Communicating legitimacy: acknowledging the right to be sick

MEDICAL schools and colleges agree that communication is important to clinical practice. Sometimes it is seen as essential for patient satisfaction or rapport building, which are important, but this is a limited view as to how communication can directly affect patient care.

As a linguist and conversation analyst, I have spent the past 15 years exploring the intricacies of doctor–patient communication – how the structures of interaction influence patient participation in one of the central parts of health care provision. As a person, I have spent the past 20 years living with illness. My drive and desire to understand what goes on in clinical consultations comes from too many experiences of what goes wrong.

Some of my struggle as someone with chronic illness has been trying to be taken seriously, especially when I was younger. With lower back pain as a 17-year-old, I was told it was just because I was still growing. As a 25-year-old, I was told it was because I wasn’t trying hard enough to get better. It was not generally talked about as a serious problem until more recently when I’ve reached an age where pain might be more expected.

Much has been written on this topic in recent years, particularly about women and minority genders when experiencing pain. This is exacerbated for people of colour.

When I teach about being taken seriously, I draw on Parsons’ sick role. In the 1950s, Talcott Parsons wrote about the social rights and obligations of people when they’re sick. While there have been critiques of this theory, particularly in considering acute versus chronic illness, we can still see both patients and doctors orienting to these rights and obligations in the way they interact in consultations.

The rights of being sick, to paraphrase Heritage and Clayman, involve an individual’s exemption from normal activities and freedom from personal responsibility while the obligations are that the individual strives to get better and that they seek appropriate help to do so. If a patient’s legitimacy for seeking care is called into question, it can threaten their role as being sick and thus their ability to claim these rights. In everyday life, these rights are seen in the provision of medical certificates for sick leave, for example. Sometimes a problem is clearly legitimate without explanation, such as an acute and obvious injury. Other times, this legitimacy is less clear and so is talked about with the patient demonstrating that they consider their problem is “doctorable”.

Patients strive for legitimacy in consultations, saying things such as “I’ve rested and taken cold and flu tablets, but I can’t shake this cough”, which shows they’ve tried to get better on their own and now need expert help. Or they might say “my wife sent me”, which implicates an external source of legitimacy. For those with referrals, they have that legitimacy built in, with an expert providing external support for the validity of pursuing care. This has its own implications within referred consultations, where the treating doctor needs to work with both the patient’s concerns and the referring doctor’s expertise in having referred the patient.

As a doctor, you can reinforce the patient’s legitimacy in seeing you. When I was pregnant with my first child, I had a placenta at the front, which means I couldn’t feel many kicks. The second time I went to the hospital to check the baby near the end of the pregnancy, the obstetrician said to me “everything is fine, but I am glad you came; if you can’t feel kicks again, please come up”. This ensured that I felt that I had requested care legitimately and that I would come again. When experiencing some strange autoimmune symptoms, an immunologist said words to the effect of “just because we don’t have a diagnosis, doesn’t mean these symptoms aren’t real, so let’s work to manage them”. These words allowed me to know that my concerns were being taken seriously and that I could trust her to help me, rather than looking elsewhere.

Why are these kinds of statements important? They address the sick role: if a patient’s concerns are dismissed, it implies that they are misusing the sick role, that they should not have sought care in the first place. This can cause people to distrust medical care, which may, in turn, create more problems. Providing legitimacy through talk can go a long way to making patients feel heard, that they are being taken seriously and that their concerns are reasonable and deserving of care. Legitimising the patient experience in turn assists in a smoother conversation, a better relationship, and very likely improved adherence to treatment.

Dr Sarah J White is a Senior Lecturer in the Faculty of Medicine, Health and Human Sciences at Macquarie University. Dr White is the current Australian National Representative for the International Association for Communication in Healthcare.

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.