I must speak out bluntly what I think and how it shall come to pass. (Achilles, in the Iliad, Bk 9, lines 309–10)i

Learning how to communicate now features prominently in the curriculum of most health workers at undergraduate and postgraduate level. How to elicit a history from a patient, to discuss treatment options, and to break bad news and deal with the distressed are regarded as clinical skills to be acquired through books, seminars and workshops. It is easy to forget that 40 years ago they would have seemed extraordinary and unnecessary. Perhaps they were felt to be unteachable. There are still plenty of students who doubt that this is a skills issue, believing that the ability to communicate is innate.1

In the ancient world, Homer was regarded as the father of many branches of knowledge—rhetoric, tragedy, philosophy, theology.ii This paper presents him as the father of communication skills too. What has he to tell us across three millennia about talking and listening to patients, their relatives and our colleagues? And what may we learn from Homer that distinguishes him from other authors? We concentrate on one book of the Iliad, book 9, to argue that the speeches and silences of Agamemnon, Odysseus and Achilles show or conceal the same hopes, fears and anxieties as those our patients experience. With this familiarity, however, is mingled a strangeness of language, attitude and belief. It is this commingling of familiar and strange, of civilised and barbaric, in one of the greatest of literary works that lets Homer teach us across nearly 3000 years. We should learn from the close parallels, entwined with what is foreign, even repugnant, that any attempt to regiment the teaching of communication skills renders them banal and oversimplified. We can learn something of the contextual nature of these skills from modern literature, from Austen or Shakespeare. It is learnt with greater force from a story that juxtaposes a familiar, domestic scene (Hector saying farewell to his wife and baby son) with events barbaric and fantastic (a hero who fights with rivers, as Achilles does with Scamander towards the end of the Iliad) and that engages our emotions with immediacy in a language supposedly dead and a vocabulary and metre archaic even when they were first written.

Book 9 of the Iliad is not essential to its action but is critical as an examination of the psychology of Achilles and the morality of his implacable anger. There may well have been an earlier version of the Iliad that was simply a saga of war. There is evidence in this book of much original, unusual composition. A high proportion is direct speech as opposed to the author’s narrative. It is tempting to attribute this special flavour to the genius of the “Homer” who crafted the final version of the story that has come down to us; tempting to suppose that he wanted to reshape the story and give it an ethical dimension that was entirely new to its audience. It is a special book. “[Book 9] must have been created by the poet we call Homer, who would not have found the sort of pre-existing material for it which existed, say, for a standard battle scene. Both times we find direct speech deployed with great power”.4

The following is a précis of the events up to and including book 9, which provide most of the material on which our arguments are based.

These arguments centre on learning how to communicate from an episode of miscommunication, itself set in an epic arising from an utter failure of communication. This failure arises partly from poor communication within a group and partly from a failure to move from entrenched positions. Both will strike a chord with anyone working in healthcare.

THE EMBASSY (BOOK 9)

The whole of the Iliad occupies just a few days at the end of the Trojan war, which has already lasted 10 years. The first word sets the theme and the content—μηνιν, wrath, the wrath of Achilles. (Robert Graves’ idiosyncratic translation of the Iliad is entitled The anger of Achilles.5)

Agamemnon, the Greek leader, has taken Briseis, the woman of Achilles, from him. Achilles was barely restrained by the goddess Athene from killing Agamemnon and has now sworn to take no further part in the fighting. He is by far the greatest fighter of the Greeks and his absence will be a disaster, causing many deaths. He departs to his section of the Greek camp with his army, and his anger festers.

The Trojans, assisted by Zeus, face the Greeks in open battle and beat them back to the Greek camp. As night falls, the Greek leaders debate how to avert inevitable disaster the next day and recommend to Agamemnon that he send an embassy to Achilles, offering gifts by way of apology to entice him back to action. Agamemnon agrees, recognising his error and detailing the gifts he is prepared to offer by way of restitution.

Three ambassadors of very different character are selected—Phoenix, an old retainer of Achilles’ father; Odysseus, skilled in counsel; and Ajax, a simple, straight-talking soldier. Achilles greets the ambassadors warmly, calling them “old friends”. They are taken into his shelter and given food and drink. In an enigmatic start to the debate, Ajax nods to Phoenix to lead off, but the glance is intercepted by Odysseus, who begins. He makes a speech of 80 lines, the central part of which, nearly half, is a virtually verbatim repetition of Agamemnon’s offer of goods of restitution. He begins with brief thanks for their meal, then moves on to the military defeat that has occurred and the worse that threatens, emphasising the successes of Hector—guaranteed to irritate Achilles, for Hector is the only Trojan on a par with him. He urges Achilles to get back to battle now—there will be no point after their ships are burned. Achilles’ own father warned him to govern his pride (or “great-hearted spirit”). Then he lists Agamemnon’s promised gifts. He ends by asking him to take pity on the beaten Greeks, who would heap glory on him if he returns, especially if he kills Hector.

Achilles’ reply is half as long again as Odysseus’—much longer, given that it lacks the repetitive offer of gifts in Odysseus’. It is an argument of passion rather than logic, of a young man consumed by notions of honour and dishonour. He replies to the last of Odysseus’ arguments by saying that there is no point in being brave and active: the cowardly and the brave are rewarded alike; when he sacked many a town round Troy, the lion’s share of the booty went to Agamemnon. He goes on to question whether the sons of Atreus (Agamemnon and Menelaus) are the only men who love their wives. Agamemnon robbed him of the woman he loved. He will pack up his booty and return home. Not all the gifts in the world could win him back; first Agamemnon must pay in kind for the humiliation he has endured. Let them relay that back to the Greek leaders forthwith.

There is a shocked silence. Phoenix bursts into tears and asks what is to become of him, Phoenix, if Achilles returns home. He gives a lengthy account of how he had to leave his own home, was welcomed and honoured by Achilles’ father and became Achilles’ nurse and mentor. This gives him the moral power to tell Achilles to abandon his pride and inflexibility. He tells—part metaphor, part theology—how Prayers, the daughters of Zeus, follow Sin (or Atee) around the world. (Sin is a poor translation of the Greek ατη, atee.iii) The man who fails to listen to these daughters of Zeus is himself punished by Atee. Let Achilles be placated by the generous offer of Agamemnon and the entreaties of his friends. Phoenix goes on to tell a long story about an earlier hero, Meleager, as an example of another inflexible, angered hero. Meleager had refused all gifts and entreaties until his town was in flames. He then, of his own conscience, came out and beat off the attackers, winning neither honour nor goods.

Achilles’ reply is brief. He has no need of honour from the Achaeans. Phoenix should not curry favour with Agamemnon by trying to persuade him. Let Phoenix stay the night and sail home with him in the morning. Achilles then signals to his comrade Patroclus to make up a bed for Phoenix, expecting the other two to take the hint to leave. Ajax, rather than speaking to Achilles, says to Odysseus that they should report their failure at once to the Greek leaders; and, continuing as if they had already left Achilles, condemns him as cruel and arrogant for spurning his comrades. Even the family of a murdered man accepts blood money from the killer. Then he addresses Achilles directly: the gods have made him implacable over a single girl and here is Agamemnon offering him seven more. He should remember his friends and his obligations as a host. Achilles very briefly repeats his fury over the way he has been dishonoured. He will not return to war before Hector has set fire to the Greek ships. Ajax and Odysseus then depart, leaving Phoenix behind.

DISCUSSION

“Communication skills” in medicine are usually understood to mean communication between healthcare worker and patient. We would like to interpret the term more broadly—communicating with patients, other professionals and the public, through the written and spoken word. “Communication” is a dynamic and complex “activity system”, an embodied cognition situated historically and culturally as “discourse”.8 To disaggregate individual “skills” from this complex is a dangerous business, potentially reducing communication to only the communicator and an instrumental act. We use this scene from the Iliad almost as a metaphor for our own communications. In many of our interactions we listen and interpret confidently and comfortably, but we can be jolted out of our preconceptions by physical or verbal incongruity. So, in this passage, we have to set the rationality of the argument of the protagonists against the savagery of the battle scenes, the boasting of heroes over the corpses of the vanquished and the petty vindictiveness of the gods.

Preparing for interviews

In a chapter devoted to the angry, aggressive patient, Coid emphasises the importance of preparation, getting right those factors that are outside the interview itself—preconceived attitudes, having the right colleagues with one and body language.9 When the Greek leaders meet before the embassy, two of them make clear their condemnation of Agamemnon. By implication, the ambassadors approach their interview in sympathy with the anger of Achilles. The three colleagues were chosen with care by the venerable counsellor, Nestor, and he ensures that they are fully prepared before they leave:

Nestor the Gerenian charioteer gave them many instructions,

Looking to each man, but especially to Odysseus,

To try to persuade the noble Achilles. (Bk 9, lines 179–81)

We are not given the reasons for their selection, but they are self-evident. Phoenix helped to raise Achilles from childhood. Ajax is a comrade in arms, almost an equal in battle. Odysseus is essential because he is a great speaker; his eloquence was described by Helen in an earlier book:

But when he let forth his great voice from his breast

And words like to winter snowflakes,

No other mortal might then contend with Odysseus. (Bk 3, lines 221–3)

Odysseus is also renowned for his cunning. “Polumetis”—“of many counsels”—is one of the epithets most commonly applied to him. The arrival of the three colleagues is reminiscent of the “three wise men” system, which was used in the British National Health Service as a mechanism for resolving professional and management difficulties with consultant doctors (outlined in a publication by the Department of Health and Social Security).10 To have these rather shadowy figures, chosen more for eminence than wisdom (very like Greek heroes), arrive on your doorstep must have engendered similar feelings in their victim as in Achilles.

As with many modern encounters, Achilles, Odysseus and Ajax all carry a baggage of emotion, reputation and history with them into the meeting. At one point, Achilles says:

The man is as hateful to me as the gates of Hell

Who hides one thing in his heart and says another. (Bk 9, lines 312–3)

On first impression, this refers to the hated Agamemnon, but there is an implicit reference to Odysseus “of many counsels”.

As for body language, the interview starts strangely, with Odysseus intercepting a nod from Ajax to Phoenix intended to encourage the latter to speak first. But Odysseus pre-empts Phoenix. Why? What is the tacit underpinning to the explicit nod and its interception? We are not told. The Iliad has many touches of theatre like this but it is the sort of incident that might foul an interview.

Good and bad communication—the cultural and emotional context

A recent examination of interviews between students and patients led to a summary of the components of good and bad communication styles.11 Good communication involved attentive responding, joint problem solving, and face saving (directed at the patient); poor communication was characterised by inappropriate responses, schema-driven progression (that is, moving the conversation on to fulfil the speaker’s own agenda) and insensitivity to the patient’s level of understanding. The authors also felt that the interviews often hinged around one or more critical moments or remarks. A final element was the set of assumptions that the interviewers brought with them to the encounter. The authors might have been describing this book of Homer. The ambassadors exhibit great powers of listening in this book, but there is more listening than hearing. They are goal-driven and approach the meeting with a fixed agenda that cannot mould itself in response to Achilles’ passionate rejection.

It is interesting above all to see “face saving” emerging from a discourse analysis of modern patient interviews. Face was everything to a Greek hero. The loss of face that Achilles suffered from Agamemnon’s taking of Briseis is the main problem with which the ambassadors have to grapple in this book (as well as the source of the wrath that is central to the theme of the Iliad). In his reply to Odysseus’ offer, Achilles himself says, “Agamemnon will not persuade my spirit until he has repaid me all the bitter humiliation” (Bk 9, line 387). The implication is that Agamemnon can repay only through his own humiliation; any gifts offered through Odysseus can never be adequate recompense. This is the crux of the argument and it is ignored. Achilles himself is not playing by the rules because, in an honour society, both sides must save face and he is wishing humiliation on Agamemnon. Hainsworth states that the language is deliberately obscure at this point. Otherwise, Achilles might be too obviously at fault (p113).6

However, this is an instrumental reading of the Iliad. It is easy to be seduced by the simplicity of models of communication skills. We might learn more from broader reflections about the sensitivity engendered by close reading of a great and, to us, strange epic. Reading the Iliad for this purpose rather than just for pleasure is like opening a Russian doll—there is always one more level of interpretation. Pendleton and colleagues recognise the importance of the cultural context within which consultations are embedded. (“Doctors and patients and the nature of the consultations between them are profoundly influenced by the social and cultural context in which they take place.”)12 Examining discourse so far removed from our own should make us reflect not how strange it is, but how strange our own might be. Making the familiar strange is the first rule of post-modern thinking.

Angry patients make for complex consultations. Maguire and Pitceathly tell us that doctors tend to distance themselves from these encounters partly to protect their own emotions and partly because they believe they are protecting the patient.13 This belief is mistaken, because an exploration of the anger can reveal causes of which patients are themselves unaware. The ambassadors attempt no such exploration. Probably they feel its causes are obvious, since all of them were present at the original quarrel. (Perhaps this does Phoenix less than justice. Harris argues that the story of Meleager’s anger clearly recognises and parallels that of Achilles. It is, however, an unsubtle sermon, not likely to appease—the speech of a man going into a meeting with an agenda.)14 But anger is rarely simple and cannot be isolated from both cultural and motivational settings. Although it has been mentioned only once so far in the Iliad, Homer’s audience would have been aware of the choice Achilles has already made between a long but obscure life with a loving family, and death at Troy, which will bring everlasting fame. In his angry reply to Odysseus in this book, Achilles refers to this choice explicitly for the only time in the Iliad:

My mother, the goddess Thetis of the silver feet, tells me

That two fates await me on the path to death.

If I stay and fight at the city of the Trojans,

There will be no homecoming for me but I shall have glory imperishable.

If I return to the beloved home of my fathers,

My goodly fame shall perish, though I shall have long life

And no swift end of death shall come near me. (Bk 9, lines 410–6)

This sense of the futility of his sacrifice is an obvious spur to his anger but is not acknowledged by his colleagues. Indeed there is a striking absence of reply by any of them to the individual points that Achilles makes. Schein describes the complexity of Achilles’ reply, which swings between rational argument and passionate outburst.15 It is a denial of the very heroic principles on which Achilles’ life is based, a denial that makes it a very modern argument and juxtaposes the strange and the familiar within Homer’s storytelling. The language and images that Achilles uses emphasise how alone he is, how set apart from other mortals. It is a wonderful speech, which his colleagues completely ignore.

Ancient ambiguity, modern simplification

The three ambassadors are chosen for the different attributes that they bring. For a Greek audience, this understates it. Ajax and Odysseus would have been archetypes of the qualities for which they were renowned. Ajax goes into the interview as great warrior, bearer of a massive shield, slow in attack but indomitable in defence, a simple thinker. Odysseus, as we have seen, is the wily tactician and eloquent persuader. Such archetypes are characteristic of Homer. We look to the modern novel for psychological subtlety and complexity. Not so in communication skills training, where facilitators of professional or student groups are taught to deal with the Achilles and Agamemnons of those groups in terms that transmute archetypes into stereotypes. (Hackett and Martin categorise participants as the mummy, the windbag, the rambler and the homesteader,16 and Hanson categorises them as the turtle, the bull in a china shop and the interviewer.17) An archetype stimulates deep thinking because it is invariably both complex and ambiguous. Stereotypes are purposely simplified to get things tied up, explained. Perhaps they are as likely to fail as the ambassadors for making caricatures. There is a rigidity about communication skills training, as if it is all about transmitting a set of reproducible, transferable and dependable skills. Kurtz and colleagues make no bones about this, saying, “communication is not a personality trait but a series of learned skills”, the justification being that “the acquisition of skills can open the path to changes in attitude.”18 Robert and colleagues clearly felt qualms about this approach, commenting that “a more fine-grained understanding of the attributes of good and poor medical communication is needed to improve communications teaching.”11 Stereotyping is just one area of communication skills training that will lead us to a mechanistic, oversimplified approach, which we cautioned against at the beginning.

Archetypes are rarely stable. Odysseus becomes a devious and ruthless manipulator in another story, Sophocles’ Philoctetes. In the Iliad, Homer, too, is capable of complexity. Just a few hundred lines beyond book 9, Odysseus shares in the savage killing of a Trojan spy. Ajax, after the Trojan war, is driven mad and commits suicide when he fails to win the armour of the dead Achilles.

Rhetoric

The Greek equivalent of “communication skills” would have been rhetoric, which was one of the cornerstones of ancient Greek education. Homer was regarded as the father of rhetoric, a reputation that depended in large part on this book. Ancient rhetoric had a purpose different from modern communication skills, being designed above all to persuade, by reason and emotion. There was a real need to develop rhetorical skills in the ancient world. The young democracies arose in city-states small enough to let every citizen have his (definitely “his”) say quite literally on matters political and legal. With no skill, a citizen would be disadvantaged materially and could find himself banished or even executed if at the wrong end of a lawsuit (remember Socrates). It is a sort of democratic process—the need to give patients more “voice”—that drives communication skills training now. We should remember, then, that training in rhetoric fell into the hands of the Sophists, much despised by Plato as purveyors of technique without knowledge, particularly moral knowledge. Our communication skills training follows the orthodoxy of our day. It is not in some absolute sense “right”. Indeed, it is rare to see study of rhetorical devices on communication skills curricula, although study of communication through rhetoric has revealed that surface “communications” dissimulate, distracting or negating deeper motives.19

The speeches of this book, particularly that of Odysseus, were regarded as exemplars from which later rhetoric developed. One feature that must strike a modern reader is the degree of straight talking. At the beginning of the book, when the embassy is being planned, Diomedes tells Agamemnon that Zeus may have given him power but failed to give him courage. During the embassy, Odysseus tells Achilles that he has forgotten his father’s injunction to keep his temper, Phoenix tells him he should not have a merciless heart and Ajax refers to him as merciless and wicked—all apparently without offending Achilles, who shows a robustness in receiving criticism now lost. (Achilles himself at the beginning of the Iliad calls Agamemnon a “drunken sot, with the eyes of a dog and the courage of a deer,” brave words to one’s commander-in-chief) (Bk 1, line 225). This straight talking is at odds with current concepts of “feedback” to students and peers. These recommend that critical comments should be introduced only after consideration of what was good; blunt talk is likely to be considered unprofessional. Straight talking developed into the skilful and eloquent vituperation of Demosthenes and Cicero. Both in Homer and in later Greece and Rome, those skills were not without risk. Orators put their lives at risk from their powerful opponents.

Understanding the outcomes of communication failure

The action of the Iliad is predetermined: Achilles knows he will die soon; we know that he will rebuff his colleagues so that the tragic sequence of events can unfold and “the will of Zeus be brought to pass”. The literature on communication skills has little to say about the consequences of failure. They are well illustrated by many anecdotes in the Fillers sections of the British Medical Journal or by standing in the queue at your butcher’s. We leave many patients and colleagues and meetings with a feeling that failure was inevitable. Perhaps we should read our own communication failures as part of a wider story, learn from them and take that store of wisdom to future encounters. Book 9 functions to develop not the action but the ethics of the poem. In the passionate speeches of Achilles we see him first realising the emptiness of the heroic ideal, a theme to which he returns at the end of the Iliad after killing Hector.

There is a huge gulf of understanding of the origin of emotional life between Homer and our 21st-century lives. We tend to think of emotions as personal and interior. As Ruth Padel’s meticulous analysis of the language of the ancient world shows, “emotion” is something that visits us, from outside, and lodges in us.20 A fear, an ecstasy, a chilling anxiety, was often personified as a god, a force or an animal-like presence, which gripped you or entered the liver, heart or lungs. When standing on the edge of a cliff, where we would say that the fear of falling is “in” us, the ancient Greeks would say that the fear is “in” the fall. Emotion is already shared, collaborative, distributed. Surely this has something to tell us about “communication skills” for clinical teamwork? In a team setting, how is an “atmosphere” or “climate” initiated, distributed, maintained, resisted and felt collaboratively?21 Is this not key to effective teamwork around patients?

Part of that “fine-grained understanding” that Robert and colleagues speak of might come from considering how the reader of the Iliad is aware of both strangeness and familiarity: strange in its language, which predates classical Greek by several hundred years; strange in the part played by the gods—immortal, mighty and largely irresponsible; strange in the habits and beliefs of the human protagonists; strange as it must be after three millennia.11 Yet modern readers constantly identify with its themes and find echoes to take into their own encounters. Book 9 ends with the return of the ambassadors to the main camp and a gloomy discussion of events among the Greek leaders. We, 21st-century readers, steeped in the romance of recent centuries, feel our hearts go out to Achilles mourning his lost love. But just before the end of book 9, the episode with Achilles ends with Achilles, Phoenix and Patroclus settling down for the night. Achilles—he who minutes before described passionately how he was robbed of the woman he loves, who because of the wrath he attributed to that love is prepared to let Greeks die and the Greek army come to the brink of defeat—seeks solace in the arms of Diomede of the lovely cheeks. This Diomede, and Briseis the woman stolen from him, are both prizes of war—in 21st-century terms, victims of rape. We need to pause often in our interpretations of any narrative to detect the lenses through which the story is refracted.