Sticks and stones

Changing terminology is no substitute for good consultation skills

Letters p 1081

As children many of us learnt the old rhyme “Sticks and stones may break my bones but words can never hurt me.” As we grew older we discovered that the adage was untrue. For most of us whose profession involved interacting with other people it became obvious that clumsy or inapposite use of language could cause pain. An attempt to avoid such pain has provoked Hutchon and Cooper to suggest that distress in women who have miscarried would be reduced if changes were made in the language used by their professional carers (p 1081).1 The writers recommend that the word “abortion” should be avoided because the lay public interprets it as applying to a termination of preg- nancy. The authors cite alternatives that could be adopted in journal papers and medical records. These recommendations seem harmless enough. But are they likely to be effective if implemented? And do they represent the most effective intervention available?

A miscarriage is an example of a common event which is rarely a medical emergency and from a biomedical perspective may be viewed as a normal variation of early pregnancy, but the mother may view it entirely differently.2Furthermore, perceptions may differ radically from woman to woman depending on knowledge, expectations, and previous experiences. How a consultation is conducted may affect whether a woman chooses to reveal such fears, worries, and concerns to the doctor.3

There is ample evidence of patients' frequent dissatisfaction with doctors'communication skills.4 Despite increasingly liberal provision of information, many patients still want to know more than they are told,5whereas others do not want to participate in decision making: they need absolute, uncritical confidence in their doctors' skills. A skilful doctor will achieve the correct balance between autonomy and paternalism for each patient. To determine the appropriate balance it is useful to have a framework to help identify the necessary tasks and skills.

Such a framework is provided by the “three function” model of the consultation developed by Bird and Cohen-Cole6:gathering data to understand the patient; developing rapport and responding to the patient's emotions (to enable the patient to feel understood); and patient education and behaviour management. These functions relate to the three purposes and effects of communication:informative (to exchange information); promotive (to bring about action); and evocative (to arouse certain feelings)7 and also to the three domains (cognitive, affective, and psychomotor)widely used by educationalists to categorise educational objectives. Each function has specific objectives and demands specific explicit skills of the doctor if they are to be achieved. Fortunately, considerable evidence now exists that such skills can be successfully acquired.8

However, no single model can fully convey the complexity of the doctor-patient relationship and the three function model needs to be expanded by drawing on other concepts of the consultation. These include the idea of the consultation as a “meeting between experts”9;the patient-centred clinical method described by Stewart et al10;the problem based approach11;the stages of motivational interviewing described by Miller and Rollnick12; and the family systems approach, which emphasises the importance of taking into account the patient's family and social networks.13

Finally,the individuality of the professional cannot be ignored. All sorts of factors, some based on the professional's own life experiences, can both consciously and unconsciously influence his or her behaviour and decisions. This has led to the notion of the doctor as a drug,14 with both powerful effects and side effects. When listening and talking to patients, professionals need to be aware not only of the words they use, both to discover and convey information, but also their own feelings and how to cope with them.

Thus a recommendation to change terminology, while laudable in its intentions, may not be enough to alleviate mothers' dissatisfaction with the care that they receive. The risk is that mere use of the “correct” terminology, with no attention paid to the wider aspects of a consultation, could lead to professional complacency.