Unheard: The medical practice of silencing – by Dr Rageshri Dhairyawan

A new book from the highly respected HIV consultant Dr Rageshri Dhairyawan is a fresh and careful review of how people accessing care are still marginalised and how this leads to poorer clinical outcomes. This is at least partly because medical training is still suspicious of listening to first-hand experience and needs.

This book is compelling reading, compressing individual experiences and social history, with advice for further reading and practical suggestions to improve care, whether you are an excellent doctor (who is sure that negative feedback must mistakenly be about someone else) or are already keenly aware of the inequity in care and want to change this in the future.

The book connects Serena Williams, Tyrone Airey, Winnie Sseruma and Angelina Namiba – all people you should know. It includes dozens of examples of how well-meaning health workers miss the simple importance of learning to listen. This is often because medical training elevates doctors to be experts in a hierarchy that can be difficult for patients to challenge. The same education often fails to highlight how health workers own prejudices undermine their roles as gatekeepers to treatment.

The book was initially a response to the denial of appropriate treatment that Dr Rageshri faced when trying to access health services as a patient, which, despite her medical background as a leading senior doctor at a large London hospital, was only overcome with advocacy support. The experience brought a different perspective on inequalities of NHS care.

The book looks in detail at health inequity based on social distinctions including age, sex, gender, sexuality, class and ethnicity. Current inequalities are rooted in historical inequalities. It critically challenges well-intentioned suggestions that people “should just speak up about poor care”. These are actually disconnected from the reality of trying to challenge a doctor who feels threatened by questions – and whose position as a gatekeeper can negatively impact on our care.

This power imbalance is neither rational nor equal and doesn’t necessarily lead to better care.

Instead, listening and listening better is highlighted as an important basis to improve healthcare.

The opening chapter on management of sickle cell disease in the UK is particularly moving as numerous recent cases have detailed how suboptimal and inappropriate care lead to unnecessary deaths, filtered through racist assumptions about young Black men.

Although mainly focussed on UK healthcare it also covers global inequity based on similar colonial and racist histories and includes a chapter on the impact of approaches to HIV activism in the UK.

An audiobook read by the author is also available, so even if your busy life restricts your reading, there are no excuses to bypass its energy and wisdom.

As disclosure, advocates at i-Base are included in the chapter on HIV activism.