Introduction to Spoken/Unspoken: hidden mechanics of the patient-doctor relationship

Since publishing the last collection of posts in Motives, emotion and memory – exploring how doctors think I have asked myself – where am I going with this? What is the common thread?

These posts came from a desire to explain how doctors arrive at medical decisions. They required a degree of honesty and a willingness to enter into uncomfortable areas of human motivation. For instance The moment: a tale of three doctors focuses on the place of reputation when considering how actively to advocate for a patient, and The eyes and the ears: why Adam blew the whistle (a sequel to Why Michael didn’t blow the whistle: pub scene) exposes the personal concerns that are balanced against the right course of action. In Signals: the language of uncertainty I look at the way doctors try to communicate their fears for patients without actually saying so – a form of self-protection. Overt self-preservation from the emotional challenges that a career in medicine presents lies at the heart of Too close: from empathy to over-identification and The needle and the damage done. Rainstorm (the most popular so far as judged by ‘page hits’) imagines a demotivated junior doctor on the brink of resigning. Why? The thickening atmosphere of direct accountability in the post-Francis Report, post-Mid Staffs era. He must learn how to function in a world where errors or omissions can no longer be ignored with a ‘that’s just how things are’ attitude.

But an inquiring approach to the medical mindset does not explain the posts in which I tried to imagine what patients might be thinking, such as Signs, Don’t tell me the odds or I hear you. These are complete fictions, as I have never been a genuinely ill patient at risk of death, and I have never been trapped in bed unable to communicate. But nor have most doctors (especially young ones) so the value of these exercises in imagination, or ‘hyper-empathy’ might be in demonstrating how we believe they respond to the day-to-day challenges of being on the ward. They are also valuable in demonstrating how far doctors can go in trying to understand what their patients are thinking as we interact with them; do they see through our prevarications or justifications for delays or errors?

Then there are the reflections on chance and hazard. Intersection looks at how patients who never see or know each other can influence each other’s clinical progress. Fate night examines how a young doctor’s social plans are scuppered by a series of unfortunate events, such that she must decide whether to stay or go, and A night in the system shows how a relative must assert herself to make the apparently oblivious, disconnected machine that is a hospital work for a patient.

As in the last volume I have written longer pieces on practical medical ethics that reference freely available resources on the internet, such as The cusp: ethics of the learning curve, Blaming patients: a very human temptation and Substitutes (which is about who we ask when trying to discover what incapacitous patients would have wanted.)

Finally there are several more political pieces, an arena in which I do not feel very comfortable as a doctor who spends more time looking down at the individual level than across at the societal level. Nevertheless, Journeymen: why aren’t doctors more loyal to the NHS, Precious: a legacy of understaffing and NHS2 in year 2053 are honest reactions to recent events.

So, returning from that quick tour, where am I going with this? The answer is…across a divide. That is my ambition. In An opaque code: the Liverpool Care pathway and a gap in perception I discuss the gulf of understanding between doctors and their patients (and their patients’ families) which drives many of the controversies that we see in medical practice. The articles in this book were written to shed light on factors driving the motivations and behaviours that directly affect patients. I hope they are good enough to serve as bricks in the fine bridge that others (such as Jonathon Tomlinson in his wonderful blog A Better NHS, or Kate Granger in her position as doctor, patient and generous communicator) began long before I started writing.


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