'Geraniums (red) and Delphiniums (blue)': Trauma, Ethics, and Medical Communications

Abstract

More official complaints about medical treatment in the UK relate to poor communications than to wrong diagnoses. This article, in considering the importance of communications training for clinicians, is structured into three sections. From use of a story that introduces the idea of miscommunication and trauma in the first section, the article moves, in the second, to a theorisation of trauma as a concept, addressing issues of intersubjectivity, the relationship between embodied and psychological being, and ethics. From this, the third section engages directly with medical communications training, exemplifying a particular literary-studies approach to matters of communication.

Endnotes

¹ For statistics and commentary on patients' complaints considered valid for investigation, see GMC Report (2012, 21; 61-62). Cf: 'Complaints about unsatisfactory communication are the second largest category of complaints dealt with by the Health Service Ombudsman'. NHS England (2010, 17). The GMC is the regulatory body for doctors in the UK.

² Examples include a fairly early collection by Greenhalgh and Hurwitz (1998) containing chapters by some literary scholars and concerned throughout with dialogue between disciplines, including literary studies; and Jurecic (2012), written from a literary scholar's perspective, representing a recent growth in directly literary attention to medical issues.

³ The terms 'literary criticism' or 'textual criticism' used in this article do not imply judgment of a text in the manner of, say, a theatre or book review in a newspaper. These terms are used within the academic discipline of Literary Studies, as synonymous with 'textual analysis', to describe the activity of interpreting and analysing a textual object. The word 'text', as used in the discipline, refers to any object of study, verbal or otherwise.

⁴ In the UK, The Quality Assurance Agency for Higher Education states in its Benchmark Statement for university English (Literature) degree programmes: 'English is a versatile academic discipline characterised by the rigorous and critical study of literature and language. It is concerned with the production, reception and interpretation of written texts, both literary and non-literary…' (2007).

⁵ This story is extracted from the author's unpublished auto/biographical account of family lives.

⁶ Although the title of Arthur W. Frank's The Wounded Storyteller, a classic text of the medical humanities, might suggest an engagement with thought about trauma, it contains, in fact, no sustained reference to it. Allusion to trauma remains implicit in Frank's text, in the references to a range of post-modern thinkers whose writing is underpinned by, or in concord with, the contemporary trauma paradigm and its epistemological implications, as well as in his central question: consideration of how to describe 'stories as told through the body'. (1995, 2).

⁷ Blankaard (1684, 151): 'Troma, is a Wound from an external Cause'. Browne, (1678. 10-11), referencing Galen and making, '…a brief and generall Division of Wounds…' distinguishes 'Trauma' from other forms of wound such as an ulcer [ulcus or ἑληὸς]; a fracture [catagma]; or a spasm [spasma].

⁸ For a particularly lucid history and overview of the concept of trauma, see Luckhurst (2008, 1-15).

⁹ A working, consensual definition of what is meant by an 'epigenetic trait' was formed at a conference at New York's Cold Spring Harbor Laboratory in 2008, as a: 'stably heritable phenotype resulting from changes in a chromosome without alterations in the DNA sequence' (Berger et al. 2009).

¹⁰ While there has been scientific excitement about this, there is, of course, some scepticism, as the process has not yet been established at a molecular level. Although this experiment has led to speculation about the heritability of emotional responses to experience and the plasticity of germ cells in humans, there is, as yet, no fully accepted demonstration of this. For a representative, influential article on the implications of human epigenetics (not in the specific context of trauma), see Kaminsky et al. (2009).

¹¹ See Ehlers et al. (2010) and Foa et al. (2009) for critical overviews of therapies currently evaluated as effective and Levine (2010) on body-centred trauma therapy.

¹² See Lockhurst (2008, 5-15) for an overview up to 2007.

¹³ For a recent attempt to integrate mind and body in relation to meaning, making connections between cognitive science and study of language, meanings and the aesthetic, see Johnson (2007). On the relation of body and selfhood in medical transcripts and narratives, see, for instance, Charon (2006, 85-104).

¹⁴ Cf. Frank (1995, 14-15; 176-82). In spite of his not referencing thought on trauma directly, Frank similarly invokes Levinas' thinking in order to ponder matters of pain, the communicability of suffering, and of the inter-human.

¹⁵ Here Levinas is critically diverging from Heidegger's concept of Dasein, or Being, which originates in the experience of being-in-the-world, but is focussed through reflexive self-recognition crucially achieved by awareness of death, and most particularly of '[t]he fact of dying for and by ourselves [which] is what gives the self authenticity, making it a "being-toward-death."' (Levinas 1989, 3) For Levinas, infinity resides within the human, rather than in the surrounding nothingness that Heidegger's thought presents as the 'complement' of being. Laplanche's notion of the function of the 'traumatically enigmatic traumatic signifier' in triggering ego development, mentioned earlier, parallels Levinas' thought here.

¹⁶ The word 'encounter' is borrowed from the terminology of travel writing studies where the 'encounter' signifies what occurs in the 'contact zone', a phrase coined by Mary Louise Pratt to denote the point or place of meeting between those who are radically other to one another and where there is an asymmetrical power relation (1992). The word 'encounter' is also commonly used in relation to Levinas' thought.

¹⁷ The UK's General Medical Council crucially describes the relationship between patients and medical practitioners as a partnership (2013a, Domain 3, paras 46-52; 2013b; 2013c, 5). Niall Dickson, Chief Executive and Registrar of the GMC, commented on the publication of the second document: '… it is meant to be a constructive document which reflects the evolving nature of the doctor-patient relationship. Patients increasingly expect to be and are partners of that relationship. It was important that as well as simply setting out to doctors what we expect from them, patients should be aware of what we are expecting from doctors, so that is why we have decided to produce this booklet’(Soteriou 2013).

¹⁸ For an elaboration of the implications of this, see Phillips and Bersani (2008) who see conventional models of intimacy as being never safe from violence, since humans find difference unbearable. Roth (2008), reviewing Intimacies and quoting Phillips, writes: '"For Bersani, pleasure is not an enhancement of the ego as it masters the world. Pleasure is a shattering of the ego as it encounters the world." What does this splintering have to do with intimacy?' Roth suggests that in Intimacies the authors 'explore new modalities of affection and relation that would not repeat old repressions and poisonous violence. These would be new intimacies that embrace shock and fragmentation, that seek out self-shattering rather than repair and redemption. Bersani and Phillips call these "impersonal intimacies".' Questions of the im/possibility of avoiding violence are, of course, at the heart of this article.

¹⁹ The name relates to the home universities of two (the medical two) of the three authors. This work of naming could itself be seen to enact a depersonalisation: from authors as individuals to institutions as legitimating points of origin.

²⁰ These are intended for use in training student doctors. Offshoot, adapted versions are used in the training of nurses and other healthcare workers.

²¹ As a vocational and practical subject, medicine has always had a central skills-acquisition content. The history and implications of the recent turn to a new utilitarianism (and the development of quantifiable skills in all areas of education, in a context of recent questioning of the 'value' of the arts and humanities) is addressed in Bate (2011, 5-13) and Small (2013). The related and fraught question of whether medical-history teaching to medical students should foster professional identity on one hand, or involve critique of current and past medical claims, on the other, is discussed in Kushner and Leighton (2013).

²² Menzies Lyth (1960) influentially analysed anxiety and institutional structures in relation to nurses in the 1950s. Recent re-evaluations of her work have mapped both the continuance of such anxieties and institutional defence processes and aspects of change in contemporary institutions.

²³ See Greenhalgh (1998) on 'evidence' and narrative in medicine.

²⁴ Such a blend of tones and positions is apparent, for instance, in Care UK's patient leaflets.

Introduced by the statement, 'A younger, better educated patient may take a more assertive role…', issues of consumerism are briefly discussed by Silverman et al. (2005, 179), largely in the context of disempowerment of practitioners and diminution of expertise and in contrast to a paternalistic model where it is a patient's agency that is denied.

²⁵ The title of Balint's influential book, The Doctor, his Patient and the Illness (1957), encapsulates neatly the ideological underpinnings of patient-practitioner relationships of that era, not only in its overt patriarchalism, but in its attribution of full identity and agency to the practitioner and the illness – 'THE Doctor'; 'THE Illness' – and its representation of the patient, 'HIS Patient' [my capitalisations] only as a possession or effect, someone whose being is constructed purely in relation to the doctor and to illness. The words 'Doctor' and 'Illness', rhetorically linked through the rhythm and structure of the title, and bracketing the patient, produce the patient as a site on which the doctor engages with his agonist, illness.

²⁶ One particular aspect of institutionalisation (with a range of ideological implications) that affects medical students is identified by Greenhalgh and Hurwitz (1998, 13): 'It has been shown that, somewhere between the first year and the final year of medical education, undergraduate students exchange a native facility for eliciting and appreciating patients' narratives for the learned expertise of constructing a medical history.'

²⁷ The decision to end national implementation of 'The Liverpool Care Pathway' for dying patients, after an independent review for the UK Government, was based on recognition of the inadequacy of a generic protocol in the case of care for individuals at the end of their lives. This might stand as an extreme example of the dangers of teaching procedures without facilitating understanding at a deep level (Department of Health, 2013).

It is, initially, surprising to humanities scholars to find that degree-level, and even graduate, medical students are taught from textbooks, rather than being asked to assemble their own thought through structured, critical study of primary texts. Different disciplinary notions of knowledge acquisition and of understanding are at play here.