Dialectic is one of those words that’s used the most by those who hardly understand it. Even philosophers like Hegel struggled to explain it. To make matters worse, its meaning has shifted over the course of history as it found new purpose in new political movements.
The most famous of which, of course, is Communism. But dialectic thinking was used long before Karl Marx usurped the term to describe a socialist utopia. At its core, dialectic is a way of thinking about systems as cyclic patterns. That’s it. It can describe anything from religious beliefs to political identities. Ironically, in recent years, its application has overshadowed the actual method itself.
But dialectic thinking holds tremendous potential in improving our understanding of medicine, because it’s the ideal way to understand patient behavior. It explains why patient behavior is so hard to change and why we make unhealthy decisions despite knowing better.
We think in waves, oscillating between an idea, its opposite, and the application of that idea – only to then merge that applied idea with a new idea. On it goes. Suppose you’re at a friend’s New Year’s party. Everybody’s eating cake. You’re supposedly getting a head start on a New Year’s diet. You see the cake in front of you. You tell yourself not to eat it. You quickly remind yourself of how you skipped deserts at holiday parties throughout the month of December. You then contextualize the decision to eat cake relative to previous decisions not to eat poorly. You mix in thoughts about how your diet technically doesn’t start until the first of the year, which is still a few hours away. You blend your decision to eat or not to eat the cake in front of you with previous decisions where you ate well and pending decisions about how you assume you will eat in the future. After merging all of this together, you arrive at a decision to eat the cake. Congratulations, Mary Antoinette would be proud.
This is dialectic thinking. This is how we make clinical decisions regarding our health – most, if not all the time. It’s non-linear, irrational, and above all, decidedly dialectic.
It explains why traditional clinical interventions don’t work. We tried nudges. They became nuisances. We tried guidelines. They became a maze of revisions. None of these interventions work beyond a certain point because patient behavior, beyond a certain point, is dialectic.
It lives at the fringes of rational thought. This isn’t to despair patient behavior or cast aspersions about us as individuals. It’s an honest assessment of how we behave clinically.
Think about vaccine hesitancy and how pervasive it was during the pandemic – and how it’s still rampant among certain patient populations. The more providers tried to fight against hesitancy, to denounce it, the stronger it became. In many ways, the paternalistic approach to medicine – “I am your doctor, listen to me” – simply exacerbated vaccine hesitancy among the misinformation-weary masses.
But by acknowledging vaccine hesitancy, justifying the skepticism that many patients developed over the pandemic – “I know it’s hard to know what to trust” – it became easier to overcome vaccine hesitancy. This is dialectic thinking applied to patient behavior.
In the mind of a patient, there aren’t just two distinct decisions: to trust vaccines or to not trust vaccines. There are various gradations of beliefs that sift one way or another. A vaccine hesitant person may acknowledge the merits of the science behind vaccine technology, but may also think its side effects are consequential. Deciding whether to get a vaccine by comparing its benefits with its side effects appears logical. But those thoughts are also mired in the decision to trust or not to trust the vaccine based on the policy makers advocating for the vaccine.
It doesn’t seem logical that a patient would consider whether to trust vaccines by thinking about vaccine technology alongside public policy communication, but that’s the point of dialectic thinking. There’s no logic in the thoughts that appear. There are only fluctuating relationships among the thoughts that influence the final combination of beliefs that coalesce into a decision.
Trusting vaccines, therefore, is never only about the science or the political affiliations or America’s closet fascination with conspiracy theories. It’s a blend of all three patterns of thought, oscillating side by side until they synthesize into one coherent decision, unique to each individual.
Yet, healthcare providers only focus on the decision, not the process, so they fail to understand how patients think and lump them into convenient narratives – an educated patient or a vaccine denier.
Instead, providers should focus on how patients reach their conclusions, so they may have a better sense of how to intervene clinically. Providers can then focus on the patterns of thought and respond in ways that shift a patient’s thinking patterns toward healthy decisions. This would be more effective than traditional methods seen in clinical care.
