Doctors' communication of trust, care, and respect

Authors' reply

EDITOR—Qualitative research is important because it allows patients to express views that may not fit the investigators' or others' preconceptions. We, like some correspondents, were surprised by our findings, so we had to question what we previously thought. Although extensive research and training by some correspondents has greatly improved clinical communication, to imply that we have no more to learn is disturbing. In their different ways, correspondents indicate the need for yet more research to pursue the challenge that these and previous findings present to existing ideas and established interests.1

Jones and Willis, Carter, and Bundy all point out the limitations of a “one size fits all” model of communication. Disabled and marginalised people have different needs, while the emphasis on discrete tasks, such as “breaking bad news,” misses important functions of communication. Jones and Willis identify patients' role in good communication, and the perils of being too directive. This balance is central to effective communication—and to several commentators' responses. Clinically and intellectually, we find that reconciling patients' need for autonomy with the lead that frightened people seek from their expert clinician is harder than some commentators appear to find it. Coulter thinks that the distinction between respecting patients' “option” and avoiding unwanted choice is muddled, but the muddle reflects the limitations of empowerment of patients, from which perspective she assesses our paper.2

In practice, processes of effective communication and communication teaching are rich and complex, as Fallowfield indicates. But practitioners, managers, and researchers respond to the simplifications disseminated in research and government publications. For example, the emphasis on more information means that, locally, patients with breast cancer can receive 10 information leaflets—but some prefer to leave them unread or still feel uninformed.

Clinical communication needs still to be an area of inquiry, not just practice. Research should match the sophistication of what good practitioners already know and do, and it needs to develop new theoretical frameworks within which to evaluate what they do. Claims to patient centredness do little to illuminate or discriminate. We are, with McPherson, looking for more light and less heat.3