Real dialogue: six conditions, six ground rules, three barriers
Johny Van Aerde, MD, PhD
ARTICLE
Back to Index
Unlike debate and discussion, dialogue does not seek initial agreement, but rather a rich grasp of complex issues for which there is no certainty and no clear agreement, as is the case for many issues related to health systems. Leaders require not only good facilitating skills to guide dialogue successfully, but also the ability to move a group between dialogue and discussion, knowing that the rules and goals of both types of conversation are different.
KEY WORDS: dialogue, discussion, debate, complex issues, leading dialogue
Our society has lost the art of dialogue. For many complex and long-term issues facing our health system, we rely mostly on discussion and debate, rarely engaging in true dialogue.1 Because these are incomplete tools for dealing with problems around social complexity, the solutions we end up with are mostly of limited value. As a result, the same problems keep recurring. Top
This paper addresses the various types of conversation and the advantage of dialogue to address complex issues in the Canadian health care system. It also includes simple guidelines for physician leaders who want to use dialogue. Top
Debate versus dialogue versus discussion
Conversation is the summation of all forms of oral communication. Debate, discussion, and dialogue are three very different types of conversation. The aim of debate is to argue and win, and the word comes from the Latin dis (expressing reversal) and battere (to fight). Its combative style, with winner and loser, has no place in health care.
“Discussion” comes from the Latin word discutere (to squash to pieces), with the same root as concussion and percussion.2,3 Discussion promotes fragmentation, the topic is dissected into parts, different views or facts are presented, analyzed, and defended as one fundamentally wants one’s view to prevail. Through discussion, experts find solutions to problems based on certain evidence, and they find agreement in the context of mechanistic systems thinking. It is a powerful mode of information exchange and tends to force people into an either/or thinking mode. It tries to contain and guide separate parts into a coherent order, and it does not assume an existing or underlying wholeness.2 It is about making a decision on one specific problem or element within a system and produces important and valuable results for the many situations we face. An example of appropriate use of discussion is when various experts get together to plan an integrated treatment approach for a patient with multiple chronic disease problems. Top
According to David Bohm, the great quantum physicist, thought is to a large degree a collective phenomenon: “As with electrons, we must look on thought as a systemic phenomenon arising from how we interact and discourse with one another.”3,4 Dialogue is about exploring possibilities, evolving insight, and reordering our knowledge.2 It is a self-organizing system that evolves based on the principles of complexity. That is why, in dialogue, inclusive “and” statements trump “either/or” expressions. Because “dialogue is a conversation with a center, not sides,”2 it lifts us out of polarization by accessing the combined intelligence of people.
The word “dialogue” comes from the Greek words dia (through) and logos (word or meaning). As participants become observers of their own and others’ thinking through dialogue, they reach new understanding and meaning, forming a completely new basis from which to think and act, and creating context from which many new agreements might originate.3 As a result, entering into true dialogue builds trust, as it is a forum for open and transparent communication.5,6 Top
Dialogue does not seek initial agreement, but rather promotes a rich grasp of complex issues for which there is no certainty and no clear agreement, as is the case in many issues related to health systems. In other words, dialogue is the type of conversation to be used around issues for which there is no clear answer. A successful example of such dialogue can be found in Brazil’s approach to HIV, which was an intractable problem 20 years ago, yet was kept under control much more than in other developing countries.7 Closer to home, examples of issues where real dialogue is needed are obesity in the western world, how to involve the elderly in a healthy community, and the sustainability of the Canadian health care system. Dialogue is not reserved only for large-scale systemic complexity; it is also helpful in addressing smaller complex issues for which there is no straightforward answer. Top
Leaders require not only good facilitating skills to guide dialogue successfully, but also the ability to move a group between dialogue and discussion, knowing that the rules and goals of both types of conversation are different (Table 1). Failing to distinguish between them results in non-productive discussions and a lack of true dialogue.3 Once the wholeness of the dialogue topic has been addressed satisfactorily, specific parts and elements of that topic can then be solved using discussion.
8,952,3,10-14 Top
Six conditions for real dialogue
Six ground rules
At the beginning of a dialogue, a few points can form the basis for agreement.
Three potential barriers to watch out for
(Based on Stoner and Stoner.12)
In short, through dialogue, people learn how to think together, not just in the sense of analyzing a shared problem or creating new pieces of shared knowledge, but in the sense of occupying a collective sensibility in which the thoughts, emotions, and resulting actions belong to all stakeholders. Whether it is used for large or small complex systems, the outcome is often unexpected, innovative, and transformational.
Let’s consider where and when physician leaders can use dialogue as a conversation tool across Canada, not only for the large-scale issues in our health care system, but also for the local, often seemingly intractable questions and problems. Top
References
1.Waddell K, Moat KA, Lavis JN. Addressing health-system sustainability in Ontario: stakeholder dialogue. Hamilton, Ont.: McMaster Health Forum; 2016. Available: https://tinyurl.com/ycruafyw (accessed 12 July 2017).
2.Isaacs W. Dialogue and the art of thinking together. New York: Currency Doubleday; 1999.
3.Senge PM. The fifth discipline: the art and practice of the learning organization. New York: Currency Doubleday; 2006.
4.Bohm D, Edwards M. Changing consciousness: exploring the hidden source of the social, political and environmental crises facing our world. San Francisco: Harper; 1991.
5.Reina ML, Reina DS, Rushton CH. Trust: the foundation for team collaboration and healthy work environments. AACN Adv Crit Care 2007;18(1):103-8.
6.Van Aerde J. Embedding trust in the Canadian healthcare system (editorial). Can J Physician Leadersh 2016;3(2):37-8.
7.Glouberman S, Zimmerman B. Complicated and complex systems: what would successful reform of medicare look like? Discussion paper 8. Ottawa: Commission on the Future of Health Care in Canada; 2002. Available: https://tinyurl.com/bwjmwa9 (accessed 12 July 2017).
8.Dickson G, Tholl B. Bringing leadership to life in health: LEADS in a caring environment. New York: Springer; 2014.
9.Medical leadership competency framework, 3rd ed. Coventry, UK: NHS Institute for Innovation and Improvement; 2010. Available: https://tinyurl.com/ya4zz87u (accessed 8 Aug. 2017).
10.Senge PM, Kleiner A, Roberts C, Ross R, Smith B. The fifth discipline fieldbook: strategies and tools for building a learning organization. New York: Currency Doubleday; 1994.
11.Ellinor L, Gerard G. Dialogue: rediscover the transforming power of conversation. New York: Wiley; 1998.
12.Stoner CR, Stoner JS. Inspired physician leadership. Tampa: American Association for Physician Leadership; 2015.
13.Baldwin C. Calling the circle: the first and future culture. New York: Bantam Books; 1998.
14.Fisher D, Rooke D, Torbert B. Personal and organizational transformations: the true challenge of continual quality improvement. Monmouth, UK: Harthill Group; 2000.
15.Chatham House Rule. London: Royal Institute of International Affairs; 2017. Available: https://tinyurl.com/oqdvs3s (accessed 23 Aug. 2017).
Author
Johny Van Aerde, MD, MA, PhD, FRCPC, is editor-in-chief of the Canadian Journal of Physician Leadership and past-president of the Canadian Society of Physician Leaders.
Correspondence to: johny.vanaerde@gmail.com