American Association for Physician Leadership

Operations and Policy

More Than Words Can Say: How Delivery Affects the Message

Joan Lowery, MEd

November 15, 2017


Effective leaders and physicians can enhance their trust and credibility if they learn to speak with awareness and skill.

Effective leaders can enhance their trust and credibility if they learn to speak with awareness and skill. How can you avoid the vocal pitfalls that get in the way?


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Most people are unaware of how they actually sound when they communicate. Yet, according to research, the vocal dimension accounts for up to 38 percent of the overall message that listeners receive. Effective leaders and physicians can enhance their trust, believability and credibility if they use the vocal dimension with awareness and skill.

Conversely, if they fall into poor vocal habits such as using fillers, trailing off at the ends of sentences, using “up talk” or “vocal fry,” or speaking too fast, too loud, too soft, hesitantly or in a monotone manner their desired messages may be considerably diminished.

Unfortunately, unless you were trained as an actor, singer, broadcaster or professional presenter, it is unlikely that you actually hear your vocals when you speak. To improve your vocal delivery will mean investing time and effort to master this important communication channel.

Doing so is well worth it, because your vocal delivery has a significant effect on how you are perceived and understood as both a leader and a physician.

Vocals and Physician-Patient Communication

When it comes to physician-patient communication, it’s worth noting research findings by social psychologist Nalini Ambady1 that a surgeon’s voice is a predictor of whether or not he or she has been sued for malpractice. Ambady found that within 40 seconds of hearing on audio recordings, participants’ responses to his or her voice tone correlated positively with the surgeon’s malpractice history.

Surgeons perceived as demonstrating dominant voice tone traits were most often sued for malpractice. This was conveyed by deep, loud, moderately fast, unaccented and clearly articulated speech. The researchers speculated that expressions of dominance may communicate a lack of empathy and understanding for the patient, as well as indifference.

Conversely, vocal delivery that conveyed concern or anxiety was often interpreted as expressing caring and empathy. These surgeons were less likely to be sued. Ambady’s research indicates that the manner, or tone, in which a physician communicates, might be as important as the words in determining whether patients will sue.

Paralanguage: Going Beyond the Words

Paralanguage, or vocalics, is the vocal characteristics of a communication. They include pitch, rate, volume, tone, intonation pattern, vocal variety, articulation, rhythm, resonance, fillers (such as “um,” “uh,” “well,” “like” and “so”) quality of breathing, word emphasis, pausing, use of silence and more. How a speaker manages these elements has a direct impact on how a message will be received and interpreted.

For the purposes of identifying positive and negative aspects of paralanguage, it helps to divide vocal delivery into two categories: clarity, or understandability, and expressiveness. While these categories blend together to produce an overall impression of the content, intent and emotionality of a message, it is useful to isolate them for our discussion.

Clarity: We must take care to communicate clearly and vocalize in a manner that is easily discernible to listeners. For example, if, as a leader, you are tasked with communicating unpleasant or difficult news, make sure that your tone, pitch and volume are appropriate to the message you wish to communicate. Pronounce your words clearly and perhaps speak slower than usual to take into account that a stressful message is typically more difficult for a listener to absorb. Make sure to pause appropriately for word emphasis, reflection and to invite listener response. The effective use of silence can provide a much-needed opportunity for both parties to ponder what has been said before continuing the conversation.

If listeners are hearing impaired, or if English is not their first language, take this into account in your delivery. If you speak with an accent, it is important to articulate clearly and slowly enough for listeners to understand your words.

Expressiveness: Paralanguage also conveys the intent and emotional tone behind your message. Using our example of communicating unpleasant news, leaders should prepare for how their messages may be received and take into account the emotional tenor they wish to create. Empathy can be portrayed by a warm, gentle, yet audible tone. Use appropriate pauses, sighs or sounds to acknowledge that the subject may be difficult for the listener to assimilate. A calm and reflective tone can help make the message more palatable. Strategic hesitation points can give the impression that the speaker is sensitive to the reality that the news may be difficult for the listener to hear.

Strategic Volcal Delivery

How a speaker can use paralanguage most effectively will vary, depending upon the situation. Different contexts require different approaches. A leader who is charged with delivering bad news may use vocalics very differently than when conversing with patients. When interacting in a day-to-day context with staff, or upper management, leaders should consider how their vocals will best illustrate the intent and content of their messages.

Note: When conversing over the phone, or on voicemail, the vocal dimension, sans the visual channel, becomes more predominant. Vocal congruence takes on even greater importance under such circumstances.

Power, Persuasion and Leadership

According to research on power and persuasion, speaking at a faster rate, with higher volume, lower pitch and full resonance carries the sound of authority. Vocal variety is also strongly associated with perceived, and actual, status and dominance.2 Other characteristics associated with higher social status, such as leadership, include clear articulation, sharp enunciation of consonants and vocal variety.3 Conversely, the use of fillers and frequent pauses are associated with lower status. As the research suggests, the use of paralanguage can substantially enhance, or hinder, a leader’s influence and image.

Potential Vocal Pitfalls

There are a host of vocal pitfalls to avoid. Speaking too quickly, loudly or softly can make it difficult for the listener to focus on the message. Pausing too much and using frequent fillers gives the impression that the speaker hasn’t prepared and doesn’t really know what to say. A flat, monotone voice gives the impression that the speaker doesn’t care about what he or she is saying. Trailing off sentences or slurring words together is distracting and also makes it difficult to comprehend what the speaker intends to communicate.

VIDEO: Watch comedian Taylor Mali’s entertaining piece on up talk.

Falling prey to the latest media-generated vocal trends can distract from the message and leave listeners wondering why you seem to be “on automatic,” less credible or disconnected from your content. “Up talk,” in which speakers end sentences in an upward cadence that sounds like a question, gives the impression the speaker is unsure about what he or she is saying. For example, imagine that a physician uses “up talk” to inform a patient that her glucose levels have risen and that this is cause for concern. The doctor’s tone may give the impression he or she is uncertain about the significance of the diagnosis. This can result in the patient taking the results less seriously or wondering about the credibility of a physician who seems so unsure.

VIDEO: Vocal fry and the potential medical harm it can cause.

Another trend is “vocal fry,” in which it sounds like the words are being gargled in the back of the speaker’s throat. Not only does this Kardashian family-promoted technique make the speaker sound childlike and somewhat robotic, it can also cause permanent damage to the vocal cords.

Be Your Own Vocal Coach

The recipe for achieving consistently excellent vocal communication includes building awareness of how you sound and being motivated to improve your paralinguistic skills.

Here are some tips:

  • Set a goal to hear what you say while you are saying it. This practice is second nature to professional presenters. Record yourself frequently and play the recordings to assess vocal strengths and areas for improvement. Work on weaker areas and make them strengths.

  • Practice hearing and managing your vocal delivery by reading aloud and listening carefully to your vocals. Use notations to help you vary your delivery.

  1. To emphasize, color words, circle them or write the words in capital letters.

  2. Indicate pauses by a backward slash.

  3. Use an up arrow to indicate your intonation should go up.

  4. Use a down arrow as a cue to bring your voice down.

  • Experiment with ways of vocalizing words and statements. Build in pauses. Practice speaking more slowly, then more quickly. Vary intonation and volume.

  • Before an important conversation or speech, practice your part out loud and listen to how you sound. Try different approaches to achieve the best vocal impact.

  • Ask for feedback from people you trust and respect about your strengths and needed improvements in your vocal delivery.

  • Commit to hearing yourself while speaking with others and “course correcting” to optimize your vocal delivery.


Leaders and physicians who take seriously the adage, “It’s not just what you say but how you say it,” seek to ensure congruence between their words and paralanguage. By expanding vocal awareness and developing vocal flexibility and acumen you can achieve greater clarity, believability and credibility in all communications.

Whether serving as a leader or a practicing physician, skillful vocal delivery is integral to achieving professional goals.

Joan Lowery, M.Ed., is a communication skills trainer and coach specializing in health care.


  1. Ambady, N, LaPlante D, Nguyen, T, Rosenthal, R, Chaumeton, N, Levinson,W. Surgeons’ Tone of Voice: A Clue to Malpractice History. Surgery, 2002 July; 123(1)

  2. Harms, LS. Listener Judgments of Status Cues in Speech. Quarterly Journal of Speech, 1961; 47(2):164-168.

  3. Moe, JD. Listener Judgments of Status Cues in Speech: A Replication and Extension. Speech Monographs, 1972; 39(2):144-147.

  4. Argyle, M. Bodily Communication. New York, NY: International Universities Press, 1975

  5. Carney, DR, Hall, JA & LeBeau, LS. Beliefs About the Nonverbal Expression of Social Power. Journal of Nonverbal Behavior, 2005 June; 29(2): 105-123.

Joan Lowery, MEd

Joan Lowery, MEd, is a communication skills trainer and coach specializing in health care. 

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