Learning to Listen

Effective communication involves more than mastering speech; it is also vitally linked to our desire and ability to listen. Although many veterinarians have had some training in how to effectively read, write, and speak, few have received a balanced training program on how to effectively listen. Most of us acquired listening skills informally. Our lack of training in listening skills is unfortunate because successful communication with clients is dependent on our ability to listen and understand their needs and feelings. Communication cannot occur without understanding. Thus, effective communication requires not only use of your vocal cords and intellect (figuratively, the brain) but also your ear and emotional nature (figuratively, the heart). The combination of listening and empathizing is sometimes called listening with your third ear, a wordplay based on the letters of the word ear being contained within the letters of the word heart.

The first step in collecting diagnostic information typically involves listening to our clients as they describe their concerns. Our patients cannot talk, so practicing good listening skills not only is essential for the accurate evaluation of a patient's illness, but also conveys our interest in the overall welfare of the client and patient. The type and quality of patient care is established through skillful use of the various components of communication. Only by listening can veterinarians learn what their clients want. The level of care selected by a client tightly bonded to his or her specific dog is likely to be different from the level of care selected by a client who simply wants to own any dog. Therefore, veterinarians must continue to develop their ability to identify and assess the emotions and concerns of others through listening.

When we 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 veterinarian-centered component of the clinical interview. Some may contend that this is our primary goal and that if clients are seeking our expert advice in our role as health-care providers, they should be listening to us for our recommendations.

But ask yourself, have you ever had the experience of visiting a physician who didn't take the time to carefully listen to your concerns before making a diagnosis and recommending treatment? Have you experienced encounters with physicians whose dominating and controlling style of inquiry about your concerns felt more like an interrogation than a conversation? Such complaints are common. In one study,³ for instance, physicians were found to interrupt 69% of their patients before the patient could complete his or her opening statements, most often by asking questions directed toward a specific concern. In that study,³ the mean time elapsed to the first interruption was 18 seconds. Once interrupted, fewer than 2% of patients went on to complete their statement (ie, state their chief concern). Similar observations have been reported in veterinary medicine. In a study⁴ of companion animal practitioners, for example, veterinarians were found to interrupt their clients a mean of 15 seconds after the client began his or her opening statement. Following an interruption, 72% of the clients did not complete their statements.

If a doctor responded to your concerns without really understanding them, how would you feel? Would you have confidence in his or her recommendations? Would you return to that doctor for advice again? Now, compare this feeling to the feeling you would have when a physician listened to you with the intent of understanding your concerns. The point is that failing to listen with the intent to understand our clients' feelings and viewpoints can be a major obstacle to further communication.^5–7 In this situation, many clients may lose confidence in our desire to help them. In fact, 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 reactive listening (listening with the primary intent to respond) to empathic listening (listening motivated by the desire to understand). Empathy encompasses our capacity to understand and acknowledge our clients' feelings and point of view, regardless of whether we agree with them.^2,8 Empathic listening encompasses our 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 the nonverbal elements of our clients' communication. Therefore, the initial phase of the interview with our clients should involve asking open-ended questions designed to clarify our understanding of the clients' concerns and listening attentively to their responses. This may be categorized as the client-centered component of the clinical interview.

The goal of empathic listening is to promote the free flow of information. If interrupting becomes necessary because of a lack of understanding, then the interruption should be limited to clarifying the client's comments. At the appropriate time, we can exert more influence on the interview by making a transition from open-ended to closed-ended questions (eg, “Compared with last month, is urine volume increased, decreased, or unchanged or do you not know?”).

Veterinarians should also use summary statements to check understanding with their clients. The objective is to paraphrase or summarize the clients' concerns and points of view in such a way that clients will recognize that we empathically understand them and that we have not missed any important concerns.

In addition to learning how and when to listen, we must learn to want to listen. Wanting to listen involves patience and openness without being passive as well as a desire to understand. Wanting to listen also involves courtesy, respect, and appreciation of the other person. We should let others complete speaking their thoughts without interrupting, and we should avoid completing other's sentences.

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 may initially require more time than is required with a tightly controlled doctor-centered clinical interview. However, in the long term, it often is more efficient and requires less time than trying to correct misunderstandings or compensate for the loss of our clients' confidence that may occur as a result of an imbalance between empathic (patient-centered) and reactive (doctor-centered) listening.⁵

Nonverbal factors such as facial expression, body position, and personal appearance are also 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 that is devoid of expression may raise questions about our sincerity. On the other hand, a warm smile conveys the message that we have a kindly feeling toward our patients and our clients. Smiling at opportune times also puts clients at ease.

Eyes and eyebrows also function in listening because they communicate attitudes and emotions. They may convey surprise, compassion, fear, grief, doubt, or dislike. Maintaining friendly—but not piecing—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 with them during our conversation. Yet, in the context of communication, discernment is often required. Some individuals may view intense eye contact as rude, aggressive, or challenging.

Common Barriers to Effective Listening

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

• • Language barriers (eg, failure to ensure that our clients understand our questions and vocabulary and that we likewise understand them).

• • Interruptions that divert our attention and focus (eg, answering or checking a cell phone).

• • Physical barriers (eg, a desk or examination table that physically separates us from our clients).

• • Emotional barriers (eg, an uncomfortable feeling when dealing with a distraught or irate client, embarrassment at a client's show of emotion, an unwillingness or inability to engage in open communication, or reacting defensively).

• • Body posture and body language barriers (eg, postures and actions that could convey indifference, such as standing above seated clients with folded arms when listening to their concerns or fidgeting, tapping fingers on a hard surface, or shuffling papers while the client is speaking).

• • Time barriers (eg, maintaining a poorly organized appointment schedule that causes us to focus on the clock and not on our patients).

• • Mental barriers (eg, focusing on other problems while giving the pretense of listening to our clients).

Summary

Listening skills are of paramount importance to effective communication.^4–7 However, learning how to listen and when to listen is not enough. We must also want to listen. When clients realize that we are empathically listening to them because we want to understand them, they are more 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 effective patient care. Stephen Covey,⁹ author of The Seven Habits of Highly Effective People, summarized this important concept in this way: “Seek first to understand, and then seek to be understood.” When we empathically listen 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 or options to solve them.