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How will doctors work democratically with patients, realizing authentic patient-centred care, until they put their own house in order? Medicine is still an autocratic institution, riddled with hierarchies. Medical education’s major task is to democratize medical work practices. However, ‘democracy’ must first be understood conceptually—as universal franchise democracy—and literacy in democracy must be established. Further, meritocracies must not be mistaken for democracies, especially in non-technical professional work. Medical educators interested in communication studies should possess fluency in micro- and macropolitics.

Where does the idea of ‘patient-centredness’ come from and where is patient-centredness going as a practice? Patient-centredness offers conceptual confusion, where the future of communication in medicine is not necessarily about ‘centres’ at all. Indeed, centres—including the traditional self-centred autonomy of physicians—afford the problem, not the solution. In focusing upon neither the doctor nor patient as driver of a relationship, perhaps ‘relationship-centred’ care provides a better term for communication in medicine, where the emphasis is more upon the dialogue. There is still, however, that pesky ‘centre’ at play!

‘Empathy’ is a modern term that has achieved the status of mantra. The term is glossed uncritically as ‘positive’ and beneficial to professional relationships. ‘Empathy decline’ amongst medical students and junior doctors is seen as one of the paradoxical results of work-based medical education and often explained as a growing cynicism and loss of idealism of novices as they encounter the realities of clinical life and come under the influence of ‘hardened’ clinicians. ‘Empathy’, however, is rarely critically interrogated, especially in a historical context. Empathy is also often reduced to an instrumental skill that can be taught, rather than being seen as a way of being.

Cultural–historical activity theory (CHAT) is one of a group of social learning theories that has powerful explanatory power for work-based learning in medicine. Team communication can be explored fruitfully through CHAT, particularly to explore how differing aims between team members with differing roles can create tension within a team that can be both constructive and destructive. How might team members with different objectives align activities? Activity systems are inherently dynamic, unstable, and constantly seek expansion. Team members must be reflexive about such dynamics in order to manage the activity system as it progressively expands its knowledge and horizons.

Cognitive clinical reasoning and communication of the outcomes of that reasoning are necessarily and intimately entangled. Communication has a high affective component, as well as being complex and uncertain. Yet we often treat education in communication as if it were a jigsaw, refusing dynamism and complexity and readily taught as a protocol. While research findings indicate, for example, precisely how a good consultation may be conducted, this is hard to translate into practice because of unique contexts, but more so, because of ingrained structural restraints resulting from the hierarchical nature of medical culture.

Medical error is largely grounded in poor communication in clinical team settings (between and across teams). It would seem obvious that we could address this through curriculum change by improving teaching provision of professional communication in undergraduate medical education. However, such communication training has traditionally focused on doctor–patient relationships and not on team communications. Further, despite over 30 years’ worth of such training, the incidence of medical error remains at a high level.

While Michel Foucault’s work on the birth of the clinic in Enlightenment France, and the subsequent development of the ‘medical gaze’ as a diagnostic method, has been widely discussed and critiqued, there is little in medical education that deals with his later work on ‘technologies of self’. This work focuses on identity construction as a ‘work’ that is both aesthetic (self-forming) and ethical (practices of the self in relation to others). Foucault returned to late Greek and early Roman sources to show that the forming of self is a characteristic strand throughout Western cultural practices and not a modern invention.

Foucault’s framework shifts attention away from power relations in communication in medicine as sovereign (power over, or authority) to how forms of resistance are established, where power flows through a system (capillary) and is productive of new structures rather than reproductive of existing structures. Deleuze reads power for its intensity or potency. The identity construction of the doctor is described in terms of the intensity of a work that is always in progress—one of ‘becoming’ rather than a final ‘being’. How is such a permanently labile and multiple identity construction managed, temporarily stabilized, and understood as a process amongst many intersecting processes, particularly in the process of becoming an interprofessional team player or ‘becoming a democrat’?

Actor-network-theory (ANT) is one of three key social learning theories that has recently been mobilized to explore work-based learning in medical education. Such theories suggest that context is all important to learning and that identities of practitioners are constituted by context. Communities of practice (COP) and cultural–historical activity theory (CHAT) (discussed earlier) are the other two approaches. Each theory has strengths and weaknesses for explaining and exploring particular kinds of contexts in medical practice.

A major shift in medical practice is the move to coordinated interprofessional teamwork, often requiring several clinical teams working around a patient on a pathway of care. Doctors must now become expert communicators with colleagues. Evidence shows, however, that the majority of medical errors are grounded in poor teamwork. Teamwork is not traditionally a focus of communication skills training in medical schools, which has concentrated on the patient consultation. Before designing teamwork medical education fit for purpose for the emergent era of healthcare, we must conceptually clarify what we mean by ‘teams’. The new work order of team settings means that doctors need to develop identities as ‘interprofessional teamworkers’.

Complexity theory challenges reduction of learning to simple, linear principles and explanations. Each complex system—at the levels of neuronal networks, persons, teams, and cultures—provides a legitimate unit of analysis. Complexity thinking focuses upon differences or relations between these units as ‘nested’—one within the other. Learning can be thought of as the overall process by which a system’s emergent properties are transformed into adaptive innovations, where the person, team, or organization alters its own structure as a response to emergent properties of the system.

Communication in medicine is extended from doctor–patient and doctor–colleagues in team settings to doctor–researcher and researcher–researcher dynamics. How might we build collaborative communities of researchers around the issues of communication discussed in this book? Again, conceptual work is suggested to clarify what ‘collaborative community’ means. Alfred Adler’s notion of ‘fellow feeling’ can underpin the formation of such communities. Without the generosity and understanding of fellow feeling, communities will disintegrate. While medicine is theoretically open to democratization through medical education, it is medical education research that promises to democratize medical education through provision of an evidence-based challenging assumption. However, such democratic intentions will not be realized without effort towards community fellow feeling, and this is also an issue of building genuine interdisciplinarity.

There are multiple ways of performing patient-centred medicine. Conceptual clarification of the term ‘patient-centredness’ reveals a number of approaches, here represented as a taxonomy. Conceptualizing patient-centredness is important because it helps to address what kind of care may be appropriate for context. For example, a blanket ‘patient choice’ approach may wrongly displace the value of specialized patient care under expert knowledge.

‘Patient-centeredness’ is a relatively new term in the medical lexicon. Yet it has become a mantra, expressed often and with little critical attention. For this reason, we might aspire to an ‘authentic’ patient-centeredness—as a patient-centeredness-to-come. And for this aspiration to become reality, we must shift medical culture from autocratic to democratic habits, to achieve a mutuality of care. Such mutuality in care benefits patients and so should be taught as an integral part of a medicine curriculum. However, first we must conceptualize ‘patient-centeredness’ as there are many varieties to this approach. I suggest a patient-centeredness without a centre, where mutually enhancing conversation is the ideal model. This recognizes both the doctor’s and the patient’s expertise within a narrative mode of care, with attention to, and tolerance of ‘difference’ as the key factor.

Having taken an exhaustive tour through current and historical issues concerning communication in medicine, what can be concluded? The key focus for medical education is the wider cultural issue of the democratizing of medical practice. The feminizing of medicine may play a key role in this, but certainly the most important factor will be the thoughtful empowerment of patients and the mobilizing of patients’ collective expertise. In parallel, doctors must be politicized, to form a new identity of ‘medical citizens’.