Active listening : More than just paying attention

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 skil s courses are an essential component of undergraduate and postgraduate training and effective communication skil s
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 skil s, and examines how these theories apply in general practice.
‘If we could al just learn to listen, everything
undivided attention to the speaker. Knights9
language of the other... We simply try to
else would fal into place. Listening is the
defines free attention as: ‘... placing al 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 fol ow through a train of thought without
key consulting skil s 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 al5 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 verbal y and nonverbal y. It
not introduce their own views or solutions,
Levenstein and his team at the
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 skil s 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
Active listening skil s
of the components:
listening means giving one’s total and
• exploring both the disease and illness
undivided attention to the other person and
Active listening skil s are an extension of
experience
tel s the other that we are interested and
generic communication skil s and involve
• understanding the whole person
concerned. Listening is difficult work that
both verbal and nonverbal communication
• finding common ground, and
we wil 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 skil 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 wel . We
active listening requires the listener to avoid
simple information gathering.
listen to what is going on within ourselves,
common responses when listening, even
Active listening
as wel as to what is taking place in the
internal y, and these are very difficult habits
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
cal ed ‘road blocks’.11
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Education: Active listening – more than just paying attention
Roadblocks
away from the habit of labelling people
because that is what patients general y 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
However, there can be risks in
• criticising
if this is accurate, is to deny al their other
suggesting solutions. It takes responsibility
• name cal ing or label ing
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
Bolton11 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 actual y 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 al ,
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 wel . To suggest otherwise
of reference based on extensive training
Suggesting solutions
is an insult to their intel igence. 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
al 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
real y 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 stil , try to convince them that they
• Summarise the major issues
real y 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

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Education: Active listening – more than just paying attention
Avoidance can be conscious or
judgment and expertise, it is quite tiring
3. Stewart M, Brown JB, Weston WW, et al. Patient
unconscious. Sometimes people simply don’t
when done well. To completely empty
centred medicine. Transforming the clinical method.
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.
choice. Perhaps the topic is too chal enging
try to understand al of this about another
Oxford: Oxford University Press, 1989.
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.
particular time. Perhaps they wish to remain
but mental energy and a preparedness to
6. Novack DH, Dube C, Goldstein MG. Teaching
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
is inappropriate to actively listen in any given
the details are clumsy. And in the process of
and Aged Care, Commonwealth of Australia:
Canberra 2000.
situation, but rather than deny the need,
exploring a situation so that another person
8. Kel y L. Physician as listener. Can Fam Physician
it is usual y more helpful to acknowledge
fully understands it, the situation often
2001;47:233–5.
it, and arrange a more appropriate time or
becomes clearer to the speaker as wel , and
9. Knights S. Reflection and learning: the importance
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.
If a person’s concerns and worries are not
10. Mackay H. The good listener. Better relationships
Learning active listening
through better communication. (Previously
addressed, they tend to compound over
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
Macmil an, 1994.
timely interventions when the issues are
learning it is not like learning a skil that is
11. Bolton R. People skil s. How to assert yourself, listen
first raised.
to others, and resolve conflicts. New Jersey: Prentice
12 As McWhinney points out in
added to what we know. It is a peeling away
Hal , 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
is that, while time in the short term is
respond to what we hear’.
physician. New York: Praeger, 1986.
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 natural y fol ows the
listening, as wel as an identification of
natural evolution, and (hopeful y) resolution
the skil s involved. Two references in
of life problems. General practitioners
particular offer approaches to teaching
active listening: reference 3, and 13.
can use the passage of time to their own
As with most communication skil s
advantage, and divide the exploration of
however, active listening is most
issues, and the application of coping
effectively learnt experiential y, for
strategies into manageable ‘chunks’.4
example through Balint groups, or the
Active listening in clinical practice
University of Melbourne’s Advanced
Consulting and Communication Skil s
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 skil s of the GP.
awareness to avoid slipping into the patterns
summarised as roadblocks. It is not a skil
Conflict of interest: none declared.
that can or should be used al the time, for
example in a medical emergency, or when
References
the patient is drug affected or psychotic.
1. Kel y L. Listening to patients: a lifetime perspective
from Ian McWhinney. CJRM 1998;3:168–9.
Besides being clinical y 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

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