Patient agency: connecting the dots in my research

As I transition from full-time academia to my own adventures in business, it’s given me pause to reflect on the story of my research. I have always tried to pursue research projects that I have felt would be important, impactful, or interesting. Preferably all three.

I started researching communication in healthcare due to personal interest. As a young person with what had become chronic pain, I had experienced what might be called “bad” communication. These experiences occurred at the same time as when I studying linguistics in my undergraduate degree. I’d fallen in love with a course I took on Conversation Analysis — it was so fascinating and opened up a whole way of looking at the world.

“To gain an understanding of what goes wrong we must first understand what actually goes on in doctor-patient consultations.”

Instead of assuming doctors are bad communicators, I wanted to understand how doctors and patients get things done through conversation. Starting with surgeons, I began by examining how consultations happened — how did surgeons and patients get from the first greeting to the end of the conversation.

This led to an exploration of patient agency and, in reflecting on the story of my research, I realise this is a thread that has continued through my research as well as my teaching and advocacy. It has been important to me to describe how patients are not passive recipients in healthcare. How they contribute to the consultation in ways that are active yet with consideration of the expected socio-cultural norms of communication when seeing the doctor.

“‘Patient agency’ … refers to a patient’s ability to participate in a consultation and associated decision-making about their care.”

Agency has remained a core component of my research even as I’ve researched other clinical professions and had different focal topics. In researching telehealth for specialists and surgeons and then for general practitioners, we found ways in which patients manage to initiate additional contributions to the consultation and how conversational (rather than transactional) approaches by GPs can facilitate additional patient contributions.

Patients can exert agency and clinicians can be proactive in supporting agency within the consultation through their conversational choices.

This has extended to my research on teaching communication in healthcare. We have demonstrated how in simulated interactions actors-as-patients do not communicate in the same way that actual patients do and that sometimes clinicians need individualised feedback to identify the ways in which they may inadvertently be hindering patient agency.

Consideration of how patient agency is collaboratively achieved has informed my teaching, with inclusion of conversation analytic conceptualisations of agency into communication curricula. In reflecting on current approaches to teaching and assessing healthcare communication, I have also identified the potential harms to patient agency to which such simplified approaches may contribute.

Agency has also constituted a key component in position papers and opinion pieces, including an Australia and Aotearoa New Zealand collaborative conversation starter in which we argue for tailored communication that supports active patient participation. And I argue that the responsibility for supporting patient agency rests with the clinician.

When I tell people what I research and teach, I am often confronted with stories of when consultations have not been a positive or productive experience. This can stymie patient attempts to exert agency. These stories motivate me to continue public-facing communication through social media and industry publications.

“patients have interactional means through which they can assume agency”

As I continue on my journey in supporting clinicians, students, and organisations to improve communication, patient agency and how it is achieved and how it can be better centred in consultations, will remain central to my work.

Is communication an art or a science?

Actually, I think it’s a craft.

We’re probably familiar with arguments around communication being an “art” and also that there is a growing appreciation of the role of evidence in understanding communication both abstractly and in practice. I argue that instead of contrasting “art” to “science”, we focus on the “craft” of communication. This is particularly relevant when considering teaching and assessing communication for specific professions, where learning through doing with individualised feedback is more likely to improve a learner’s communication skills.

A “craft” involves skills that “can only be learnt and employed in [a specific] occupational setting” and that are “refined through experience”.

By using the term “craft”, we can move away from the false dichotomy of art versus science in referring to communication and engage with the reality of conversation that incorporates and applies both in iterative, participant-managed ways. In doing so, we are resisting the notion that communication is either wholly subjective or objective. We can then more accurately reflect how we implicitly and explicitly improve how we communicate.

In analysing question design across a series of institutional phone calls, Heritage and Clayman use an analogy of a wind tunnel to describe how we learn and modify our conversational conduct through our experiences, finding paths of less resistance in the ways we choose to design each turn at talk.

“As in the design of a car, the aerodynamics of this question has gone through a wind tunnel of testing by repeated use. This judicious, cautious, even bureaucratic question design is the kind of design that develops in contexts where officials have to do interactionally delicate things on a repetitive basis.” Heritage and Clayman 2010, p.46

This is our implicit education in the craft of communication. In referring to coffee tasters, Liberman notes that “they say that by applying their knowledge and craft, they can repair nearly any difficulty”. That is, the skill of a craft is being able to use knowledge and experience to manage challenges in situ, as they unfold. This, too, is the goal of learning communication. The skill is in the responsiveness to each moment and knowing what each interactional choice is most likely to be understood as doing.

References

Gilligan, C., Powell, M., Lynagh, M. C., Ward, B. M., Lonsdale, C., Harvey, P., James, E. L., Rich, D., Dewi, S. P., Nepal, S., & Silverman, J. (2021). Interventions for improving medical students’ interpersonal communication in medical consultations. Cochrane Database of Systematic Reviews, 2021(2), Article CD012418. https://doi.org/10.1002/14651858.CD012418.pub2

Heritage, J., & Clayman, S. (2010). Talk in Action: Interactions, Identities, and Institutions. Wiley-Blackwell.

Liberman, K., 2022. Tasting Coffee: An Inquiry Into Objectivity. State University of New York Press.

Lynch, J.M., van Driel, M., Meredith, P., et al., 2022. The Craft of Generalism: Clinical skills and attitudes for whole person care. J Eval Clin Pract., 28(6), pp.1187–1194. https://doi.org/10.1111/jep.13624.

Travers, M., 2020. Craft skills and legal rules: how Australian magistrates make bail decisions. In: B. Dupret, J. Colemans & M. Travers, eds. Legal Rules in Practice: In the Midst of Law’s Life. 1st ed. Routledge. https://doi.org/10.4324/9781003046776.

White, S.J., 2025. Complexity and objectivity in teaching interprofessional healthcare communication. Patient Education and Counseling, 131, p.108558. https://doi.org/10.1016/j.pec.2024.108558

Communication in healthcare— a soft skill?

Spoiler: there is nothing soft about communication

“Patients dying daily due to poor ‘soft skills’ among Australian surgeons, experts warn”

Working in within University schools for health and biomedical sciences as well as for business, I have found that the conceptualisation of communication as a “soft skill” is common across research and teaching. This has often bothered me. As a conversation analyst, my job is to analyse how people get things done through interaction. “Things” include all parts of social life — ordering coffee, chatting with friends, and, of course, all the interaction needed for work.

This work is done collaboratively. It isn’t “message sent and message received”. We co-create a shared understanding. We build relationships through interaction. While “soft skills” as term may not be intended to minimise such skills, they can often been side-lined or taken less seriously as compared to “hard skills” or “technical skills”. Interpersonal communication is central to doing our jobs and, given that this often requires specialised approaches for different jobs (e.g. negotiation, discussing difficult news, etc), it can be seen as a “technical skill” too.

In exploring this idea of shifting from “soft skills” to “core skills” or “critical skills”, I came across a paper by Erica Darcis who provides the following recommendations for improving communication education in management training:

1. Increasing interdisciplinary efforts to bring together organisational scholarship and linguistics in research and teaching.

2. Steering away from communication training as skill development, focusing on raising language awareness and the development of analytical skills.

3. Using linguistic and discourse awareness as a basis for self-reflexive, responsible management practice.

These recommendations are echoed in healthcare communication literature, with a systematic review demonstrating that personalised feedback is the most reliable way of improving medical student communication skills. Such feedback relies on all three of the above recommendations.

Effective communication should be integrated as a core clinical skill. How else do you find out why someone has come to see you or whether the treatment you’re recommending considers their preferences and concerns?

Building relationships and communicating effectively with patients are not soft skills — they are clinical skills. As Dr Ben Bravery commented in his reflections on humanity in medical school:

“I thought the things that mattered weren’t being rewarded”

Communication training is often front loaded in healthcare degrees, leaving plenty of time to unlearn it when the pressures of placements and then practice combined with its “soft” status mean that it’s given less importance. This is reflected in the lack of resourcing and investment in education and research on communication, even though there are systemic, scientific ways of observing, understanding, and improving communication skills.

Communication is a core skill in healthcare. Not a soft one.