There is evidence that effective communication practices lead to higher quality patient outcomes, such as greater satisfaction, greater understanding and recall, lower costs of care, better compliance with prevention and treatment protocols, and even better treatment outcomes (1, 2, 3, 4).Communication is clearly important.
But why does communication sometimes fail? In this article, I aim to cast light on the foundations of the problem, identifying ways to avoid communicative pitfalls with patients by outlining three false assumptions:
- Language is precise and objective.
- Patients will interpret your words as you would.
- The “inferential distance” between dentists and patients is short.
The slipperiness of language
In the late 1960s, Jacques Derrida, a French philosopher, argued that language does not accurately map onto the world it seeks to describe. Using ideas from Ferdinand de Saussure’s linguistic theory, Derrida tried to show that a word, or “sign,” does not inherently mean what it refers to. The word “sun” does not inherently mean the bright yellow thing in the sky, in a direct correspondence. Not only is the sign itself arbitrary, but once we’ve learned a large portion of a language, its meaning is tied up with a whole system of other signs and associations, such as “light,” “star,” “sky,” etc.
Once we recognize that we speak in a language, we can see that the sign, in some sense, floats free of its object, suggesting other words and emotions and associations that the hearer brings to bear on it. The meaning of a word, Derrida says, depends on how it relates to other words, and so part of that meaning is “absent”when we use it. Every word calls to other related words and contains a “trace” of other meanings that are associated with it.
Importantly, this means that our language is not entirely in our power. The moment it leaves our mouths, its reception is subject to interpretations that are impossible for us to control. Sure, we can be more or less specific and accurate with our language, but on a certain level, what we say does not have its origin in what is intended by us, because much of its meaning is in the subjective reception of what we say (5).
This might be great when writing poetry, but potentially harmful in health care. We know what we mean by our words, so we might expect our patients to know it, too, giving us an “illusion of transparency” whereby we assume that our meaning is as clear to others as it is to ourselves (6, 7, 8).
When speaking with patients or teammates, we should be conscious of the slippery, generative nature of language. We may be forced to contour our meaning to the patient and lasso our language with loops of explanation to control the errant associations that try to insert an otherwise unrelated message. Understanding this slipperiness can allow us to prevent the problem.
Horizons of understanding
If the meanings of the words we use are informed by the meanings of associated words, then can’t we just be more aware of the associations our words carry? Well, yes … but actually no. The problem is that everybody has a different interpretation of words, concepts and situations, based on our own experiences, biases and mental models of the world.
In the 18thcentury, philosopher Immanuel Kant proposed that our perception of the world is molded by the constraints of our cognitive hardware. In his view, our experience of the world is largely a product of our mind, instead of being an objective reflection of reality (9).In recent years, a significant amount of neuroscience and computing research has served to strengthen this idea, known as representationalism (10, 11, 12).
Hans-Georg Gadamer, another German philosopher, applied this concept to communication. According to Gadamer, all information is mediated by what he calls our “horizon” of understanding — that is, by the historical conditions of our culture, upbringing, and beliefs (13).Each of us has our own horizon of understanding that uniquely influences our perceptions. When we engage in communication with others, our horizon begins to overlap with theirs, and a common horizon emerges (14).
This contact between different horizons, Gamader says, is what makes communication possible, but at the same time, it is what confounds it. For example, in our everyday interactions, we often assume that others, if they were just given the same set of information, would interpret things as we would. In psychology, this is known as “self-anchoring,” where we model other minds as though they were just slightly modified versions of our own (15, 16, 17).
In dentistry, this can be particularly damaging, since we will often encounter patients from all walks of life, and it is important they understand us. It is imperative we are aware of the extent of our own horizon and to assume that the horizons of others may be different from ours. We must broach any topic with delicacy, respect and understanding since we do not know the intricacies of their personal situations, nor how their beliefs will sift and filter meanings from our words. This will enable us to minimize unnecessary miscommunication and prevent any degradation of our image as honest and respectful health care providers. To maximize beneficial results, then, we must contour our meaning to the mind of the patient, rather than to our own.
Dentists must first learn basic sciences, dental anatomy and material science before they could ever hope to perform a restorative treatment. Our patients likely do not understand biochemistry, anatomy, material science or informatics, yet we will have to explain these to them — and in a short time, no less. What’s more, many of them will come to us with preconceived notions about many of these topics, having read about them from internet sources.
This gap in background knowledge between dentists and patients is the idea of “inferential distance” (18).It represents how many steps we would need to discuss before we could get to the actual matter at hand. Due to self-anchoring, we find it difficult to step outside our own minds, leading us to expect short inferential distances during communication (19, 20, 21, 22). Thus, when we try to explain something, we end up not going deep enough. Patients may appear to understand our conclusions, but they may be unaware of the whole logical pathway we took to get there, and so remain skeptical of the whole affair.
Our job will be to educate our patients and explain things as simply as possible, starting from premises they already accept. To be successful in this, we should (a) expect long inferential distances, (b) try to be as clear and simple as possible, and (c) lay out a logical pathway, without skipping steps, starting from what the patient already knows or accepts. Because if you do not go back far enough, you might as well be talking to yourself.
‘Err rather in opening than in keeping closed’—Dante Alighieri
With these three assumptions outlined above, we can see how easy it is to be misunderstood. My aim is that these assumptions underscore the importance of focusing our personal efforts to improve our communication abilities and encourage you to take a more expansive, nuanced view of communicating — one defined by humility, compassion and expected misunderstanding. There are plenty of routes to miscommunication, but at least we may be able to avoid these more prominent ones. If we keep this in mind, even when we think it may not be the case, it may save us — and our patients — some future pain.
~Geoff Pippin, Tennessee ’23
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- Melchert, Norman (2011). “Deconstruction: Jacques Derrida.” The Great Conversation: A Historical Introduction to Philosophy. Oxford University Press. 703.
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- Yudkowsky, Eliezer (2007). “Illusion of Transparency: Why No One Understands You.” LessWrong. Retrieved 06/19/2020.
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- Palmer, Richard (1969). Hermeneutics: Interpretation Theory in Schleiermacher, Dilthey, Heidegger, and Gadamer. Northwestern University Press. 209.
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