Abstract
Can you think and listen at the same time?
Videoing consultations is a well recognised tool that facilitates the ability to watch oneself and reflect on performance. A previous colleague of mine said she was shocked when watching her first video revealed her fidgeting habits and a realisation of a horrid shirt she was wearing.
I was intrigued when a trainee reported her surprise at what she had missed the patient say during a video consultation. She reflected that this was a result of her ‘reflection-in-action’ (Schön,1991), focusing on thinking about formulating a management plan while the patient was talking. I often think of our decision making in a consultation as a mind flow diagram, where what the patient says leads you down different routes of questioning, examination, investigations and management. Phrases such as ‘refer physio, rapid access chest pain clinic, chest X-ray, bloods’ can spring into the mind while the patient is talking. The challenge for us as doctors is that we get no quiet time or space in the consultation to do this and are often forced to think and listen at the same time. But is this really possible? I wonder whether the doctor can beg for some thinking time where the patient remains silent? I once heard someone describe this as the ‘silver minute’ in the consultation, a jewel in the consultation for the doctor.
The concept of reflection-in-action (thinking on your feet) versus reflection-on-action (thinking after the event occurred) is well described by Donald Alan Schön, a philosopher who developed the theory of reflective practice and organisational learning. Your learning logs are based on reflection-on-action, where one has time to ponder and analyse, often bringing about profound understanding and critical analysis. A consultation allows you no such privilege. It is not uncommon for doctors to chase a patient after leaving the consultation room asking them to return or waving a blood test form. This is after reflection-on-action has facilitated safe clinical practice and is to be embraced.
Conversely to the above scenario, I have also come across a trainee who listened intently to the patient but was then notably unsure of her management plan. In this scenario, it seemed the trainee had focused so hard on listening that she sacrificed her thinking, or reflection-in-action, that led to uncertainty in her explanation. Perhaps if this trainee had listened less and thought more, the plan would have been more clear and better thought out. It seems bizarre to conclude a doctor is listening too much. Does a balance need to be struck here? Most doctors strike this balance subconsciously and successfully. It would be interesting for one to reflect on the time in the consult spent listening and thinking. Perhaps some are able do this simultaneously?
The spectrum of listening versus thinking is an interesting one. The concept of multi-tasking is one of those valuable chestnuts in the consultation skills toolbox. Thinking while the patient is getting onto the examining couch or providing a urine sample is time that a good doctor does not waste. I was once faced with a patient presenting with a history of being violent. I was unsure of my management plan so used some slow and reassuring phrases to give me time to think and come up with a strategy.
The concept of sharing uncertainty would encourage us to think aloud with the patient. Perhaps this is the ultimate solution, where shared decision-making is fostered. It is also a space for the doctor to disclose his or her own ideas, concerns and expectations; it’s not just the patient who has an agenda.
At a consultation skills course run by Roger Neighbour, we were tasked with having to count the number of times the patient used the word ‘and’. The answer was ‘it doesn’t matter!’, but it did lead to a very different listening style, where one wasn’t thinking about the diagnosis or management plan for a change.
Happy listening.