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Active listening

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  • 1. Training • EDUCATION Active listening 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. k.robertson@unimelb.edu.au 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 L 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
  • 2. 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, Judging 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 Suggesting solutions 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 really need. Following skills (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 • diverting • 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
  • 3. 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: afp@racgp.org.au Reprinted from Australian Family Physician Vol. 34, No. 12, December 2005 4 1055