A “code-switching” model for healthcare communication

Abstract

This article examines how technical terminology in public-facing communication creates epistemic barriers that undermine trust between experts and the public—especially in multilingual, multicultural healthcare systems. It argues that health leaders can foster trust by employing a “code-switching” model within institutions and in patient- or public-facing communications. Code-switching is a linguistic phenomenon in which individuals switch between languages, dialects, or language varieties based on the social context. Recognizing “public-speak” and “medical-speak” as distinct codes would facilitate patient understanding of information relevant to their care and promote trust. Health leaders play a crucial role in ensuring that complex medical information is translated into accessible language, bridging the gap between experts and the public.

Introduction

As patient-centred care remains a key focus of ethical healthcare, ¹ an emerging concern for all healthcare professionals—from practitioners to leadership—is ensuring that patients can understand and use crucial health-related information. Building trusting communicative relationships is inherently difficult due to the power differential between practitioners and the public. This gap arises from differences in technical knowledge and expertise but is exacerbated when members of the two groups trying to communicate are from different cultural, linguistic, or educational backgrounds. In diverse, multicultural settings such as Canadian urban healthcare systems, these differences can lead to miscommunication, undermining trust in the medical institution.

Trust between professionals and the public is weakened by epistemic barriers. These barriers are epistemic because they relate to the ability (or inability) to convey information. While epistemic barriers and their impacts have been discussed in the literature at the practitioner-patient level,^2-4 they have rarely been examined in the broader context of how healthcare institutions communicate with the public. Since patient-centred care extends beyond the clinical encounter, this broader institutional and societal level is equally important.

Amongst medical professionals, health leaders operate in the unique intersection of public engagement, patient care, institutional and governmental policy collaboration, and medical expertise—making leadership a crucial level from which to address the ethical issue of epistemic barriers. This article details the nature of these epistemic barriers, how they undermine trust, and how a “code-switching” model of healthcare communication can address this problem. Code-switching is a linguistic phenomenon wherein persons switch linguistic “codes” by changing languages, dialects, or word choices to best fit the social context. Applying this model to healthcare, code-switching from medical terminology to layperson-friendly language ensures good communication between experts and the public, which promotes trust. Presently, many medical professionals naturally code-switch when speaking to patients. Health leadership can contribute to ethical institutional conduct that promotes trust by formalizing this existing practice of code-switching into clinical and organizational guidelines.

The relationship between language and trust

In her 2021 book, philosopher Maya Goldenberg argued that inefficacies of public health interventions stem from a “crisis of trust”—a fiduciary gulf between experts and the public—caused by scientists and the institutions they represent failing to convince the public that they are acting in their best interests. ⁵ Goldenberg identifies the public’s inability to access or understand the mechanisms which guide the actions of the scientific expert “in-group” as a key reason for a lack of trust in the scientific consensus. This inaccessibility and its impact on trust are not limited to scientific research but extend to medicine.^5-7

A long and well-documented history of distrust in medical institutions exists among patient populations who feel unrepresented, mistreated, or misunderstood.^8,9 This is not a new issue. However, in the wake of the COVID-19 pandemic, distrust in the healthcare system is a pertinent problem. One emerging area of research is how subtle cues and speaking the same language—literally and metaphorically—can foster trust. ¹⁰ In contrast, epistemic barriers which prevent speaking the same language create a communicative environment where persons feel that experts are “speaking past them,” reinforcing a sense of inaccessibility that undermines trust.

Epistemic barriers create an “in-group” and “out-group” dynamic. Persons who are “in the know” and able to understand what is being said are part of a group of insiders, separated from an “out-group” of persons who are not clued in on the meaning of terms being used to communicate. In the case of healthcare, often the patients and public are the “out-group” and medical professionals are the “in-group.” An example of an epistemic barrier is when highly trained medical practitioners use technical terminology that is not known to the layperson public, and the two groups fail to speak the same language and communicate effectively. These barriers have two possible impacts: (1) the barrier could be used by the in-group to intentionally exclude or dismiss the out-group, or (2) the in-group can unintentionally render their communications with the out-group unknowingly inaccessible. Incorrectly assuming a level of understanding leads to ineffective communication, and multilingual and multicultural healthcare systems are particularly vulnerable. If trust requires epistemic access and current communication practices create epistemic barriers, a new model is needed to ensure more accessible healthcare communication to foster trust.

What makes communication understandable?

Effective public communication is clear, concise, and simple. For example, a recent Health Canada guideline on alcohol consumption states: “Drinking alcohol has negative consequences. The more alcohol you drink per week, the more the consequences add up.” ¹¹ The language used is straightforward and accessible to the average member of the public.

If medical communications are to effectively bridge the gap between experts and the public, then these communications should be as accessible as possible. Epistemic barriers arise when technical terminology is used in public- or patient-facing communications, such as public health announcements, treatment decision aids, or informational pamphlets. The use of technical terminology in these communications creates epistemic barriers that exacerbate the expert-layperson divide, undermining trust.

Unnecessarily complex phrases impede understanding, particularly when the terms used are not likely to be familiar or understandable to a member of the public who is less educated or from a non-native English-speaking background. This can take the form of (1) the use of technical terms that have widely known colloquial equivalents (e.g., “heart attack” versus “myocardial infarction”) or (2) medical terminology used without an accompanying layperson explanation (e.g., “anaphylaxis” in a vaccine information packet, or “metastasis” in a post-diagnosis cancer fact sheet). ¹²

Technical terminology is a necessary feature of a technical field such as medicine, and not all concepts are perfectly translatable in simple terms. There are cases where technical terms are necessary for the sake of precision or accuracy. However, when technical terminology is assumed to be common knowledge and is employed without accessible explanation, this undermines understanding and trust. Hence, there is an ethical duty to provide accompanying “layperson” explanations—not necessarily translations—that ensure comprehension by providing context for how a term is being used, why it matters, and how it relates to the health decision at hand. Explanation requires understanding, beyond mere word substitution. Failing to ensure understanding would unfairly assume patient knowledge, impeding efficient patient-centred care, especially in a system where the patient population is diverse. Balancing the technical precision of the science behind medicine with ensuring public comprehension is the key to preventing epistemic barriers that compromise trust.

How epistemic barriers create injustices

The argument that knowledge gaps that impede understanding are an ethical concern is not new. The concept of “epistemic injustice,” coined by Miranda Fricker, refers to the harm done to a person when they are unethically excluded from knowledge-sharing owing to bias or lack of interpretive resources. ¹³ Epistemic injustice takes the form of testimonial injustice (when testimony is deemed less credible because of prejudice against the speaker) and hermeneutical injustice (when a subject lacks the resources to convey or understand an experience). ¹³ Existing discourse in the literature on epistemic injustice in medicine largely focuses on cases that occur in clinical or research settings, for example, when a patient is assumed to be lying about their pain owing to biases based on the patient’s race or gender.^2,12 However, the epistemic barrier created by inaccessible public communications (as opposed to one-to-one communications) is also a form of epistemic injustice worth addressing.

Since trust relies on epistemic access, and the use of technical or medical terminology creates epistemic barriers, this communicative practice hinders trust between the healthcare institution and the public. Patient-centred care requires patient involvement in their care, and this involvement is contingent on understanding and trust that requires epistemic accessibility. ¹ At face value, the purpose of public-facing medical communications is informative—that is, they convey medical facts from professionals or experts to the public. However, they serve a secondary, implicit purpose. They are an instance of communication between medical professionals and the public that shapes the perception of, and the relationship between, the public and the medical institution. Bridging the gap between the in- and out-groups by lowering epistemic barriers creates trust between experts and the public.

The ethical weight of language choice

Some might question whether the employment of technical language is necessarily exclusionary or if it is truly ethically loaded. On one hand, if a layperson can infer the meaning of an unfamiliar word based on context clues, the message is nonetheless conveyed, and there is no issue. On the other hand, avoiding medical jargon could be construed as oversimplifying the message in a way that is condescending to the layperson, creating epistemic injustice by attributing less credibility or respect to a person than they deserve. However, social epistemologists have argued that technical terminology is value-laden, beyond being difficult to understand. The sharing of a language is an act of social inclusion, and the use of a different, non-shared language can be leveraged as a tool of social discrimination. ¹⁴ The use of technical terminology serves to distinguish the language and the “voice” of medicine from the voice of everyday life and, therefore, the language of the public. Its use creates a “language of medicine” that creates a social and epistemic asymmetry between doctors and patients.

Social epistemologists characterize technical terms into necessary “specific technicalities” (e.g., “laryngoscope”) that are terms used specifically for their technical meaning and “collateral technicalities” that carry purposefully exclusionary connotations. ¹⁴ Collateral technical terms serve no function or purpose beyond signalling expertise. ¹⁴ An example of a collateral technical term would be the use of “ab estrinseco,” for example, in “ab estrinseco colon infiltration.” The Latin term simply means “from the outside”, and the translation into a common language term would lead to no loss of meaning; hence, its employment here is not in service of changing the meaning of the term but to change the term’s social register. While specific technical terms can be learnt by non-specialists, collateral technical terms create unnecessary barriers to understanding.

Even though a layperson could infer meaning from context, the employment of unnecessary technical language risks alienating patients and the public. The shift from the paternalistic model of healthcare to the patient-centred care model—wherein patients are involved in their care and treatment—represents a democratization of medical care that is undermined by unnecessary asymmetries in the relationship between medical professionals and patients. And, While laypersons have a duty to work towards a shared understanding by improving their health literacy, existing power dynamics and the large gap in technical education between trained medical practitioners and the public mean that laypersons are at a disadvantage. Furthermore, this disadvantage is compounded into tangible harm if issues of injustice and exclusion arise in the realities of healthcare provision in a multicultural society. The distrust that arises from gaps in understanding should be addressed by adapting styles of communication between experts and laypersons. Language can be a tool for professionals to demarcate the region over which they have epistemic power, or it can be leveraged to share knowledge. In other words, what one says matters, but it also matters how it is said.

The code-switching model for healthcare communication

Epistemic inaccessibility contributes to public mistrust of medicine by widening the gap between experts and laypersons. This inaccessibility creates public scepticism and distrust of medicine by creating barriers between medical professionals and the public. Whilst solutions to the broader problem of epistemic injustice are multifaceted and complex—rendering it difficult to prescribe specific solutions—the epistemic barrier created by the employment of inaccessible medical terminology can be resolved: communications from experts to the public should be concise, clear, and as accessible as possible without oversimplification. A “code-switching” model achieves this balance and provides a structured approach.

Code-switching is a linguistic phenomenon wherein individuals switch between linguistic codes, such as languages or dialects, depending on the social context.^15,16 In linguistics, the relevant shifts in social contexts are often demarcated upon differences in race or socioeconomic class. This is commonly seen in bilingual persons who switch word choice, speech patterns, demeanour, and register when switching between languages.

A code-switching model is not a far-fetched proposal. Medical professionals naturally “code-switch” at the clinical level, often without thinking. For example, clinicians use a different “voice” in an exam room discussing a diagnosis with a patient than the “voice” used when discussing the same case with colleagues. Encouraging the formal adoption of this existing practice into a code-switching model of communication within institutions and when issuing public-facing messages promotes this existing laudable habit. ¹ Health leaders are uniquely situated in their roles and expertise within the healthcare institution to encourage the adoption of the code-switching model through clinical practice guidelines and professional education and training.

The code-switching model prevents epistemic barriers by, first, encouraging conscious recognition of “medical-speak”—which is formal in its register and technical in its word choice—as a separate “code” to “public-speak”—which is less formal and requires the use of layperson terminology. Subsequently, through recognition and conscious effort, medical professionals can learn to switch codes to adhere to “public-speak” when communicating with laypersons. Code-switching into “public-speak” entails consciously avoiding unnecessary technical terms, providing lay explanations for necessary technical terminology, simplifying sentence structure, and making sure to check in on comprehension. Recognizing “public-speak” versus “medical-speak” as two disparate language codes that one should switch between depending on the context aids in addressing epistemic barriers. Treating the public as being an “out-group” by consciously choosing against using “medical-speak” and choosing to use simpler and more accessible language is not condescending or unethical; in fact, it is beneficial.

The code-switching model applies to all levels of healthcare, including, but not limited to, health leaders. In face-to-face interactions in the clinic and in written communications with individual patients, the code-switching model ensures patients understand diagnoses and treatment plans. In public health messaging, such as informational communications like pamphlets or health advisories, avoiding unnecessary technical jargon that creates epistemic barriers ensures public comprehension and facilitates trust.

These are difficult and crucial issues to balance even between a monolingual and homogeneous “expert” and “public” class, but in Canada’s multicultural and multilingual society, accessibility must be actively prioritized, not assumed. Health leaders and professionals play a crucial role in ensuring that complex medical information is effectively translated for public comprehension, thus helping to bridge the gap between experts and the public.

Conclusion

Epistemic barriers in healthcare communication hinder trust and patient-centred care. The use of inaccessible medical terminology serves as a key locus of this divide, creating an in-group/out-group dynamic that perpetuates mistrust. A code-switching model provides a solution that can help address this gap, ensuring that communication is understandable and accessible without sacrificing technical accuracy or respect for the public. Recognizing and actively mitigating epistemic inaccessibility through deliberate linguistic choices empowers patients, enhances trust, and aligns with the ethical imperatives of modern healthcare in a multicultural society. Bridging the epistemic divide is not just about better communication—it is essential for a more equitable, effective, and trustworthy healthcare system.

Ethical approval

Institutional review board approval was not required.

ORCID iD

Stacy S. Chen https://orcid.org/0000-0003-0827-5175