The ideal of patient centred medicine remains only partially realised. Within modern Western society, the highly individualistic culture and religious decline linked with medicine's reluctance to relinquish an outmoded form of scientific rationalism can act as reductive influences, stifling conceptual development. Some examples of the recent literature on communication skills in medicine are analysed to discern the underlying philosophy. A rationalist stance invites an examination of the possible nature of rationality. Another example accepts the need to accommodate the emotional and the unconscious. Issues of human suffering with an inherent spiritual dimension seem to remain excluded. The need to move beyond a duality of reason and emotion to embrace the existential and spiritual is suggested as a theoretical prerequisite for developing a more inclusive concept of patient centred medicine, which only then may be realised. Some brief examples are considered of the sort of notions and types of discourse that might effectively inform “teaching” of communication skills.

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