Silence

Øystein Figenschou, Harald Jodalen About the authors
Artikkel

Communication is a key tool in the doctor-patient relationship. However, the use of silence as a monumental instrument is rarely mentioned. Why? Silence is not emptiness. Silence plays a key role in the consultation and should receive more attention.

Illustration: Øystein Figenschou

‘Add a new dimension to the communication, and enrich the encounter between the doctor and the patient’ (1).

It important to allow for silence. This will enable the exploration of more aspects of the consultation and improve communication skills considerably. Deliberate use of silence may help improve patient compliance, save time and prevent misunderstandings on the part of both patient and doctor.

Silence has become a scarce resource. Noise is increasing and time is diminishing. Silence is manifest and concrete, and is a very powerful tool if used correctly. To be able to use silence, we need to recognise that it exists and is meaningful. Thereafter, we need to be aware of the processes that it sets in motion. Silence can be used destructively as well as constructively in dialogue. Because silence is such a powerful instrument, musicality and empathy are required for its performance.

A good doctor-patient relationship can be established quickly or gradually. Irrespective of whether this is acknowledged or not, it invariably includes a subject – the doctor, and an object – the patient (2, Ch. 9). This distribution of roles forms the basis of the clinical dialogue. The magic of clinical communication comes about in the encounter with the patient. Giving the patient space in the form of silence means giving the patient recognition.

Time-consuming or time-saving?

Like all acoustic phenomena, silence is played out along a timeline. It is easy to believe that using silence is time-consuming, but it makes more sense to consider this time as an investment, rather than as a cost that cannot be recouped. In the long term, using silence is time-saving. Hunskår’s textbook of general practice medicine highlights a study from 1984, which shows that on average, the doctor interrupts the patient after 18 seconds (3). By letting the patient speak freely, one can arrive sooner at the heart of the matter. Interruptions in an attempt at efficiency may quickly prove counterproductive. Silence is the ultimate open question.

Giving the patient space in the form of silence means giving the patient recognition

The length of a silence is a strong indication of its meaningfulness. A very brief pause can underscore a point, a somewhat longer pause facilitates dialogue, while the longest pauses provide breathing space after communication of a large amount of information. The longer a pause lasts, the more meaningful, and more weighty, it becomes. How long should the silence last? There is no exact blueprint, and it requires intuition and timing. Already after 0.2 seconds, silence signifies that it is the other’s turn to speak (4, 5). Rhetorical silence is achieved after 1–2 seconds, and a silence of 4–5 seconds will often be perceived as an anticipative gesture or a pause for reflection. Silence that lasts for 10–15 seconds is meaningful as a separate element of the conversation, on a par with a statement and with a meaning consistent with how the ground has been prepared and what body language indicates. This kind of silence can be confrontational, calibrating or processing, and all these types of silence have their place as independent meaningful elements.

In our auditory perception we are always dragging a ‘tail’. We listen, process, and plan simultaneously. This is key to our understanding of sentences. In the absence of this ability we would hear only the individual words and lose their connection with the other words. Not unexpectedly, it requires more cerebral processing to plan responses during a chat than during a silence (6).

It is common to react to silence with uncertainty. Silence may indicate danger. In a study that explored brain activity during silence, both in conversation and after a musical chord was played, it was found that silence activates the temporal cortex (7). This indicates that the perception of silence is more than a passive process. Silence creates expectation. By letting an attentive silence prevail, we leave room for the patient to choose the direction. It also gives the doctor time to reflect. Depending on body language, silence may also function as a natural closure. In this case, silence will have a clarifying effect (8).

Silence in clinical communication

Illustration: Øystein Figenschou

Silence is dynamic, since it can grow or shrink. It can be macroscopic or microscopic, insignificant or monumental. Silence arises and silence is created. This is a fundamental feature of silence. Often, the silence that occurs is perceived as a problem, rather than as an opportunity. Used as a tool in the clinical dialogue, it has considerable potential.

By letting the patient speak freely, one can arrive sooner at the heart of the matter

Silence can be intentional and unintentional. Because silence often arises unintentionally, many people feel uncomfortable in situations where silence reigns. When things happen that are out of our control, it is natural to react with confusion and insecurity.

A sensible use of silence presupposes good intentions on the part of the doctor. The doctor controls, provides space and focuses. The intentional silence is of particular interest, because it requires the doctor to actively facilitate or create this silence. Intentional silence also needs to be actively maintained.

Silence is more than a passive process. Silence creates expectation

Unintentional silence requires interpretation and contextual understanding. I will not go into detail about this interpretational situation here, since we will focus on the deliberate, intentional use of silence. We have limited ourselves to three powerful variants of intentional silence, which all require awareness and facilitation on the part of the doctor: calibrating, confrontational and processing silence (1) (Table 1). In addition, silence can be categorised according to its effect (Box 1) (1).

Table 1

Matrix illustrating how intentional and unintentional use of silence can function as a tool in the consultation, based on a resource-oriented and a problem-oriented understanding of the situation.

Resource-oriented understanding

Problem-oriented understanding

Intentional/active use

Calibrating silence
Processing silence

Confrontational silence

Unintentional/passive use

Can be a resource if interpreted flexibly and understood contextually

Uncomfortable silence

Box 1 Potential effects of silence

Destructive silence

Silences with potentially harmful effects on the doctor-patient relationship.

Reckless use, lack of understanding of the situation or wrong body language may have a negative effect.

Silence for gathering and communicating information

Silences that help gather and communicate information.

Silence is facilitatory and helps improve information processing (1, 2).

Silence for processing of emotions

Silences in the context of emotional situations.

Silence permits the doctor to face the patient’s emotional situation without having to enter it.

Silence as an instrument

Use of silence as an instrument to control various aspects of the consultation dialogue.

Silence can accentuate, guide, facilitate and conclude.

Calibrating silence

Each time we meet a patient, we readjust and adapt ourselves. Calibrating silence is a deliberate pause intended to let us tune in to the patient in the situation at hand. The time that passes from the first greeting until we are ready to speak is an example. A small calibration at the start can be positive for establishing both trust and professionalism. During a consultation the doctor and the patient may drift apart, or topics and issues may come up that call for a reorientation. A calibrating silence may also aim to determine where the problem lies.

Confrontational silence

Confrontational silence is a powerful instrument. It is externally directed and aggressive. Its purpose is clearly confrontation, for example a wish for a clarification or enlightenment of an issue. It is not infrequently the patient who resorts to this method. The confrontation can be formulated as a question, with body language or tone of voice indicating that an answer is expected. The doctor can also use confrontational silence. A good example are situations where alcohol abuse and driving are addressed. Here, caution is needed. Firm trust in the relationship is often required to be able to use confrontational silence without causing a conflict.

Processing silence

If we have something important to say, we cannot keep talking endlessly. After giving or receiving information that has a momentous impact, a pause may be especially called for. As a rule, such a pause should last longer than we think, so it should be given a little more time. The greater the impact, the longer the silence should last, simply because such cases take more time to process. Furthermore, momentous messages prompt trains of thought that can take time.

Discussion

It matters little what name we give to a silence. It exists, and it can and should be used actively. The practical use of silence requires an ability to listen. Effective communication takes some experience, and not least musicality in the form of timing and tone of voice. In the clinical context, this can be translated into how something is said and when it is said, comparable to pathos and kairos in rhetoric. When using silence, the question of when is perhaps most important. To get away with using silence, it has to come at the right place and the right time. Taking turns in a conversation is a finely tuned instrument. Even the minutest variations in pauses or overlaps are picked up (4).

If we have something important to say, we cannot keep talking endlessly

How we enter and leave silence is not immaterial. Starting at a low volume and speaking gradually louder has a dramatic effect. This builds up tension, and what follows after such a build-up will have a potentially momentous effect. A silence will appear deafening. Using silence as an instrument requires first and foremost an awareness of when to use it and why.

The use of silence in communication with patients takes some practice. Silence is like any other powerful tool: potentially dangerous when used recklessly – and highly effective when used appropriately. Silence can have a destructive effect on the conversation and the relationship if used without a clear intention, but when applied sensibly and tastefully it can elevate the relationship and the conversation to new heights.

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