Reconsidering patient centered care: between autonomy and abandonment podcast

Transcript

Reconsidering patient centered care: between autonomy and abandonment

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Rebecca Torr (RT): Hello, I’m Rebecca Torr and welcome to the Emerald Podcast Series. Patient centered care is a fundamental health and social care policy within the UK National Health Service (NHS) and other healthcare organisations around the world. It was a medical approach that came into its own in the 1980s, replacing the traditional, paternalistic medical approaches that had become problematic. But what is patient centered care? And is it as effective as we think it is in delivering positive health outcomes? To discuss these issues, I’m joined by two professors with an incredible wealth of knowledge in this space. They are Professor Alison Pilnick, Professor of Language, Medicine and Society in the Faculty of Social Sciences at the University of Nottingham and Professor Ruth Parry, Professor of Human Communication and Interaction at Loughborough University. As part of the discussions, Alison will draw on the insights from her new book entitled, Reconsidering Patient centered Care: Between Autonomy and Abandonment.

Alison Pilnick (AP): I'm Alison Pilnick, I am Professor of Language Medicine and Society in the School of Sociology and Social Policy at the University of Nottingham. And my working life began as a pharmacist, and I initially became interested in communication in healthcare as a practitioner. But then, for the last 25 years or so, I've been researching communication across a whole range of healthcare settings, mostly using the method of conversation analysis. I've worked in settings in the UK and beyond, funded by a range of funders. But in those settings, I've been interested in some core practices that recur pretty much wherever healthcare gets delivered. So things like advice giving, things like communicating risk, things like decision making. And then I'm also interested in what happens when one party has a condition that might affect their communication. So something like dementia, for example, and more recently, I'm really interested in communicating where parties don't share a first language and what that does to healthcare consultations and how they unfold. But I suppose whatever setting I'm researching in, and what I'm interested in is using social science methods to try and produce practice and policy relevant research findings. And that always includes developing training resources for practitioners.

RT: Fantastic. Oh, it's really interesting in such a broad range of subjects and interests. Thank you. And Ruth, would you describe sort of your interests and introduce yourself, your current position.

Ruth Perry (RP): Of course. So I'm Ruth Perry. I'm an Emeritus Professor of Human Communication and Interaction at Loughborough University. In some ways, Alison and I have quite a bit of shared background, so I used to be an NHS physiotherapist, that was the first part of my career. And I ended up doing a PhD with Alison and another colleague, Robert Dingle, looking at communication in physiotherapy. In doing the PhD, Robert, Alison and I got very interested in the same kind of research approach that Alison uses, which is called conversation analysis. And I know that we'll be talking a bit about that later on. And my particular focus has tended to be sensitive and difficult conversations between practitioners and patients. I think when I was a practitioner, I wasn't always particularly good at those. And it became an increasing interest for me to actually work on. Like Alison, I do work on projects that are intended as part of them to provide more developed resources for training and for guidance and policy. Since 2010, I've worked specifically in palliative and end of life care, and focusing on when and how people managed to talk about particularly sensitive and difficult topics like prognosis and end of life. And that's still a key area of my work now. 

RT: Wonderful. Thank you. Well, I'm absolutely delighted to have you both here on the podcast. As you know, the podcast is focusing on a research project on patient centered care, and Alison's new book, Reconsidering Patient centered Care: Between Autonomy and Abandonment. As a starting point, could you explain what we mean by the term patient centered care?

AP: I can try. You think that would be really easy, but it's actually surprisingly difficult. And the reason it's surprisingly difficult to give you any sort of widely accepted definition of patient centered care, is because there isn't a single agreed definition. And that's something that really surprised me when I came to this area, you know, you would think, given the ubiquity of this term in policy and practice, that there would be some clear statement about what this means. So, there isn't any kind of single agreed definition, what does exist, there are a huge number of measurement tools and models. The UK charity, the Health Foundation says that there are more than 160 of them that are commonly used. And I think that gives you some idea that if there are more than 160 things in common use, they can't all be measuring the same thing. Because otherwise they'd just be duplication. You also have the problem that sometimes definitions of patient centered care are imposed a priori. So people start their work with the definition, sometimes they emerge from the work that people do. But I guess if you're asking me to identify key common principles, what all these tools and approaches and models tend to do is emphasise the importance of a transfer of control from Dr or the healthcare professional to patients. So a patient centered approach is conceptualised as giving back this control to the patient and very often with a really strong emphasis on patient choice and patient autonomy. And what I'd say about that as well, is that what makes it even more confusing is that the term patient centered, sometimes gets used interchangeably with other terms. So very often person centered care, but sometimes other things too, like individualised care, or personalised care. And, one of the things that I've tried to do in the book is talk about the different roots of those terms, and why I think it's problematic that they get used interchangeably in that way.

RT: I think it's so interesting what you're saying about the different definitions. And I think, you know, just researching a little bit about this work, you know, person centered care, it would never have occurred to me that that was anything different than the patient centered care. So it must be quite confusing for people that are working in the sector to understand what definition they're working under, and what that means for their roles. So I can see, you know, why it was important for you to, to define that and to discuss, you know, sort of all those different areas coming together. Obviously, you've done a project on reconsidering patient centered care. And I was just quite interested in why you wanted to do this project and what was the need for it, and what you were hoping to achieve, really.

AP: So for about 25 years, as I've said, I've been working on projects, looking at communication in healthcare across a range of settings. So that started with my own PhD. But all of those projects were funded to look at specific aspects of communication. And along the way, I began noticing and collecting examples of the ways in which an attempt to practice patient centered care was sometimes problematic in these places. But I knew that I was never going to have time to look at these systematically in the gaps between other projects and teaching and all the other things that we do. And so I was able, first of all, to do a very small bit of work with the support of the Academy of Medical Sciences and bear their flyer program. And then to use that very small bit of work to develop a proposal for the British Academy Senior Research Fellowship Scheme. So I was lucky enough to get that funded. And what that did was give me the space to go back to my whole corpus of 25 years worth of data to try and reanalyse it with that patient centered care lens.

RT: I bet that's been absolutely amazing to be able to focus on a project that you've really wanted to get under the skin off for such a long time and weren't able to. So during that experience then of this project? What did you find out? What were the sort of main outcomes or implications of that work?

AP: Yeah, so I think there were a few things. So I mean the first and the most fundamental thing is the thing that I think I've already said that, that despite its absolutely ubiquity, across the NHS, but you know, policy, service delivery and beyond, there's not that much of an evidence base for patient centered care. So what it really rests on is a moral position that seems to make intuitive sense, rather than any kind of empirical evidence that it has a positive impact on people's health. So if you look at studies in isolation, you can find individual studies which report positive impacts, but if you look at systematic reviews, which collects those interventions and those studies together, they show a pretty mixed picture. So what I found was that research repeatedly fails to show a clear link between the adoption of patient centered care in a setting and any kind of improvement in health outcomes. What studies do sometimes show is an increasing patient satisfaction where patient centered care is practiced. But even that's not universal. So you've kind of got this situation where it's not making people's health better. It's making some people feel better about the service that's delivered, but not by any means all of them. And the only really consistent finding that comes out of these reviews is that training practitioners in a patient centered care intervention increases the practice of patient centered care, as measured by that particular intervention. But given how many different interventions there are, and the fact that they're not all measuring the same thing, it seems to me that that's not a terribly helpful circularity. And so then you're left thinking well, despite the fact that that patient centered care doesn't seem to work to improve health, why does this problem usually get framed in a way that is really in terms of professional failings, that patient centered care would work, if only healthcare professionals were more or somehow better trained in it? So I suppose that was my first finding. The second thing that you then ask yourself is, once you've established that sort of link doesn't work in the way it was intended. The next obvious question is, well, why doesn't it work? You know, why is it not having this impact on health outcomes? And that comes back again, to what I've said about patient centered care being grounded in a moral position rather than empirical evidence. Because if you examine real life healthcare interactions, as I did, what you find is that there isn't generally this kind of grand struggle for control that patient centered care assumes. So the language of patient autonomy and patient choice that patient centered care uses, it really serves to obscure the way that choice and control are actually negotiated and constructed by healthcare professionals and patients together based on the way that they share their professional and personal expertise. So you know, in real life control and choice are discrete properties that can only rest with one person or another person. And if you conceptualise them like that, if you conceptualise choice and control as resting solely with patients, or as things that should rest solely with patients, then there's no longer any clear role for medical expertise in healthcare decision making, so that you know, the things that professionals know by virtue of being professionals, there's no obvious place for those in the consultation. And what I find is that the ultimate consequence of that is in practices of patient affirmation. So you go along with patient's views about the care that they feel that they might want. But the risk of that is that you're offering care or ultimately providing care that doesn't meet care standard. Or it's in patients feeling abandoned, because medical decisions get framed as private matters, private decisions that they have to make on their own, depending on how they feel about different options. And I think if you understand those two things, then you begin to understand why patient centered care doesn't result in the improved health outcomes that you might imagine it would result in.

RT: It’s very interesting, isn't it? Because you would have thought that it's been going on for decades, this type of approach? And you'd think, well, it must be working, it must be making a difference to people's health, it must be, it's such an eye opener to find out that actually it's not about that at all. Whereas that space for what the practitioner has to say, the experts have to say, and what priority is that given, I guess. It's a huge contribution to have this knowledge available, and obviously, you've gone on now to publish this work in a book. And I'm just quite interested to find out a little bit more about what's in the book and why you felt now was the right time to publish this book after all that time.

AP: Yes, the book was really a way of pulling together all of this work and to disseminate it. I wanted to write a book because I wanted to show the broad range of material I was drawing on in this analysis. The problems that I was identifying were not limited to one or two settings, so I know I need the space to make that intellectual argument and to show the evidence that underpins it. In answer to the why now I suppose the why know felt right for a variety of reasons. So, as I said, patient centered care is becoming ever more ubiquitous in healthcare policy and practice over recent years, but still in the absence of any real evidence for its impact. And when I started to collect the examples that I use in the book years ago I naively assumed that this is how health care policy works.  I kind of thought that if this is happening, then there must be evidence that underpins it. The second thing I think is the global health care content over the last few years is a reason to give us all pause for thought. The emphasis that Western society places on individual choice and autonomy… so Annemarie Mol who is a philosopher and who’s brilliant work I draw on in the book says that choice is the pivotal liberal principle that in neo-liberal terms citizens are defined by the ability to control their own bodies. I think we can see how that plays out in modern life in a variety of ways, but I also think that it is particularly problematic when you apply it to healthcare because the problem is if you need health care for any reason then you are not entirely free because there will be consequences if you are left entirely alone.  And I think in many ways the COVID pandemic is another perfect illustration of a thing that Mol said although she was writing pre-COVID. She says microbes and neo-liberalism don’t go well together. And I think if we think about responses to the COVID pandemic then that shows us how often it is not sensible to conceptualise health care choices as individual choices. It also shows us how even if we frame things in terms of individual choice, then not only individual choices are not seen as equal. I am sure that you have things to say about that Ruth.

RP: Well, I guess as I have been listening to you one of the things that I have been thinking about with that lovely quote about microbes is I think that something that isn’t mentioned within the book specifically is that some people in our field, particularly someone called [Doug Opall???] and colleagues looked, for instance, at parents taking babies for vaccinations, with all the data recorded in America and what the study found was that the more the practitioner gave space to the parent to discuss or challenge, or ask questions about vaccination than the more satisfied the parent was post-consultation but the consultations took longer and there did end up a slight change in whether the baby was vaccinated. And certainly there was a significant difference between how much push back there was from parents against having the vaccination whereas if the practitioner started out with ‘‘you brought her for a vaccination today ‘‘then it went much more rapidly and smoothly.  I can see the conflict there between being more satisfied with the enormous consequences that we know are now playing out in our society of not vaccinating babies. So, these things work through in very, very practical terms and that is just a very neat example…and, um. I know you have had other examples of that problem in the book. But as you say the pandemic has made it very clear.

RT: But this is a completely different perspective on how we talk about life generally now. Everything now is about putting people in control of their lives and making the decisions and stuff. But in the end what is the outcome that everyone wants – is the goal having the health care that everyone wants if you go to the doctors’ surgery and you already know the answer, but you go in there for a reason. So, it’s a very different perspective and its great to hear research that’s backed up with all these great examples, particularly where it hasn’t played out as according to what you might think. So even though you think logically that patients ok are more satisfied, then that’s a great outcome in itself. Ultimately they are not going to be satisfied if they are dealing with the consequences like in the vaccine example if your child does develop one of those illnesses and, you know, the consequences of those illnesses. It is really a completely different perspective and in the book you examine a values-driven health care policy could be contentious in practice. I just wondered if you could elaborate on this explaining why this might be the case. Ruth, do you have a couple of things that you would like to say in the research fields that you are working in? And I think it is really great to have those practical examples as well just to bring it to life, so our audience can have a different perspective to.

AP: Yes, I think that that is an interesting question because I think the issue really is that it’s not at all contentious but that it is problematic. So, you know, I have said that patient centered care derives from a moral position – the issue of moral rightness that you give control to the patient – and that is part of a broader shift to values -based policy, which is largely a reason that the response to successive health care scandals, so things like the Francis Inquiry into North Staffs hospital which had been investigated how unquestionably appalling cultures and practices   have come to develop in particular organisations or settings. And the response to that has been to suggest that if only practice was underpinned by moral values such as compassion or dignity, then those kinds of scandals wouldn’t occur. But I think that the problem then becomes one where because of the moral infallibility that is assumed by practitioners that there is patient centered care. It then becomes impossible to even discuss it. So, I can’t tell you how many times I have tried to have this conversation with people who say ‘‘you want to go back to the old days, the bad old days then…or you think doctor knows best.’’ When in the first place that is not what I am arguing at all and in the second place I don’t think they are simple binary choices, and I don’t think it does us any favour to pretend that they are. So, I suppose, what I think the problem is that I don’t think it is healthy for any kind of policy to be beyond any type of discussion in that way, and I think value-based policies are particularly prone to being seen as beyond discussion. But then I think there are other problems in that moral values are not necessarily stable and that they can and do conflict dependant on context which, I guess, takes us back to COVID again and the way in which autonomy had to be balanced for the collective good. And while moral values make really good policy soundbites, they are really difficult for practitioners to enact in practice as they lack specificity. We know that there is no agreement over what patient centered care actually constitutes in practice. But you could ask the same questions about compassion, dignity, you know what do they look like on the ground in health care in health care interactions. And I know that this is something that you have been really interested in Ruth. 

RP: It is. I think things like compassion and empathy, dignity are in some ways like patient centered care in itself in that on the surface it sounds, yeah, only a moral good and so on. But, actually, understanding it or putting it into practice in a concrete way is very difficult it doesn’t just naturally flow from, say, listen more empathically or, you know, treat people with compassion. And there can be times when there are even conflicts between different ways of treating someone with dignity or compassion or even, and I am going to slightly shift examples, but even things like ensuring that the patient understands and your clear with them. So, an example from my own area of interest is another idea how policy or how policies about how to be compassionate or how patients really understand their situation is the idea   - and there is really strong debate within practitioner fields especially in palliative care around the fact that practitioners say or are told to say ‘’you are dying’’ or ‘’your relative will die shortly’’ or those kind of things. It is using the D word and is sometimes talked about in oncology using the C word. Now it sounds morally the right thing to do and logically you think: ‘’yes, that’s the right thing to do’’ because then people will understand, but in studies that have actually recorded very experienced practitioners and where the patients are pretty experienced themselves in palliative care and if you look at how they talk about end of life and dying and so on it is very rare that people use the D word whether that’s patients or relatives even doctors when someone is very close to the end of their lives. And so that makes us wonder why, why is there is policy and this guidance that seems morally compelling and makes logical sense and so why don’t practitioners do it.   It can be a source of guilt or as Alison was talking about earlier a source of judgement that this practitioner needs training or is practising badly because they don’t use those words necessarily. Well, of course, the reason why is that directly referring to my own death or if the practitioner directly refers to my own death   it can been really distressing. We sort of know it but actually verbalising these things can cause so much emotional distress. It can then derail whatever the consultation is doing. For instance, you might be talking about whether you want a relative to be with me or about my pain symptoms and the management of those. But you know maybe someone has used that D word in a very brusque, blunt way or if you find it in a very brusque or blunt way. So that is why people don’t generally actually apply this policy and are often made to fill guilty when they don’t do so. And one of the strengths I think of the field that Alison and I work in one can then look and what do people actually do then. One of the things that I feel is really important in our field is that we analyse what people do in real life. We almost go in with an assumption that there are some reasons and there will be some good reasons for, for instance, not using the D word and sometimes, often, we can actually work out those good reasons through looking at how interactions actually work. And then after we can see how some people, practitioners or patients, come up with rather neat and clever ways of getting around some of the problems. So, to finish my little story of this to use the D word in policy when we look closely what some practitioner and may patients and relatives do is that they will refer sometimes indirectly to death or dying or to the end of their lives or prognosis. But where it is still indirect but not ambiguous…so, for instance, in English passed away, you know, we all know what that means or a medical colleague of mine she talks about may not survive. Those kinds of things. What we know though is that sometimes people are so indirect or in an ambiguous manner, so say ‘‘I don’t know if I will be here tomorrow’’ and where I have a bit of recording where a patient says that to a practitioner it is not clear whether here at the hospice or whether I am going to be dead tomorrow as it were. So, one of the neat things we were able to do or will are able to do looking at different ways of handling this kind of problem. We can then produce guidance more fitted to how real life works. So, we might say if I was being really simplistic with guidance don’t necessarily feel you should use the D word because of all the problems with it, but when being indirect do it in a non-ambiguous way. 

RT: I mean, it's really interesting. And when you were speaking there, you were just so emotive, and I think anyone that's been in that situation where you've had a relative that is gonna die, and to hear that it's an honest thing, it's a very blunt thing, and in practice, interesting that you know, what looks good on paper, what sounds great in a policy, when it's rolled out is quite different. And as a, you know, a patient on the other end, you know, you really do appreciate it when there is tact around using those kinds of words, and not everyone wants to hear it so blatantly. And I think it's wonderful that there are people like yourself that are doing research in this area, and that actually interrogate the practical application of policies and what's recommended, because, you know, talking about sort of what the outcome, what's the what's the last part of that person's life or their families that have to deal with it? It is really important. That's what you remember, isn't it? And that's what stays with you, I think in terms of experiences, and I can think of, you know, recent ones from my own personal point of view. And just, you know, you're very grateful for those experts, and they really are experts that have been doing it for so long that they really understand that in practice that doesn't always play out. It's very interesting. And I'd like to move on to sort of conversation analysis because I know you mentioned quite a lot about that in the book. And I just like to understand sort of how it can be helpful in understanding healthcare interactions.

AP: Yeah. So I think I think Ruth and I could write a really big book about that. And maybe one day, we will, picking up on some of the things that Ruth just said that you know that the most important thing for me, the most useful thing about conversation analysis is a method is that it shows you how healthcare interaction actually works in practice, as opposed to how people think it works, or how people think it should work. So, if you like, it's an incredibly useful way of looking at that policy practice gap. It's also at the opposite end of the spectrum, you know, it's far away, as you can get from the sort of top down values based development of policy. So it very much brackets, those values and opinions. And it's able to look at and show instead, what works on the ground and why it works. And something Ruth and I talk about all the time is the fact that people rarely think about the fact that most healthcare policies actually have to be tucked into being some where health care policies happen, is in the consultations or in the interactions between healthcare professionals and their clients, whether that's in the consulting room, on the board, over the phone, or wherever else it might be. And so, as Ruth has said by looking at that talk, you can see where difficulties in policy implementation arise. And you can see why. And what that often points to is the fact that healthcare policies are asking staff to do things, which are incredibly difficult interactionally you know that they might be a good idea in theory, but they don't work interaction really. And I think from my data and my research, knowledge, directedness is a great example of that. So non directive, it is a policy that's pursued across a range of genetic maximum services as part of a patient centered care ethos. But what you see, when people try and practice this is that it's virtually impossible to deliver information in a way that's heard is completely neutral. Because given that, that patients or clients orient to a practitioner, as, as the experts in a field, they'll try and make meaning out of whatever it is that a professional says, in order to help them make decisions. And then I think the other reason why compensation analysis is so useful is again and picking up on things that Ruth said that because healthcare practitioners are doing this all the time. They develop resources for dealing with interactional, difficulties and dilemmas, you know, some of which are created by the policies that they're asked to implement, that you can identify, and you can explicate. And those can be incredibly useful training resources for full of practitioners, you know, who may be new to that setting, or who may not have dealt with those particular issues or difficulties before. And I'm sure you've got plenty you might like to add about that Ruth.

RP: Sometimes with my physio kind of background, I sometimes think it's helpful to think in terms of an analogy to how anatomists work. So you know, all of us know our bodies, skin deep And we could talk about that skin deep aspect, but what's what we don't know, unless we're fortunate enough to study it, and so on is what's under that skin. The anatomy of an itchy is it's incredibly beautiful, and complex and clever, and neat, and so on, the way that our bodies work under the skin. And that's it's the same with interaction. So in a way conversation analysis versus doing anatomy of interaction. 

RT: It's really a very useful way to look at it, isn't it? Because I think you get sort of forms to fill out and things like that. And you think it'd be great for if everyone just, you know, could go into a box, you know, and it'd be so simple to say that's the outcome that's, you know, what it should produce, or you follow this rule, and then that works. And then but we're as individuals, as humans are so complex, and we've got our own characters and our own ways of dealing and to be intuitive, you know, as mums or dads or whatever, you know, you have this intuition, that of what is right, but try to articulate why that feels the right thing, I suppose must be really quite tricky. And the main thing in terms of an outcome for the research that you've done, if you had any ideas of how your work might support changes to the way we view and implement patient centered care, and ultimately, as you've been describing how it would lead to better health outcomes for patients in the future.

AP: I think the most fundamental thing my research does is highlight the importance of looking at the actual evidence rather than beginning with a moral position, because the problem is then that you can become so invested in that moral position that it becomes very difficult to act in the face of contradictory evidence. So, in the book, I draw very briefly on some data collected from an NHS gender clinic. And I think that's perhaps the clearest contemporary example of what happens when moral positions obscure debate. So, you know, what we know is that the Cavs review into services provided by the Tavistock clinic in London as highlighted some serious concerns over practice. But what I think we've then seen is that practitioners and policymakers are afraid to engage with those for fear of stepping out of that moral shelter. So that's a kind of much broader thing. Beyond that, in more practical terms, I think, firstly, we need to try and rehabilitate medical expertise a bit. So, you know, I think in rightly problematising medical authority, which you know, which has been at the root of some of the scandals that have talked about, you know, kind of unchallenged medical authority, allowing cultures to develop that, you know, we're at rageous and unhelpful, and we've problematised expertise as well. And so, you know, there's a big difference between who has a right to know stuff, which is how I conceptualise expertise, and who has a right to decide what should happen, which is what I'd conceptualise as, as authority. So, you know, I think patient centered care, right, you problematises that authority, but we need to think about how we bring that expertise back in ways that are acceptable to, you know, to contemporary 21st century patients. So, so rather than trying to train professionals to do better patient centered care, whatever that looks like, I think we need to think about how what we're understanding is patient centered care has problems, highest that expertise. Alongside that, I think, I think we need to lose some of our obsession with individual choice and autonomy and this focus on individual consultations and think more about relational autonomy, which, which reflects the fact that we don't generally make decisions in a in a vacuum. So, I'm absolutely not suggesting that there isn't an important role for patient experience. But I think that rather than scoring hang that's been taken into account into a, in a specific consultation, you know, and choosing which of the 160 measurement tools that you use to do that, I think we'd be better placed if we're thinking stead about how that experience can be used in co-design of services and co-production of healthcare resources, so that that patient expertise is embedded at that stage of service provision. And then picking upon on things that Ruth and I've just been saying about conversation analysis, given that many, if not, most healthcare policies have to be tucked into being at the point at which care is delivered. I think we need to advocate for policy to be grounded in a solid understanding of how healthcare interaction works in practice. So, you know, not what people think it does or what it should do. 

TR: It sounds like this is just the start for you, and you've got a lot more coming. So maybe you can give us just a little bit of a highlight into or an idea of what's next for your research and what you think is really important in the next phase.

AP: In general terms, what I'm going to do is carry on trying to use social science methods, and particularly conversation analysis to improve health care policy and practice. So, at the moment, I'm working on project looking at how we might better manage distress in people living with dementia who've been admitted to acute hospital wards. And the endpoint of that project as for most of my projects will be to develop a training intervention that's grounded in real life interaction from the wards. With colleagues, I've also developed a method for improving simulated interaction by using conversation analysis to inform it. So, it's really important that we think about how healthcare professionals are trained and most healthcare professionals I've trained at some stage and to some degree through interactions with stimulated patients or actors who play patients. But there are all sorts of questions over authenticity of simulated interaction, that conversation analysis methods can help to address. And then, I suppose given globalisation and increased migration worldwide, I'm also really increasingly interested in the use of additional languages by patients in healthcare settings. If you can't talk about your health care concerns in a third language in order to access care, what impact does that have on your consultations on how your agency gets exercised in decision making, and so on but to answer to your question, I think is more of the same, but in different settings. And I think one of the really interesting things about working with this approach is that you're drawn to where you see the issues are arising, you know, rather than kind of having this, this top-down notion of these other things that I think is important. My questions, and my projects are usually generated by the things that I can see are problematic or difficult or challenging in healthcare interaction. And so where there's a need for, you know, for guidance or for training for practitioners.

RT: Yeah, I mean, I suppose, you know, like you mentioned earlier in the conversation about COVID. We never know what's next. We never know what the need might be or what what will arise. So, I don't know, will there be an opportunity for the two of you to work together again, do you think?

AP: I'd like to think so. Maybe we'll write that book.

RP: Maybe.

RT: Thank you for listening to our episode on reconsidering patient centered care. You can find more information about our guests and a transcript of the episode on our website. I'd like to thank my guests for joining me and sharing their knowledge and expertise. A huge thanks also goes to Podcast Producer Daniel Ridge and the studio This Is Distorted.