“Listen to your patient; he is telling you the diagnosis.”
William Osler
Listening is an art and in clinical practice its value cannot be over emphasised. Learning to listen fully with body, mind and heart is the foundation for compassionate care in medical practice.
Being listened to is a fundamental human need(1) particularly when a person is facing illness and needs to understand what is happening to their body and mind. In the medical setting, attentive listening is a core skill for patient care(2) and active and attentive listening is the basis of effective clinical practice. In her book, “Dying for a chat”(3) Dr Ranjana Srivastava talks about the need for good communication in hospital settings and how indeed failing to listen has the potential for incorrect diagnosis and management.
How often do our patients or their families feel dissatisfied with their care because they feel they have not been heard?
Just as a stitch in time is said to save nine, so effective listening can save time, help to make the correct diagnosis and increase patient satisfaction.
Recently after an exercise in history taking, a fourth-year student commented in his feedback that he had learned clinical communication in second year and did not need reminding. I had to chuckle, as 40 years later I am still learning. Many of us as clinicians believe we are skilled listeners, but in practice this may not be the case.
A 2001 study(4) of communication in 60 consultations in a primary care setting, reported that patients spoke, uninterrupted, for an average of 12 seconds after the resident entered the room. 25% of the time, residents interrupted patients before they finished speaking. Residents averaged interrupting patients twice during a visit. The time with patients averaged 11 minutes, with the patient speaking for about 4 minutes. Could this be called effective and supportive listening?
Carl Rogers, known as the father of client centered psychology, presenting his work in 1957(5) talked of the value of “active listening”. He says that active listening can be a growth experience for both the listener and the person being listened to. When an atmosphere of equality and freedom, permissiveness and understanding, acceptance and warmth is created by the listener and they are listened to sensitively, the speaker tends to feel unthreatened, listening to themselves with more care and bringing clarity to how they are thinking and feeling. For the listener, listening with genuine interest, a positive relationship deepens as understanding develops.
Patients put a high value on being heard and one of our patients’ most common criticisms of their medical care is that they have not been listened to. In a survey of general medical patients who were asked what should be included in medical training all participants, unprompted, talked about clinician listening skills.(6)
Why is listening so important?
In clinical practice, it is important to consider why we are listening and what information we are hoping to gather. While Adam Brenner in his paper, Listening: An Underlying Competency in Psychiatry Education(1) is talking about training of psychiatrists, much of what he says is relevant to family practice, where a large proportion of our patients have psychiatric problems and indeed to any branch of medicine because wherever we are working good communication is vital.
He suggests there are 3 essential tasks achieved through listening: listening for content and data; listening for the patient’s distress; and listening for narrative meaning.
The first we are trained for well in medicine and from first year emphasis is put on “taking a good patient history.” However, are we truly listening? We are sometimes too quick to break the patient’s flow, following the opening: “How are you, what is concerning you today…….” with closed questions: “Have your bowels opened” and the like.
In doing this we may indeed have gathered the information to make a diagnosis, but we may well have missed or at least delayed completing our other tasks and in doing so failed to identify the patient’s underlying and perhaps most important concerns and the level of their distress. We may have failed to support the patient to come to an understanding of their own problems and to find their own solutions. We have perhaps failed to demonstrate the compassion patients need to heal. We forget that in truly being heard our patients may feel that their suffering, be it physical or mental, has been acknowledged and validated and this is in itself therapeutic.
Physician overload, fatigue and time constraints may be barriers to giving our patients the space they need to process their own thoughts and feelings.
How to listen effectively
Listening is a learnable skill.
We tend to think of listening being merely focusing our ears, but listening is really a whole body activity, using all of our senses!
Listening with our own body
First comes the use of a sense we utilise all the time but rarely define or speak about; being aware of energy. We continually have our antennae out, but become most conscious of this when a new situation presents itself. This is the very basic instinct which “feels” the difference between safety and danger but as doctors we can use it to feel all ranges of emotions from anger to sadness to joy. We can feel where there is harmony or disharmony. We can observe this in how close we seat ourselves, are there barriers there?
Developing this energetic awareness is not something we are taught in medical school but it enhances our understanding of our patients. To do this we need to be consciously present – focused on the speaker and what is being said – keeping eye contact if that is what they are asking for, and also being aware of ourselves, our own reactions and the messages we are giving out.
Listening with our ears
Then of course to listen we use our ears but never on their own, for we are not only hearing but trying to make sense of what is being said. It is not a time to be thinking of what we will say next, but rather of concentrating on what is being said, how it is being said and bringing meaning to this. That is the difference between listening and merely hearing. This means being aware not only of content but of intonations, volume and emphasis.
Allow the patient to speak, offering only encouragement but trying not to interrupt. Acknowledge their emotions and when their flow has finished there may be need for clarification but not yet for offering opinion. When I practise this with my students it is harder than it seems, in under a minute they are struggling. Sometimes patients struggle, so used are they to being given good advice. It is useful as the listener to consider yourself supporting the patient to make their own decisions rather than as the clinician making decisions for them. And as the Dalai Lama has said:
“When you talk, you are only repeating what you know; but when you listen you learn something new.”
Observing body language
Observing body language is an important aspect of listening. What does the body language on its own tell you? Is the body language congruent with what is being said? Is the patient making eye contact? What are the eyes telling us? Even when a patient is unable to speak coherently we can learn much by taking time to observe – are they sitting peacefully in no distress, or are they distressed and agitated? Allow for silences – these are times for the speaker to reflect on what they have just said and how it has made them feel. Listen too for what is left unsaid, for there may be another whole story in that.
Being aware of self
Be aware of yourself in the encounter. When actively listening, our own bodies have much to tell us. What are we feeling, how are we reacting? I was observing this with a patient who was describing to me what he would like to do with his neighbour, how he would like to tie him up and drag him behind his car. My lack of fear or distrust told me these were empty threats and the emotion behind them was not anger but grief. Equally I have felt very threatened by patients who have not said a word, raised a voice or clenched a fist. How we feel may also tell us how other people feel and react when meeting our patient.
Using all of our senses
We use all of our senses in interpreting what we are being told, putting the story together, making sense of it, building a picture of the patient, their life and their concerns. It tells us how best to communicate, where to tread lightly, what we need to clarify and how to respond to them in a way that will best support them.
What does this encounter taste like, what is the flavour? What does it smell like? Does it smell fishy?
We set the foundation for shared understanding and through this our relationship with our patient deepens.
When listening in this way is accompanied by listening with heart, with compassion we are taking communication to another level, a level of healing. Our patient not only feels heard, but held and loved. This allows them to express from their deeper selves, feeling they are valued for themselves and not judged. It allows them to connect with their own deeper wisdom which will help them to come to decisions which are right for them. Yes, what you are suggesting is right. No, that path of treatment is not for me.
Our patients deserve no less than this – to be listened to in a way where they know they have been fully heard, where they have felt completely safe to speak, where they have been held in compassion and where they themselves have been able to hear what their own heart is saying.
References:
- Brenner A, Listening: An Underlying Competency in Psychiatry Education; Acad Psychiatry (2017) 41:385–390
https://www.ncbi.nlm.nih.gov/pubmed/27882521
- Boudreau JD, Cassell E, Fuks A. Preparing medical student to become attentive listeners. Med Teach. 2009;31:22–9.
https://www.ncbi.nlm.nih.gov/pubmed/19140065
3. Rajana Srivastava “Dying for a Chat”: Penguin
https://www.penguin.com.au/books/dying-for-a-chat-penguin-special-9780143569640
4. Rhodes, KF McFarland, Speaking and interruptions during primary care office visits. – Family Medicine 2001
https://www.ncbi.nlm.nih.gov/pubmed/11456245
- Carl Rogers and Richard E. Farson: “Active Listening”, Excerpt from 1957 article, Chicago (University of Chicago Industrial Relations Center) (25 pp.);
http://info.gmu.edu/TrainingManual/ActiveListening_RogersFarson.pdf
6. Boudreau JD et al.: Patients’ perspectives on physicians’ roles: implications for curricular reform. Acad Med. 2008; 744–753.s
Great article, you make some very important points.
If the medical practitioner does not truly listen as you have outlined, then he/she may not pick up vital clues in being able to fully diagnose the cause of the illness, pain being suffered etc. It is in the subtle messages that emerge from a truly open discussion without unnecessary interruptions from the practitioner. It is more than just good manners to listen closely to what the patient is sharing, in some cases it may be vital information.
A deeply rich and beautiful read, thank you Dr Barker. It is not always easy to listen in such a way as we can get caught up in finding a solution or a fix at times. I know I have. Awareness of ourselves goes a long way and allowing space. I have often been amazed at how much further is learned about a patient’s situation when space is allowed and how, often the patient or their family member come to an understanding or a choice for themselves which is so empowering for them and a joy to observe and be part of.