How Humans Talk is an SBS Audio podcast produced by Onomato People and SBS Audio. Follow on the SBS Audio App, Apple Podcasts, Spotify, Listnr, or wherever you get your podcasts.
Credits:
Host: Rune Pedersen joined by Stefan Delatovic
Producers: Rune Pedersen at Onomato People, Stefan Delatovic
Writers: Rune Pedersen and Stefan Delatovic
Artwork: Wendy Tang
Post production and sound design: Dom Evans and James Coster at EARSAY
SBS Audio team: Joel Supple, Max Gosford, Bernadette Phương Nam Nguyễn
Guests: Dr.Sarah J. White, Director of Bedside Manners Pty Ltd. + Dr Maria Dahm, Senior Lecturer at Deakin University.
Transcript:
Stefan
How Humans Talk is an SBS podcast recorded on Wurundjeri country. We pay our respects to the custodians of this land, which has been shaped by stories and language and love for generations.
Rune Pedersen
Oh, hey, Stefan, are you? You? All right,
Stefan
I'm a little sick. A little sick, yeah, like standard cold flu symptoms, all right, I'll just keep my distance.
Rune Pedersen
That's a good idea. Do you enjoy a good conversation?
Stefan
You know, I do. Rune,
Rune Pedersen
well, what if I told you that a good conversation could actually save your life?
Stefan
You know, that is the exact kind of stuff that you tend to say, so
go on,
Rune Pedersen
I've been thinking about like, the way healthcare workers talk doctors clinicians. So when you visit the doctor, you're basically having a big conversation about your health.
Stefan
Yeah, I go to the doctor and I need to say suddenly some really personal stuff to someone who is in a quite a position of power over me.
Rune Pedersen
So the way they talk to you, or the way they talk to their colleagues about you, can actually be the difference between you getting the right care. So good communication should be seen as a core part of any kind of treatment.
Stefan
Yeah, yeah, certainly. I mean, I am. And look, this may come as a bit of a hard right turn, but I had testicular cancer, and I remember the doctor sitting me down to tell me, and he just sort of looked me in the soul and said, All right, I'm gonna give you some news, but before I do don't do anything silly. Don't leave your wife, don't quit your job, don't sell everything. You're going to be fine, because in five years, you will have forgotten all about this, because you'll be all better. And he was right,
Rune Pedersen
Yeah. I mean, first of all, yeah, sorry that happened to you. And happy you didn't blow up your life!
Stefan
Yeah, yeah, exactly. And look, it sucked. Would not recommend, but I do like to talk about it, because I hope it sort of cuts through some of the stigma.
Rune Pedersen
Yeah, so the thing I've been thinking about is like, when I, when I go to the to the doctor and I need treatment, I'm not, I'm not just like a body that needs treatment. I just remember from like, when, when our, when our baby boy was born, we're in the hospital like it was a life changing event for us, obviously, right? But for other people, it was just Tuesday.
Stefan
I remember when our daughter was born, there was a young nurse who for an hour stood in the corner just absolutely going to town, clacking on a keyboard, like she would come over and check my partner's blood pressure and stuff. And then she'd go into the corner and wear like and like lighting candles and stuff. Like, let's just keep it calm. Everybody's fine, do your breathing and stuff. And then one meter away, she'd walk over, like, I
Mary Dahm
I once had a a scenario that we recorded with a doctor where there was a stroke patient, and the doctor was meant to assess whether this patient could go back and live on his farm by himself somewhere, and He was really proud of the farm that he lived on. So he tells this doctor all about how he did this massive landscaping and he put in a waterfall and everything. And the doctor is like, yeah, yes. And then instead of saying, Wow, that sounds wonderful, or something like that, I bet you want to go back to live there, she says, and do you smoke at all, this complete disconnect between what you show is happening and what is actually happening, this is often where, where things go awry, and it's again, nothing that they necessarily do intentional they might have seen, yes, this is what you do when you're listening to someone. You show you're listening. You're meant to show that you're listening. Yep, yes, you do you're not but that you also then need to follow it up, is a step that maybe no one ever really explained to them, and that takes another sort of step of awareness to recognize that happening in other people?
Rune Pedersen
Who you just heard speaking is Mary Dahm. Mary is a linguist and lecturer at Deakin medical school, and she knows an awful lot about how to talk nicely and effectively to people. Mary teaches students how to behave ethically and professionally in healthcare.
Mary Dahm
So I've studied how people use medical terms, how they talk in health communication, how they talk across different cultures in health communication, but also how doctors talk to each other or to nurses,
Rune Pedersen
For something we do all the time. Forget to talk about it once in a while in a sort of doctor patient setting, How do humans talk?
Mary Dahm 05:07
I think often they don't talk different than they would in normal life. It just happens that you feel that the parameters outside around all of this are different. So when you think about it, you have different ways of talking depending on what kind of situation you're in. So how you talk to your parents, how you talk to your children, how you talk to your boss, there are all different situations, and depending on that situation, you change how you talk. So that idea comes sort of what, what my linguistic sort of discipline is, in a sense, is called pragmatics, where you look at the unspoken rules of conversation, and that's basically what you have grown up with. So from the first time that your parent would have taken you to a doctor, and the way that they talked to the doctor, or that the doctor talked to them would have socialized him in their ideas of, okay, this is how I need to behave, or what I can say, or how I can talk in this situation. So if you ask, Do we speak differently? Yes, in a sense, but we still use the same types of language that we use in other areas of conversation as well. Like, if you're not polite, like a doctor patient situation would be something where you feel like if the if the patient would be too demanding, if they're don't come across as polite, or not perceived as polite, that would create problems, the same with a doctor, like if a doctor would just come and say What's wrong, or orders you around, sit down, take off your dress or whatever. That that does not gel with the expectations that you have, and it's really interesting and complex, because all these sort of experiences that you have and how you grow up with them and become socialized with them are, first of all, they're unique to you. So if you have lots of experience as a child, like visits to the doctors, your experience would be a lot different than to someone who only occasionally sees a doctor for, I don't know, an ear infection here and there or something, and then layered on that is for both of us, probably very interesting is, how does it work where we grow up? So I grew up in Germany, kind of different than here, I think, bit more formalized even than it's here in Australia. And that also will have a big impact on it. So that's a social slash cultural aspect that also comes into play when you look at how do we actually talk in these interactions, and what makes them feel right in quotation marks, and what makes them feel less so.
Rune Pedersen
That's such an interesting topic in the context of Australia, right? Because we are such a diverse population of people with so many different cultures. How do how do we then go about that in Australia from, maybe we can start from the doctor side, like, how do we the clinician side? Sort of healthcare side? How do we go about it then managing that? Because, you know, in one moment you have someone in who's born here and lived their whole life here, and then the next moment, you might have someone who's been here for a handful of years and hardly speaks any English. How do we? How do we navigate that from a healthcare perspective in terms of communication?
Mary Dahm
It's really, really interesting. So the first starting point from for any clinician probably should be gaging or evaluating what the English proficiency is like, what the health literacy of this person is like. Do you need an interpreter or not, and and oftentimes getting interpreters can also be hard, obviously, but then I think one of the biggest thing, things, and it goes across the board, regardless of you speak a different language or have a different cultural background, is to move away from making assumptions.
Rune Pedersen
How do we manage the diversity of patients in terms of communication? Because, like, it's not a lot of jobs where you have to actually, you know, you have to know your craft, your technical skills, but then you actually also have to engage with such a variety of people in such a short amount of time. So people working in healthcare are exposed to a lot of different people, that a lot of people working their jobs maybe, wouldn't, you know what I mean, because they the only, the only common denominator is that people are needing medical treatment, but that that's everyone, yeah.
Mary Dahm
So really, I think not making assumptions is a really important one. So just because someone looks or talks a certain way, you can't really make assumptions of what they might want or what they might not want. But as this conversation that you have, or a clinician has with a patient evolves, you can find out and probe in between. In whether patients are willing or interested in making their choices, or if they really rather want the doctors to make the choice for them. What's the cultural background behind that? The problem with that is obviously that all clinicians face, and it's not their fault. Is they are under constant time pressures. There's constant resource pressures. So some of these things don't take a lot of time, sort of doing signposting at the start, or little check ins in between. Other things that you can do, sort of to build trust or to sort of practice and encourage questions and things like that, they can take more time, or if you want to provide specific, helpful materials or visual aids or something for someone that doesn't speak English that well, or if you have to organize an interpreter that takes time so that can often be compromised, not by malice, but just By sheer systemic underlying issues,
Rune Pedersen
Are we providing the necessary information and education and time for people working in these fields to upskill them so they can they can focus on communication, or is it sort of falling to the wayside?
Mary Dahm
People often sort of say it's or they assume communication is something that you either can do or can't do, and it's not really a skill to be learned, or if they even consider it as a skill to be learned, it's like on the sidelines, and it's not really important, but it's, it's genuinely at the core of everything that happens in in healthcare, because if you can't communicate well, or if you can't extract sort of what the medical history is or what is of significance, if you can't talk to other clinicians about it, effectively, if you can't talk to your patient about it, effectively, it kind of all falls flat. And in answering the question of, Do they have enough support for it or enough time? No, no, I think there's a lot of people that, if they had less pressures of their normal job, that yes, they have that at the back of their mind, but it might just fall by the wayside for some of them, because they have so much other things to do and take care of that's not to say that some of the things you could do is really are really small and can make a huge impact, like there's studies out there around the impact and the perception that people might have about how much time you spent with them come depending on whether you sit or stand next to the bed. So they actually had a study where post surgically a doctor came in to a patient and they would either sit or stand, and the actual time that they would sit was significantly shorter than the actual time that they would stand. But obviously, what would you guess the patient had the complete opposite perception. So even if the doctor was only sitting with them a minute, they felt they were there for five and if they were standing there for two and a half minutes, they felt they were only there for one so even little things like that can make a difference, like where you stand, do you cross your arms? Do you face them? Do you face a computer? Those are little things that patients pick up on and that are easy, sort of to rectify in in sort of busy clinical practice, and that can make a difference. And really, I think all clinicians that have ever talked about they understand what the importance of of communication is. They just feel really constrained by what the systemic and resource opportunities are.
Mary Dahm
But I think it's important just to make people understand that a lot of the time when there is miscommunication, that it is not necessarily something that happens intentional on either side, either you don't know what the rules are, and then you say something that is either completely inappropriate to the rules, like, I don't know, swearing off the top of your head in in in a medical appointment, or or for international doctors, not knowing that It's fine to actually have a bit of small talk while you, I don't know, walk from the waiting room to your office or something like that, or even at the start that you just sort of comment on weather or traffic or how are the kids or whatever might be important just to Get into it,
Rune Pedersen
Yeah, exchanging those pleasantries, right? Like, yes.
Mary Dahm
And that's sort of one instance of where it really instantly can sort of not build trust, but build a connection, and some depending on how you were socialized, like I said at the start, like, how did you become? How did you come to know? Know these interactions, either as a patient or as a doctor, and importantly, really interestingly, most of doctors would have come to know this as patients, and then change their roles. And as they change their roles, they become sometimes desensitised to some aspects of it.
Rune Pedersen
So when doctors use medical language out of habit or maybe efficiency, how does that land with patients? I'm thinking especially when those words have different meanings in everyday language or across cultures like you, you do find things that are quite familiar or just like used quite loosely, because in English, medical terms and lay usage of those terms overlapped.
Mary Dahm
The first time my son ever had a cold sore, I went to a pharmacy and I wanted to get a cold sore patch, and I did not really have cold sore in my head at all, because we speak German to each other at home. So I basically went into the pharmacy and said, Oh, my son has herpes. And you can imagine how they looked at me, because, yes, obviously my son does not have herpes. He has a cold sore, which technically is the same virus. And if someone in Germany would say herpes, that's what they would think of like, they would think of a cold sore before they would think of herpes. But you can see how that could be problematic, especially if I would have taken him to the doctor, and the doctor would not have explored what I mean with this term. Yeah, and there's other things like that, like German term, angina, for example, is a sore throat here, it's a heart condition. So if you don't explore these things and take them at fair as well, you and that. And that does not just extend to people that don't have English as their first language. But if someone comes with a term and that's not further explored, or if someone tells you a term but doesn't give you a proper explanation of what that actually means, that can create complications, obviously, and there's so much research out there that shows like that complaints and malpractice claims and all of this stuff is much higher for instances where patients feel the doctors were rude or didn't communicate well with them. So you can have something that you have as a doctor developed over years and years, and you have, like your script that you use when you talk about a particular thing, or you have a particular metaphor that you use, and it works well often, but not all the time. I think this is the most important thing, is that clinicians and doctors do not get stuck with the thing that works most of the time, but not all of the time. So there's ideas around explaining things more individualized. So if you have a plumber that comes in, yes, you can use plumbing terminology, and that will be really, really interesting to them, and they will like, oh yeah. That makes all sense now. But if a 16 year old girl comes in, plumbing terminology is not gonna mean anything to her, if I came in and you started using plumbing terminology at me or car terminology, and it's like, well, if I go to my mechanic, I can't understand and they could tell me anything. Why do you now use the same metaphor? This is not helping. So again, this is about sort of the assumptions and finding out who is this person. What does this person maybe do? What's their background, what's they're interested in, and then trying to find metaphors to use to explain things and make medical terms more transparent. Then again, in that way, you can build trust. You can build rapport. You show that you're listening, you show that you're interested in this person. If you use something that's completely offside, chances are patients are going to feel alienated.
Stefan
Oh, good morning, doctor. I was just telling the nurse how well I slept. You know, all things considered. You know, shame about the food here, hospital, hospital. Joke. Seriously, though, sorry, good morning,
Rune Pedersen
Good to hear now. How are you going today?
Stefan
How, how am I? How am I going? Amazing. You mean I'm leaving today. I mean, I never even thought about how I'll be going today. I suppose I could get a taxi
Rune Pedersen
Oh No, no, no, no. I mean, sorry, I meant to ask you, how are you feeling?
Stefan
Oh. Doctor, I mean, yeah, I'm not feeling much of anything. You've you've bandaged both of my hands.
Rune Pedersen
Oh, God, I just are you? All right?
Stefan
All right, all right, Doctor, left handed. You should know that, what are you trying to say? Oh, god, did something happen to my left hand?
Rune Pedersen
Oh, look, look, I'm just going to leave now. I'm gonna go and get my foot out of my mouth.
Stefan
Well, yes, that sounds serious. You should go down that immediately.
Sarah J. White
I'm Sarah White. I'm a conversation analyst. So I record people and analyse their conversations, how they unfold, how people make sense together, the words they choose, what order things go in, things like that.
Rune Pedersen
Dr, Sarah J White is a social scientist. She's the director of bedside manners, where she trains professionals to communicate effectively, and she holds honorary roles at UNSW and Macquarie University, so as a as a conversation analyst, and working with this on a daily basis, but also just being a participating member of society, what is it that you see that that happens often between people when, when things go wrong in conversation?
Sarah J. White
Yeah, so in conversation, there are two kind of driving forces that are sometimes in opposition with each other. So one is inter subjectivity, and that's the idea of, are we on the same page? And then the other side is progressivity, or like conversational flow, keeping the conversation moving. And so what can happen is that we have a bit of a social preference for keeping a conversation moving. So the an example of that is when someone says something to you and it's kind of mumbled, and you're like, sorry, and they repeat it and blah, blah, blah, you might try another time. You're okay, sorry. Can you say that again? And they kind of mumble it again, and you go, like, you do that? Like, weird.
Rune Pedersen
Like, yeah, I'll just kind of laugh. Yeah, I did that yesterday.
Sarah J. White
Yeah, exactly. So we do it all the time because we are trying to keep a conversation moving. We don't want to get, you know, stuck in a moment where we're not understanding each other. And so that can be one of those issues where we have just preferred to keep it moving, but then we've lost that moment of making sense of each other. And that's not necessarily a problem, but it can be a problem, you know, that we're not checking that understanding. You know, particularly, I think, in situations where people might not have the same language background, even different Englishes, because then you can have different meanings for different terms or words. And so someone may understand something as meaning something else when we're going on. So it isn't just those moments where you don't understand someone, it may be also that you don't know that you don't understand someone. And we just, you know, I'm not going to double check that information, because I feel like it makes sense to me, so we'll keep the conversation moving.
Rune Pedersen
So how, instead of sort of moving forward and progressing, is there an opportunity for us to stop and and, or is it just like we can help ourselves and we want to move the conversation forward? Or is it given the cunt? Given the context, that we don't give ourselves time to stop the conversation and start over?
Sarah J. White
I think it would be dependent on how important it is to be on the same page. Is it crucial so we can correct people all the time, so we can correct things that they say it even happens in medical interactions. You do get, you know, clinicians correcting patients misunderstandings in ways that are delicate and sensitive. So looking at telehealth consultations, which I've done some work on, you can see, well here GPS, for example, repeating medication words a lot more than they do in face to face interaction, also repeating days and dates and those kind of things as a check. So if someone says, oh, it started on Wednesday, they might say, okay, Wednesday, you know, as a way of of giving that the person say, the patient an opportunity to correct the record, as it were, but sometimes you do need to have a moment of like, Wait a second. I think we're talking about slightly different things, and it can be awkward to do that. But if it's really vital information, or vital that the that you're on the same page at that moment, then sometimes you just have to do that and be a bit awkward.
Rune Pedersen
We need to be a little bit more awkward. Yeah, be awkward in medical settings. How does structure of conversation influence the quality of care a patient might receive?
Sarah J. White
So things like handover between clinicians and those kind of transitions of care can be problematic, team communication and operating theater, those kind of things, they can all have impacts on the safety and the quality of patient care, particularly if information is missed or misunderstood in a consultation between a patient and a doctor, I. Things can go wrong because information can be missed. So there was this great study out of the US, referred to as the sum any study. So when people are seeing GPS, or in America, family physicians, they often have more than one problem, and that can be an issue for when you're trying to manage a consultation as a clinician, because you get to the end of, you know, discussing the problem they've presented, and then the patient's like, also this thing. So what, what is advised is that a GP says, and near the start of a consultation, the patient's presented their first problem, they say, is there anything else you want to discuss today? What the this study did, and it was a big randomized control trial, using what we understand about conversation, so any is more likely to get a no response than some. So any questions, some questions, what questions do you have? These all have different kinds of answers that are more expected or more expectable. Okay, and so they trained one group of doctors after that first problem to say, Do you have some Do you have something else? And another group to say, Do you have anything else? And they recorded them because they didn't always ask the question, even though they'd been asked to ask the question as they recorded them to check they also asked the patients beforehand, how many concerns do you have today? Right before the consultation, the researchers are asking them this. So for the patients that had multiple concerns, if they are asked, Do you have anything else you want to discuss today? Only 53% of those who had said just before that they had more than one concern, said yes. When the group of patients that had multiple concerns were asked, is there something else you want to discuss today, over 90% said yes, wow. So one little word can make a difference. Now, this isn't, you know, predictive in like, it's not a one to one. Like, if you say this, this this is going to happen, there was still almost 10% of people who still said no, even though they had said that they had multiple concerns beforehand. But the way in which we design our questions, and in clinical settings, it's particularly important, can impact the kinds of answers that we give. In my own experience. I had some emergency surgery a few years ago, and it was late at night, and the anesthetist said to me, do you have any heart problems? And I said, No, and that's not true. So when I'm, you know, under a general anesthetic, he's looking at the monitor and going, what the heck is going on this person's heart? Because it was showing something called ventricular ectopic beats, which I know and but it's not a problem. So he used the word problem, but for me, it's not a problem. It's been investigated. There's no problem with it. And he said any So also, I was in a hugely distressed emotional state as well. So there's lots of things going on. And so sometimes you'll see doctors kind of trying to get around this thing where they say, Do you have any other health problems? Someone might say, No, and they ask a follow up, and they'll say, Is there something you see the doctor about regularly? Or they might say, Do you have any problem heart problems? No. So any arrhythmias, any rhythm issues, any you know, they'll, they'll kind of ask the question again with specific examples to kind of mitigate that risk of something being missed that's critical to to whatever it is that they're, you know, diagnosing, or The treatment they're recommending or the treatment they're administering.
Rune Pedersen
What's the magic that sits in the word some, and what's the difference between any and some?
Sarah J. White
So some is what's called a positive polarity item or marker, and any is a negative polarity. It's just the way in which our language has developed. And we do things like say any questions to save face for the other person. So we don't want people to feel pressured into answering or to, you know, so to to have a response, you know, to think on their feet. So we we use any because we're being nice, right? Yeah, but being nice can sometimes be a problem. So, you know, we can. You can feel put on the spot when you're asked, what questions do you have? But it does open it up more for asking questions.
Rune Pedersen
What's your sort of wish in terms of communication,
I feel like we really haven't improved.
Sarah J. White
There have been some improvements to communication, for sure, but there are still lots and lots of complaints. There's still lots and lots of errors and issues with the safety and quality of healthcare that are related to communication and. Yeah. And while we talk a lot about how communication is important, we're almost not specific enough, in my view, because often it is, you know, if you ask open questions, you know, you'll find out everything you need to know. But that doesn't always work, and so we really need to look at what it is people are really doing. So the kind of work that I do and other colleagues do around analyzing people's conversations and understanding what's really going on, because we're not really great at remembering what we do. So a lot of research on communication, a lot of advice has been based on people's remembering their experiences or imagining what they do. You know, showing the impact of that can be really important. One of the things I did do a few years ago was record someone on their ward rounds, and this, this is a research project, so as well as a training project. So I have, I have published this one, recorded him on ward rounds and then analyzed and found things that he did inconsistently. So one of them was the opening question. So the opening question of, how are you? He was using that as a clinical question to saying, how are you? The patients would hear it as a greeting and say, Fine, ah, yeah, okay. And then he'd move on, wow. So these were post op kind of conversation. So he'd go, fine. Oh, they're fine. So I'll just continue the spiel I've got, or I'll, you know, ask other questions. But so then you hear the patients would start going, Oh, actually, like, I'm in pain. They were trying to get that so I could show him that was happening. And the great thing was that one of the times he said, How are you feeling today? And he got the kind of answer that he wanted to get, because that was a more specific question. It was a question that wasn't interpretable as a greeting. It was, how are you feeling today? So he we then, you know, that's one of the one of the things. And we recorded him a month later, after, you know, I went through, did a one to one training with him, and he had improved. He was actually very consistently saying, How are you feeling today? So sometimes we don't know how we're doing it, and sometimes the feedback we get isn't specific enough. So you might get feedback that is you need to get better at building rapport. Well, what does that actually look like, and what does it look like in this interaction with this person at this moment? Yeah. Where do you learn that as well, right? Yeah. And how do I do it without it being a bit like being disingenuous? I'm going to do my rapport building now. I
Stefan
Rune, I want to give you some specific actionable feedback on communication. Yes. Stefan, those interviews were just what the doctor ordered.
Rune Pedersen
Well, that's very kind, but, but to be honest, this episode has really radicalized me to the importance of communication between doctors and patients, because I see communication everywhere, right? This podcast is how humans talk and when we then look to healthcare, it can actually make the difference between life and death, right? And I know we have brilliant people such as Sarah and married to train staff, but I I know this falls Wayside anyway, right? And communication usually just does. It's seen as a soft skill. It's seen as something, oh, well, you know, you already know how to ride the bicycle, so let's not improve, but we can improve, and in this area, we need to improve. We need to put it on as an agenda and see it as a hard skill. And I think this like goes across the board in every industry, but if there's one industry where it's really, really, really important, this is the one.
Stefan
Yeah, I could not agree more. As someone who works on communications, you often come up against the attitude that communications is a flippant, nice to have, thing that there's the core business in this case, it's saving lives and helping people and curing sickness, and then the way you talk about it is lovely, but whatever, we're not here to have a chat. We're here to save lives. But the thing that you and I very passionately, stridently understand is communication is the way that you share information and the way that you ensure that you are understood, and so without communication, you cannot be understood, and your information dies with you.
Rune Pedersen
We need a system that supports this and support our healthcare workers more in upping. Their skills and putting a bigger emphasis on it, because right now, we don't,
Stefan
And that's the prescription
Rune Pedersen
How Humans Talk is produced and written by Stefan Delatovic and by me RunePedersen from Onomato People. Post Production and Sound Design for the series was done by Dom Evans and James Coster at Earsay. The SBS team is Joel Supple and Max Gosford, and our artwork is by Wendy Tang. Follow and review us wherever you found this podcast.
