Introduction

Effective use, and interpretation, of silence is a sophisticated and important communication skill.¹ Proficient use of silence is associated with enhanced empathy, understanding, thoughtfulness, and self-awareness [1,2], important for good medical practice [3,4]. Despite this, research into silence in healthcare communication is lacking and the topic is poorly covered in communication skills curricula [5,6]. Having an in-depth understanding of physicians’ use, and experiences of, silence, could apprise communication skills training to enhance good physician-patient communication.

Silence is not merely the absence of verbal communication; it functions in dynamic relation to speech, forming a communicative continuum [7,8]. In clinical contexts, silence is typically defined as a pause in verbal audio signal, lasting longer than required for turn-taking (approximately 2 seconds) [9]. However, silence carries meaning beyond its technical definition. Its communicative significance is shaped by context, ambient sounds, and surrounding utterances. Silence can signal reflection, empathy, or tension, depending on these factors. Moreover, silence is rarely ‘empty’ – it is often accompanied by non-verbal cues such as eye contact, gestures, movement, posture, and paralinguistic communication, all of which contribute to its role as an active form of communication [10–12]. Culture also plays a role in silence. For example, in Asian contexts silence can be a sign of respect and is also acknowledged as being full of meaning. In contrast, in Western cultures, especially North America, silence can be perceived more negatively, as a sign of unfriendliness or not being worthy – with an expectation that speakers must ‘add’ something to the conversation [13].

Silence can play many roles in a consultation. In day-to-day language, silence, as expressed through pauses, is used to organize speech, such as turn-taking. For example, a physician may pause to invite a response, giving a participant a moment to gather their thoughts and think a bit longer about the subject matter. Silence can also afford emotional acknowledgement, for example following a moment of gravity. Silence can be non-productive, as in awkward silences, when the information being communicated is ambiguous or poorly understood. An awkward silence can also arise in the context of uncertainty, or distraction/ inattention. Non-productive silence can also be hostile, as in the withholding of information or judgement – a ‘conspiracy of silence’, or to prevent the sharing of anxiety. To date, several authors have attempted to characterize silence, using different terms such as compassionate silence [14,15], connectional silence [9,15], profound silence [16] and awkward silence [14].

Despite its significance, silence as a focus of research in healthcare is relatively limited, primarily originating from psychotherapy or palliative care [14,17]. A 2008 meta-ethnography of silence identified 18 studies, of which only 4 were empirical studies, the remainder consisting of opinion pieces, or commentaries [17]. This review identified that studies drew on literature from psychology, communication, and spiritual traditions. More recently, researchers in oncology and palliative care have audio-recorded consultations documenting the epidemiology of silence, coding for frequency of silence, duration, and several authors propose varying typologies of silence, often related to the duration and purpose of the pause [9,14,18,19]. However, the relationship between silence, nonverbal cues, and verbal communication, and how they influence each other, remains unclear. This scoping review seeks to address this research gap by examining how silence is described and conceptualized in the clinical literature. This protocol delineates the procedures for conducting the review, guided by good practice and protocols for scoping review development [20].

The primary objective of this review is to identify, analyze and synthesize how silence is engaged in interactions between physicians (including physicians in training) and patients, in the clinical setting. This information will, we anticipate, be useful to enhance physician-patient interactions through communication skills training for medical education.

Review questions:

1. How is silence conceptualized in the clinical literature involving physicians and patients?
2. What roles/ functions does silence play in physician-patient interactions?

Methods

We chose to conduct a scoping review given the breadth of ways in which silence can be engaged. Scoping reviews are well suited to answer broad and exploratory research questions. They are used to explore new research areas, to clarify key concepts and identify research gaps by mapping the literary landscape, elucidating methodologies, core concepts, evidence types, and characteristics [21]. They frequently unveil a wider spectrum of evidence, serving as a foundation for systematic reviews and pinpointing knowledge voids [20,21]. This protocol has been reported using the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for systematic review protocols (PRISMA-P) [22] (S1 Appendix).

Stage 1: Identifying the research question

We used the Population Concept Context framework (PCC), recommended by the Joanna Briggs Institute for scoping reviews to develop our review question [25] (Table 1). We will focus our review on communication between physicians and patients, as these constitute a distinct form of interaction, central to the clinical encounter. This includes, for example, diagnostic reasoning, prognostic discussions, and treatment planning. While other healthcare professionals also play key roles in patient communication, including them would broaden the scope of the review, and may introduce heterogeneity in communication goals and relational dynamics, making it more difficult to derive insights that are specifically applicable to medical education. Further, the role of silence in physician-patient communication might be very different from that of other healthcare professionals due to variations in the professional hierarchies, responsibilities, and relationships with patients.

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Table 1. Inclusion/ Exclusion criteria.

https://doi.org/10.1371/journal.pone.0307620.t001

Our review question is ‘how is silence conceptualized in clinical literature involving physicians and patients?’ This question may be refined, or new ones added, as the authors gain increasing familiarity with the literature.

Stage 4: Charting the data

Before the extraction process, the team will collaborate to pilot five of the included studies to confirm accuracy, ensure mutual comprehension, and assess the suitability of the data extraction tool. A preliminary version of the data extraction tool is provided in Table 2. Modifications to the tool will be made as necessary and additional categories may be identified during data extraction. Any modifications will be carefully noted and disclosed as part of our audit trail. In instances where essential data for extraction is not readily available within the published paper, authors of the respective publications will be contacted for clarification.

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Table 2. Preliminary Data Extraction Tool.

https://doi.org/10.1371/journal.pone.0307620.t002

Limitations

Whilst we will do our best to identify all relevant literature, it may be that our search strategy may miss some studies. Additionally, our search is restricted to English language studies, this exclusion could potentially lead to missing relevant cultural and regional perspectives on silence in healthcare communication, which limits the generalizability of our findings.

This protocol is restricted to physicians and physicians in training. By limiting the scope to physicians, the findings are more likely to have clear implications for medical curricula, communication skills training, and clinical practice, which may not be generalizable to other healthcare professions. Additionally, our findings may not inform silence in interprofessional settings. This could be a focus for future research. We anticipate study heterogeneity, which may limit the type of analysis possible.

Discussion

This protocol presents the methodological framework and approach we will employ to identify and map the existing evidence regarding the experiences of physicians with silence in clinical settings. By identifying, analyzing, and synthesizing existing literature on this topic, the review will offer insights into the various roles and functions of silence in physician-patient interactions. The review will help recognize the diverse roles that silence plays in clinical consultations. These roles encompass diverse aspects such as invitational silence, emotional acknowledgment, non-productive silence, and hostile silence, among others. Understanding these roles holds the potential to enhance the communication skills of healthcare professionals, enriching patient care experiences, improving their quality of life, and fostering a safe and comfortable environment within healthcare settings. Such insights can inform the development of tailored educational initiatives aimed at augmenting physicians’ proficiency in communication. Through dissemination via peer-reviewed presentations and publications, the findings of this scoping review will contribute to ongoing dialogues on optimizing physician-patient communication and refining healthcare delivery practices.

Supporting information