{"paper_id":"1e9583dd-01ee-4e77-815a-f6ba2a7c35c1","body_text":"Page 1 of 19\n1 Silence in physician clinical practice: a scoping review protocol \n2\n3 Martina Ann Kelly1, Stefanie Rivera1, Caitlin McClurg2, Catherine Sweeney3, Stephen Mosca4, \n4 Ellen McLeod5, Deirdre Bennett2, Megan Brown6\n5\n6 1Department of Family Medicine, Cumming School of Medicine, University of Calgary, \n7 Calgary, Alberta, Canada\n8 2Libraries and Cultural Resources, University of Calgary, Calgary, Alberta, Canada\n9 3Medical Education Unit, Brookfield Health Sciences Complex, University College Cork, Cork, \n10 Ireland\n11 4Division of Palliative Care, University of British Columbia, Canada\n12 5Division of Palliative Care, University of Calgary, Calgary, Alberta, Canada\n13 6School of Medicine, Newcastle University, Newcastle, United Kingdom\n14\n15 Corresponding author: Catherine Sweeney. ORCID  0000-0002-2073-9457\n16 Address: School of Medicine, Brookfield Health Sciences Complex, University College Cork, \n17 Cork, Ireland\n18 Email: C.Sweeney@ucc.ie  \n19\n20\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted July 11, 2024. ; https://doi.org/10.1101/2024.07.10.24310250doi: medRxiv preprint \nNOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.\n\nPage 2 of 19\n21 Abstract \n22 Objective\n23 The objective of this review is to map, describe and conceptualize how silence is discussed \n24 within literature on interactions between physicians and patients, in clinical settings. \n25\n26 Methods\n27 We will use the methodological framework of Arksey & O’Malley, adapted by Levac et al and \n28 Joanna Briggs Institute. Empirical studies including quantitative, qualitative, mixed methods, \n29 observational studies and reviews will be included. Commentaries, editorials, and grey literature \n30 will also be examined. The databases MEDLINE, Cumulative Index to Nursing and Allied \n31 Health Literature, PsycINFO, Scopus and Web of Science will be searched. A two-part study \n32 selection strategy will be applied. First, reviewers will follow inclusion and exclusion criteria \n33 based on ‘Population-Concept-Context’ framework to independently screen titles and abstracts. \n34 Next, full texts will be screened. Data will be extracted, collated, and charted to summarize \n35 methods, outcomes and key findings from the articles included. \n36\n37 Expected results and implications\n38 This scoping review will provide an extensive description of how physicians engage with silence \n39 in clinical settings. Findings will identify how silence is perceived in physician patient \n40 interactions, the roles it plays, what factors influence use of silence and guide development of \n41 educational initiatives on use of silence in clinical settings. \n42  \n43 Keywords: silence, communication, non-verbal communication, scoping review \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted July 11, 2024. ; https://doi.org/10.1101/2024.07.10.24310250doi: medRxiv preprint \n\nPage 3 of 19\n44 Introduction \n45 Effective use, and interpretation, of silence is a sophisticated and essential communication skill.1 \n46 Proficient use of silence is associated with enhanced empathy, understanding, thoughtfulness, \n47 and self-awareness,1, 2 essential for good medical practice.3, 4 Despite this, research into silence in \n48 healthcare communication is lacking and the topic is poorly covered in communication skills \n49 curricula.5, 6 Having an in-depth understanding of physicians’ use, and experiences of, silence, \n50 could apprise communication skills training to enhance good doctor-patient communication. \n51  \n52 Silence is not merely the absence of verbal communication, but rather silence and speech organize \n53 each other, forming a continuum.7, 8 Silence in clinical contexts is defined as an absence of verbal \n54 audio signal, lasting longer than required to take turns to speak (2 seconds). 9 The meaning of \n55 silence is impacted by the context, ambient sounds, utterances before and after the silence. Silence \n56 is also configured through non-verbal cues such as eye contact, gestures, movement, posture, and \n57 paralinguistic communication. 10-12 Culture also plays a role in silence. For example, in Asian \n58 contexts silence can be a sign of respect and is also acknowledged as being full of meaning. In \n59 contrast, in Western cultures, especially North America, silence can be perceived more negatively, \n60 as a sign of unfriendliness or not being worthy – we must ‘add’ something to the conversation.13\n61  \n62 Silence can play many roles in a consultation. In day-to-day language, silence, as expressed \n63 through pauses, is used to organize speech, such as turn-taking. For example, a physician may \n64 pause to invite a response, giving a participant a moment to gather their thoughts and think a bit \n65 longer about the subject matter. Silence can also afford emotional acknowledgement, for example \n66 following a moment of gravity. Silence can be non-productive, as in awkward silences, when the \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted July 11, 2024. ; https://doi.org/10.1101/2024.07.10.24310250doi: medRxiv preprint \n\nPage 4 of 19\n67 information being communicated is ambiguous or poorly understood. An awkward silence can \n68 also arise in the context of uncertainty, or distraction/ inattention. Non-productive silence can also \n69 be hostile, as in the withholding of information or judgement – a ‘conspiracy of silence’, or to \n70 prevent the sharing of anxiety. To date, several authors have attempted to characterize silence, \n71 using different terms such as compassionate silence, 14, 15  connectional silence, 9, 15  profound \n72 silence16 and awkward silence.14 \n73  \n74 Despite its significance, silence as a focus of research in healthcare is relatively limited, primarily \n75 originating from psychotherapy or palliative care. 14, 17  A 2008 meta-ethnography of silence \n76 identified 18 studies, of which only 4 were empirical studies, the remainder consisting of opinion \n77 pieces, or commentaries.17 This review identified that studies drew on literature from psychology, \n78 communication, and spiritual traditions. More recently, researchers in oncology and palliative care \n79 have audio recorded consultations documenting the epidemiology of silence, coding for frequency \n80 of silence, duration, and several authors propose varying typologies of silence, often related to the \n81 duration and purpose of the pause.9, 14, 18, 19 However, the relationship between silence, nonverbal \n82 cues, and verbal communication, and how they influence each other, remains unclear. This scoping \n83 review seeks to address this research gap by examining how silence is described and \n84 conceptualized in the clinical literature. This protocol delineates the procedures for conducting the \n85 review, guided by good practice and protocols for scoping review development.20\n86  \n87 The primary objective of this review is to identify, analyze and synthesize how silence is \n88 engaged in interactions between physicians (including physicians in training) and patients, in the \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted July 11, 2024. ; https://doi.org/10.1101/2024.07.10.24310250doi: medRxiv preprint \n\nPage 5 of 19\n89 clinical setting. This information will, we anticipate, be useful to enhance doctor-patient \n90 interactions through communication skills training. \n91  \n92 Review questions:\n93 1. How is silence conceptualized in the clinical literature involving doctors and patients? \n94 2. What roles / functions does silence play in physician-patient communication? \n95   \n96 Methods  \n97 We chose to conduct a scoping review given the breadth of ways in which silence can be \n98 engaged. Scoping reviews are well suited to answer broad and exploratory research questions. \n99 They are used to explore new research areas, to clarify key concepts and identify research gaps \n100 by mapping the literary landscape, elucidating methodologies, core concepts, evidence types, and \n101 characteristics.21They frequently unveil a wider spectrum of evidence, serving as a foundation \n102 for systematic reviews and pinpointing knowledge voids.20, 21 This protocol has been reported \n103 using the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for \n104 systematic review protocols (PRISMA-P)22 (S1 Appendix). \n105  \n106 Methodological Framework  \n107 Our scoping review will follow the Arksey and O'Malley framework for scoping reviews,23 \n108 adapted by Levac et al.24 and the Joanna Briggs Institute.25 Components will include: identifying \n109 a research question; identifying relevant studies; study selection; charting data; collating, \n110 summarizing, and reporting results; and consultation. The findings of the review will be \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted July 11, 2024. ; https://doi.org/10.1101/2024.07.10.24310250doi: medRxiv preprint \n\nPage 6 of 19\n111 presented following the guidelines of the Preferred Reporting Items for Systematic Reviews and \n112 Meta-analyses extension for scoping reviews (PRISMA-ScR).26 \n113  \n114 Stage 1: Identifying the research question \n115 We used the Population Concept Context framework (PCC), recommended by the Joanna Briggs \n116 Institute for scoping reviews to develop our review question. 25 The population are physicians \n117 and patients, the concept is the experience of silence in professional caregiving interactions with \n118 physicians and patients, and the context is clinical settings. Our review question is ‘how is \n119 silence conceptualized in clinical literature involving doctors and patients?’ This question may \n120 be refined, or new ones added, as the authors gain increasing familiarity with the literature. \n121\n122 Stage 2 Identifying relevant studies  \n123 Types of Sources. Empirical research on silence encompassing various study designs will be \n124 considered, including qualitative studies, observational studies, surveys and questionnaires, \n125 longitudinal studies, meta-analyses or evidence synthesis, and conversational analysis. We will \n126 also include commentaries, personal reflections and grey literature sources (conference \n127 proceedings, abstracts, thesis etc). Only English-language sources will be included due to \n128 feasibility and translation issues, with no restrictions on publication dates. \n129\n130 Table 1 Inclusion and exclusion criteria according to the PCC framework\nInclusion criteria Exclusion criteria \nPopulation Physicians, ranging from general Other healthcare professionals, such \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted July 11, 2024. ; https://doi.org/10.1101/2024.07.10.24310250doi: medRxiv preprint \n\nPage 7 of 19\npractitioners to specialists, resident \nphysicians, and medical students. \nas Professional Nurses, Registered \nNurses, Enrolled Nurses, Nurse \nAides, Nursing Students, Dentists, \nPharmacists, Nutritionists, EMTs, \nand Medical Laboratory \nTechnologists. Additionally, \nProfessional Therapists, Clinical \nPsychologists, Counseling \nPsychologists, as well as Professional \nPastors and Spiritual Counselors \nConcept The role of silences in professional \ncaregiving interactions with patients and \nclients. \nThis involves analyzing how silence is \nused in clinical settings and \ncommunication skills curricula. \nThese roles encompass silence in \ncommunication, verbal and non-verbal, \nas well as the concept of the \"conspiracy \nof silence,\" where silence is wielded as \na tool for power or control \nSilence in religious contexts\n \nSilence external to human interaction \ne.g. nature   \nSilence in relation to hearing \nimpairment\nContext Clinical settings, such as hospitals, Academic environments such \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted July 11, 2024. ; https://doi.org/10.1101/2024.07.10.24310250doi: medRxiv preprint \n\nPage 8 of 19\nclinics, physician's offices, urgent care \ncenters, nursing homes, long-term care \nfacilities, rehabilitation centers, mental \nhealth clinics, palliative care units, and \nhome care environments \nTelemedicine \nclassroom, simulations, lectures etc.\n131\n132  \n133 A preliminary search was conducted on Google Scholar to gain an overview of existing literature \n134 and identify seed studies. Text word from titles, and abstracts of seed papers, along with the \n135 MeSH terms from MEDLINE were tailored to develop an initial search strategy for MEDLINE \n136 (table 1). Comprehensive searches will be carried out in the following databases: Scopus, Web of \n137 Science, CINAHL Plus with Full Text, APA PsychINFO, and MEDLINE. Reference lists of \n138 included studies will undergo screening to identify any additional relevant studies. The search \n139 strategy will be adapted for each database and further refined in consultation with a research \n140 librarian (CmC). \n141\n142 Table 2 Search strategy terms for MEDLINE (PubMed)\n143\nMeSH terms Related terms\nPopulation exp Education, \nMedical/ \nprovider*.tw,kf. \nclinician*.tw,kf. \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted July 11, 2024. ; https://doi.org/10.1101/2024.07.10.24310250doi: medRxiv preprint \n\nPage 9 of 19\nexp \"Internship and \nResidency\"/ \nexp Faculty, \nMedical/ \nexp Physician-\nPatient Relations/ \ntrainee*.tw,kf. \nresiden*.tw,kf. \ninterns*.tw,kf. \npreceptor*.tw,kf. \nphysician*.tw,kf. \ndoctor*.tw,kf.\nConcept exp \nCommunication\nexp Mindfulness\nexp Voice\nexp Social \nIsolation/ \nor exp Loneliness/ \nexp Interpersonal \nRelations\nsilence*.tw,kf. \ndiscuss*.tw,kf. ,support*.tw,kf., relation*.tw,kf. \nconnect*.tw,kf., communicat*.tw,kf., convers*.tw,kf., \ninteract*.tw,kf., contemplat*.tw,kf., acknowledg*.tw,kf.\npeace*.tw,kf., hope*.tw,kf. \npaus*.tw,kf., mindful*.tw,kf. \nawkward*.tw,kf., grie*.tw,kf. \nstigma*.tw,kf., violen*.tw,kf., abus*.tw,kf\nsolitude.tw,kf., still*.tw,kf.,tranquil*.tw,kf\nContext exp Telemedicine/ \nexp \nVideoconferencing/ \nexp Remote \nConsultation/ \n(telehealth* or teleconsult* or teleconf* or virtual care or\nzoom* or skype*).mp\n144\n145\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted July 11, 2024. ; https://doi.org/10.1101/2024.07.10.24310250doi: medRxiv preprint \n\nPage 10 of 19\n146 Stage 3: Study Selection  \n147 After completing the search, all located records will be uploaded to Covidence systemic review \n148 software (Veritas Health Innovation) and duplicates removed. A pilot test will be performed on a \n149 random subset of 50 titles/abstracts to refine the inclusion/exclusion criteria, if necessary, and to \n150 ensure consistent application of selection criteria among reviewers. \n151   \n152 Screening will take place in 2 phases. All citations will be screened independently by 2 \n153 reviewers, based on title and abstract. Any discrepancies that arise during each stage of the \n154 selection process will be resolved by consulting a third reviewer. Next full texts will be imported \n155 into Covidence and reviewed by 2 independent reviewers. Reasons for exclusion will be \n156 documented. Findings of the search and the study inclusion process will be comprehensively \n157 reported in the final scoping review, following the reporting guidelines outlined in the Preferred \n158 Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews \n159 (PRISMA-ScR).26 \n160   \n161 Stage 4: Charting the data  \n162 Information drawn from each publication will encompass details such as authorship and year of \n163 publication, location, and study methodology. Additionally, particulars about the study \n164 population, concept, context, and pertinent findings relevant to the review question. A \n165 preliminary version of the data extraction tool is provided in Table 3. \n166\n167 Table 3. Preliminary Data Extraction Tool \n168\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted July 11, 2024. ; https://doi.org/10.1101/2024.07.10.24310250doi: medRxiv preprint \n\nPage 11 of 19\nCategories Questions\nPublication Details\nAuthor(s) Who are the authors of the publication?\nYear of Publication When was it published\nCountry of origin Where was the study carried out?\nGeneral Overview of Study\nObjective and aims What was the objective and aims of the study?\nMethods What methods (e.g. qualitative, quantitative, mixed \nmethods) were used?\nHow were patients and/or physicians engaged in the design \nprocess?\nPopulation Who were the participants, sample size?\nConcept What type of data concerning silence was included?\nIn what manner is silence described, and characterized \nincluding the terms used, such as invitational, hostile, etc.?\nWhat, if any factors influence engaging with silence\nContext In what setting did the employment of silence take place?\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted July 11, 2024. ; https://doi.org/10.1101/2024.07.10.24310250doi: medRxiv preprint \n\nPage 12 of 19\nFindings/results What are the roles, purposes, or functions of silence?\nAny challenges/limitations reported?\n169  \n170\n171 Before the extraction process, the team will collaborate to pilot five of the included studies to \n172 confirm accuracy, ensure mutual comprehension, and assess the suitability of the data extraction \n173 form. Modifications to the data extraction form will be made as necessary and additional \n174 categories may be identified during data extraction. Any modifications made to the tool will be \n175 carefully noted and disclosed as part of our audit trail. In instances where essential data for \n176 extraction is not readily available within the published paper, authors of the respective \n177 publications will be contacted for clarification. \n178  \n179 Stage 5: Collating, summarizing and reporting the results \n180 Scoping reviews, differing from systematic reviews, generally do not evaluate the \n181 methodological quality or bias risk of the studies included, nor do they perform data synthesis \n182 like meta-analyses. Instead, they offer a descriptive overview of the studies encompassed.20 Our \n183 approach involves both numerical and narrative summarization of various aspects of the included \n184 studies. These aspects include the year of publication, geographical location, clinical setting, \n185 participants, and study design. This analysis aims to map how silence is described in clinical \n186 interactions between patients and physicians.\n187 Qualitative data will be analyzed using thematic analysis.27This will involve coding extracted \n188 data and grouping it iteratively to identify patterns of shared meaning in the data extracted. This \n189 will be complimented by drawing on our experiences as author group of family physicians (MK, \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted July 11, 2024. ; https://doi.org/10.1101/2024.07.10.24310250doi: medRxiv preprint \n\nPage 13 of 19\n190 CS, DB), palliative care doctors (SM, EmL) and medical educationalists (MB) working across \n191 different health contexts. We anticipate the need for regular team meetings to facilitate data \n192 charting and analysis.24 \n193  \n194 Stage 6: Consultation\n195 In line with Levac et al.'s recommendation, we will integrate consultation as a component of our \n196 planned scoping review.24 The outcomes of this review will be shared through presentations to \n197 palliative care physicians, ensuring a comprehensive exploration and understanding of silence's \n198 role in clinical healthcare settings. This consultation phase will gather insights into our initial \n199 findings and their significance, explore potential applications and dissemination strategies, and \n200 identify areas requiring further research. Through this collaborative approach, we will facilitate \n201 discussions on implications and practical insights e.g. to improve communication skills training. \n202 Engaging in conversations with physicians will offer valuable insights into the practical \n203 implications of the research, enriching our skill set by incorporating diverse perspectives into the \n204 research process. \n205  \n206 Limitations\n207 Whilst we will do our best to identify all relevant literature, it may be that our search strategy \n208 may miss some studies. Additionally, our search is restricted to English language studies across 5 \n209 databases. This protocol is restricted to physicians and physicians in training. Whilst \n210 understanding silence across health care professionals would be informative, the decision to \n211 restrict our search to physicians is based on a mix of pragmatic limitations and to focus our \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted July 11, 2024. ; https://doi.org/10.1101/2024.07.10.24310250doi: medRxiv preprint \n\nPage 14 of 19\n212 findings relative to our expertise in medical education. We anticipate study heterogeneity, which \n213 may limit the type of analysis possible. \n214\n215 Discussion \n216 This protocol presents the methodological framework and approach we will employ to identify \n217 and map the existing evidence regarding the experiences of physicians with silence in clinical \n218 settings. By identifying, analyzing, and synthesizing existing literature on this topic, the review \n219 will offer insights into the various roles and functions of silence in physician-patient interactions. \n220 The review will help recognize the diverse roles that silence plays in clinical consultations. \n221 These roles encompass diverse aspects such as invitational silence, emotional acknowledgment, \n222 non-productive silence, and hostile silence, among others. Understanding these roles holds the \n223 potential to enhance the communication skills of healthcare professionals, enriching patient care \n224 experiences, improving their quality of life, and fostering a safe and comfortable environment \n225 within healthcare settings. Such insights can inform the development of tailored educational \n226 initiatives aimed at augmenting physicians' proficiency in communication. Through \n227 dissemination via peer-reviewed presentations and publications, the findings of this scoping \n228 review will contribute to ongoing dialogues on optimizing doctor-patient communication and \n229 refining healthcare delivery practices.\n230\n231 Authors’ contributions:  Conceptualization: MK, SR, MB, CS, Methodology: all, Writing: MK \n232 and SR wrote the initial draft, this was reviewed and edited by all members of the team, who \n233 approved submission of the final protocol.\n234\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted July 11, 2024. ; https://doi.org/10.1101/2024.07.10.24310250doi: medRxiv preprint \n\nPage 15 of 19\n235 Supporting Information: PRISMA-P\n236\n237 Data Availability Statement: No datasets were generated or analyzed during the current study. \n238 All relevant data from this study will be made available upon study completion.\n239\n240 Funding: The authors received no specific funding for this research.\n241\n242 Competing interests: The authors have declared that no competing interests exist.\n243\n244 References\n245 1. Kenny C. The Power of Silence: Silent Communication in Daily Life. Abingdon, Oxon: \n246 Routledge; 2011.\n247 2. Ruiz-Moral R, de Leonardo CG, Martínez FC, Martín DM. Medical students’ perceptions \n248 towards learning communication skills: a qualitative study following the 2-year training \n249 programme. Int J Med Educ. 2019;10:90. \n250 3. 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