Comprehensible and effective language
What does the following sentences
mean to you? "Very thorough analysis has been able to show that very few
alternatives are available. These can be reduced however to three essential
options: 1. a readiness to accept statements and reports, the contents
of which cannot be convincingly proven to be true, 2. an attitude which
is characterized by a tendency to regard events from a positive vantage
point, and finally by 3. the ability for intense emotional involvement.
It is the last which dominates the other two possibilities.
|If the language is not
in tune, what is said is
|not what is
Did you understand? Probably
not. It can be expressed in language that everybody can understand: "In
a word, there are three things which last for ever: faith, hope and love;
but the greatest of them all is love." (1. Cor. 13 v. 13). This formulation
contains all of the elements of speech, which serve to make it understandable,
since this language is:
||and the words are in common
The Bible, especially the
New Testaments, is an excellent teaching text for clear, comprehensible
and convincing language.
Intelligibility is a prerequisite
for successful discussions between doctor and patient. The doctor thinks
and lives and moves in his own language which is for him, the expression
of his "reality". However this contains the source of multiple interference's
ranging from simple misunderstandings to complete incomprehension on both
parts. This problem is made worse as the doctor often believes that he
has been understood. It can be totally astounding to later hear critical
remarks from the patient, such as: "The doctor didn't talk to me about
that...", "I really didn't understand what the doctor wanted ...". One
of the best questions to check why discussions later turn out to have been
"unsatisfactory", is: "Did I use language that my patient could start to
is as much a question of content as of style of speech. Schulz von Thun
described 4 properties of intelligible speech:
||Smooth and ordered
||Brief and precise
What do each of these imply?
Simple speech uses short
sentences and common words. If technical terms are unavoidable,
they should be explained. Descriptive speech raises the level of
intelligibility. A doctor who talks to his patient like a "normal person"
will be better understood, and be able to motivate the patient better than
one who uses "scholarly" speech.
It is just as difficult to
speak simply as to write simply. In fact repetitious lectures or "double
dutch" fall easily from the lips. However this style is full of pitfalls.
It is likely to maintain an undefined distance from the other, and prevent
real involvement in discussion. It is only unequivocal facts that
can be expressed in simple language. Long-winded speech is often an indication
of vague thinking. Simplicity does not only increase intelligibility, it
also seems genuine, and creates trust.
Smooth and ordered:
These requirements are fulfilled
by language which is transparent from the outside and intrinsically
consequential. Ludwig Reiners said: "A person can not express two thoughts
at the same time: this means that he has to put them one after the other."
What Schopenhauer described about writing also applies to speaking: "Very
few people write in the way that an architect builds, in that he first
makes a plan having considered all of the details. Most write as though
they were playing dominoes."
"Associative speech" is a
typical example. The flow of speech does not depend on thoughts which have
been put together in order, but from coincidences that arise as the person
is talking. Almost everybody tends to use associative speech, which is
certainly not a rare method of speech. Associative speech leads to long-winded
explanations, which rapidly result in the other person losing interest.
Brief and precise:
This brevity applies to language
as well as factual content. Most people have difficulty in expressing
themselves briefly, and it can usually only be attained with practice and
discipline. Even Goethe wrote to his 18-year old sister: "As I haven't
the time to write you a short letter, I am writing you a long one ..."
The telegram is the briefest
form of language, and the aphorism is the extreme of factual brevity. Neither
of these are of course suitable for discussion between patient and doctor.
The style of the telegram has an impersonal effect, and misses the contactive
function of speech. Aphorism can also lead to strain created by concentration
on understanding so much that has been expressed so briefly.
Brevity also means that not
too many sentences should follow one after another. Studies have shown
that an untrained listener is unable to easily recall the contents of a
series of sentences which last more than 40 seconds. Brevity also means
giving much information with few words, as well as not too many
pieces of information one after the other.
The guideline has to
Use sentences with a length and information content appropriate
to the extent to which the patient can take it in and assimilate it.
Brevity should also not be
won at the cost of minimizing contact and self-revelation. Although the
telegram contains highly concentrated information, it is not ideal from
the point of view of information theory.
Elements of a communication
which could theoretically be left out as they contain no additional information,
might appear redundant at first glance. They are however necessary
to support and complement the basic information. Since at least two thirds
of what is said only once is forgotten, a certain amount of "redundancies"
are unavoidable when talking.
Pictures and metaphors in
speech are important supports for the lucidity of what is said. They are
a vital rhetorical stimulus and, as it were, the salt in the soup of information.
Goethe said: "Don't keep metaphors from me or I won't be able to explain".
Most people are "visual". Our
speech is full of pictures, even if we are not always consciously aware
of them: "He jumped at the chance", "She stole a glance at him."
Speaking in pictures and
metaphors is an effective method to make oneself better understood by "plasticity".
Medical language is full of abstract terms, and here in particular, the
use of pictures and metaphors can lead to better comprehension.
The New Testament (and in
German, the Luther translation in particular) is a mine of effective metaphors
and illustrations. The parable of the lost sheep could hardly be better
expressed more pragmatically than in Matthew 18 v. 12: "And what do you
think? Suppose a man has a hundred sheep. If one of them strays, does he
not leave the other ninety-nine on the hill-side and go in search of the
one who strayed?"
This text is also a good
example to show that a statement clothed in a question is a very effective
tool to convince. The New Testament says that Jesus "... only spoke to
them with parables." It had already been said of Him in Psalm 78 v. 2:
"I will open my mouth in parables, I will utter hidden things, things from
of old ..."
There are limits to the extent
to which one can learn to use pictures and metaphors. There are however
two possibilities which one can use in order to make one's style of language
more vivid for the patient.
check whether abstract terms could be better explained by a picture
or metaphor from daily speech.
of the pictures you use have proven to be the most effective, and
use them more often in discussions with patients.
Here is an example from routine
It is particularly difficult
to convince patients with illnesses unaccompanied by symptoms that they
should be treated. The most common counter-arguments are: "I don't feel
anything ...". "Everything has been alright so far ...". In these cases,
I argue with the following comparison: "What you say reminds me of a man
who fell from the roof of a block of flats, and called out to those in
the first floor: 'I really don't know why men are afraid of falling. Everything
has been great so far!'"
Metaphors as well as examples,
comparisons and the sparing use of quotations, sketches, demonstration
material or cartoons can be further stimuli to increase understanding.
They assist discussion, but should not replace it, and always need explanation.
Doctors themselves probably don't encourage their patients enough
to make themselves better understood by the use of a sketch or drawing.
One patient with severe angina pectoris could best describe the pain, which
mainly occurred in the back, by means of a sketch (figure).
The highly symbolic content
of pictures drawn by patients with cancer often allows very real
insight into their condition. Patients with tumors frequently have great
difficulty in finding their real attitude to their illness and in verbalizing
their perception and understanding of it.
Simple pictures and drawings,
even though no great works of art, sometimes allow a staggering insight
into the world of feelings and experience of the patient, who does not
know how to begin to express them in words.
The style of speech
Speaking style must take account
of the patient as an individual along with his age, sex, education, job,
social status, role, and cultural group. The actual medical situation has
a specific implication.
Observation of the style
of speech of the patient is of relevance for mutual understanding and
for comprehending his world and the effect on him of the society in which
he moves. Wilhelm von Humboldt remarked many years ago that differences
in styles of speech did not only depend on learning, talents or intellectual
ability, but also on the totality of the person.
The same words can have completely
different meaning depending on the age of the person, as in young people's
Turns of speech which are
typical for certain groups (and therefore acceptable there) have no place
in conversations between doctors and patients. As modern medicine becomes
more technical, technical terms have tended to appear in medicine such
as "change batteries", "hook you up for a quick infusion" etc.
A further extreme of this
is the excessive "psychologization" of speech, so that for example "goal-orientated
communication with erotic components and tendencies to emotional fixation"
is used instead of "to flirt".
The social reality of certain
groups of people determines the style of speech or code. Code means
a predetermined way and attitude as to how one of the group expresses himself.
Codes are therefore "Sociolect". There are said to be 2 codes:
code = EC
As regards speech behaviour,
EC and RC have the following differences:
language in EC is less stereotypic in its effect, and the way of expression
is more differentiated;
||It is easier
to express individual points of view and judgements in EC
||Logical and factual
relationships can be expressed more easily in EC
||Superiority and inferiority
can be more explicit.
The various language patterns
can (at least statistically) be classified according to certain social
is more associated with conventional, status-orientated rather than person-orientated
||RC tends to maintain
an acquired opinion through thick and thin.
||RC tends to be
characterized by anxiety rather than guilt.
||RC has a tendency to be
conservative rather than radical.
It has been estimated that
90% of the adults in West Germany use an elaborated code. That does not
mean that the remaining 10% should be "down-graded" as using restricted
code. Neither is superior as regards style of speech. Intelligence and
affect can be developed equally in one as in the other. However somebody
who uses an elaborated code, usually soon learns to use a restricted code
as well, whereas the reverse practically never occurs. There is one style
of speech used by many politicians, that the doctor should avoid at all
costs. This is the blathering and long-winded formulation of zero or minimal
information, which leaves the patient with the impression that he can never
get a straight answer.
Geisler: Doctor and patient - a partnership through dialogue
Pharma Verlag Frankfurt/Germany, 1991
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