Listen to the patient. He is telling you the diagnosis.
Sir William Osler, Physician (1904)
Communication skills don’t just involve choosing the right words to say, and saying them in the right order, and in the right way. Equally important are:
- The ability to listen effectively, without interrupting
- The ability to control our 'body language'
- Being able to interpret the 'body language' of others.
- Making sure that both parties properly understand what is being said
- Trying to form an understanding of the underlying feelings of the other person.
We all enjoy talking to people we like and get on well with; but in the surgery this can create problems, as it is easy to allow these conversations to take us away from other patients and other important work that needs to be done.
A similar situation arises with people who, it appears, could talk for ever. Their most important message can easily get lost within masses of unnecessary detail, or simply because it is difficult to maintain your concentration within such a torrent of words. Some people just never stop talking and rather than interrupting them, ignoring them or stopping them in a rude or abrupt way, the challenge is to steer them very gently so that they are talking about what you want them to talk about.
When listening to someone, our own body language can be very revealing. Similarly we can also learn a lot by observing the body language of the people that we are speaking to. Examples of non-verbal signals of particular relevance in this context are;
Appearance
The way we feel like is influenced by our physical size, the clothes we wear (uniform), our hair, makeup etc. In a professional healthcare environment, appearance is important whether one is working in a surgery, or in a reception role, although different considerations apply. Here again, it can have a major influence on the attitudes and behaviour of both patients and team members, and the interactions between them.
Face
Because the face is the most obvious and visible part of the body, your mouth/smile, eyes (eye levels and degree of eye contact) and facial expressions are critical. They must all be sending out the same message. Eye levels are particularly important as it is much easier to communicate when your eyes are at the same level as those of the other person. Eye levels are affected by whether the people are sitting or standing or by relative heights, if both are standing. The person whose eye level is highest is placed in a more dominant / controlling position, and this disparity can adversely affect the ability of both parties to listen effectively to the other.
Body language tips for effective listening
1. Maintain as much direct eye contact as possible. Don't look around the room, at the floor ,or at other people.
2. Make a conscious effort to avoid blank expressions and distant stares.
3. Look interested. Use appropriate facial expressions and be aware of what your face is saying... is it smiling? revealing anger or irritation? conveying concern? expressing regret? suggesting empathy and/or support? looking bored and disinterested?
4. Nod your head to indicate interest and understanding, without the need to interrupt
5. Sit / stand upright, but lean slightly towards the speaker where this is possible without invading the personal space of the speaker.
6.Avoid distracting hand/foot mannerisms (eg. tapping your foot, fidgeting with documents, pens and similar items)
7.Use 'open' gestures and avoid overt 'closed' gestures like crossing your arms high on your body, which most people would interpret as a defensive orresistant gesture.
8. Avoid extreme movements/posture like leaning back and crossing your legs, or clasping your hands behind your head.
When meeting someone for the first time, it is important to "read" their body language in order to ensure that what you are saying and doing, and your own body language, is creating the right impression for them. They will be forming impressions about you from the second you meet.
Be a good listener
Effective listening is a skill which can be learned. Many people have a tendency to 'half listen', their attention drifting in and out of a conversation. A person's willingness and ability to listen will be a reflection partly of their underlying personality, partly of the subject matter and the other demands on the person at that time, and partly of their communication skills.
Good Listening Styles
I. Suspend judgment - at least initially.
2. React to the words, not to the person. Don't dismiss a message too readily, simply because of your perception of the person who is conveying it.
3. Remind yourself why you need to listen.
4. Forgive and ignore delivery faults and irritating mannerisms.
5. Be flexible and look for strengths and key points /themes in what is being said
6. Stay cool - don't be too quick to interrupt.
Overcoming Listening Barriers
I. Understand your own communication style and habits
2. Select an environment in which it is easy to listen and use it to maximum advantage
3. Establish a suitable physical separation and appropriate eye levels.
4. Remove or resist distractions (background noise and the proximity of other people can seriously impede the ability to listen)
5. Avoid jargon (people often stop listening when they become confused or can't understand what is being said to them)
6. Seek common ground
7. Actively reduce stress - this will improve communication. Patients do not listen well when they are anxious or frightened, or when they are annoyed or angry.
How to Listen Well
I. Be warm, approachable and friendly wherever possible.
2. Use overt physical signals that you are listening (nodding, eye contact etc)
3. Concentrate - however busy you are. Elicit the meaning of what is being said.
4. Look for, and read the non-verbal signals of others.
5. Note mixed messages and wait until the message becomes clearer.
6. Fill in blanks mentally, but don't feel the need to do so verbally.
7. Take notes and recall key words. These notes would be written in the case of a phone conversation but mental in any other instance.
Effective listening takes less time than ineffective listening; don't make the mistake of thinking that you haven't got time to listen; if you disengage from a conversation it will often take longer than if you had remained actively involved in it.
Studies have demonstrated differences in the communication styles of men and women. Women tend to use more hint language whereas men tend to be more direct/blunt and less subtle. There are variations in language (meta-language) that occur in male-male conversations, and female-female conversations. Men tend to interrupt earlier in a conversation, and also to interrupt more frequently once a conversation is under way.
There are also some potentially confusing differences when words and phrases are used by people for whom English is not their first language. A skilled communicator needs to understand all of these individual variations, and take them into account.
Active listening
This is a specific, structured way of listening and responding to others, where the listener's attention is focused heavily on the speaker. The benefits of this approach are not simply that more of the message is reaching the listener; equally important is the fact that the speaker can see that the other person is really listening, and is actively engaged in the conversation. It therefore has a particular importance in consultations between patients and clinicians.
If a clinician can convey to a patient that they are not only hearing and understanding the words that the patient is speaking, but also understanding the patient's feelings, the quality of the interaction is significantly enhanced. Reflective listening has been described by Carl Rogers and others as a particular technique of active listening, widely used in psychotherapy. The starting premise is that at the start of any consultation, only the patient really knows what/how they are feeling. If the clinician jumps to conclusions and reaches a diagnosis on the basis of the first piece of information they hear, the patient may well be denied the chance to provide other, highly valuable information and perspectives. As a result there is a danger that only part of the patient's problem will be treated, or worse still, the real problem(s) may be missed entirely. Using the reflective listening technique, the clinician asks questions which reflect what the patient has said, and seeks confirmation from the patient that s/he has correctly understood the patient's underlying feelings.
Here are some specific techniques used in active listening
(1) SILENCE
A powerful tool - it can show interest by encouraging the patient to speak, and letting them know that you are ready to listen. Used incorrectly or excessively, it can show disinterest or withdrawal, but it is possible to use active listening techniques (such as nodding, raising eyebrows to demonstrate attentiveness etc) to actively participate in a conversation without actually saying anything at all.
(2) SUMMATION
By pausing to review the information given by the patient you can let the patient see that:
a) you have been listening
b) you are keen to interpret their information correctly.
Summation allows the patient to reject this emphasis if it has been incorrectly assumed.
"Am I right in understanding that you would prefer not to go ahead with having the tooth crowned right now?"
"What I think I am hearing from you is that you are more concerned about the shape of the tooth than the actual colour of it. Is that correct?"
(3) FACILITATIONS
A facilitation (eg. ˜In what way?") is a verbal or non-verbal response that encourages the patient to say more, without specifying the area or topic to be discussed. A variation on this is to ask the speaker something like "Could you give me an example of that?" This lets the speaker know that you are interested, and that you are actively involved in and thinking about what they are saying.
(4) REFLECTION
Responding in a way that repeats, recaps, or mirrors the general drift of the patient's previous remarks. Reflections are best kept short - for example,"I follow you" or " understand" or "I see what you are saying"
Reflection is used to demonstrate empathy with what the patient is saying without actually interrupting.
(5) INTERPRETATION
Linking statements and drawing conclusions or ascribing feelings or motives to what has been said
"...and this made you wonder whether it wasn't the back tooth after all, did it...?"
Summary
The ability to listen effectively is one of the most powerful ways to build and strengthen the rapport we have with our patients. Many studies have shown that this ranks very high on the list of what patients want most from healthcare professionals. It can help to maximise patient satisfaction and strengthen the patient:clinician relationships, improve treatment outcomes, reduce the frequency of claims and complaints, and assist dental team members in resolving dissatisfaction and complaints quickly and easily when they do arise.
Further reading on listening skills
Silverman J., Kurtz S. and Draper J. Skills for communicating with patients. Radcliffes, 1998.
Better Communication
Richard Mulvey, Perception 1998.
Body Language & how to read others thoughts by their gestures.
Allan Pease. Camel Publishing 1981.
Talk Language
Allan Pease & Alan Garner 1985.
Listening to our patients
Chest 2005 June 127(6): 1877-8
Reclaiming the lost art of listening
Michael Westerhaus (Harvard Medical School)
Current Surgery Vol 62Â Issue 4 page 447
Becoming a better listener
J Med Pract Manage 2006 May-June 21(6):348-350
Beckman H.B. & Frankel R.M.
Ann Int Med, 1984 Nov ; 101(5) 692-696
The effect of physician behaviour on the collection of data
Levinson W, Roter DL. Physician-Patient Communication. JAMA 1997.277;5533-559.
DiMatteo M.R., Taranta A, et al. Predicting patient satisfaction from physician'son-verbal communication skills. Med Care 1980;18 (4): 376-87.
DiMatteo M.R. et al 1986
Lester GW, Smith SG. Listening and talking to patients: A remedy for malpractice suits? West J Med. 1993 158:268-272.
Rhoades, McFarland, Finch & Johnson. Speaking and interruptions during Primary Care office visits. Fam Med 2001 July-Aug ; 33(7) 528-532
DiMatteo , Hays and Prince Penn State University Press 1980
Non verbal communication in the medical context; the physician patient relationship
Weinberger et alThe impact of clinical encounter events on patient and physician satisfaction
Social Science in Medicine; 15 ; 239-244
Larsen and Smith Assessment of non-verbal communication in the patient-physician interview
Fam Pract 1981Â 12: 481-488
Suchman Markakis K, Beckman H, Frankel R JAMA 1997; 277 ; 678-680
A model of empathetic communication in the medical interview
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