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Making meaning
  1. John Launer
  1. Dr John Launer, London Department of Postgraduate Medical Education, Stewart House, 32 Russell Square, London WC1B 5DN, UK; jlauner{at}

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Here is the transcript of a remarkable conversation. It was captured on a police audiotape some years ago. It took place between a woman driver on Highway 85 in California, using her cell phone, and the switchboard controller at the police department. It resulted in someone’s death.

Controller: San Jose police…

Driver: Um yes, I wanted to report that there is a mattress in the middle of the freeway. Cars are dodging it left and right...

Controller: OK. You’ll have to call the highway patrol for that.

Driver: Why don’t you call them for me… or otherwise, I’ll just leave the mattress in the middle of the road! I mean, it’s Highway 85! Highway 85!

Controller: Is there a reason you’re so upset?

Driver: Well it took me forever to get through, and people are dodging this mattress and I just wanted to maybe…

Controller: OK. But what I’m telling you ma’am is that the San Jose police do not respond to the freeway. It’s the Highway Patrol’s jurisdiction. I’d be more than happy to give you the number if you’d like.

Driver: Never mind. I’ll just let someone get killed.

Some while after the phone call took place, a car hit the mattress, rolled over, and a person in the car was killed.

The transcript appears in a book about by the American communication expert W Barnett Pearce.1 As Pearce points out, the conversation is remarkable for being so ordinary. Both parties acted reasonably from their own points of view: the woman caller was unwilling to spend more time on the phone while driving, and the police controller knew that he had no authority to call out the highway patrol. There are identifiable moments in the conversation where each person missed the chance of changing tack, but neither did so. Tragically, the link between the quality of the communication and its fatal consequences are clear. Usually things are not so clear but, as Pearce points out, the consequences of our conversations may be just as momentous without us ever realising this.


Barnett Pearce and his colleague Vernon Cronen have spent their careers looking at communication, and in particular at how muddles and misunderstandings can build up—at every level from marriages breaking down to corporations going bust and nations declaring war on each other. Their work is quite well known among organisational consultants, coaches and mediators. However, their system of communication analysis and training—known as the Co-ordinated Management of Meaning (or CMM)—is unfamiliar to most doctors. This is a pity, because what they say is equally relevant for medicine. It could offer an effective way of understanding why things go wrong in communication with patients, and between professionals, and why critical moments in everyday conversations can lead to catastrophic outcomes—or alternatively to far more effective collaboration.

Pearce and Cronen start from the premise that most communication is about trying to coordinate action of one kind or another. Whether you have a conversation with a relative, a friend, a colleague or a patient, you are generally addressing one question: who is going to do what? According to CMM, the way we each contribute to coordinating actions is by quite short speech acts: commanding, questioning, recounting, chatting and so forth. These speech acts then gradually build up into distinct conversational episodes. The episodes build up into relationships, which then form part of wider systems like cultures, professions, nations and the whole range of our “social worlds”, as Pearce calls them.

One crucial concept of CMM is that communication is not principally a matter of one person transmitting information to another, as people commonly suppose. The meanings we create by each speech act, and in each episode, carry a force that can, quite literally, create reality. To quote a powerful example that Pearce cites in his book, when President George W Bush declared a “War on Terror”, he didn’t just describe the kind of interaction he thought was going on: he summoned it into being.


One of the most common things that goes wrong in communication, at every level from marriages to nations, is that the participants are working from different but unexamined assumptions about what is going on. Here, for example, is another exchange quoted by Pearce—this time a far more trivial, everyday one:

Woman: Are you hungry?

Man: No.

Woman: (Pause) You’re so selfish!

Man: What? What are you talking about?

Woman: I’m hungry and you don’t even care!

Man: Of course I care! I didn’t know you were hungry! If you want something to eat, why don’t you say so?

Woman: I did say so. Why don’t you listen better?

Man: There’s a good Italian restaurant in the next block. I’ll stop there.

Woman: Don’t bother. I’m not hungry any more. Take me home.

I expect that most women reading this exchange would instantly recognise that the woman’s opening speech act is a sign that she is hungry, and most men will be totally perplexed that she doesn’t just say so. What is interesting is that neither person in this couple is able to disclose, or even to notice, the underlying assumptions or contexts governing their speech acts. Both parties are “right” in their own way, but they unintentionally get themselves into positions where they are seen by the other party as “wrong”. This would scarcely matter, except that these micro-misunderstandings have effects. If they are not addressed, or at least tolerated, they have a habit of escalating, as is the case here. Eventually, they come to define the way in which people see each other and then behave towards each other. They then carry a “logical force” that makes people believe that the things they have heard—or think they have heard—justify extreme actions ranging from domestic violence to terrorist atrocities and military invasions.

The positive side of this is that we all have the power to make choices, and CMM argues that these choices are not really made at the “macro” level, like deciding to divorce or declaring war. Essentially, they are made at every juncture in every conversation we ever have. Taken collectively, our own speech acts, and the responses we choose to make to the speech acts of others, are the building blocks of everything from harmony in the home to smooth teamwork in organisations, and arguably to world peace. Pearce suggests that we should learn to stand back from our own conversations—in effect to be “observer-participants” in them. This means identifying our own assumptions, noticing other people’s, and becoming aware of how the two sets of assumptions are interacting. We can then be freed up to act in a way that offers unusual and creative ways forward, instead of going round in circles of mutual incomprehension.


If we look at medicine in terms of this framework, we can see our everyday activities—clinic consultations or encounters on the ward—as conversational processes where every moment matters. Rather than thinking of our work under just a few big headings like getting the right diagnosis or choosing the correct treatment, we could understand it as a much more detailed and precise exercise in communication where things can and indeed often do go wrong at every possible turn. For example, while I was preparing my notes for this article, I happened to be sitting in an outpatient waiting room, watching a fairly typical interaction between a junior doctor who was running late, and a patient who was anxious to be seen on time. In a fairly predictable fashion, they went into a standard conversational routine, with the doctor pointing out that the clinic was heavily overbooked through no fault of his own, and the patient asserting that she had to pick up her children from school and it was unfair to be given an appointment time that could not be honoured.

The conversation went round in increasingly heated circles, until the woman walked out of the department in a huff without rebooking her appointment, leaving the doctor to shrug at his (rather unsympathetic) audience as if he felt he had done all he could.

Yet the junior doctor might have briefly taken the woman aside to ask if hers was a routine appointment for review or the first assessment of an alarming symptom, and the woman might have asked when was the best time to rebook her appointment so that her children were not left unattended. Either way, the real possibility of a delayed diagnosis with serious consequences might have been averted—just as the mattress might have been removed from Highway 85, saving a life.



  • Competing interests: None declared.