Training • EDUCATION
More than just paying attention
Kathryn Robertson, MBBS, FRACGP, MEd, is Senior Lecturer, Department of General Practice, University of
Melbourne, and a general practitioner, Victoria. firstname.lastname@example.org
Communication skills courses are an essential component of undergraduate and postgraduate training and effective communication skills
are actively promoted by medical defence organisations as a means of decreasing litigation. This article discusses active listening, a difficult
discipline for anyone to practise, and examines why this is particularly so for doctors. It draws together themes from key literature in the field
of communication skills, and examines how these theories apply in general practice.
‘If we could all just learn to listen, everything undivided attention to the speaker. Knights9 language of the other... We simply try to
else would fall into place. Listening is the defines free attention as: ‘... placing all of absorb everything the speaker is saying
key to being patient centred’. one’s attention and awareness at the disposal verbally and nonverbally without adding,
Ian McWhinney1 of another person, listening with interest subtracting, or amending’.4
and appreciating without interrupting’. This It is unusual to be given the opportunity
istening is consistently included among is a rare and valuable commitment, as to follow through a train of thought without
key consulting skills in both medical texts2–6 most discussions involve competition for a interruption. To do so is both a validation
and results of patient surveys.7,8 Silverman space to speak. Active listening is a difficult of the thought processes (although not
et al 5 in particular, provide an excellent discipline. It requires intense concentration necessarily of the views themselves), and
summary of the evidence then available and attention to everything the person is of the individual. While the listener does
supporting the importance of listening. conveying, both verbally and nonverbally. It not introduce their own views or solutions,
Leve n s t e i n a n d h i s t e a m a t t h e requires the listener to empty themselves they are far from passive. Instead they
University of Western Ontario developed of personal concerns, distractions and draw on high level skills in assisting the
a patient centred model consisting of six preconceptions. 4 Hugh Mackay points out speaker to reflect: listening and exploring,
interconnecting components. 3 While in The good listener that this takes courage, understanding and relating, and focussing
listening to the patient underpins the whole generosity and patience.10 and assisting.9
model, it is particularly fundamental to four As Carl Rogers said in 1980: ‘Attentive
of the components: listening means giving one’s total and
Active listening skills
• exploring both the disease and illness undivided attention to the other person and Active listening skills are an extension of
experience tells the other that we are interested and generic communication skills and involve
• understanding the whole person concerned. Listening is difficult work that both verbal and nonverbal communication
• finding common ground, and we will not undertake unless we have deep (Table 1).5,10,11 In some ways, active listening
• enhancing the patient-doctor relationship. respect and care for the other... we listen is characterised more by what is not done,
Active listening extends this core skill and not only with our ears, but with our eyes, than what is done. This is because real
further develops its therapeutic role beyond mind, heart and imagination, as well. We active listening requires the listener to avoid
simple information gathering. listen to what is going on within ourselves, common responses when listening, even
as well as to what is taking place in the internally, and these are very difficult habits
Active listening person we are hearing. We listen to the to break. In other circumstances many of
Active listening is a specific communication words of the other, but we also listen to the these responses may be entirely appropriate,
skill, based on the work of psychologist messages buried in the words. We listen but in active listening these are commonly
Carl Rogers, which involves giving free and to the voice, the appearance, and the body called ‘road blocks’.11
Reprinted from Australian Family Physician Vol. 34, No. 12, December 2005 4 1053
Education: Active listening – more than just paying attention
Roadblocks away from the habit of labelling people because that is what patients generally seek
by their disease, eg. to refer to ‘a person from their doctors – solutions, answers,
with epilepsy’ rather than ‘an epileptic’. To cures, and guidance.
Judging may include: label someone by one characteristic, even H oweve r, t h e r e c a n b e r i s k s i n
• criticising if this is accurate, is to deny all their other suggesting solutions. It takes responsibility
• name calling or labelling experiences, talents, weaknesses, and away from the other person. It implicitly
• diagnosing personality traits. It reduces them to their disempowers the other person by saying:
• praising evaluatively. disease, and denies them their individuality. ‘You can’t solve the problem, but I am
Carl Rogers stated that the natural tendency Bolton 11 quoted the psychologist Clark better/smarter/more worldly than you, so
to evaluate from the listener’s own frame of Moustakas in his book People skills: ‘Labels I have to do it for you’. This can make the
reference, and approve or disapprove of what and classifications make it appear that we person feel belittled or patronised.
another person is saying, is the major barrier know the other, when actually, we have A person will usually have been
to successful interpersonal communication. caught the shadow and not the substance. pondering their problem for some time
He felt this was particularly the case when Since we are convinced we know ourselves before they present with it. If a solution
the topic was linked to strong emotions. and others... [we] no longer actually see seems obvious to the listener after only a
This is an area that can be especially what is happening before us and in us, and, short time, the chances are it is obvious
difficult for medical practitioners. After all, not knowing that we do not know, we make enough to have occurred to the person with
evaluating and diagnosing, using a frame no effort to be in contact with the real’. the problem as well. To suggest otherwise
of reference based on extensive training is an insult to their intelligence. Therefore
and experience, is exactly the task of most the issues then become: have they already
medical consultations. However, in special These type of ‘roadblocks’ include: tried the solution? Presumably it has already
circumstances that benefit from active • ordering failed, what factors led to its failure? If they
listening, the doctor must consciously • threatening have not tried the obvious solution, why
recognise the need, commit to actively • moralising not? What are the other factors about the
listen, and move into a different domain of • excessive/inappropriate questioning situation that means they have decided not
interaction with their patient. • advising. to proceed with the obvious solution? More
There have been strong moves from This is another area that can be particularly active listening is needed!
consumer groups to encourage doctors problematic for medical practitioners A sign that suggesting solutions at
this particular point is not appropriate
Table 1. Active listening skills is when the speaker starts to block the
suggestions. This can be frustrating to both
Attentive body language parties, and distract them from teasing out
• Posture and gestures showing involvement and engagement all the thoughts and emotions about the
• Appropriate body movement problem. Alternatively, some people simply
• Appropriate facial expressions ‘shut down’, outwardly appearing passive
• Appropriate eye contact and compliant, but inwardly disengaged
• Nondistracting environment and resigned to not getting the help they
(Giving the speaker space to tell their story in their own way) Avoiding the other’s concerns
• Interested ‘door openers’
A third type of ‘roadblock’ is avoiding the
• Minimal verbal encouragers
other’s concerns by:
• Infrequent, timely and considered questions
• Attentive silences
• logical argument
Reflecting skills • reassuring.
(Restating the feeling and/or content with understanding and acceptance) These roadblocks deny the person the
• Paraphrase (check periodically that you’ve understood) opportunity to talk about their problems, or
• Reflect back feelings and content worse still, try to convince them that they
• Summarise the major issues really aren’t serious problems, and they are
foolish to be worried about them.
1054 3Reprinted from Australian Family Physician Vol. 34, No. 12, December 2005
Education: Active listening – more than just paying attention
Avo i d a n c e c a n b e c o n s c i o u s o r judgment and expertise, it is quite tiring 3. Stewart M, Brown JB, Weston WW, et al. Patient
centred medicine. Transforming the clinical method.
unconscious. Sometimes people simply don’t when done well. To completely empty Thousand Oaks, California: Sage Publications,
hear the cues, the requests to be listened oneself of ones own prejudices, patterns of 1995;267.
to. But sometimes avoidance is a conscious responding and frame of reference, and to 4. McWhinney IR. A textbook of family medicine.
Oxford: Oxford University Press, 1989.
choice. Perhaps the topic is too challenging try to understand all of this about another
5. Silverman J, Kurtz S, Draper J. Skills for
to the listener, perhaps they simply don’t person is an act of great generosity and communicating with patients. Oxon: Radcliffe
have the time or energy to expend at this respect. It is a commitment of not only time, Medical Press, 1998.
6. Novack DH, Dube C, Goldstein MG. Teaching
particular time. Perhaps they wish to remain but mental energy and a preparedness to
medical interviewing. A basic course on interviewing
in control of the conversation, to keep it in explore another person’s world and see the and the physician-patient relationship. Arch Intern
areas in which they feel comfortable. way life appears to them. 10 People often Med 1992;152:1814–20.
There may be legitimate reasons why it respond to this intention, even if some of 7. General Practice in Australia. Department of Health
and Aged Care, Commonwealth of Australia:
is inappropriate to actively listen in any given the details are clumsy. And in the process of Canberra 2000.
situation, but rather than deny the need, exploring a situation so that another person 8. Kelly L. Physician as listener. Can Fam Physician
it is usually more helpful to acknowledge fully understands it, the situation often 2001;47:233–5.
9. Knights S. Reflection and learning: the importance
it, and arrange a more appropriate time or becomes clearer to the speaker as well, and
of a listener. In: Boud D, Keogh R, Walker D,
setting to address it. It is also surprising the possible directions for changing the situation editors. Reflection: turning experience into learning.
power of simple acknowledgment in itself. emerge from the mire.12 New York: Nichols Publishing Company, 1985.
10. Mackay H. The good listener. Better relationships
If a person’s concerns and worries are not
addressed, they tend to compound over
Learning active listening through better communication. (Previously
published as Why don’t people listen?) Sydney: Pan
time, which may be prevented by small, ‘You can learn to be a better listener, but Macmillan, 1994.
timely interventions when the issues are learning it is not like learning a skill that is 11. Bolton R. People skills. How to assert yourself, listen
to others, and resolve conflicts. New Jersey: Prentice
first raised.12 As McWhinney points out in added to what we know. It is a peeling away Hall, 1986.
his book A textbook of family medicine, a of things that interfere with listening, our 12. Stuart MR, Lieberman JA. The fifteen minute
particular characteristic of general practice preoccupations, our fear, of how we might hour. Applied psychotherapy for the primary care
physician. New York: Praeger, 1986.
is that, while time in the short term is respond to what we hear’.
13. Kurtz S, Silverman J, Draper J. Teaching and
pressured and difficult to find, the ongoing Ian McWhinney1 learning communication skills in medicine.
relationships between GPs and their patients Abingdon: Radcliffe Medical Press Ltd, 1998;245.
means that there are abundant opportunities The references for this article provide a AFP
to revisit issues in the long term. And, taking theoretical and evidence base for active
a long term view more naturally follows the listening, as well as an identification of
natural evolution, and (hopefully) resolution the skills involved. Two references in
particular offer approaches to teaching
of life problems. General practitioners
active listening: reference 3, and 13.
can use the passage of time to their own
As with most communication skills
advantage, and divide the exploration of
however, active listening is most
issues, and the application of coping effectively learnt experientially, for
strategies into manageable ‘chunks’.4 example through Balint groups, or the
University of Melbourne’s Advanced
Active listening in clinical practice
Consulting and Communication Skills
McWhinney asserts that the greatest single course. Ultimately, experiencing the
problem in clinical interviewing is the failure impact of active listening on our patients
to let the patient tell their story. 4 Active and our consultations provides the most
listening is an advanced communication powerful insight into its inclusion among
skill, which takes practise and constant the communication skills of the GP .
awareness to avoid slipping into the patterns
summarised as roadblocks. It is not a skill Conflict of interest: none declared.
that can or should be used all the time, for
example in a medical emergency, or when References
1. Kelly L. Listening to patients: a lifetime perspective
the patient is drug affected or psychotic.
from Ian McWhinney. CJRM 1998;3:168–9.
Besides being clinically inappropriate, when 2. Fraser RCE. Clinical method. A general practice Correspondence
what a situation requires is professional approach. London: Butterworths 1987;87. Email: email@example.com
Reprinted from Australian Family Physician Vol. 34, No. 12, December 2005 4 1055