Helen Morant: Hierarchy makes communication harder

helen_morantPatients and their voices are starting to be heard in the world of medicine. From a low starting point, admittedly, but it is happening.

Recently I was asked to take part in a BBC Radio programme about The Listening Project archive in the British Library, which hits 1000 submissions this month. The project is part oral history, part radio show, all conversation. Local radio producers record conversations between two people about any topic that the participants feel is important to them. Some of the conversations are selected and edited for broadcast. All of them are archived in full in the British Library. (There’s a similar, longer term project in in the US called StoryCorps). Alongside journalists, social scientists, and psychologists, I was asked why I had used clips from this archive when talking at the International Forum on Quality and Safety in Healthcare in Gothenburg last year. I made two main points.

The first point was that the rules about these recordings are that the recorded conversation happens between peers. One of the things we know about good communication is that hierarchies make it harder. The WHO surgical safety checklist requires  “… that all team members have been introduced by name and role”. This round of introductions effectively flattens the hierarchy with the clinical team, and aids communication, with the aim of reducing errors. But the doctor-patient hierarchy needs similar attention. Although we all accept there are critical times when we need healthcare professionals to be in charge, few doctors deliberately aim to assert their authority over patients. But the structure of healthcare systems means that patients often feel they have to speak up and against the cultural grain to get into the conversation about their care. The flat hierarchy of the participants in The Listening Project conversations allows for a rich and open conversation, which gets into the things that are really important to people.

The second point is that it is only in these “flat hierarchy” conversations that we get to the bottom of the “what matters to me” question. As Maureen Bisagnano, Institute of Healthcare Improvement’s President Emerita, saysdon’t ask “what’s the matter?” but ask “what matters to you?” And these conversations really get to the bottom of what matters. The intimacy of radioor any audiodemands that you truly listen to these conversations, and it allows us to hear what people are sayingsomething that we may never get to know as professionals. I wholeheartedly recommend giving the full unedited conversations a listen on the British Library website.

If you are interested in experiencing more about hierarchies and status in communication, we also have a lot to learn from the world of theatre, particularly improvisation. Playing with status is a key part of the actor’s toolbox—it helps the audience understand the character and their motivations. Recognising how we as healthcare professionals can inadvertently reinforce our place at the top of the hierarchy and keep patients at the bottom, is the first step to knowing how to change that dynamic. There’s a session on Improv skills at this year’s International Forum, in London on 26-28 April, 2017.

Helen Morant is Content Strategy, Delivery Lead, BMJ.