Did you understand? Probably not. It can be expressed in language that everybody can understand: "In a word, there are three things which last for ever: faith, hope and love; but the greatest of them all is love." (1. Cor. 13  v. 13). This formulation contains all of the elements of speech, which serve to make it understandable, since this language is:

-	simple
-	short
-	lucid
-	ordered
-	and the words are in common usage

The Bible, especially the New Testaments, is an excellent teaching text for clear, comprehensible and convincing language.

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Intelligible speech is as much a question of content as of style of speech. Schulz von Thun described 4 properties of intelligible speech:

•	Simple
•	Smooth and ordered
•	Brief and precise
•	Additional stimuli

What do each of these imply?

Simplicity:

Simple speech uses short sentences and common words. If technical terms are unavoidable, they should be explained. Descriptive speech raises the level of intelligibility. A doctor who talks to his patient like a "normal person" will be better understood, and be able to motivate the patient better than one who uses "scholarly" speech.

It is just as difficult to speak simply as to write simply. In fact repetitious lectures or "double dutch" fall easily from the lips. However this style is full of pitfalls. It is likely to maintain an undefined distance from the other, and prevent real involvement in discussion. It is only unequivocal facts that can be expressed in simple language. Long-winded speech is often an indication of vague thinking. Simplicity does not only increase intelligibility, it also seems genuine, and creates trust.

Smooth and ordered:

These requirements are fulfilled by language which is transparent from the outside and intrinsically consequential. Ludwig Reiners said: "A person can not express two thoughts at the same time: this means that he has to put them one after the other." What Schopenhauer described about writing also applies to speaking: "Very few people write in the way that an architect builds, in that he first makes a plan having considered all of the details. Most write as though they were playing dominoes."

"Associative speech" is a typical example. The flow of speech does not depend on thoughts which have been put together in order, but from coincidences that arise as the person is talking. Almost everybody tends to use associative speech, which is certainly not a rare method of speech. Associative speech leads to long-winded explanations, which rapidly result in the other person losing interest.

Brief and precise:

This brevity applies to language as well as factual content. Most people have difficulty in expressing themselves briefly, and it can usually only be attained with practice and discipline. Even Goethe wrote to his 18-year old sister: "As I haven't the time to write you a short letter, I am writing you a long one ..."

The telegram is the briefest form of language, and the aphorism is the extreme of factual brevity. Neither of these are of course suitable for discussion between patient and doctor. The style of the telegram has an impersonal effect, and misses the contactive function of speech. Aphorism can also lead to strain created by concentration on understanding so much that has been expressed so briefly.

The guideline has to be: Use sentences with a length and information content appropriate to the extent to which the patient can take it in and assimilate it.

Brevity also means that not too many sentences should follow one after another. Studies have shown that an untrained listener is unable to easily recall the contents of a series of sentences which last more than 40 seconds. Brevity also means giving much information with few words, as well as not too many pieces of information one after the other.

Brevity should also not be won at the cost of minimizing contact and self-revelation. Although the telegram contains highly concentrated information, it is not ideal from the point of view of information theory.

Elements of a communication which could theoretically be left out as they contain no additional information, might appear redundant at first glance. They are however necessary to support and complement the basic information. Since at least two thirds of what is said only once is forgotten, a certain amount of "redundancies" are unavoidable when talking.

Additional stimuli:

Pictures and metaphors in speech are important supports for the lucidity of what is said. They are a vital rhetorical stimulus and, as it were, the salt in the soup of information. Goethe said: "Don't keep metaphors from me or I won't be able to explain".

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Speaking in pictures and metaphors is an effective method to make oneself better understood by "plasticity". Medical language is full of abstract terms, and here in particular, the use of pictures and metaphors can lead to better comprehension.

The New Testament (and in German, the Luther translation in particular) is a mine of effective metaphors and illustrations. The parable of the lost sheep could hardly be better expressed more pragmatically than in Matthew 18 v. 12: "And what do you think? Suppose a man has a hundred sheep. If one of them strays, does he not leave the other ninety-nine on the hill-side and go in search of the one who strayed?"

This text is also a good example to show that a statement clothed in a question is a very effective tool to convince. The New Testament says that Jesus "... only spoke to them with parables." It had already been said of Him in Psalm 78 v. 2: "I will open my mouth in parables, I will utter hidden things, things from of old ..."

There are limits to the extent to which one can learn to use pictures and metaphors. There are however two possibilities which one can use in order to make one's style of language more vivid for the patient.

1.	Systematically check whether abstract terms could be better explained by a picture or metaphor from daily speech.
2.	Consider which of the pictures you use have proven to be the most effective, and use them more often in discussions with patients.

Here is an example from routine clinical practice:

It is particularly difficult to convince patients with illnesses unaccompanied by symptoms that they should be treated. The most common counter-arguments are: "I don't feel anything ...". "Everything has been alright so far ...". In these cases, I argue with the following comparison: "What you say reminds me of a man who fell from the roof of a block of flats, and called out to those in the first floor: 'I really don't know why men are afraid of falling. Everything has been great so far!'"

Metaphors as well as examples, comparisons and the sparing use of quotations, sketches, demonstration material or cartoons can be further stimuli to increase understanding. They assist discussion, but should not replace it, and always need explanation. Doctors themselves probably don't encourage their patients enough to make themselves better understood by the use of a sketch or drawing. One patient with severe angina pectoris could best describe the pain, which mainly occurred in the back, by means of a sketch (figure).

Simple pictures and drawings, even though no great works of art, sometimes allow a staggering insight into the world of feelings and experience of the patient, who does not know how to begin to express them in words.

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Observation of the style of speech of the patient is of relevance for mutual understanding and for comprehending his world and the effect on him of the society in which he moves. Wilhelm von Humboldt remarked many years ago that differences in styles of speech did not only depend on learning, talents or intellectual ability, but also on the totality of the person.

The same words can have completely different meaning depending on the age of the person, as in young people's speech.

Turns of speech which are typical for certain groups (and therefore acceptable there) have no place in conversations between doctors and patients. As modern medicine becomes more technical, technical terms have tended to appear in medicine such as "change batteries", "hook you up for a quick infusion" etc.

A further extreme of this is the excessive "psychologization" of speech, so that for example "goal-orientated communication with erotic components and tendencies to emotional fixation" is used instead of "to flirt".

The social reality of certain groups of people determines the style of speech or code. Code means a predetermined way and attitude as to how one of the group expresses himself. Codes are therefore "Sociolect". There are said to be 2 codes:

•	Elaborated code = EC
•	Restricted code = RC

As regards speech behaviour, EC and RC have the following differences:

•	The language in EC is less stereotypic in its effect, and the way of expression is more differentiated;
•	It is easier to express individual points of view and judgements in EC
•	Logical and factual relationships can be expressed more easily in EC
•	Superiority and inferiority can be more explicit.

The various language patterns can (at least statistically) be classified according to certain social behaviour patterns:

•	RC is more associated with conventional, status-orientated rather than person-orientated behaviour patterns.
•	RC tends to maintain an acquired opinion through thick and thin.
•	RC tends to be characterized by anxiety rather than guilt.
•	RC has a tendency to be conservative rather than radical.

It has been estimated that 90% of the adults in West Germany use an elaborated code. That does not mean that the remaining 10% should be "down-graded" as using restricted code. Neither is superior as regards style of speech. Intelligence and affect can be developed equally in one as in the other. However somebody who uses an elaborated code, usually soon learns to use a restricted code as well, whereas the reverse practically never occurs. There is one style of speech used by many politicians, that the doctor should avoid at all costs. This is the blathering and long-winded formulation of zero or minimal information, which leaves the patient with the impression that he can never get a straight answer.

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