century and early twentieth century.
Because they were so powerful in what they revealed about the diseased human body, these investigative techniques lent the now rapidly expanding array of medical interventions special significance (Bliss, 2011). This status was consolidated by medicine becoming associated with – and legitimated by – two increasingly prestigious institutions: the modern hospital and the university academy (Abel-Smith, 1964; Porter 1999; Szasz & Hollender, 1987 [1956]). The training and certification of doctors provided by the academy bolstered the status of the modern hospital. In turn, the research on actual subjects made possible by their connection with hospital consolidated the scientific prestige of medicine.
Figure 2.2 The Sick Woman, Jan Steen (1663–66), Rijksmuseum, Amsterdam
Increasingly, medicine prided itself – and continues to pride itself! – on the self-sufficiency of its methods and science. For medicine, personal, social and cultural influences became less and less relevant to its scientific truths and knowledge, and thus to its patient consultations (Good, 1994). The patient’s object status was reinforced in ‘clinical teaching manuals that were published in the nineteenth and early twentieth centuries … [which] … barely mention[ed] the process of obtaining reports of symptoms (“the medical history”) from the patient’ (Armstrong, 2002, p. 59). For medical science and medical practice, then, knowledge had become quite disconnected from the ‘patient as person’. Patients were to be informed, rather than communicated with.
For its part, nursing prides itself on a long history of caring for the unwell without the intervention of elaborate cures. Nursing reaches back to the time of the early religious orders whose monasteries institutionalised separate shelters for sick people. The practice of nursing was, of course, greatly influenced by the rise of clinical medicine, its institutionalisation in the modern clinic, and its annexation of nursing as ‘hand-maiden’ (Thompson & Stewart, 2007). This annexation required nursing to shift from a charitable institution providing custodial care to an institution that complemented and increasingly extended the new doctors’ medical and surgical expertises into curative care. Nurses were now expected to be submissive towards the ‘paternal’ doctor and ‘maternal’ towards the patient, producing frequent interprofessional tensions that could have damaging consequences for patients’ care (Wicks, 1999).
Allowing the patient to speak
In the second half of the twentieth century, people became more educated and socially mobile, thanks to a host of technological, social and cultural developments. Armstrong describes the twentieth century as the time when disease became seen not as purely a body issue, but also a person issue: disease was ‘released from its prison of the body’ (Armstrong, 2002, p. 149). With this, doctors began to realise that patients, too, could have important insights about their own bodies and about the underlying and circumstantial factors of their disease.
This realisation was accompanied by medicine’s appreciation that patients’ health could be affected by socio-cultural factors – not just intrinsic anatomical and bio-physiological ones. This helped soften doctors’ view of patients, and made them realise they needed a different way of communicating with patients. As medical practitioners began to acknowledge that afflictions were not fully explainable with reference to body-internal lesions alone, they understood that patients had biographies that warranted being explored for clues as to the origin and trajectory of their disease.
Around the 1950s and 1960s, this development culminated in patients being formally inaugurated as an important and credible source of information in medical training. Indeed, patients were now expected to assist doctors in their quest to identify and explain the signs, symptoms and progress of their disease. Perhaps as much due to general societal change as to developments in medicine proper, patients were now expected to assume a role as informants about the world external to them and about how it affected them, their behaviour, their bodies and their disease.
We must not think, however, that this heralded the advent of open communication between the patient and the doctor. On the contrary, healthcare practitioners continued to be advised that they needed to maintain an ‘objective view’ of the patient’s body. To achieve this, they were to practise ‘detached concern’ (Lief & Fox, 1963). Instead of letting themselves be swept along by the patient’s account, doctors were to practise detachment while at the same time communicating to the patient that their focus was on their cure.
Communication here served not to nurture an intimate interpersonal relationship, but to achieve scientific–medical accuracy through careful elicitation and intelligent interpretation of patients’ talk. This accuracy was best assured when the health practitioner kept their distance from the patient as person. It was left to nursing to attend to the subjective and emotional needs of the patient (Radcliffe, 2000; Stein, 1967).
As patients were increasingly expected to report on their diseases and each patient’s specific ‘life world’ circumstances, healthcare practitioners were encouraged to realise that the patient’s disease, at least in part, might be an expression of the individual’s personal lifestyle and unique psychology. Encouraged by forward-looking post-war thinkers and educators like Michael Balint, clinicians were encouraged to understand the patient and their motivations, as well as their behaviour.
This necessitated an entirely new approach to how healthcare practitioners were to communicate with their patients. In this new schema, for example, the doctor–patient consult was to consider not just the patient’s physical environment and habits, but also their social and practical circumstances. Critical here became the patient’s employment history and their living circumstances. This meant giving the patient the opportunity to discuss their job worries, interpersonal adjustments and disappointments, and even their marital history (Armstrong, 2002, p. 62). This was the birth of the ‘bio-psycho-social’ approach to clinician–patient communication (Engel, 1977).
The ‘biopsychosocial’ approach was first evident in Michael Balint’s work (Balint, 1955). During the 1950s and 1960s in the UK, Balint began to promote an approach to patient–health practitioner communication that emphasised the psychological dimension of their relationship as being at the heart of the healthcare process. There was much more at stake here than eliciting biopsychosocial issues from the patient. Balint emphasised the importance of health practitioners enabling the patient to speak, but this was on top of the health practitioners paying attention to themselves. They now were to communicate in a reflexive manner, assessing their own responses and their effects on the patient. Here, the healthcare professional was to ask questions not just of the patient, but also about their own behaviour, their own communication. All this was in order to avoid ‘objectifying’ the patient and their disease.
To a large degree, the rise to prominence of the biopsychosocial patient occurred as a counterpoint to the overwhelming and taken-as-given paternalism (a father-like attitude) that prevailed among doctors at the time, paralleled by nurses’ maternalism (a mother-like attitude) (Wilson-Barnett, 1986).
As Peter Ubel explains, doctors’ paternalism meant that they routinely made decisions for patients:
In the pre-revolutionary days of physician paternalism, [a prostate cancer] patient’s urologist would have told him that he had a small growth in his prostate and needed surgery. Or, if the surgeon felt that the patient was too frail to benefit from the surgery, he would have withheld information about the tumour and monitored it without the patient’s knowledge.
(Ubel, 2012, p. 3)
This paternalistic relationship between the doctor and the patient meant moreover that the doctor could consider the patient ‘too fragile’ for bad news and therefore withhold it to protect the patient.
If the patient were deemed too fragile for bad news, the doctor would turn to euphemism or out-and-out evasion. The tumour would be described as ‘an X-ray shadow’ or ‘an infection’. In those days, doctors made decisions and patients were expected to follow orders. (Ubel, 2012, p. 3)
The post-war years – the 1950s and 1960s – introduced new and probing questions about how medicine, nursing and hospitals generally conducted their healthcare processes, relationships and communication. A prominent example of this questioning was Glaser and Strauss’s work, asking why patients (or their relatives) were not or were rarely informed about their impending deaths (Glaser & Strauss, 1965). In a study done over three years, Glaser and Strauss reassessed the degree to which health practitioners discussed dying with their patients. They concluded that only limited progress towards open information sharing had been achieved in the intervening years (Glaser & Strauss, 1968).
This change in attitude towards patients’ role in their care arose from a post-war dissatisfaction with established institutions (Marcuse, 1991 [1964]). This post-war sentiment turned people away from all kinds of institutional authority, and reoriented them towards interpersonal relationships. For Balint and colleagues, this involved identifying medicine as ‘illness-centred’ and doctors’ approach as paternalistic. What they saw as needed instead was ‘person-centred’ medicine, defined as paying increasing attention to patients’ unique needs, circumstances and preferences. Questioning the priorities of illness-centred medicine, person-centred care necessitates very different communicative skills on the part of the healthcare practitioner (Balint et al., 1970) – skills that to date had not been a priority in medical and nursing training (Stewart, 1995).
Balint’s ‘illness-centred versus patient-centred’ distinction became the origin of a new range of ‘patient-centred’ communication practices that began to make their way into healthcare communication in the second half of the twentieth century. Prominent among these are ‘informed consent’ and ‘shared decision-making’. More recently still, we have begun to talk about the importance of ‘patient choice’ and ‘patient involvement’. Common to these new concerns is that healthcare practitioners and health systems generally are to become more attentive to their patients, and more responsive to their needs and preferences.
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