January Focus

David Jewell

‘If you can't communicate, it doesn't matter what you know.’ So says Iain Lawrie, quoting from a book on communication reviewed on page 68. Not everyone agrees.

On page 40 John Skelton quotes an anonymous writer on a BBC website: ‘But what good are doctors who empathise, smile and maintain eye contact if they do not know their stuff?’. Of course, we have had numerous debates of this nature in the last 20 years; part of Skelton's thesis is that we are hamstrung by professional attitudes so stuck in the past that the research into communication continues to focus on the glaringly obvious, so that ‘the profession has burdened itself with a low threshold of challenge.’ He ends up challenging us to think more about the attitudes in order to demonstrate the need for skills.

The tension or coherence between knowledge and communication skills, and the need to make the research relevant to contemporary general practice is illustrated by Edwards et al's study on page 6. Here, doctors were trained according to both the best evidence concerning conventional treatment for a number of conditions and the skills required to engage their patients in shared decision making. The results were mixed: readers will be encouraged that the participants in the trial found the skills useful and generalisable to other problems, but the occasions when they could be used were limited — perhaps just as well considering the additional time such consultations took. Phil Hammond's editorial on page 3 warns that everything is going to take much longer, especially what was, until recently, the simple matter of helping patients to understand and agree to all medical procedures.

On page 47 Innes et al explores why surface skills can only take us so far. The models of consultations developed in the 1980s help us to navigate simple interactions, but so many consultations simply don't follow a linear path, and we need models that help us to understand the messy uncertain world in which we so often find ourselves.

One of the difficulties is that whenever we look at a single aspect of the task, we find that there is more to do than we had previously thought. We have all been taught, and have taught others, about the importance of exploring patients' beliefs. All generalists have to equip themselves to work with patients from different cultures, and on page 26 a study of beliefs on the causes of epilepsy illustrates how open-minded we have to be. And before anyone is tempted into a feeling of cultural superiority, they should reflect quite how recently mental illness in the UK was ascribed to possession by evil spirits. Fear and ignorance about mental illness persists elsewhere as much as it does here.

This is also reflected in comments on the importance of the cultural beliefs about mental illness in Armenia on page 64, and how they influence what the doctors can achieve. Finally James Willis on page 72 takes (another) swipe at Advanced Access; he also reminds us that good communication in not just about what goes on in consulting rooms, but also how the whole team, especially receptionists, interacts with the rest of the world.

The BJGP is fundamentally in the business of communication — of science, ideas, letters, reports, anything that we think has any kind of relevance to the world of primary care — and the analogy with communication between doctors and patients is useful. We too need both the content that is worth communicating, and the means to communicate it clearly and effectively. We have always worked at both of these aspects, but one criticism is that the medium — the print itself — has intruded too often. So, for the second time in a short period, we have had the Journal redesigned. This time we think the print is cleaner, there is more white space so it is more restful on the eye, and we think the presentation of data is much better. In the end it is, of course, for readers to judge. But then communication should be a two-way affair and, as always, we should like to encourage lots of feedback — good, bad, and insulting — to swell the letters pages.

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