Lessons on listening

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

— Ecclesiastes 3:1-8

Most would agree that there is an art as well as science to the practice of veterinary medicine, and that communication is a vital component of providing highly effective patient care.

Whether one thinks of communication as an art, 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.

Which of these communication components is, in your opinion, most important: listening, speaking or understanding?

This month we consider the importance of listening. Speaking and understanding are topics for future columns.

Learning to listen

Effective communication involves more than mastering speech. It is vitally linked to our desire and ability to listen. Although many of us have had formal training in reading, writing and speech, how many of us have been trained to listen effectively?

Listening is a skill most of us acquire informally. Our lack of formal training in listening is ironical, considering that successful communication with our clients depends on listening and understanding their needs and feelings. In fact, the first step in collecting diagnostic information typically begins with listening to our clients' concerns.

Good listening skills are not only essential for accurate evaluation of a patient's illness, but empathic listening conveys our interest in the overall welfare of the client and patient. Therefore, in addition to developing our IQs, we must learn to develop our EAR-Qs.

An ear toward reactive listening

When we to listen to our clients, what should be our primary motive? Should we listen mostly with the intent to reply? If so, we are practicing reactive listening.

When we listen reactively, often we provide responses that convey our point of view about clients' concerns. This may be categorized as the "doctor-centered component of the clinical interview." Some may ask, "But, isn't this our primary goal? Isn't it true that if clients are seeking our expert advice, they should be listening for our recommendations?"

Have you ever visited a physician who didn't take time to carefully listen to your concerns before making a diagnosis and recommending therapy? Have you encountered doctors whose controlling style of inquiry about your concerns felt more like an interrogation than a conversation? If you have, you are not alone.

In one study, physicians interrupted 69 percent of their patients before they could complete their opening statements. The average time-lapse 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? Did you have confidence in his recommendations? Would you return to him/her again?

Now, compare this feeling to the response you had 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 clients' feelings and viewpoints can be a major obstacle to further communication. In this situation, many clients may lose confidence in our desire to help them. Many won't care about how much we know until they know how much we care. To some, caring is more important than curing.

Contrast reactive listening (with the primary intent to respond) to empathic listening (with the primary intent to understand). In the context of this essay, 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 desire to understand the feeling of what is being said in addition to the content. It encompasses sensitivity to nonverbal elements of our clients' communication.

Out in the open

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 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 (e.g., "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, we can simply say, "Excuse me; I didn't completely follow your last comment."

At the appropriate time, we can exert more influence on the interview by making a transition from open-ended questions to close-ended questions. The objective is to paraphrase or summarize the clients' concerns 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 valid? It is true that patient-centered empathic listening may take more time initially than a tightly controlled, doctor-centered clinical interview. In the long run, however, 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 as a result of an imbalance between empathic (patient-centered) listening and reactive (doctor-centered) listening.

Nonverbal factors such as body position, facial expression and personal appearance are key components of listening. 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 devoid of expression may 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 relax and be more responsive in communicating with us.

A wise man once said, "We listen with our eyes." We could add eyebrows to that. Our eyes and eyebrows communicate attitudes and emotions, including surprise, compassion, fear, grief, doubt or dislike (e.g., He gave her the evil eye.).

Maintaining friendly eye contact with others often promotes trust. On the other hand, our clients may doubt our sincerity or competence if we avoid respectful eye contact during conversation. Still, discernment is needed. Some may view intense eye contact as rude, aggressive or challenging.

A matter of trust

In addition to learning how and when to listen, we must want to listen. When clients realize we are empathically listening to them because we want to understand them, they are more likely to feel we are serving them to the best of our ability. That helps build trusting relationships that enhance our ability to provide effective patient care.

Stephen Covey, author of The Seven Habits of Highly Effective People, summarized that important concept this way: "Seek first to understand, and then be understood."

By empathically listening to our clients, they in turn are more likely to listen to our interpretations of the causes of their concerns, and ultimately to comply with our recommendations.

Common barriers to effective listening

Removing barriers is important to being able to listen effectively to our clients. Barriers can come in many forms, including:

• Language: Do we attempt to ensure that our clients understand our questions, and do we understand them?

• Interruptions: Do we allow cell phones routinely to interrupt us while listening to our clients?

• Physical barriers: Is there a desk or an exam table that physically separates us from our clients?

• Emotions: We may be uncomfortable dealing with a distraught or irate client. Conversely, a client may be embarrassed by his or her show of emotion and be unwilling or unable to open the door to communication.

• Body posture: Do we stand above our seated clients with folded arms when listening to them?

• Time: Are we focused on the clock and not on our patients?

• Mental focus: Are we thinking about other problems while giving the impression that we're listening to our clients?

In summary

So, what have we learned? Here are 25 statements to consider:

• Good listening skills are an essential part of conveying our interest in the overall welfare of patients and clients.

• In addition to developing IQs, we must keep developing our EAR-Qs, listening with the goal of understanding meanings and noting the feeling with which concerns are stated.

• To be good listeners, we must take note of what is not said.

• Empathic listening is motivated by the intent to understand.

• Many people don't listen with the intent to understand; they listen with the intent to reply.

• Many clients won't care how much we know until they know how much we care.

• Empathic listening encompasses our capacity to understand and acknowledge our client's point of view, whether we agree with them or not.

• By paraphrasing or summarizing our client's concerns, they will be more likely to recognize that we empathically understand them.

• In addition to learning how and when to listen, we must want to listen.

• A good boss is one whose ears get as much exercise as his or her mouth.

• Listening involves patience, openness and a desire to understand.

• We should be quick to listen, but slow to speak.

• We must want to empathically listen to others, and practice for it to become a personal communication style.

• Too often we do not listen with the intent of understanding (empathic listening), because we have developed the habit of listening with the intent to reply (reactive listening).

• Listening shows courtesy, respect and appreciation.

• Good communication is dependent on an open mind as well as an open door.

• Good listeners generally make more sales than good talkers.

• Allow others to complete their thoughts without interrupting.

• When someone replies to a matter before hearing it completely, that is foolishness.

• Reacting defensively is a barrier to further communication.

• Non-verbal nodding and good (but not piercing) eye contact tells our clients that we are listening.

• One component of effective listening is to be patient without being passive.

• Smiling at opportune times puts the client at ease.

• Nervous fidgeting (shuffling papers, tapping fingers) may be perceived as disinterest toward the speaker.

• Finally, we have learned that we were given ears that don't close, and a mouth that does — for a very obvious purpose.

Dr. Osborne, a diplomate of the American College of Veterinary Internal Medicine, is professor of medicine in the Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Minnesota.

Lisa Ulrich is a certified veterinary technician, a 1983 graduate of the University of Minnesota-Waseca. She joined the team at the Minnesota Urolith Center in 1987.