Pain is the main symptom in palliative care. Practitioners need a detailed picture of the nature of the pain the patient is experiencing, including severity, location, duration, and factors that exacerbate or improve it. Clinical guidance on pain communication encourages practitioners to ask patients questions and use pain inventories. It is often difficult for patients to quantify or describe their pain. Therefore, considerate communication needs to involve giving patients adequate opportunity to describe their experiences, whilst remaining sensitive to whether or not they are able to provide further detail.
In addition to questions and inventories, general guidance on communication skills encourages “active listening” techniques such as nodding, tolerating silences, and also repeating patients’ answers to help them feel understood and to encourage them to say more. Unfortunately, most guidance is based on what people can say about their own communication; as a result the advice tends to be rather abstract. By studying (recorded) real-life practitioner/patient conversations, we can add detail and nuance on precisely how to support patients in describing pain and how to check that you have fully understood what they are conveying.
In one of our studies of communication about pain within conversations involving experienced palliative care consultants, patients, and sometimes the patient’s companion, we looked at occasions when doctors repeat patients’ answers to questions about pain. As a result, we discovered when and how doctors repeat patients’ answers about pain, and how these repeats help in developing a detailed picture of a patient’s pain.
In this ‘Nutshell’ we begin by explaining the variety of things that people can convey when they repeat what someone else has just said. We then explain that people work out the meaning of a repeat by (subliminally) picking up on specific features of repeats: things like intonation, eye gaze, and the topic under discussion. After our overview of repeats, we focus on our study of when and how doctors repeat patients’ answers about pain, and how patients respond to doctors’ repeats.
Repeats are very versatile
Communication training and guidance advises practitioners that repeating what patients say shows the patient that the practitioner is listening. But in fact, repeats are deceptively sophisticated and complex devices that can do all sorts of things. One job a repeat does is to show bewilderment or disbelief at what has just been said. For example, in the movie “Moana”, Maui, a self-assured demi-god responsible for extensive destruction, tells Moana that he was actually doing mortals a favour, he says: “So what I believe you’re trying to say, is thank you.” Moana says, “Thank you?” in a very questioning tone of voice accompanied by a frown. Done in this particular way, Moana’s repeat conveys confusion and shows she doesn’t agree that Maui should expect thanks. This is one of the many things a repeat can do – it can show that there’s a problem with what a person has said.
In fact, people quite often use repeats to show surprise or even disagreement. There are many other things people do through repeating, including: showing they didn’t understand what was just said; showing agreement; or simply showing they have heard and registered what has been said – as when we repeat back a phone number. The fact that repeats can do all sorts of different things presents a puzzle: how do we manage to work out what a person means when they repeat our talk? During conversation, we are constantly examining what somebody has said to find out what we should say next. Take this example of a doctor repeating a patient’s answer:
Doctor: Is it painful at all?
Patient: Just a bit.
Doctor: Just a bit.
Unlike Moana, the doctor here doesn’t seem to be showing surprise or disagreement. When we look closely, we can see that this repeat contains several clues that help us figure out why someone is repeating, and that help us work out how we should respond.
So, the answer to our puzzle: ‘How do we manage to work out what a person means when they repeat (a bit of) our talk?’ is as follows: how we understand repeats depends on the tone of voice used, the topic being talked about, and the person’s body language.
Figure 1: Why is someone repeating talk? Three clues
Tone of voice
The first clue is tone of voice. Moana doesn’t copy the way Maui says thank you – she repeats it as if it is a question, with intonation that gets higher towards the end of the final word. This is a tell-tale sign (that Maui overlooks) which shows Moana has a problem with what Maui has said. Questioning intonation can also show that the person has heard what’s been said, but doesn’t understand it. In example 1, the doctor repeats “Just a bit” copying both the patient’s words and their sound pattern, and in a way that sounds like the end of a sentence rather than rising like a question. Importantly, the doctor doesn’t emphasise part of what the patient says– e.g. by saying “JUST a bit.” or “Just a BIT.” If the doctor had done this kind of emphasis, this would work to point to a problem in what the patient has said, and to request more information about it. Instead the doctor copies both what the patient has said, and how they have said it. Repeating in this way typically lets a person know that they have heard what has been said, and does not indicate that more needs to be said.
Topic under discussion
The second clue is topic under discussion. In example 1, the conversation is about the patient’s painful shoulder, something that the patient obviously already knows about, and that the doctor wants to find out about. The fact that the shoulder is “Just a bit painful” is news to the doctor, and by repeating this, the doctor shows that she has received the information. We can contrast this with a scenario in which the person asking the question actually already knows the answer. For example, when teachers ask questions as a way of testing students’ knowledge. The teacher already knows the answer, and the repeat shows whether the student got the answer right:
Teacher: What is the capital of France?
If the teacher had said “Paris?”, this would suggest that the answer is wrong. We interpret repeats according to what all the speakers know and understand about the matter that is being talked about. If the matter being repeated is something that a patient knows the most about, as in their pain, then they may well reply to the repeat by confirming what has been said, by saying “yes,” or “that’s right,” and maybe even expanding with more detail.
The third clue is body language. If people repeat what you have said whilst writing something down, or with a frown, or raised eyebrows, or a grin, these features give us clues about whether they are repeating to make a note of what you said, or to show that they haven’t understand, they are surprised, or that something you said was funny. People tend to look away when they have finished talking about something, whereas continuing to look someone in the eye suggests there’s more to discuss. Non-verbal clues help us work out whether we are expected to respond to a repeat – if the person is facing us and leaning forward, we are more likely to understand that they are expecting us to reply in some way.
In figure one, we describe the clues that help us work out why someone has repeated something we’ve said include:
- The way the repeat is said: copying the original talk; emphasising part of it; or saying it like a question
- The topic under discussion: is the person on a mission to find something out or to test your knowledge?
- Whether the person’s body language and facial expressions suggest that they are waiting for you to say more
We used these clues to help us better understand one common way that doctors repeat patient answers about their pain.
Repeating patients’ answers in palliative care
We noticed that experienced palliative care consultants often repeated patient answers when they are assessing pain in video-recorded real-life consultations in a large U.K. hospice. We found 23 repeats that were all very similar: they repeat a patient’s answer; they copy the way the patient has said their answer (that is, unlike Moana, they echo the same sound pattern the patient has used); and they all happen after the patient has answered a question about their pain. We used a research approach called conversation analysis to describe in detail exactly when practitioners repeat patients’ answers in this way, and to examine what patients do next. We wanted to map out precisely when, within pain assessments, doctors repeated patients’ answers. And we wanted to see whether repeats encouraged patients to say more about their pain. Next, we explain what we discovered.
Repeats are useful when new pain issues arise
The doctors in our recordings repeated patients’ answers in two specific circumstances. One being when a new aspect of pain is emerging in the discussion, the other being when the patient and doctor have just managed to resolve some sort of difficulty in reaching mutual understanding about the patient’s pain.
At these particular moments, it is useful for the doctor to clearly show the patient that they have recognised this new pain, or the new understanding of the pain. They do so by repeating it back word for word. This gives the patient an opportunity to check and confirm this understanding, and/or to elaborate further. What we found is that the doctors’ repeats do this in a very sophisticated way. One of the clever things about these repeats is that they provide an opportunity for patients to say more but they do not pressure them to do so.
Repeats encourage but don’t oblige patients to say more
Sometimes, as in Example 2, the doctor repeats the patient’s answer, and the patient says nothing further. At other times, as in Example 3, the doctor’s repeat prompts the patient to elaborate.
Doctor: You’re holding your arm at the moment.
Patient: ‘Cause it’s throbbing.
Doctor: ‘Cause it’s throbbing. (doctor looking at patient)
(pause – doctor is looking at patient)
Doctor: Right. Just to find out a bit more about you….
Doctor: Is it painful at all?
Patient: Just a bit.
Doctor: Just a bit. (Doctor looking at patient)
Patient: Yeah, it’s like somebody pulling your arm out a socket.
The reason that these repeats sometimes prompt patients to say more is that they cleverly do two things at the same time – they show the patient their answer has been heard, and they also invite but do not oblige the patient to say more. Several features of the way that the doctors repeat patient answers contribute to this.
A key feature that shows the patient that their answer has been heard is intonation, the sound pattern of the repeat. In Example 2 and Example 3, the repeats copy the way the patient originally said their answer, with intonation that drops as if the sentence is ending. The doctor doesn’t emphasise any part of the patient’s answer in a way that might suggest something in the answer is problematic, or hasn’t been understood. Because of this, the repeat can be heard as the doctor simply acknowledging what the patient has said, rather than prompting them to say more. When the patient says nothing further, as in Example 2, the doctor doesn’t try to get the patient to say more, for example, by saying “Did you hear me?” or “You said ’cause it’s throbbing?” Instead, the doctor leaves it up to the patient to determine whether or not to say more following the repeat, and in Example 2, by adding nothing further, the patient conveys that his original answer is complete in itself.
While it is true that repeats show the patient that the doctor has heard their answer, it is also the case that they simultaneously invite the patient to say more. That is, these repeats also contain features that provide an opportunity for the patient to add to their answer should they choose to do so. One of these features, which we call ‘highlighting’, relates to the fact that since doctors don’t repeat every answer in a consultation, when they do repeat something (as in Examples 2 and 3) this gives the patient a clue that the doctor is highlighting this particular answer. As we mentioned above, doctors do this highlighting when some new information about pain has come up, or when some new understanding has been achieved. In Example 2, the throbbing nature of the pain is a new piece of information, in Example 3, the new information is on the particular location of pain – the patient’s shoulder. By highlighting a patient’s answer, the doctor gives them opportunity to say a bit more about it.
Another feature is the doctor’s body language, specifically, eye gaze. In the repeats we studied, when the doctor repeats, they also continue to look at the patient. Continuing to gaze at someone is a regular way in which we show that we are not ready to move to a new topic yet. A final feature of the repeats that works to encourage patients to say more is what we call ‘respective knowledge’. That is, the topic under discussion is something that the patient knows more about than the doctor – their experience of their pain. This means it is for the patient to (dis)confirm whether the doctor has correctly understood their pain and, to add further detail if need be. The repeats in Examples 2 and 3 are identical in relation to when they happen; how they are pronounced; and what they concern. Nevertheless, the patient’s response is different: in Example 2 the patient doesn’t say anything more on the matter, whereas in Example 3, they opt to elaborate on their pain experience with an analogy, describing the pain as “like somebody pulling your arm out a socket”. This implies a significant level of pain. As a result of the doctor’s repeat, the patient adds important detail – indicating more pain than his initial “Just a bit” answer implied.
So, we’ve explained that repeating part of what someone has just said is a communication practice that people use to do quite a broad range of things. Through repeats we can show disagreement or lack of understanding, conversely, repeats can be used to show we have heard and registered what has been said, and also to show agreement. Crucially, people interpret what a repeat means by (subliminally) attending to precisely when it occurs, how it is voiced, and the context – in particular, who knows what about the matter at hand. We’ve suggested that communication advice about repeating what the patient says underplays the range of things that repeating can do.
We have described our study of one particular sort of repeat that we noticed cropping up quite frequently in our video-recordings of doctors and patients talking about pain in a palliative care context. These were repeats where a doctor repeats word-for-word and with the same sound pattern, a patient’s answer to a pain question. We found that this kind of repeating gives patients an opportunity to say more about their answer, whilst avoiding pressuring them to do so. Repeating a patient’s answer both acknowledges and accepts the patient’s pain description, and invites – but does not impel – the patient to provide more detail. This puts the ball in the patient’s court, giving them an opportunity to expand their answer, but without requiring them to do so.
We explained that in our video recordings of real life hospice care, doctors repeated patients’ answers in two very specific circumstances within pain assessment sequences: either when new aspects of pain emerge or when there’s been some trouble reaching a shared understanding of some feature of the patient’s pain. This raises a question: Why repeat at these particular junctures? What our study shows is that in a pain assessment context which is typically dominated by questions asked by the doctor, repeating answers “holds the door open” a little longer to empower patients to add more. These repeats ‘press pause’, allowing the patient to add further information which could contribute to effectively building a full picture of their pain. At the same time, these repeats remain sensitive to whether or not the patient is able to provide further detail.
Loughborough University, the University of Nottingham, LOROS Hospice Leicester, Leicestershire and Rutland, The Health Foundation, and the National Institute for Health Research (NIHR) Academy. Ruth Parry is funded by a National Institute for Health Research (NIHR) (NIHR Academy Career Development Fellowship CDF-2014-07-046) for this research project. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.