[ Words: Sasha Scambler and Christina Lovey ]

The way in which dentists communicate with their patients is fundamental to the delivery of care, patient adherence, positive clinical outcomes and to the notion of person-centred care (PCC) (Scambler & Asimakopoulou 2014).  In line with General Dental Council guidelines (2011), the provision of person-centred care has become central to the undergraduate dental curriculum and to dental practice more widely.  Research suggests that the power dynamic that exists when a patient enters the dental surgery means that, for some patients, they are unlikely to be enabled to participate fully in a patient-centred consultation and to engage in shared decision making (Scambler et al. 2014; Asimakopoulou et al. 2014).  One of the challenges that researchers and academics face when teaching the next generation of dentists is to demonstrate how the power inequalities within the dentist/patient relationship can be reflected and reinforced through particular speech patterns and vocabulary.  This is essential if students (and practising dentists) are to become more aware of how they might adapt their speech to make the dynamic between the patient and dentist more equal and balanced.

There has been limited research undertaken into person-centred communication within a dental setting (Newton and Brenneman 1999) although communication in healthcare settings more widely has received significant attention.  Psychologists suggest that it is not just what is said but the way that it is said that is important, termed paralinguistic communication.  Asimakopoulou and Newton (2016) suggest that “Gestures, posture, pitch, eye contact or lack of it, proximity, facial expression and the like” can all help people interpret what is being communicated.  Current methods for looking at communication in clinical settings focus on verbal and non-verbal communication but little attention paid to paralinguistic aspects of communication.  There has been no work undertaken, to date, on the speech dynamics that exist between the dentist and their patients. 

With this in mind, the aim of our project was to develop a methodology or process that would enable the visual and audio re-presentation of speech patterns and rhythms present in dental interactions.  The theory of communicative musicality provided a starting point to explore rhythm and pitch in dental consultations. 

Communicative Musicality

Communicative musicality is the theory that human interaction is intrinsically musical in nature.  The term was developed through research on mother/infant communication to describe the way in which emotions are communicated through a series of rhythmic exchanges (Malloch, S. 1999)   Acoustic analysis on the vocalisations of mothers/baby dyads in this study showed noticeable patterns of timing, pulse, voice, timbre and narrative.  This follows many of the rules of musical performance and led to the term communicative musicality.  The theory of communicative musicality has been used to look at the impact of rhythmic exchanges on hospitalised infants through the use of live music therapy (Malloch et al. 2012).  The study found that infants who received music therapy were less irritable and cried less when interacting with adults.  Using a similar methodology, a study by Robb (1999) also found that depression changed the rhythm and pitch of communications between a mother and her infant with postnatal depression resulting in vocalisations that were lower-pitched and quieter with longer pauses between sounds.  This illustrates the potential importance of pitch and rhythm in communication in clinical settings. 

Method

This proof of concept study drew on an analytical mixed-method approach to compare traditional thematic analysis of qualitative interviews with dentists to a paralingual analysis of the rhythms and pitch of the speech.  Five dentists working in Special Care dentistry and/or with anxious patients in primary and secondary care settings were interviewed by an experienced qualitative researcher.  The dentists were asked about whether patients could be classified as ‘easy’ or ‘challenging’ to work with and what makes a patient ‘easy’ or ‘challenging’. This notion drew on research regarding patient/clinician interactions and good/bad patients (Jeffrey 1979; Kelly and May 1982) and was picked to provide the potential for positive and negative speech within the interviews.  The recordings of dentists talking about their work the content of the speech were then analysed separately and independently in two ways.  A thematic analysis of the recording was undertaken using a framework developed around the hierarchy of PCC in dentistry model (Scambler et al. 2014).  Concurrently a rhythmic analysis was undertaken to map key dynamic distinctions such as power, authority and empathy and the rhythmic patterns within the speech.  The first analysis focus on the language used and the second focused on the rhythms rather than the words.   

Thematic Analysis

Each interview was coded using a framework derived from the ‘hierarchy of PCC in dentistry’ model.  This model incorporates different styles and contents of communication in a dental consultation.  The foundational components of the model are: context, a holistic approach, the ethos of the relationship and shared responsibility.  The provision of information, choice and control then build from these foundations (Scambler et al; 2014).  Each interview was mapped to the model.  Narrative accounts of each interview were also created and, along with the coding and mapping, this enabled us to rank the 5 interviews in relation to their level of person-centredness.       

Each of the narratives is summarised below followed by the ranking. 

Participant	Narrative summary
One	Focused on patients’ expectations and demands. The relationship was the focus and context was only mentioned in relation to the location of care. Information was mentioned.
Two	Focused on understanding the wider context and a holistic approach. All four foundational components were mentioned along with information.
Three	Focused on the need to build a relationship with the patient. Personal responsibility was emphasised in all cases and context and holistic care were not mentioned.
Four	Focused on the ease of interaction and the willingness of patients to comply with treatment.  The relationship was the main focus, but context was considered to some extent.
Five	Focused on the expertise of the dentist. The focus was almost solely on the relationship from the perspective of the dentist.

From this analysis the participants were ranked as follows from 1 (most) to 5 (least) person-centred:

1. Two (most person-centred)
2. Four
3. One
4. Three
5. Five (least person-centred)

Concurrently with this, a rhythmic analysis was also being undertaken. 

Rhythmic analysis

For this analysis, the interview recordings were mapped to determine distinctions, differences and speech qualities. The purpose of this was to see whether the specific dynamics of speech can be heard rhythmically.  Once the interviews were recorded, the rhythmic patterns within the speech patterns could be considered in isolation, regardless of the language content of the interviews. To facilitate this the interviews were sped up by 35% so that the patterns, rhythm and pitch could be easily heard. The central section of each interview was selected as it had the least amount of peaks and troughs hence giving a more comprehensive perspective of the speech patterns.

Initially, a visual image of sound waves for each interview was created.  This gave an insight into the variation of each speech pattern.  Within these images, the pitch and tone are clearly displayed and the density of the patterns reveal the rhythm and the way in which this fluctuated throughout the sections selected.

Dance theorist Gabrielle Roth’s 5rhythms (1998) were combined with the five elements of Chinese philosophy (Flowing/Water, Staccato/Wood, Chaos/Fire, Lyrical/Earth, Stillness/Metal) and were used to map the interviews.  Each element was further divided into Yin and Yang, which stand respectively for the matriarchal, nurturing and patient-led model of health care and the patriarchal, authoritative and bio-medical led model.

Keywords have been used for each element and each quality.

Element	Rhythm	Yin	Yang
Flowing	Water	Sensitive, Compassionate, Flexible, Intuitive	Passive, Fearful, Malleable, Manipulative
Staccato	Wood	Ethical, Committed, Appreciate limits, Compassionate, Team player	Hard work is good for you, Overwhelmed, Dependent on others, Irritability, Anger
Chaos	Fire	Confident, Forms strong bonds, Joyful	Hypersensitive, Impatient, Restless, Competitive, Needs to learn compassion
Lyrical	Earth	Patient, Reliable, Intuitive, Empathetic, Idealistic, Respected	Stubborn, Questions instincts, Controlling, Lack of self-esteem
Still	Metal	Tenacious, Self-reliant, Confident, Problem solver, Inner strength	Forceful, Unreasonable, Likes power, Demanding, Holding on

The dynamics within each interview were also considered. In order to make this explicit, a set of notation was drawn up, using five stanzas to categorise and mark where the speech patterns were distinctive and exceptional. By careful listening, it was possible to mark the distinctions within each speech pattern and to respond accordingly. This mapping process was undertaken three times, in order to triangulate the results and see whether the process was effective. The response consisted of coding the dynamics, using the elements, and additionally categorising them as Yin or Yang: masculine or feminine.

The five stanza notations are presented above. Here the words used are mapped to the notation and the two analyses come together. When listening to the interviews, it was evident that the rhythmic patterns changed according to what was being said, for example, when discussing types of patients, most interviewees spoke more distinctly and rapidly. It was interesting to hear the silences and to note there were different types of silence, ie interviewees were silent when thinking about how to respond to a question, and again when they had said something specific as if to let the weight of what they had said settle.

Results and evaluation

The final stage of the process was to evaluate the rhythmic analysis and see if the rhythm rankings matched the thematic analysis for person-centredness.  The abstract nature of the re-presentations encouraged an intuitive response. The visual re-presentations were presented to a mixed audience of 42 artists, dentists, academics and members of the public.  Alongside each set of visual re-presentations, the rhythmic analysis was performed by Dr Christina Lovey in the form of tap dance.  The audience were asked to listen to the rhythms and fill in an evaluation form which consisted of the three questions and two rankings. The three questions and results are presented below:

1. Which of the dentists do you find most pleasing in terms of their re-presentation?
2. Which of the dentists would you most like to visit for a consultation?
3. Which dentist would you choose to make an appointment with for a vulnerable family member?

Dentist Two is rated as by far the most pleasing re-presentation with Dentist One as the least pleasing. There are only three votes between second and fifth place. This correlates with the thematic analysis on person-centredness with two being the most person-centred.

Dentist Two is the dentist that people would most like to visit whilst Dentist One is the one they would least like to visit. This correlates with the thematic analysis in that Dentist Two is the most person-centred. Dentist One was the third most person-centred according to the thematic analysis, but again there are only three votes between second and fifth place. 

Dentist Two would be the overwhelming choice for a consultation for a vulnerable family member whilst the other four dentists share the remaining 11 per cent of votes.  The results of the evaluation seem to suggest that, at least for the most person-centred dentist, the rhythmic presentation and visual re-presentations of their speech are correlated with the thematic analysis of the content of their speech. The evidence on the remaining four dentists is less conclusive, however.

Discussion

The evaluation of our rhythmic and visual re-presentations of dentists’ speech suggests that there may be some correlation between the person-centredness of the dentist and the perception of their paralinguistic speech patterns. This suggests that the theory of communicative musicality may provide an alternative way of getting dentists and dental students to think about not just the content of the speech in consultations but also the ways in which they speak.

This method has the potential to enable us to use communicative musicality as a way of better understanding dentist/patient interactions in a number of ways.  In the short term, we have developed a method to enable the use of visual and audio formats to re-present elements of speech dynamics in-patient/clinician communications. This can be used to supplement existing teaching in the undergraduate dental curriculum around communication and the provision of person-centred dentistry.  It can also be used as a way of representing communication through alternative (non-written or spoken) modes to dental professionals more widely.   

Analysis of the communications between dentists and their patients would also allow us to compare both the content and the rhythms of speech of the different participants in the consultation and create a visual/audio representation of the interaction. We could then look for rhythmic, pitch and tonal indications of power, empathy, consensus and the other aspects we might expect to find in a consultation. Further research is needed to explore the impact of gender and accent on the rhythmic presentations.

Conclusion

The conceptual work we have undertaken has the potential to be impactful in several different ways.  It could be used as a demonstration within a teaching context to raise awareness of the importance of speech patterns.  It could be used to provide examples of how to better communicate with patients or of contrasting approaches that currently exist within dentistry.  It could also help aid discussions about power in dental consultations and consideration of the patriarchal model of health care and the alternative matriarchal perspective.

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References

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Tags: baby, communication, interaction, Musicality, patient centred care, treatment