Involving patients – or abandoning them?

The Covid-19 pandemic seems to be subsiding into a low-level endemic respiratory infection – although the associated pandemics of fear and action are slower to follow suit. However, it is an opportunity to get back to the day job and catch up on some reading. One book in particular has caught my attention: Reconsidering Patient Centred Care: Between Autonomy and Abandonment by Alison Pilnick. I should declare a potential conflict of interest in that, in a dim and distant past, I supervised her PhD – but that past is so dim and distant that no-one should question the originality of the work.
Professor Pilnick starts from the question of why, after years of research, polemic and investments in training, there is so little evidence of shared decision-making in recordings of real interactions between health professionals and patients/clients/service users. At least three generations of policymakers, researchers and patient advocates have asserted the ethical and political value of patient-centered approaches in such interactions. Reviewing her own 30-year experience of research in many different contexts, including advice-giving by pharmacists, genetic counseling, antenatal screening, and dementia care, together with the findings of other studies from the US, the UK, Europe and Asia, she that it just does not happen in practice. She argues, instead, that the patient-centered model is fundamentally incompatible with what is known from more than half a century of research in conversation analysis about the nature of talk in any encounter between humans.
The growth of the patient-centered agenda has led to endless negative evaluations of consultations between health professionals and patients, and cycles of basic and in-service training in communication skills for those professionals, that are costly and doomed to failure. The result is a kind of patient abandonment which she documents in detail. In prioritizing autonomy over beneficence, it is ethically problematic. Politically, it does not empower patients so much as cut them adrift as the isolated subjects of neo-liberal fashion. She calls for a reconsideration of this approach and the reassertion of the importance of a sociology of medicine that stands outside the medical project and can appraise it critically rather than succumbing to its embrace.
Professor Pilnick calls on policymakers to recognize that many of their ideals and aspirations need to be ‘talked into being’. If they are radically incompatible with the basics of human interaction, they will inevitably fail. This does not mean that the goals are unworthy but that they must be grounded in an understanding of how talk works, and go with the grain rather than trying to cut across it. Patient centered care has failed to understand the difference between authority that comes from knowledge and authority that comes from status. The legitimacy of professional expertise has been associated with status rather than knowledge. That expertise, however, is the very reason why the patient is consulting in the first place – because health professionals know stuff that they do not. It is not an abuse of professional authority to make that expertise openly available and guide patient decision-making, provided that the patient retains the right to disregard medical guidance because their valuation of options is different from that of the professional. Democratising professional/client interactions does not mean denying a division of expertise, so much as defining its scope and making it transparent.
Professor Pilnick argues for reframing interactions between health professionals and patients as patient-oriented or patient-focussed rather than as patient-centered. Grand talk reform projects should give way to interactions that are more sensitive to the specific contingencies of different locations, patients and conditions. The communication skills of health professionals are not nurtured by one-size-fits-all models but by training in options, possibilities and reflections that equip the professional to be an ethical improviser rather than a robot driven by a checklist.
This is a pathbreaking book in its use of conversation analysis to revisit core issues in medical sociology, going back to Parsons’s analysis of the sick role and Freidson’s dissection of professional expertise. It shows a deep knowledge of the history of debates in the field and a breadth of scholarship that situates conversation analysis firmly as a sociological practice. It is extraordinary that a productive body of work, valued across many other disciplines, should be so marginalized within the discipline that created it. This book clearly shows the value of detailed, painstaking and thorough empirical work for challenging self-defined assumptions of virtuous practice. It needs to be read by anyone with an interest in the communication skills of health professionals.
Alison Pilnick offers both a compelling explanation of a generation of policy failure, despite the good intentions of its authors, and a realistic alternative that is likely to be both more civil and more humane.

Pilnick, A. (2022) Reconsidering Patient Centred Care: Between Autonomy and Abandonment, Emerald Publishing Limited, Bingley, UK.. https://www.emerald.com/insight/publication/doi/10.1108/9781800717435