In Europe and the USA, expectations for how cancer doctors should communicate with patients are shaped by three linked assumptions: (i) Doctors should respect patients’ autonomy by providing detailed information and choice around treatment options; (ii) they should support patients by engaging in emotional talk; and (iii) they should learn the communication skills to perform these tasks. Patients and settings vary greatly, and general rules will inevitably not apply universally. Nevertheless, there are now clear theoretical and empirical reasons why these assumptions are the wrong starting points for thinking about cancer doctors’ communication with patients. Taking each assumption in turn: (i) Autonomy is a more subtle concept than envisaged in Western ideas of self-determined decisions based on informed choice. More recent ideas of relational autonomy emphasize trusting clinical relationships as the basis of patients’ autonomy. Moreover, research indicates that patients often gain their sense of being involved in decisions from being able to trust doctors. (ii) Emotional support is also more complex than envisaged by the view, originating in psychotherapy, that it requires explicit emotional talk. Attachment theory helps to understand how, when people feel vulnerable, emotional comfort arises from trusting someone who provides a sense of safety. Consistent with this theory, research indicates that patients can feel comforted emotionally by doctors’ demonstrations of conscientious and expert care rather than by their emotional talk. (iii) The concept of communication skills is too limited to explain ‘skilled communication’. That arises when doctors judiciously use their skills, based on their understanding of clinical relationships in general and their unique knowledge of what they and the patient bring to a specific relationship. In many instances, the quality of a doctor’s judgment about how to communicate with a patient at a specific moment will be opaque to an observer, who would lack the doctor’s clinical knowledge of the case and personal knowledge of the relationship. Therefore, recognizing the importance of doctors’ judgments in communication means setting aside the emphasis on communication rules in western clinical communication education and guidance. Doctors communicate well if they are equipped to make good judgements about what each patient needs, not if they follow pre-established rules.

The challenge for communication researchers and educators is therefore to develop ways to ensure that doctors make good judgments about communication. While there will be a place for adherence to some rules, there will need to be more attention to doctors’ character, knowledge and motives, and their ability to reflect on themselves and on their clinical relationships. The literature already contains some pointers to how communication teaching might be approached from this perspective.