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Reflections on the concept of communication: second international goal of patient safety

How to cite this article: Medrano-Mariscal J. Reflections on the concept of communication: second international goal of patient safety. Rev Med Inst Mex Seguro Soc. 2015 Jul-Aug;53(4):518-22.



Received: July 17th 2014

Accepted: July 29th 2014

Reflections on the concept of communication: second international goal of patient safety

Joel Medrano-Mariscala

aHospital General Regional 200, Instituto Mexicano del Seguro Social, Tecámac, Estado de México, México

Communication with: Joel Medrano-Mariscal

Telephone: (55) 5775 1679, 5177 6214;

Effective communication is an element of prime importance, especially as it relates to health professional staff. Reflect on the concept and its meaning in a specific sector, taking into account their cultural and socio-environmental, requires interdisciplinary assistance in this case tools of medical anthropology as the emic view retake and construction of indicators are proposed. Medical anthropology and other social sciences, shows that the emic communication approach transcends the individual; so it is important to emphasize that communication has to be understood as a social construction, which helps to achieve understanding between people. Only from understanding the other will be able to think of an effective communication between health professionals.

Keywords: Communication; Medical anthropology; Health Communication

Today communication is more than a fad, it's a real need, and in specific cases, such as that of health professionals, it has become a key priority, not least because the life some patients may depend on it. It is no coincidence that there are International Patient Safety Goals and that the second is "effective communication." The health system in Mexico in general and in particular the Instituto Mexicano del Seguro Social (IMSS) are working hard to implement these goals through its "Guide to the implementation of the International Patient Safety Goals of the Certificate of Medical Establishment Accreditation", but how to achieve "effective communication" in a bureaucratic, impersonal and dehumanizing system?1

We start from the premise of recognizing the other, of understanding their context and comprehending them, so that in the future a communicational diagnostic can be developed, and once we have that, then we can launch a campaign of "effective communication". If it is not done this way, we will fall into the classic pitfall of mistaking "communication" for the act of informing. In this regard, in order to get to know the natives, the “emic” element of medical anthropology must be brought back.

"Paper talks" and the concept of communication

Communication between professionals according to the international patient goals takes place through written medium, and in specific cases (such as when you are attending a patient who is in a state of emergency and / or critical condition, or in surgical process) it can be postponed temporarily, but then it should be documented, that is, definitively documented. But what is written communication really?
When thinking about the concept of communication we first refer to the old scheme: sender-message-receiver and vice versa. Medical  anthropology2 (which is the discipline that comprises the relationship: Man-Disease-Time-Culture, as well as their healing strategies in time and in different cultures) enriches the paradigm with its emic view, since it is considered that all concepts are a social construct that responds to a particular way of seeing and living life, that is, people create its concepts tacitly or explicitly, according to their own culture and knowledge.3 In this sense, communication has to be understood as a social construction, for which, first, we must learn to see as "strange" what is to us "natural" because the obvious is omitted for being obvious, which prevents recognizing particularities and understanding answers that are not equal to the problems in all cases. Underestimation and stereotypes predominate, impeding the understanding of communicative dynamics, so we wondered: What is communication between professionals like? What happens when we consider resilience in professional health personnel?

Problematizing the above, we have three types of vision for the formation of any concept: moral, ethical and emic.

  • Moral vision of the concept is a cold and impersonal vision, it corresponds to laws, rules, manuals, and procedures.
  • Ethical vision of the concept is objective and scientific, it corresponds to the vision of "experts," the conscientious, and those with "training".
  • Emic vision of the concept promotes the vision of the natives. Native is understood beyond the narrow sense of birth, it is they who have a culture and a way of life different from the "expert," and who are located in a certain site, place and time (native is not synonymous with indigenous). From this perspective several questions to get to know the native are: How do they think? How do they perceive and categorize? What are the rules of behavior? What makes sense for them? How do they imagine things? How can things be explained? (Table I).

Table I Qualitative indicator: Communication International Patient Safety Goals2
Moral perspective Ethical perspective Perspective emica
Guide for the implementation of the International Patient Safety Goals of Certificate of Medical Establishment Accreditation

Communication process: Sender-message-receiver

Refers to the human being from a human, cultural, holistic, ethnic, and anthropological perspective.

Adding to this problematization, it is resilience, ie, finding the positive factors that may arise or emerge from negative experiences, which is accompanied by physical and verbal demonstrations of affection, and comes along with various fields such as religion, spirituality, and other phenomena such as recognition for success and skill, opportunities for skill development, cultured attitude, care and love of one’s peers. Now if to emic and resilient communication we add psychological and psychosocial protective factors of individuals such as their religious beliefs, saints worshipped, good-luck tokens, and even union membership, and with these elements we ask: Do health personnel truly explicitly express the concept of communication? And to this problematization we add the accent that according to the lifestyle of each is the potential of receiving "effective" communication.

The emic allows the rescue of qualitative versus quantitative. The creators of policies and programs emphasize the "objective" and forget that the majority of us are "unscientific" and not think in terms of percentages, percentiles or confidence intervals, rather we focus on the fact that a thing might happen or not, for example, that a boss might put an employee in charge of their management files, or decision-making, or look for alternatives to streamline a process, or how to make internal assessments like PRACMED or PRACENF and their respective recognition. We must clarify that it is not against "the objective" and hard data (which, although for most of us it is difficult to understand, we know to be useful), what is needed is to recognize that which is "other," to recognize "the other."

Now if we consider that core staff, operations, those who must communicate effectively, reproduce the forms of directive communication, I think we are in serious trouble, because for them only "paper talks" and the piece of paper, almost always, has the moral vision (regulatory and / or legal) and the ethical vision of the expert, and lacks emic vision.

We need to communicate with another logic, because the prevailing logic is not working properly. Failure to recognize this means wasting human and physical resources. When popular attitudes and understanding of communication diverge from the prediction and explanation of the experts, then it is time to change the policy.

An example of communication policy could be raised in the following case: an authority gives an instruction via weekly videoconference, the manager of the unit reproduces that instruction by internal memo, but at what point is the staff asked how that instruction is perceived?

Another typical example of communication policy: In a regional general hospital, a new director comes in, and along with his team changes the vision, mission and values ​​of the unit; employees find out about this change once they are told to learn it "because we are getting certified" and they need to sign saying they have been informed. How do you expect the group to assume the mission, vision and values ​​of the unit and be guided by them, when they do not know them, they were not collectively decided, and therefore they do not adopt them as their own?

Diffusion is not communication, much less effective communication. If the thinking, feeling, living, reality-building of communities is not known, how can you expect an answer according to the policies proposed, those impersonal standards that do not seek anything other than productivity? Some bosses call it “getting the green light,” but instead of making the effort to get to know it, they preconceive and prejudge it.

For an institutional policy to achieve its objective, one must understand the moral, ethical, and emic context and do the information campaign in these three areas, democratically recognizing alternatives of different possibilities that do not prize, through power, a vision socially recognized as "most valuable" or "true". It is also about recognizing that one can disagree, one can process and evaluate from the standpoint of common sense, as understood from one’s own cultural framework, i.e. also recognizing that there are multiple "common senses".

Given this intricate problem of "effective communication", we must approach the social representation of the concept of communication. The social representation of the concept speaks of the perceived object, of the subjects who perceive it through their senses, culture, and environment of interaction.

Every social representation is a representation of something or someone. Thus, there is no duplicate of the ideal, nor of the subjective part of the object, nor the objective part of the subject, but rather it is the process by which their relationship with the world and with things is established. It is, after all, a product and a process at the same time,4 therefore, communication is a process and a product.

As a process, it has to do with how the events of daily life are learned, and it is influenced by the different forms of socialization to which individuals are exposed (groups, campaigns, media, country, education, etc.); each individual processes all such training and information through their experiences, knowledge, lifestyle, values, interests and relationships with other people, acting as mental and social image, and from there behaviors and attitudes emerge, for which each individual has its own communication concept, determined by the way in which they acquired culture, life pressures, expectations, socialization, mediations that determine concepts, experience and decision-making in the face of facts, either for us or others. Communication, and therefore, the social representation of communication, will be a decisive guidance for the actions of people.

We all conceive of a communication in one way, official discourse tells us one thing, it represents the standard (moral) measurable way, and experts stress "effective communications" (written) (Table II).

Table II Qualitative indicator
Heartfelt communication
Culturally felt
(values, norms, attitudes, practices, beliefs, meanings)

Socially felt
(social norms)

Individually felt
(personal perception)

Medical anthropology and other social sciences show that the emic communication approach transcends the individual. In a world where the state (and its devices of ideological control) have less and less interference with the welfare of its members, in which the monetary interests of transnational corporations are prized over care for the environment and workers’ quality of life, where globalization tries to break all boundaries, including the relationship of health-patient, in favor of health-customer; thus reflecting power relations and their own divisive logic. Reducing the problem of "communication" to the control of the individual, isolated from their environment, is more than utopian and unrealistic.

Understanding the problems of effective communication, grounds a theory and a necessarily qualitative method. As such, it is proposed to explore the vision of the natives, i.e. the employees living in units.

With this signal, we can include those NOT counted, the nobodies Galeano describes in his famous poem.5

We humans generate and use social representations about everything: the good, the bad, the desirable, the acceptable, health, disease, etc. However, one should not believe that representations are the concept itself, rather they include everything that knowledge synthesizes on the concepts.

Social representations of concepts are truly complex, for example the social construction of the concept "communication" should be taken as at least these elements and no one in isolation.


In the field of communications, as in all the social sciences, we cannot venture to draw conclusions, but rather open debates and discussions, so we open ourselves to analyzing the communicative situation in each unit of the IMSS, taking into account the culture of the natives, their context, their understanding, their feelings, their perceptions, their shapes, their concepts, their perceived causalities, etc. Only from understanding the other will we be able to think of effective communication between health professionals.
It is considered that if we give ourselves the task of preparing the three suggested qualitative indicators of communication between health professionals, we would have better elements to tell whether or not there is effective communication, while not ruling out that they can be modified to improve them (Table III).

Table III Qualitative indicators of communication
Forms of communication
Risks of communication
Agents of communication
Design of communication
Perception of communication
Feasibility of communication
Media of communication
Perceived susceptibility
Origin of the communication
Perceived causation of communication

These questions are left for open discussion and debate:

  • What is internal communication in IMSS units like?
  • Is it communication or information? Is it information or indication?
  • Can it be improved?
  • Is it possible to consider otherness for policy making?
  • Is it possible for governing bodies to take the operative into account for policy making?
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  2. Reverete Coma J. Museo de Antropología Médico-Forense, Paleopatología y Criminalística. [Online].; 2007 [cited 2014 Julio 10. Available from
  3. Díaz Murillo MdP. El riesgo en salud: entre la vision del lego y el experto: una perspectiva sociocultural Pública IdS, editor. Bogotá: Universidad Nacional de Colombia; 2002.
  4. Jodelet D. La representación social: fenómenos, concepto y teoría. In Jodelet D. Psicología social II. Barcelona: Paidós; 1988. p. 469-494.
  5. Galeano E. Un poema al día. [Online].; 1940 [cited 2014 Julio 11. Available from -nadies-eduardo-galeano-1940

Conflict of interest statement: The authors have completed and submitted the form translated into Spanish for the declaration of potential conflicts of interest of the International Committee of Medical Journal Editors, and none were reported in relation to this article.

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