Communication: a vital component of highly effective patient care

Most would agree that there is an art as well as science to the practice of veterinary medicine. Under which of these categories would you place the skill of communication? Whether one thinks of communication as an art or science, or both, one fact is certain: We could not practice veterinary medicine without communicating with others. How we communicate with our clients can be a source of mutual understanding and positive action or a source of misunderstanding and frustration. In this context, communication is a vital component of providing highly effective patient care.

In terms of communication, rate the following components, in your opinion, as most important: listening, speaking or understanding? Before answering this question, please consider the following points.

Listening

Effective communication involves more than mastering speech. It is also vitally linked to our desire and ability to listen. Although all of us have had formal training in how to read, write and speak effectively, how many of us have received a balanced training program on how to effectively listen? For most of us, listening is a skill that we acquire informally. Our lack of training in the skill of listening is ironic when one considers that in our role as veterinarians, successful communication with our clients is dependent on our ability to listen and understand their needs and feelings in addition to speaking in a way that they will understand us. In fact, the first step in collecting diagnostic information typically begins with listening to our clients while they describe their concerns. Good listening skills are not only essential for accurate evaluation of a patient's illness, they convey our sincere interest in the overall welfare of the client and patient. Therefore, in addition to developing our IQ's, we must develop our EAR-Q's.

When beginning to listen to our clients' concerns, what should be our primary motive for doing so? Should we listen to them primarily with the intent to reply? If so, we are practicing reactive listening. Reactive listening encompasses responses that interrupt, probe, interpret and advise? When we reactively listen, we often provide responses that convey our own point of view about our clients' concerns. This may be categorized as the "doctor-centered component of the clinical interview." But isn't this our primary goal? Isn't it true that if clients are seeking our expert advice in our role as veterinarians, then they should be listening to us for our recommendations? Before you answer these questions, please consider your personal experiences with physicians.

Have you ever felt that physicians you consulted for help with an illness didn't take the time to listen carefully to your concerns before making a diagnosis and recommending therapy? Have you experienced encounters with physicians whose controlling style of inquiry about your concerns felt more like an interrogation than a conversation? If your answer is "yes", then you are not alone. For example, in one study physicians interrupted 69 percent of their patients before they could complete their opening statements in effort to direct questions toward a specific concern. The mean time to the first interruption was 18 seconds. Once interrupted, fewer than 2 percent of patients went on to complete their statements (Beckman et al: Annals Internal Medicine, 1984, 101: 692-695). If the doctor responded to your concerns without really understanding them, how did you feel? Now, contrast this feeling to when a physician took the time to listen to you with the intent of understanding your concerns. What is the point? Failure to listen with the intent to understand our clients' feelings and viewpoints can be a major obstacle to further communication. In fact, many clients might loose confidence in our desire to help them. Furthermore, many clients won't care about how much we know until they know how much we care. To some, caring is more important than curing.

Contrast listening with the primary intent to respond (reactive listening) to listening with the primary intent to understand (empathic listening). The word empathy encompasses our capacity to understand and acknowledge our clients' feelings and point of view, whether we agree with them or not. In addition, empathic listening encompasses our heartfelt desire to understand the feeling of what is being said in addition to the content of what is being said. It also encompasses sensitivity to nonverbal elements of our clients' communication. Therefore, the initial phase of the interview with our clients typically involves asking open-ended questions designed to clarify our understanding of their concerns and also patiently listening attentively to their responses. This may be categorized as the "client/patient-centered component of the clinical interview." We can convey our genuine interest by a few words (i.e. "Tell me more", or "Then what happened?"), a nod or a gesture. The goal of empathic listening is to promote the free flow of information. If interrupting becomes necessary because of lack of understanding, then we can explain this point with a statement such as, "Excuse me; I didn't completely follow your last comment." As the interview proceeds, we can exert more influence by making an appropriate transition from open-ended questions to close-ended questions. Our ultimate objective is to paraphrase or summarize the clients' concerns and point of view in such a way that they will recognize that we empathically understand them.

Some may object by stating that in a busy clinic or hospital, empathic listening requires too much time, and therefore is not cost effective. But is this generality valid? It is true that including patient centered empathic listening as a part of the clinical interview initially might require more time than a tightly controlled doctor centered clinical interview. However, in the long run, it often is more efficient and requires less time than trying to correct misunderstandings and loss of our clients' confidence in our character and competence that occur as a result of an imbalance between empathic (patient-centered) listening and reactive (doctor-centered) listening.

Speaking

Most of us receive some formal training in speaking in order to learn how to express ourselves to others effectively. We learn that a fundamental requirement of good speech is that it be easily understood. In context of the practice of veterinary medicine, this often requires that we communicate with our clients using the language of a non-medical person. While striving to speak to our clients in a way that fosters understanding, we must use discernment so we don't give the impression that we are talking down to them. Our conversation should be gracious as well as sensible. Won't you agree that our clients are most likely to feel our respect for them if we speak in a dignified and caring manner? To paraphrase Hippocrates, our words should first do no harm. Thought and practice are often required to express the right things in the right way.

In addition, the message conveyed by what we say is often heavily influenced by how we say it. Our comments often impart latent as well as literal meanings. Messages as simple as "Look who's here!", "Guess who just walked in?", and "What next!" can convey sarcasm, irony or joy. Why? Because the tone, pitch, volume and modulation of our voice sends powerful signals of what we are thinking and feeling. Even if you do not understand the language being spoken, if one person sounds impatient, arrogant, intolerant, critical and harsh and another person sounds humble, patient, kind and compassionate, then it is not difficult to tell the difference.

Nonverbal factors, such as body position, facial expression and personal appearance, are also key components of communication. More than any other nonverbal feature, our face often reflects how we really feel. Our eyes, the shape of our mouth, and the inclination of our head all play a part. Without a word being spoken, our face can convey indifference, disgust, perplexity, amazement or delight. A face that is devoid of expression can raise questions about our sincerity. On the other hand, a warm smile tells others that we have a kindly feeling toward them. In addition, a smile can help our clients to relax and to be more receptive to what we are saying.

A wise sage once said, "We speak with our eyes." We could add eyebrows to this sentence. Our eyes and eyebrows communicate attitudes and emotions. They may convey surprise, compassion, fear, grief, doubt or dislike. (Consider this observation: He gave her the evil eye!") Maintaining friendly eye contact with others often promotes trust. Looking an individual in the eye when making an important statement can also add emphasis to what we say. On the other hand, our clients might doubt our sincerity or competence if we avoid respectful eye contact with them during our conversation. Yet, in context of communication, discernment is often required. Some individuals might view intense eye contact as rude, aggressive or challenging.

Our personal appearance also can be a factor in that it can add to or distract from our message. Dressing in a neat and attractive manner conveys respect for our clients and those with whom we work.

What are the most-important components of communication?

Please recall the question raised at the beginning of this essay: "Which of the following components is, in your opinion, most important: speaking, listening, or understanding?" Won't you agree that choosing whether speaking, listening or understanding is most important in fostering communication is comparable to choosing which leg is most important on a three-legged stool? In both examples, all three components are important and must be in proper balance with each other to achieve the desired result.

Communicating with our clients is not only a science (i.e. we must ask them the right questions), it is an art (i.e. we must ask them the questions right). To achieve this balance, considerable skill in speaking is required to efficiently direct the flow of information without stifling their conversation or putting words in their mouth.

Listening skills are also of paramount significance. In addition to learning how to listen and when to listen, we also must want to listen. When clients realize that we are empathically listening to them because we want to understand them, they are most likely to feel that we are serving them to the best of our ability. In this way, we build trusting relationships that enhance our ability to provide highly effective patient care. Stephen Covey, author of the book "The Seven Habits of Highly Effective People" summarized this important concept in this way: "Seek first to understand, and then be understood." By empathically listening and speaking to our clients, they in turn are more likely to listen to our interpretations of the causes of their concerns, and to ultimately comply with our recommendations of options to solve them.

For everything there is an appointed time. A time to listen and a time to speak.

-After, Ecclesiastes 3: 1,7