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
To explore large systemic questions around the purpose of the Canadian health care system, how we incorporate socioeconomic components of health into our system, or how we rejuvenate the Canada Health Act to serve our needs in 2020, dialogue is a more appropriate conversation tool. Physician leaders might also consider dialogue to explore complex questions related to their profession, questions without a straightforward answer. For example, how have our working conditions affected trust building and patient care service? Given the differences in scope of practice between physicians and nurse practitioners, how might we approach service delivery as a team? Given the funding model for primary care setups, how can we deliver team-based care for patients and also remunerate everyone fairly and equitably?
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.5,6Top
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.
Dialogue and deep listening are part of effective communication, one of the important capabilities needed by leaders to lead change8,9 and build trust.5 How can a physician leader facilitate true dialogue? Here are six basic conditions that must be fulfilled before initiating the dialogue, six ground rules to follow during the dialogue, and three barriers to watch out for as they could derail the purpose of the dialogue. They are a synthesis of various publications on the topic of dialogue, integrated with personal experience and practice.2,3,10-14 Top
Six conditions for real dialogue
Ensure that all the elements of the system you want to change are in the room. Unless all stakeholders are part of the same dialogue, the system will not change.3 Similarly, all parties must have equal opportunity to add meaning and content to the dialogue.12
Create a safe environment and encourage participants to raise the most difficult issues as needed.13 A safe environment helps build relationships and trust and is created partly by agreeing on and respecting the ground rules (see ground rules below). In the presence of distrust and toxicity, dialogue on their causes and on trust rebuilding must occur before the topic at hand can be addressed.5,6 Various tools for conflict resolution and reconciliation might be necessary, but are not part of this paper.
Enforce the ground rules by reminding people to suspend their assumptions and inquire into others’ assumptions during the dialogue.11 This also contributes to building safety and trust.
See others as colleagues in the quest for mutual insight and clarity.12 Having courage and establishing positive tones are critical to overcome the vulnerability inherent to true dialogue.
Appoint a leader or “facilitator,” who has the skills to create the container within which dialogue can evolve and to differentiate between discussion and dialogue.10
Set aside sufficient time for the dialogue, and allow space for silence and reflection. Selective silence can be a powerful form of engaged listening. Listening is not the same as waiting to talk. We can offer nonverbal cues showing interest and focus without jumping in with an immediate response. If the group has no previous experience with dialogue, people are likely to interrupt each other. The use of a talking stick or rock may help initially, where the holder is allowed to speak or be silent while everyone else listens.13Top
Six ground rules
At the beginning of a dialogue, a few points can form the basis for agreement.
We are open to and curious about others’ perspectives and willing to change our thinking. Be fascinated by what others say; have an open mind willing to explore the possibilities. Dialogue is a process that can help us realize more of our human potential by learning how to embrace the qualities of cooperation and balance them with our natural urge to compete.
We are respectful and supportive; we suspend judgement and preconceived beliefs. Suspension of judgement is about developing the ability to observe our own and others’ views from a neutral position. Our judging process occurs subconsciously, very quickly — faster than our conscious decisions. It is based on our upbringing, previous experiences, beliefs, and values. Although those automatic judgements will still come up during the dialogue, establishing this ground rule helps us choose not to act on them in a reflex mode.
We share the reasons behind our questions and statements (advocacy). The two most important parts of dialogue are advocacy and inquiry, which have to be balanced skillfully.14 Advocacy refers to explicitly asserting an opinion, perception, feeling, or proposal for action. As people cannot read someone else’s mind or know the assumptions behind a statement or a question, it is important that speakers make their thinking process visible. This contributes to the building of safety, relationships, and trust. Example statements: “The reason I say (or ask) this…,” “I came to this conclusion because…,” “My assumption is…,” or “The story I told myself is…” Such clarification helps people understand how and why we said what we said. One could add, “Do you see it differently?” or “What can you add?” to elicit a response to such statements.
We listen to understand and inquire into others’ perspectives. Listening to understand is difficult; even if we don’t interrupt, we are often just waiting to talk. Skillful inquiry is as important as advocacy. It explores the assumptions and thinking underlying others’ statements. Examples of exploratory questions include, “What causes you to say that?” or “What led you to that conclusion?” Be careful to use non-aggressive language and say, “Can you help me understand your thinking?” or “Can you give me an example?” rather than, “What do you mean?” or “Where is the evidence?” If you are uncertain or unclear, paraphrase by saying, “Am I correct that you are saying…?”, or “Did I understand you correctly when I say…?”
What we say here, stays here (Chatham House Rule15). Participants are free to use the information from the meeting, but neither identity nor affiliation of the speaker or other participant may be revealed.
Anything else we want to add to make this a safe and successful dialogue? Offer people the chance to clarify the ground rules and add to or change the dialogue agreement. Top
Three potential barriers to watch out for
(Based on Stoner and Stoner.12)
Groupthink is common and occurs in groups when members’ quest for unanimity overrides their motivation to realistically appraise alternative courses of thinking or action. When groupthink occurs, leadership is paramount in encouraging dissenting views and unleashing the devil’s advocate. Be acutely aware of individual or group tactics to squelch dissenting views. Sincerity and authenticity on the part of the leader are important here.
Commitment bias happens when people enter a dialogue with preconceived beliefs and assumptions. The leader will respect offbeat perspectives and ensure that they receive a fair hearing and consideration. This is where good inquiry skills come in handy.
Power bias might occur because some individuals are accorded a higher status than others in the dialogue, because of their knowledge, reputation, or position. In cross-disciplinary teams, by virtue of their specialized expertise and social status, some participants often carry differential power. It is the leader’s responsibility to minimize the coercive nature of these power differentials by reinforcing the ground rules.
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
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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).
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.