srikant sarangi a roadmap the journey metaphor€¦ · switzerland , south africa, uk , usa) ......

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The Aalborg Lecture in Humanities & Medicine

COMMUNICATION-BASED MEDICINE:

A ROADMAP

SRIKANT SARANGIDirector, DIHM

Aalborg University, Denmark

29 August 2014

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THE JOURNEY METAPHOR

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A FEW WORDS ABOUT DIHM

• Danish Institute of Humanities and Medicine/Health

(DIHM) http://www.dihm.aau.dk is a collaborative

venture between the Faculty of Humanities and the

Faculty of Medicine at Aalborg University.

• It builds on the past success of the Health

Communication Research Centre (HCRC) at Cardiff

University UK since 1997. At the time of its launch

HCRC was innovative and soon became recognised

nationally and internationally as the first centre

dedicated to health communication research and its

application to healthcare delivery in a wide range of

sites.

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A FEW WORDS ABOUT DIHM

• An interest in ‘the human condition’ brings humanities and

healthcare sciences together – both in terms of

intervention and prevention of disease as well as promotion

of health.

• The excitement underpinning a cross-faculty initiative

across the Faculty of Humanities and the Faculty of

Medicine, in the spirit of genuine transdisciplinarity

• The newness of the Faculty of Medicine and its commitment

to doing things the Aalborg way – creating the space for

translating humanities-informed research findings

into the medical curriculum.

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A MAPPING (SCOPING) EXERCISE

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• Positioning DIHM within Aalborg University (AAU): a

number of ongoing activities that need linking up –

what could be embedded within DIHM and what

could co-exist in a networked relationship

Faculty of Humanities

• Health Communication

• Centre for Health Communication (CHC)

• Danish Centre for Health Informatics (DACHI)

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Faculty of Medicine

• Research Centre for Learning and Education in Health and Medicine

• Centre for Health Science Education and Problem-Based Learning

• e-Health Tech

• Medical Informatics Group

• Public Health and Epidemiology Group

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DIHM can become an integrated platform – a directory of expertise and activities at AAU

• 27 contacts made from AAU and within Denmark

• Establishing a core group of researchers/practitioners

• Encouraging open affiliation to DIHM

• The explicit aim is to support and showcase ongoing research while creating a niche for new ideas and interventions.

• Gradually DIHM will extend its circumference to embrace a Nordic/Scandinavian perspective.

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• DIHM is currently building partner networks at

the international level – to enable scholarly

dialogues, set up comparative research projects,

share good practices etc.

• The international list now stands at 52, representing

11 countries (Australia, Canada, China (including

Hong Kong), Denmark, Norway, Poland, Sweden,

Switzerland, South Africa, UK, USA)

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• A selected list of Centres under the umbrella ‘Medical Humanities’ (8 in UK; 13 in USA; 3 in Sweden) – this list will need updating and monitoring on a regular basis.

• Centre for the Humanities and Health, King's College London, UK

• Centre for Medical Humanities, Durham University, UK

• Nottingham Health Humanities, Nottingham University, UK

• Medical Humanities Research Centre, University of Glasgow, UK

• Medical Humanities Research Centre, University of Leicester, UK

• Health Communication Research Centre, Cardiff University, UK

• Leeds Centre for Medical Humanities, University of Leeds, UK

• The Ethox Centre, University of Oxford, UK

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• The Hastings Center, USA

• Columbia University Medical Center, Narrative Medicine,

USA

• The Institute for the Medical Humanities, University of

Texas, USA

• Center for Humanities and Health Sciences, University of

California, USA

• Center for Medical Ethics and Health Policy, Baylor

College of Medicine, Houston, USA

• The Center for Medical Humanities and Ethics, University

of Texas, San Antonio, USA

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• The Maclean Center for Clinical Medical Ethics, University

of Chicago, USA

• Charles Warren Fairbanks Center for Medical Ethics,

Indiana University, Indianapolis, USA

• Center for Healthcare Ethics, Duquesne University,

Pittsburgh, USA

• Center for Healthcare Ethics, Cedars-Sinai Medical

Center, Los Angeles, USA

• Center for Healthcare Ethics, Cedars-Sinai Medical

Center, Los Angeles, USA

• Minnesota Center for Health Care Ethics, USA

• UCLA Ethics Center, Los Angeles, USA

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• Institute of Public Health, Health-Man-Society, University of Southern Denmark

• Centre for Culture and Health, University of Gothenburg, Sweden

• Centre for Person-Centred Care, University of Gothenburg, Sweden

• Department of Medical Ethics, Lund University, Sweden

• Research Centre for Health Promotion and Resources, NTNU, Trondheim, Norway

• European Association of Centres of Medical Ethics, Maastricht, the Netherlands

• Institute of Communication and Health, University of Lugano, Switzerland

• Centre for the Humanities and Medicine, University of Hong Kong

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• DIHM is unique in its mix of disciplines:

• Communication

• Culture

• Ethics

• Technology

• And, in putting communication at the centre of this transdisciplinary mix

• In future years, The Aalborg Lectures in Humanities and Medicine will mark the distinctiveness of DIHM

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PRELIMINARIES

DIHM is now home to the journal Communication & Medicine:

An Interdisciplinary Journal of Healthcare, Ethics & Society

[founded in 2004, now managed by Equinox Publishers]

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COMMUNICATION, MEDICINE & ETHICS (COMET)

•The Annual Conference Series: Communication, Medicine and Ethics (COMET)

DIHM is also host to the annual COMET Conference Series

COMET 2003 Cardiff (UK)

COMET 2004 Linkoping (SWEDEN)

COMET 2005 Sydney (AUSTRALIA)


COMET 2007 Lugano (SWITZERLAND)

COMET 2008 Cape Town (SOUTH AFRICA)


COMET 2010 Boston (USA)

COMET 2011 Nottingham (UK)

COMET 2012 Trondheim (NORWAY)

COMET 2013 Melbourne (AUSTRALIA)

COMET 2014 Lugano (SWITZERLAND)

COMET 2015 Hong Kong (SAR CHINA)

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THE COMET SOCIETY

• The COMET Society is aimed at strengthening and

sustaining a multidisciplinary network of

researchers, educators, healthcare

professionals and research students. Its

objective is to facilitate the exchange of ideas and

the promotion of the study of communication-

oriented research and development within the broad

fields of healthcare.

• www.cometsociety.com

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SMALL ACCOMPLISHMENTS& STRATEGIC POINTERS

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DIHM

• DIHM is already attracting doctoral and post-doctoral

researchers with interest in a wide range of topics:

supervisory sessions in emergency call centres;

sexual health in relation to chronic illness; patient

safety vis-à-vis adverse events; professional ethics

and motives; presence and mindfulness.

• In a bottom-up research strategy, these individual

projects will grow into intervention studies (e.g.

Emergency Call Centre in Capital Region of Denmark)

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DIHM

• 1st DIHM Summer School on Analysing Healthcare Communication, 25-27 August 2014 (attended by 22 participants representing 6 countries (Denmark, Sweden, UK, Italy, USA, Canada)

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DIHM

• Many thanks to the PhD School at the Faculty of Humanities for

providing the infrastructural support.

• The DIHM Summer School will now become an annual feature.

• The already scheduled Spring School at University College

Nordjylland (UCN, 28-29 January 2015)

• The Summer School is complemented by The Winter School

held at The University of Hong Kong in December each year.

• As part of critical capacity building, a condensed version of the

Summer School – focusing on analytical training – is also

delivered as pre-COMET masterclass (in Melbourne, Australia

and in Lugano, Switzerland in the past 2 years).

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DIHM

• Create a ‘healthcare hub’ in the Faculty of

Humanities in the new DIHM premises to encourage

projects in humanities-based medicine as part of

undergraduate and postgraduate education.

• Create a parallel ‘humanities hub’ in the Faculty of

Medicine to encourage practising healthcare

professionals for collaborative research and

educational opportunities.

• These activities will be sustained through regular

discussion/workshop/consultation meetings.

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PUTTING COMMUNICATION AT THE HEART OF HEALTHCARE

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THE CIRCUMFERENCE OF COMMUNICATION

IN HEALTHCARE SETTINGS

IN THE CLINIC/HOSPITAL WARD etc

INTERFACE OF DIFFERENT MODALITIES

PATIENT NARRATIVES;

PATIENT RECORDS;

PATIENT INFORMATION

LEAFLETS; MEDICATION

LABELS; DRUG ADVERTS

(DTCA)

RECRUITMENT FOR CONTROLLOED TRIALS,INFORMED CONSENT,POLICY DOCUMENTS,INTERPROFESSIONAL

COMMUNICATION

HEALTHCARE WEBSITES,

INTERNET CHAT ROOMS, ONLINE ADVICE,

REPRESENTATIONSIN THE MEDIA, MAGAZINES

TALK

PRACTICES

TEXTUAL, MULTIMODAL PRACTICES

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COMMUNICATION GETS A BAD PRESS

• The ethos of poor communication in the healthcare sector at all levels – not matching patients’ and public’s expectations – is often seen as resulting in (avoidable) adverse events.

• On the one hand, metaphorically speaking, communication is the disease in healthcare delivery – there are many symptoms of this ‘sick communication’ phenomenon.

• On the other hand, the causes of this ‘sick communication’ lie elsewhere – beyond levels of competencies of healthcare professionals.

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A few headlines in Denmark in recent months

• Five percent of Danes do not understand what their

doctor tells them. (National Danish TV – current

events evening show)

• Cancer patients’ health is compromised during

transfer to other units or after discharge. Lack of

communication is at fault.

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• Over 60 percent of approx. 500 doctors and 800

nurses at Danish hospitals do not fully involve

patients in the choice of treatment. (Danish Medical

Association – Lægeforeningen)

• 90 percent of young doctors (Yngre Læger under

the Danish Medical Association) say that they would

like to accommodate patient involvement, but that

the demand for reduced waiting lists prioritises

productivity instead of patient involvement or

quality of doctor-patient communication.

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• 1 in 5 surgical procedures can be avoided if patients

are generally well-informed before consultation, e.g.

via video, about the basic facts, risks and

alternatives of a given procedure.

• General Practitioners are hesitant to start a practice

in areas populated with patients from diverse

ethnic, cultural and linguistic backgrounds. One of

the main reasons is communication difficulties.

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• The Minister of Health, Nick Hækkerup, has recently

stated that to maximise efficiency and achieve

higher patient equality, healthcare professionals

should distinguish between educated and non-

educated patients. Educated people need less time

with a GP/hospital physician to comprehend and

agree with diagnosis and treatment plans, whereas

non-educated people would benefit from more time.

• Can we assume that educational qualification is a

reliable index of communicative and decisional

competence?

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• With regard to inter-professional communication

during acute births, 2 of every 3 unintended

incidents are results of poor communication.

(Horsens Hospital)

• Danish Nurses’ Organization (Dansk Sygeplejeråd)

calls for specialised communication training to

ensure inclusion of patients and their relatives at all

stages in order to secure the best possible outcome.

• Long waiting time and lack of efficiency in

Emergency 1813 in the Capital Region of Denmark

(Region Hovedstaden).

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• Only 6 percent of Danish teenagers between 13 and

18 see a doctor or a psychologist after a suicide

attempt. There is a lack of information about what

can be done to help and what a family should do in

the aftermath of a child trying to commit suicide –

an issue that is still taboo.

• Poor communication may go undiagnosed in

the reporting of adverse events or ‘unintended

incidents’ (including wrong diagnoses) –

which are on the rise.

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• What is this thing called communication? A skill-set? An art? A science?

• One problem is the taken-for-grantedness which assumes communication is a socio-cultural construct and communicative competence is omnipresent.

• At the other end, communication is seen as a skill, so training can make a difference.

• Communication is also a science – the longstanding fields of language, communication and discourse studies which have remained invisible and untapped.

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MIND THE GAPS

• Communication, like medicine, is both an art and a science.

• Not only is there an invisible gap between

communication research and medical practice/education,

but also an ever-increasing gap between biomedical

research and clinical practice: Biomedical research is not

always driven by a clinical mentality.

• “The emphasis in medical research has slowly shifted

from the study of disease at the level of patients or

their diseased organs to the study of their cells and

molecules” (Weatherall 1995: 228).

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COMMUNICATION-BASED MEDICINE

• The pitfalls of communication skills approach in medical

education and training of professionals.

• Following Schön (1987): communication … becomes

over-proceduralised through which ‘we drive out

wisdom, artistry and the feel for the phenomena’ all of

which depend on ‘judgment’ and ‘discretionary

expertise’.

• In her call for re-humanising medicine, Heath (1979:

114-115) stresses that “professionals in human services

delivery systems and linguists share a common curiosity

about communication – what it is, how it works, how we

learn to make it work.”

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COMMUNICATION BASED MEDICINE (CBM)

• Evidence-based medicine (EBM) continues to be

the benchmark for clinical practice: “The practice of

evidence based medicine means integrating

individual clinical expertise with the best available

external clinical evidence from systematic research”

(Sackett et al 1996: 71).

• Narrative-based medicine (NBM, Greenhalgh and

Hurwitz 1998) rooted in the biopsychosocial model

(Engel 1977) and the cultural hermeneutic model

(Good 1994), gives patients the power and agency

to understand and speak about their illness

experience.

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COMMUNICATION BASED MEDICINE (CBM)

• Within EBM, there is a bias in what counts as

evidence. Note that the notion of evidence relates to

populations and not individuals (and their

experience) although clinical practice always

involves individual patients and their immediate

family members.

• NBM assumes that both professionals and patients

have narrative competence – which can be

particularly challenged in the context of

multicultural healthcare delivery.

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COMMUNICATION-BASED MEDICINE

• DIHM will aim for a unique position in advancing

‘communication based medicine’ (both scientific

evidence and patients’ experience need to be

communicated). (Sarangi 2004)

• The goal is to undertake a reappraisal of a number

of trajectories at the interface of research and

practice, e.g., healthcare delivery in culturally

diverse settings, patient- and family-centredness,

professional role-responsibilities, situated ethics,

communication based reflective practice etc.

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SHAPING THE RESEARCH AGENDA

• Prioritise pilot projects which are more locally grounded in a responsive mode based on preliminary networking.

• Examples include: emergency life-saving calls; open access hospital calls; hospital hygiene; managing linguistic and cultural diversity in Danish primary care delivery; the practice of genetic counselling in Denmark.

• Extend the scope of research beyond physicians (e.g., nursing, pharmacy, dentistry, midwifery, allied healthcare).

• Identify sites where language and communication issues play a more significant role.

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COMMUNICATION MATTERS!

ANTIBIOTICS OVER-PRESCRIPTION

(When talk is cheaper)

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CONTEXT

• A group of GPs (with academic interest) approach SS, concerned about over-prescription of antibiotics for upper respiratory track infection (URTI) of children, possibly caused by parental pressure and/or GPs not eliciting patient expectations.

• Preliminary analysis based on 50 each of prescription (PR) and non-prescription (NPR) cases (audio-recorded and transcribed):

– NPR consultations usually longer in duration than PR consultations;

– Physical examination is undertaken sooner in PR compared to NPR cases;

– NPR consultations are more loosely structured than PR ones, with elaborate and complex explanation and assessment of symptoms.

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Number of turns involving symptoms discussion

0

20

40

60

80

PR04 NPR03

3 instances 7 instances31% of total turns 54% of total turns

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STRUCTURE OF PHYSICAL EXAMINATION

• Through thematic and interactional mapping of the

communicative trajectories during physical

examination, the following six nodes are identified:

– online commentaries

– directives concerning modes of examining

– relational rapport

– interpretive summaries, indications of potential

diagnosis

– offline commentaries, i.e. general explanations

about causation and (non)treatment

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ONLINE & OFFLINE COMMENTARIES

• online commentary (‘this area looks a bit

red’) is defined by Heritage and Stivers (1999:

1501) as ‘talk that describes what the physician

is seeing, feeling or hearing during physical

examination of the patient’.

• online commentary is accompanied by what

might be called ‘offline commentaries’

(‘children usually have this’) whereby the doctor

steps outside the physical examination phase

and offers explanations of various kinds

(Sarangi 2010).

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• ONLINE/OFFLINE COMMENTARIES

• he’s got a little bit of red down here across his

back … snotty nose, now, he has got a little bit

of a wheeze in his chest, and that happens

when the airways get a wee bit inflated, a

wee bit (unclear), makes it wheezy, and

if that gets down into the airways, we call

it bronchiolitis, and again, that’s a virus

infection …

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• and his breathing is okay, and he’s not having

any problem with it, and the rate at which he

is breathing… which his breathing is fine,

sometimes, with this kind of bronchiolitis

of babies, because the airways are already

tightening because babies are small, and if

this swells up, we get to run into little

problems with breathing, and once you

notice that he is running into that kind of

problem, you start to breathe

consistently…

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• you can see that he’s breathing… (unclear -

speaking away from microphone))… now, we

don’t.. at this stage he’s not got a (unclear)

and it’s not very common for it to happen,

mostly what happens is the kids will cough

their heads off for a week or more and

quietly get better, Okay?

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(NON)PRESCRIPTION OF ANTIBIOTICS

• In paediatric consultations both online and

offline commentaries function rhetorically in

anticipation of future action plans.

• Shifts between online and offline commentaries

foreground the doctor’s pedagogic role, while

positioning the parent as an expert and

spokesperson for the children.

• The offline commentaries seem to anticipate

non-prescription.

• The findings provide useful insights for medical

educators and trainers of practitioners.

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CONCLUSION

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CHALLENGES TO HEALTHCARE PROFESSIONAL PRACTICE

• Contemporary professional practice in the healthcare

domain is embedded in scientific expert knowledge but is

also routinely mediated by six major interlocking and

competing trends:

• Globalisation

• Bureaucratisation

• Marketisation

• Technologisation

• Humanisation

• Uncertainty and uniqueness

Communication is integral to all these trends

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BEYOND MEDICAL INTERVENTION[adapted from Funtowicz & Ravetz 1992; Sarangi & Candlin 2003]

Low High

MORAL/ETHICAL DILEMMAS

Present & Future Uncertainties

Consequences of Decision

MakingPSYCHO-SOCIAL

DIMENSIONS

MEDICAL INTERVENTION

High

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CONCLUSION

• Healthcare communication is constitutive (not an

additive layer) of expert knowledge manifest in

its scientific, clinical and organisational

dimensions.

• Healthcare professionals have explicit and tacit

levels of knowledge about interactional

complexity in their specific professional settings.

• Communication researchers may have analytic

expertise, but could lack content- and context-

specific knowledge – which can be minimised

through long-term collaborative interprofessional

research.

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• Communication is not a PILL: Limitations of

recipe-style training in A-to-Z of communication

skills which treats symptoms rather than causes;

one-sided view of communication where the patient

remains absent; potential for de-skilling.

• Communicative Competence is not a driving

licence that one passes for life: need for ongoing

appraisal to reflect on new challenges.

• Communicative Fallacy: Models of medical

interaction analysis work with a notion of form-

function equivalence (e.g., open questions = patient-

centredness) and thus ignore context sensitivity of

language use)

COMMUNICATION IS MORE THAN A SET OF DIY SKILLS

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CONCLUSION

• According to David Weatherall (1995: 329):

“Achieving the balance between a scientifically

based medical education and one that

introduces these new [humane,

communication-based, reflective] approaches

to training more caring and socially aware

doctors – all without overcrowding the

curriculum – is the major problem that faces

medical education today.”

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SELECTED REFERENCES

Engel, G. (1977) The need for a new medical model: a challenge

for biomedicine. Science 196: 129-136.

Funtowicz, S. O. and Ravetz, J. R. (1992) Three types of risk

assessment and the emergence of post-normal science. In S.

Krimsky and D. Golding (eds.) Social Theories of Risk, 251-

273. Westport, Connecticut: Praeger.

Good, B. J. (1994) Medicine, Rationality and Experience. Cambridge: Cambridge University Press.

Greenhalgh, T. and Hurwitz, B. eds. (1998) Narrative-Based

Medicine: Dialogue and Discourse in Clinical Practice. London:

BMJ Books.

Heath, S. B. (1979) The context of professional languages: an

historical overview. In J. Alatis and G. Tucker eds., Language

in Public Life , 101-118. Washington, DC: Georgetown

University Press.

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SELECTED REFERENCES

Sackett, D. L., Roesenberg, W. M. C., Gray, J. A. M., Haynes, R.

B. and Richardson, W. S. (1996) The practice of evidence

based medicine means integrating individual clinical

expertise with the best available external clinical evidence

from systematic research” British Medical Journal 312: 71.

Sarangi, S. (2004) Towards a communicative mentality in

medical and healthcare practice. Communication & Medicine

1, 1, 1-11.

Sarangi, S. and Candlin, C. N. (2003) Trading between

reflexivity and relevance: new challenges for applied

linguistics. Applied Linguistics 24 (3): 271-285.

Schön, D. (1987) Changing patterns in inquiry in work and

living. Journal of the Royal Society of Art Proceedings 135:

225-231.

Weatherall, D. (1995) Science and the Quiet Art: Medical

Research and Patient Care. Oxford: Oxford University Press.

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srikant sarangi a roadmap the journey metaphor€¦ · switzerland , south africa, uk , usa) ......

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