This commentary centers around why Jason Batten et al.’s contribution entitled “Treatability Statements in Serious Illness: The Gap Between What Is Said and What Is Heard” warrants your precious time and finite cognitive bandwidth.Footnote 1 This article dissects how physicians, patients and surrogate decision makers communicate about illness, and uses clinical cases to focus on how we derive meaning within and beyond what is actually said. By examining how physician statements can be variably interpreted, they have provided a simulacrum of the Indian parable where blind men touch different parts of an elephant and reach disparate conclusions.Footnote 2 One feels the elephant’s side and decides it must be a wall, one its tusk and assumes a spear. In the clinical arena this is why one patient can hear that “the chance is one-in-a million” and reply over-optimistically “so there is a chance.” It is why another patient can hear “we are running some tests” and over-pessimistically conclude “so you think I have cancer.”
Batten et al. can add themselves to the list of authors who have highlighted why communication may be the most nuanced, and therefore most perilous, “procedure” in healthcare.Footnote 3,Footnote 4,Footnote 5,Footnote 6,Footnote 7,Footnote 8,Footnote 9,Footnote 10 This body of work buttresses what may seem intuitive: the ability to speak, but also to listen, is central to building or destroying relationships, and relationships matter. Moreover, there exist vicious or virtuous cycles where communication impacts relationships, and relationships impact communication. Accordingly, communication—including the previously maligned topic of gossip—may be central to what it means to be a human.Footnote 11 Despite all of modern healthcare’s advances we still use the same ‘equipment’—namely, our voices, our ears and our cognition—to coordinate teams during crises, deliver prognoses to patients, and ‘stick-handle’ more than 150 estimated steps per hospitalized patient per day.Footnote 12 Accordingly, clinical medicine may be better understood as a branch of the humanities, rather than the biosciences.Footnote 13 Similarly, an expert clinician can be defined as someone who is verbally adroit, not just manually dextrous.Footnote 14,Footnote 15,Footnote 16
Step one is to accept that the ability to speak and listen is a skill that cannot always be intuited, but can be taught.Footnote 17,Footnote 18,Footnote 19,Footnote 20 Step two is to take responsibility for minimizing communication errors, whether healthcare provider or patient; surgeon or surrogate decision-maker; ethicist or educator. Regardless, healthcare is a useful prism through which to examine wider social phenomena. Communication is the medium through which ideas and reputations thrive or perish. The modern world has de-emphasized hierarchy, and therefore our ability to engage and persuade matters. We cannot always dictate, or predict, how others receive what we say. Similarly, the recipient cannot dictate, or identify, how speakers deliver their messages.Footnote 21,Footnote 22,Footnote 23,Footnote 24 In short, it takes humility and patience for two or more people to successfully exchange complex ideas. In contrast, it takes very little skill to misinterpret or disagree.
Batten, et al.’s work emphasizes why complex medical discussions can be duets, or duels. Words are launched from the larynx but ideas land in the brain.Footnote 25,Footnote 26,Footnote 27,Footnote 28 This metamorphosis is influenced by myriad factors including our emotions, willingness, intelligence, social cues, and prior experiences. Notably, conversing about serious illness is even tougher if subjects such as death and disability are considered social taboos, rather than inevitabilities.Footnote 29 At the risk of speculation, the newer generation of doctors now delivering bad news, and the patients now receiving it, may have grown up more comfortable interacting with two-dimensional screens rather than three-dimensional humans. There may also be less trust of experts, and more opposition to ideas that are unappealing or complex. Accordingly, while it is difficult to be a vulnerable or scared patient, it is also not easy to be a modern-day healthcare professional, or ethicist, or academic. We are all—like it or not—in the communication business. The work of Batten et al. is a laudable effort to understand the mechanics behind negotiating the modern age.
Communication: What Does it Mean?
The United States Supreme Court Justice, Potter Stewart, became famous after arguing that while he could not define pornography, he knew it when he saw it.Footnote 30 While less titillating, good communication can be similarly difficult to pinpoint. Communication typically refers to how we share meaning, or, more literally, the effort to unite as one. While it may seem ironic to define something as interpersonal as communication using impersonal scientific models, it is useful to have a framework and shared mental model.
Communication is more than just what is said. It is a bilateral, often multilateral, process that includes how it is said and how it is understood, which guides how it is responded to.Footnote 31,Footnote 32,Footnote 33,Footnote 34 As a result, nonverbal communication (which includes posture; facial expressions; gestures, and eye contact), as well as para-verbal communication (which includes pacing, tone, volume, and emphasis) are as important as verbal communication.Footnote 35,Footnote 36,Footnote 37,Footnote 38 Breaking down communication into parts is important if there is incongruence between the words used and the facial expression, or the tone or its reception. For example, if we say: “he’s unstable” or “he’s doing fine,” but in a tone that suggests otherwise, then listeners often downplay the verbal in favour of the nonverbal. Alternatively, recipients may base their response upon prior interactions: i.e., “the last doctor didn’t seem to care…therefore all doctors are uncaring.”
Healthcare practitioners should understand that humans really cannot not communicate. Failing to say anything can also send its own unintended message. Silence can be misinterpreted as agreement or disagreement, support or disinterest, cooperation or contempt. The patient safety literature has tended to treat silence as dangerous, and to encourage—indeed obligate—everyone to speak up clearly, regardless of rank.Footnote 39,Footnote 40,Footnote 41 However, the relationship between speech and silence is complex, especially in situations of power imbalance and hierarchy, such as the doctor-patient relationship, or amongst members of an interprofessional medical team.Footnote 42 Silence can still be golden: it allows time for a message to sink in, and for meaningful questions to germinate.
Communication: How Can we Understand It?
A mechanistic approach explains communication by breaking it into component parts, such as sender-message-receiver. An example is Claude Shannon and Warren Weaver’s model, which was derived from telecommunications, but has been used to explain medical communication.Footnote 43 In Shannon and Weaver’s model, transmitters (i.e., speakers) encode messages and receivers (i.e., listeners) decode them. Challenges to communication highlighted by this model include ‘interference on the transmission channel’ and ‘channel-overload’ caused by complicated messages. To avoid overload—which can result in indecision or oversimplification—the receiver must be able to decode the message into usable information.Footnote 44 For example, in the clinical realm, a skilled practitioner will receive data (“his blood pressure is continuing to fall”), but communicate this as practical information (“we have run out of therapeutic options”).
Mechanistic approaches, like the Shannon and Weaver model, highlight common sources of “noise” or “interference.”Footnote 45,Footnote 46,Footnote 47 These include distraction and stress caused by literal noise, by time-pressure, and by emotion. Whether people regard these stressors as a threat, or merely a challenge, affects how they receive information and how they respond. For some it expedites focus and understanding, for others indecision and denial. The emphasis on ‘parts’ (transmitter, receiver), rather than the ‘connections between parts’, means that Shannon and Weaver’s model does not fully account for relational factors, such as hierarchy.Footnote 48 Second, the characterization of communication as linear and unidirectional (from transmitter to receiver) oversimplifies the back and forth of higher-level communication.
The mechanistic approach also focuses on ‘data’ and ‘information’, but does not address the role of ‘meaning’. Meaning is derived from, not synonymous with, data and information. Importantly, this is why physicians cannot assume that patients or families share their conclusions.Footnote 49,Footnote 50,Footnote 51,Footnote 52 It is why good communication includes time for reflection and confirmation of understanding. Notwithstanding these limitations, the mechanistic approach is clinically useful. For example, a good communicator invests time minimizing ‘channel interference.’ This includes finding a quiet place, sitting down, and restoring nonverbal cues by removing their surgical mask. The mechanistic approach also highlights “transmitter-orientated” communication, where it is the speaker’s responsibility to be understood, rather than “receiver-orientated” communication where it is the listener’s responsibility to unravel what was meant.Footnote 53,Footnote 54,Footnote 55
The mechanistic approach highlights that it is worthwhile to ensure accurate message transmission. One simple method taught in medicine, but just as applicable elsewhere, is the three “C’s of communication”: cite names (make it clear for whom the message is intended); be clear and concise (avoid jargon or vagueness); and close-the-loop (demand a confirmatory reply).Footnote 56,Footnote 57,Footnote 58,Footnote 59 This last strategy explicitly introduces a feedback or amplification loop. It is why we often ask families to repeat back what we have said. It is also why we include a recap. It is why we encourage patients to bring others along and to talk on the journey home. There are many ways to “close the loop,” but as a strategy it confirms that the instruction was heard, understood, and carried out.
A rhetoric approach to communication uses the premise that all communication is social: it takes place in the context of relationships between individuals whose goals, perspectives, and values are partly shared, and partly in tension. Effective communication, according to a rhetorical model, means identifying with your audience in order to persuade them to share your goals, perspectives, and values. For example, a doctor may hint that it is time to switch to palliation. A rhetorical approach would argue that his or her failure resides in his/her manner of delivery, his/her inability to recognize competing motives, and his/her inability to tailor the communication.
A rhetorical model characterizes communication as having not only the sender-message-receiver components of the mechanistic model (though usually called author-content-audience in a rhetorical model), but two additional key components: purpose and context.Footnote 60 Messages are not constructed neutrally: they are used to achieve a purpose, and are delivered in a social context. In a rhetorical approach, it is the relationships between these parts that determines their effectiveness. Whereas a mechanistic approach works well in understanding how to give and take orders during an acute medical crisis, the rhetorical approach is suited to understanding more socially-complex communication.
A rhetorical approach to communication also highlights the role of genres. These are standardized ways of communicating that are also socially-sanctioned and recognizable. Doctors are taught many genres in the form of acronyms. SBAR (Situation, Background, Assessment, Recommendation) is a communication acronym/genre that originated in military and aviation, and was adopted into healthcare.Footnote 61 SBAR standardizes communication such that one team member can quickly orient another and get buy-in. For example, during a resuscitation: Situation: “this is Dr X, I need your help now”; Background: “I cannot oxygenate this patient”; Assessment: “We have a failed airway.” Recommendation: “We need to insert a breathing tube now.”Footnote 62,Footnote 63,Footnote 64,Footnote 65 Genres are powerful because they carry meaning over and above the content. As soon as the recipient recognizes SBAR they can infer the speaker’s purpose and fill in any gaps. This illustrates the authors’ point: it is possible to convey meaning over and above the literal meaning of words through inferences about the speaker’s intension. A modified SBAR can be similarly used in family conferences to explain why the patient is so sick, what the likely prognosis is, and to justify the recommended plan. However, as the authors point out, the greater the gap in shared background, the more likely it is that incorrect inferences will be made.
The best-known acronym for breaking bad news is the six-part SPIKES approach.Footnote 66,Footnote 67,Footnote 68 This includes (i) Setting up the interview, (ii)assessing the Patient’s Perception, (iii) obtaining the patient’s Invitation, (iv) giving Knowledge, (v) addressing Emotions, and (vi) Summarizing and having a follow-up Strategy. While communication about serious illness should not be scripted or robotic, these tools may be especially useful for junior team members, during complex situations, or to maintain consistency between healthcare professionals and during handovers.Footnote 69,Footnote 70,Footnote 71,Footnote 72,Footnote 73,Footnote 74
A rhetorical approach reminds us that communication is dynamic, socially-constructed, and open to dispute. For example, any discussions about limiting therapy may invoke reflex opposition from patients and surrogate decision-makers. This may not be based upon factual disagreement, but rather upon social interpretation. Setting preemptive limits may be construed as giving up or neglect, rather than prudent planning. Regardless, a rhetorical approach acknowledges the power of genres to modify ideas, and to influence actions. Even if it seems distasteful, we sell ideas as much as we deliver words.
Communication: Where Do we Go From Here?
Communication has the power to heal or to hurt. Accordingly, it should not just be left to chance, or to the most junior member. In order to deliver medicine that is safe, understandable, and caring, we need to disseminate—which is really just another word for communicate—the idea that this is serious business. This means committing resources where necessary, and creating time and space for empathy to thrive. Unfortunately, our society—with its so-called medical-industrial complexFootnote 75—is more likely to default to a focus on technical advances.
Accordingly, it might be useful to consider communication as if it is were a drug. After all, it can function as a ‘placebo’ (i.e., good communication makes things better), or ‘nocebo’ (i.e., bad communication makes things worse).Footnote 76,Footnote 77,Footnote 78,Footnote 79 On the one hand it could be employed earlier in order to mollify ‘symptoms’ such as anger and misunderstanding. On the other hand, like any potent therapy, it might come with warnings on the label. Like a drug, communication is neither one-size-fits-all nor a panacea. It should be administered in the right dosage and at the right time, and tailored to the situation.
George Bernard Shaw claimed that: “the single biggest problem in communication is the illusion that it has taken place.” Accordingly, a very useful medical quote from Marcus Rall and David Gaba—“meant is not said, said is not heard, heard is not understood and understood is not done”—offers a cognitive roadmap as to why, and where, we err in communication. While Rall’s quote was intended for anesthetic teams it is as useful when trying to understand discussions about serious illness. It has also been used to create a communication curriculum along with insights from other high-stakes industries.Footnote 81,Footnote 82
In short, good medical communication rarely happens by accident. As an intensive care physician, I hope the future will be less about technology, and more about understanding how humans connect. Doctors will need to relearn that nobody cares what you know until they know that you care.Footnote 83 Similarly, patient and surrogate decision-makers will need to remember that we cannot always save a life, but we always strive to save a death.Footnote 84 Finally, all people are less likely to remember what was done or said, than they are to remember how they were made to feel.Footnote 85 The danger is that these ideas come across as hackneyed or contrived, instead of the battle cry for a renewed focus on an age-old, quintessentially-human skill.
This commentary centers around why Jason Batten et al.’s contribution entitled “Treatability Statements in Serious Illness: The Gap Between What Is Said and What Is Heard” warrants your precious time and finite cognitive bandwidth.Footnote 1 This article dissects how physicians, patients and surrogate decision makers communicate about illness, and uses clinical cases to focus on how we derive meaning within and beyond what is actually said. By examining how physician statements can be variably interpreted, they have provided a simulacrum of the Indian parable where blind men touch different parts of an elephant and reach disparate conclusions.Footnote 2 One feels the elephant’s side and decides it must be a wall, one its tusk and assumes a spear. In the clinical arena this is why one patient can hear that “the chance is one-in-a million” and reply over-optimistically “so there is a chance.” It is why another patient can hear “we are running some tests” and over-pessimistically conclude “so you think I have cancer.”
Batten et al. can add themselves to the list of authors who have highlighted why communication may be the most nuanced, and therefore most perilous, “procedure” in healthcare.Footnote 3,Footnote 4,Footnote 5,Footnote 6,Footnote 7,Footnote 8,Footnote 9,Footnote 10 This body of work buttresses what may seem intuitive: the ability to speak, but also to listen, is central to building or destroying relationships, and relationships matter. Moreover, there exist vicious or virtuous cycles where communication impacts relationships, and relationships impact communication. Accordingly, communication—including the previously maligned topic of gossip—may be central to what it means to be a human.Footnote 11 Despite all of modern healthcare’s advances we still use the same ‘equipment’—namely, our voices, our ears and our cognition—to coordinate teams during crises, deliver prognoses to patients, and ‘stick-handle’ more than 150 estimated steps per hospitalized patient per day.Footnote 12 Accordingly, clinical medicine may be better understood as a branch of the humanities, rather than the biosciences.Footnote 13 Similarly, an expert clinician can be defined as someone who is verbally adroit, not just manually dextrous.Footnote 14,Footnote 15,Footnote 16
Step one is to accept that the ability to speak and listen is a skill that cannot always be intuited, but can be taught.Footnote 17,Footnote 18,Footnote 19,Footnote 20 Step two is to take responsibility for minimizing communication errors, whether healthcare provider or patient; surgeon or surrogate decision-maker; ethicist or educator. Regardless, healthcare is a useful prism through which to examine wider social phenomena. Communication is the medium through which ideas and reputations thrive or perish. The modern world has de-emphasized hierarchy, and therefore our ability to engage and persuade matters. We cannot always dictate, or predict, how others receive what we say. Similarly, the recipient cannot dictate, or identify, how speakers deliver their messages.Footnote 21,Footnote 22,Footnote 23,Footnote 24 In short, it takes humility and patience for two or more people to successfully exchange complex ideas. In contrast, it takes very little skill to misinterpret or disagree.
Batten, et al.’s work emphasizes why complex medical discussions can be duets, or duels. Words are launched from the larynx but ideas land in the brain.Footnote 25,Footnote 26,Footnote 27,Footnote 28 This metamorphosis is influenced by myriad factors including our emotions, willingness, intelligence, social cues, and prior experiences. Notably, conversing about serious illness is even tougher if subjects such as death and disability are considered social taboos, rather than inevitabilities.Footnote 29 At the risk of speculation, the newer generation of doctors now delivering bad news, and the patients now receiving it, may have grown up more comfortable interacting with two-dimensional screens rather than three-dimensional humans. There may also be less trust of experts, and more opposition to ideas that are unappealing or complex. Accordingly, while it is difficult to be a vulnerable or scared patient, it is also not easy to be a modern-day healthcare professional, or ethicist, or academic. We are all—like it or not—in the communication business. The work of Batten et al. is a laudable effort to understand the mechanics behind negotiating the modern age.
Communication: What Does it Mean?
The United States Supreme Court Justice, Potter Stewart, became famous after arguing that while he could not define pornography, he knew it when he saw it.Footnote 30 While less titillating, good communication can be similarly difficult to pinpoint. Communication typically refers to how we share meaning, or, more literally, the effort to unite as one. While it may seem ironic to define something as interpersonal as communication using impersonal scientific models, it is useful to have a framework and shared mental model.
Communication is more than just what is said. It is a bilateral, often multilateral, process that includes how it is said and how it is understood, which guides how it is responded to.Footnote 31,Footnote 32,Footnote 33,Footnote 34 As a result, nonverbal communication (which includes posture; facial expressions; gestures, and eye contact), as well as para-verbal communication (which includes pacing, tone, volume, and emphasis) are as important as verbal communication.Footnote 35,Footnote 36,Footnote 37,Footnote 38 Breaking down communication into parts is important if there is incongruence between the words used and the facial expression, or the tone or its reception. For example, if we say: “he’s unstable” or “he’s doing fine,” but in a tone that suggests otherwise, then listeners often downplay the verbal in favour of the nonverbal. Alternatively, recipients may base their response upon prior interactions: i.e., “the last doctor didn’t seem to care…therefore all doctors are uncaring.”
Healthcare practitioners should understand that humans really cannot not communicate. Failing to say anything can also send its own unintended message. Silence can be misinterpreted as agreement or disagreement, support or disinterest, cooperation or contempt. The patient safety literature has tended to treat silence as dangerous, and to encourage—indeed obligate—everyone to speak up clearly, regardless of rank.Footnote 39,Footnote 40,Footnote 41 However, the relationship between speech and silence is complex, especially in situations of power imbalance and hierarchy, such as the doctor-patient relationship, or amongst members of an interprofessional medical team.Footnote 42 Silence can still be golden: it allows time for a message to sink in, and for meaningful questions to germinate.
Communication: How Can we Understand It?
A mechanistic approach explains communication by breaking it into component parts, such as sender-message-receiver. An example is Claude Shannon and Warren Weaver’s model, which was derived from telecommunications, but has been used to explain medical communication.Footnote 43 In Shannon and Weaver’s model, transmitters (i.e., speakers) encode messages and receivers (i.e., listeners) decode them. Challenges to communication highlighted by this model include ‘interference on the transmission channel’ and ‘channel-overload’ caused by complicated messages. To avoid overload—which can result in indecision or oversimplification—the receiver must be able to decode the message into usable information.Footnote 44 For example, in the clinical realm, a skilled practitioner will receive data (“his blood pressure is continuing to fall”), but communicate this as practical information (“we have run out of therapeutic options”).
Mechanistic approaches, like the Shannon and Weaver model, highlight common sources of “noise” or “interference.”Footnote 45,Footnote 46,Footnote 47 These include distraction and stress caused by literal noise, by time-pressure, and by emotion. Whether people regard these stressors as a threat, or merely a challenge, affects how they receive information and how they respond. For some it expedites focus and understanding, for others indecision and denial. The emphasis on ‘parts’ (transmitter, receiver), rather than the ‘connections between parts’, means that Shannon and Weaver’s model does not fully account for relational factors, such as hierarchy.Footnote 48 Second, the characterization of communication as linear and unidirectional (from transmitter to receiver) oversimplifies the back and forth of higher-level communication.
The mechanistic approach also focuses on ‘data’ and ‘information’, but does not address the role of ‘meaning’. Meaning is derived from, not synonymous with, data and information. Importantly, this is why physicians cannot assume that patients or families share their conclusions.Footnote 49,Footnote 50,Footnote 51,Footnote 52 It is why good communication includes time for reflection and confirmation of understanding. Notwithstanding these limitations, the mechanistic approach is clinically useful. For example, a good communicator invests time minimizing ‘channel interference.’ This includes finding a quiet place, sitting down, and restoring nonverbal cues by removing their surgical mask. The mechanistic approach also highlights “transmitter-orientated” communication, where it is the speaker’s responsibility to be understood, rather than “receiver-orientated” communication where it is the listener’s responsibility to unravel what was meant.Footnote 53,Footnote 54,Footnote 55
The mechanistic approach highlights that it is worthwhile to ensure accurate message transmission. One simple method taught in medicine, but just as applicable elsewhere, is the three “C’s of communication”: cite names (make it clear for whom the message is intended); be clear and concise (avoid jargon or vagueness); and close-the-loop (demand a confirmatory reply).Footnote 56,Footnote 57,Footnote 58,Footnote 59 This last strategy explicitly introduces a feedback or amplification loop. It is why we often ask families to repeat back what we have said. It is also why we include a recap. It is why we encourage patients to bring others along and to talk on the journey home. There are many ways to “close the loop,” but as a strategy it confirms that the instruction was heard, understood, and carried out.
A rhetoric approach to communication uses the premise that all communication is social: it takes place in the context of relationships between individuals whose goals, perspectives, and values are partly shared, and partly in tension. Effective communication, according to a rhetorical model, means identifying with your audience in order to persuade them to share your goals, perspectives, and values. For example, a doctor may hint that it is time to switch to palliation. A rhetorical approach would argue that his or her failure resides in his/her manner of delivery, his/her inability to recognize competing motives, and his/her inability to tailor the communication.
A rhetorical model characterizes communication as having not only the sender-message-receiver components of the mechanistic model (though usually called author-content-audience in a rhetorical model), but two additional key components: purpose and context.Footnote 60 Messages are not constructed neutrally: they are used to achieve a purpose, and are delivered in a social context. In a rhetorical approach, it is the relationships between these parts that determines their effectiveness. Whereas a mechanistic approach works well in understanding how to give and take orders during an acute medical crisis, the rhetorical approach is suited to understanding more socially-complex communication.
A rhetorical approach to communication also highlights the role of genres. These are standardized ways of communicating that are also socially-sanctioned and recognizable. Doctors are taught many genres in the form of acronyms. SBAR (Situation, Background, Assessment, Recommendation) is a communication acronym/genre that originated in military and aviation, and was adopted into healthcare.Footnote 61 SBAR standardizes communication such that one team member can quickly orient another and get buy-in. For example, during a resuscitation: Situation: “this is Dr X, I need your help now”; Background: “I cannot oxygenate this patient”; Assessment: “We have a failed airway.” Recommendation: “We need to insert a breathing tube now.”Footnote 62,Footnote 63,Footnote 64,Footnote 65 Genres are powerful because they carry meaning over and above the content. As soon as the recipient recognizes SBAR they can infer the speaker’s purpose and fill in any gaps. This illustrates the authors’ point: it is possible to convey meaning over and above the literal meaning of words through inferences about the speaker’s intension. A modified SBAR can be similarly used in family conferences to explain why the patient is so sick, what the likely prognosis is, and to justify the recommended plan. However, as the authors point out, the greater the gap in shared background, the more likely it is that incorrect inferences will be made.
The best-known acronym for breaking bad news is the six-part SPIKES approach.Footnote 66,Footnote 67,Footnote 68 This includes (i) Setting up the interview, (ii)assessing the Patient’s Perception, (iii) obtaining the patient’s Invitation, (iv) giving Knowledge, (v) addressing Emotions, and (vi) Summarizing and having a follow-up Strategy. While communication about serious illness should not be scripted or robotic, these tools may be especially useful for junior team members, during complex situations, or to maintain consistency between healthcare professionals and during handovers.Footnote 69,Footnote 70,Footnote 71,Footnote 72,Footnote 73,Footnote 74
A rhetorical approach reminds us that communication is dynamic, socially-constructed, and open to dispute. For example, any discussions about limiting therapy may invoke reflex opposition from patients and surrogate decision-makers. This may not be based upon factual disagreement, but rather upon social interpretation. Setting preemptive limits may be construed as giving up or neglect, rather than prudent planning. Regardless, a rhetorical approach acknowledges the power of genres to modify ideas, and to influence actions. Even if it seems distasteful, we sell ideas as much as we deliver words.
Communication: Where Do we Go From Here?
Communication has the power to heal or to hurt. Accordingly, it should not just be left to chance, or to the most junior member. In order to deliver medicine that is safe, understandable, and caring, we need to disseminate—which is really just another word for communicate—the idea that this is serious business. This means committing resources where necessary, and creating time and space for empathy to thrive. Unfortunately, our society—with its so-called medical-industrial complexFootnote 75—is more likely to default to a focus on technical advances.
Accordingly, it might be useful to consider communication as if it is were a drug. After all, it can function as a ‘placebo’ (i.e., good communication makes things better), or ‘nocebo’ (i.e., bad communication makes things worse).Footnote 76,Footnote 77,Footnote 78,Footnote 79 On the one hand it could be employed earlier in order to mollify ‘symptoms’ such as anger and misunderstanding. On the other hand, like any potent therapy, it might come with warnings on the label. Like a drug, communication is neither one-size-fits-all nor a panacea. It should be administered in the right dosage and at the right time, and tailored to the situation.
George Bernard Shaw claimed that: “the single biggest problem in communication is the illusion that it has taken place.” Accordingly, a very useful medical quote from Marcus Rall and David Gaba—“meant is not said, said is not heard, heard is not understood and understood is not done”—offers a cognitive roadmap as to why, and where, we err in communication. While Rall’s quote was intended for anesthetic teams it is as useful when trying to understand discussions about serious illness. It has also been used to create a communication curriculum along with insights from other high-stakes industries.Footnote 81,Footnote 82
In short, good medical communication rarely happens by accident. As an intensive care physician, I hope the future will be less about technology, and more about understanding how humans connect. Doctors will need to relearn that nobody cares what you know until they know that you care.Footnote 83 Similarly, patient and surrogate decision-makers will need to remember that we cannot always save a life, but we always strive to save a death.Footnote 84 Finally, all people are less likely to remember what was done or said, than they are to remember how they were made to feel.Footnote 85 The danger is that these ideas come across as hackneyed or contrived, instead of the battle cry for a renewed focus on an age-old, quintessentially-human skill.