Doctor-Patient Communication: A Pain Physician's Approach

Why communication is clinical, not optional

A patient confronting chronic pain enters consultation carrying not only symptoms, but stress, anxiety, and a story — their own, their family's, often a fragmented one. The clinician who ignores this dimension loses a therapeutic lever. The clinician who engages it gains efficacy and serenity.

Engel's biopsychosocial model (Science, 1977) made this explicit nearly half a century ago. Yet, in daily practice, many of us were never taught how to communicate clinically. We learned semiology, pharmacology, anatomy. Communication was assumed to be intuitive — a "soft skill," supposedly innate.

It is not.

In my Pain Center years at Dijon, the most reliable predictor of a productive consultation was rarely the technical complexity of the case. It was whether the patient left feeling heard, understood, and trusted as a partner in their own care. That outcome is not luck — it is technique.

A pain physician who develops communicational competence achieves three things at once:

• Better diagnostic accuracy — patients reveal what they otherwise hide
• Better treatment adherence — because decisions are co-constructed
• Less burnout — because conflict and frustration decrease

The rest of this article unpacks the how.

How we perceive: a clinical primer

Before we can communicate well, we need to understand something humbling: we do not see objective reality. We see what our nervous system selects for us, filtered through need, expectation, and emotion.

Three steps structure every act of perception:

• Selection — we pick, from the flood of incoming information, what serves our current need. The rest is forgotten or simplified out.
• Organisation — the selected pieces are arranged into a "coherent" pattern, even when the underlying reality is messier.
• Decoding — the organised pattern is given personal meaning, shaped by our beliefs, expectations, past experiences, mood and emotional state.

This matters enormously in pain consultations. When a patient tells me their pain is "ten out of ten," they are not reading a thermometer. They are decoding a bodily experience through their fears, their fatigue, the words their previous doctor used last month.

And when I listen to them, I am decoding too. My fatigue. My assumptions. The five patients I have already seen this morning.

Believing one's own perception of reality is the only reality is the most dangerous of illusions. — Paul Watzlawick

This insight, formalised by the Palo Alto school decades ago, is now confirmed by neuroscience. Pain is a constructed experience, not a passive readout. So is the doctor's interpretation of it. Both can be reshaped — and that is where communication becomes therapeutic.

The Palo Alto framework

The approach I draw on most consistently is the Palo Alto school, founded by anthropologist Gregory Bateson (1904–1980) and developed by Paul Watzlawick and colleagues at the Mental Research Institute. Their landmark book, Pragmatics of Human Communication (Watzlawick, Beavin & Jackson, 1967), remains foundational reading.

Three axioms shape the clinical use of their work:

The next sections unpack each of these.

Verbal and physical communication

A note on terminology: I prefer the term physical communication to the more common "nonverbal communication." The body does not merely fail to use words — it speaks its own language, embodied and immediate. In chronic pain consultations, this distinction matters: patients read our bodies before our words.

Congruence between the verbal and the physical is itself a clinical signal. When a clinician's words say "I'm listening" but their gaze drifts to the screen, the patient receives the body's message, not the mouth's. Patients in chronic pain — often hyper-attuned to invalidation — register this gap instantly.

Congruence is also contagious. Authentic presence in the clinician invites authentic presence in the patient. It cannot be faked — but it can be cultivated.

Concretely, attention to physical communication means:

• Voice — slowing the pace, modulating volume, allowing space
• Silence — using pauses to isolate and value important words
• Posture — body orientation, eye contact, hand placement
• Synchronisation — subtle attunement to the patient's rhythm
• Restraint — knowing when to say nothing at all

None of this is intuitive. All of it is teachable.

Relational positions

The Palo Alto school identifies two dimensions structuring every clinical interaction. Recognising them is the first step toward using them deliberately.

High position / Low position

Height represents knowledge and authority. The physician occupies the high position by default — by status, by setting, by training. But the patient can also legitimately occupy it: no one knows their body and experience better than they do.

Insisting on remaining in the high position generates friction. Conversely, the low position has a quiet advantage: it is stable, energy-efficient, and invites the patient to step into expertise about themselves. Questioning — even when the answer is already known — is one of the simplest ways to move into the low position deliberately.

Symmetrical / Complementary positions

Symmetry implies rivalry, antagonism, mirror-matching. Two people pulling on the same rope from opposite ends. Complementarity is constructive: each person contributes a different role to a shared project, accommodating minor disagreements to agree on essentials.

Each posture has its uses. The clinical art is to recognise which position you are in, and to move between them by choice rather than default — depending on the goal and the strategy.

The PRATIC framework

Over years of practice and teaching, I have distilled what I have learned into a five-posture model I call PRATIC. The name keeps its French acronym — it is a signature of where the framework was developed — but the principles are universal. The five postures hold up under tension, in real consultations, especially when things go wrong.

PRATIC in physical communication

• Slow the voice; modulate tone
• Insert silences that frame the important words
• Use small attention markers — nods, gestural synchrony, eye contact
• Tolerate the silence; resist filling it

PRATIC in interaction

• Step into the low position through questioning, even when the answer is known — it invites the patient into agency
• Positive connotation — name what the patient is doing well, without flattery. Borrowed from the Milan school (Selvini Palazzoli), this technique is among the most underused in clinical practice.
• Use yes-set sequences (Erickson) — series of small, accurate affirmations that build alignment before a difficult message
• Reformulate often. If the patient agrees, you have verified understanding. If they correct you, the conversation clarifies itself. Either way, you advance.

Situational competence

There is no ideal way to communicate. Competence is situational. A skilled communicator possesses a wide repertoire of behaviours, and chooses what fits the context, the goal, and the interlocutor.

This is consistent with what Moira Stewart and colleagues have shown in patient-centered medicine (Western Ontario): the most effective clinicians are not those with one fixed style, but those who adapt their communication to who is in front of them, while keeping their own integrity intact.

The implication is uncomfortable: communication is not a natural gift. The capacity to deploy these skills in practice comes from training, repetition, and feedback — like any other clinical skill.

It is also one of the most rewarding skills a physician can develop. Once cultivated, it accompanies you into every consultation, every difficult conversation, every team meeting — for the rest of your career.

Clinical applications

The mastery of therapeutic communication serves several converging clinical aims:

• Managing patient and family stress — particularly at the moments of diagnosis announcement, treatment changes, and uncertainty
• Navigating disagreement — when patient and clinician hold divergent views on prognosis, medication, or course of action
• Preventing misunderstandings — by verifying through reformulation rather than assuming
• Mobilising the patient's own healing resources — through positive framing, narrative reconstruction, and recognition of strengths
• Supporting empathic engagement — as modelled in Suchman et al.'s influential JAMA paper on empathic communication in the medical interview (1997)

The pragmatic approach inherited from the Palo Alto school — focused on what works rather than on the abstract truth — offers a particularly useful framework for these clinical objectives. It is concrete, teachable, and immediately applicable.