Listening as Work in Primary Care

Simon Cocksedge

• Publisher: CRC Press
• Year: 2020
• Print ISBN: 9781138448735
• eBook ISBN: 9781000154313
• Edition: 1
• Topic: Medicine
• Subtopic: Biotechnology in Medicine

This book encourages health professionals in primary care to reflect on listening in their work with patients — the choices they make, the relationships which emerge and the limits that they put in place. It is useful for trainee doctors and to established general practitioners.

Section 1 Choices in listening

1 The importance of listening

Listening to the patient’s story has long been regarded as central to the practice of medicine (‘Listen to the patient, he is telling you the diagnosis.’).¹ Learning to hear a story is a core skill for any aspiring doctor and more than 85% of diagnoses in medical outpatients may be made from the history and referral letter without further examination or investigation.² Listening at the start of interactions is integral to models of the consultation (for example, understanding the patient’s problem and perspective,³ connecting,⁴ gathering data to understand the patient,⁵ engaging the patient and eliciting the story⁶), and forms the basis of much communication teaching, both undergraduate and postgraduate. But listening in medicine is more than simply hearing a story at the start of an interaction, and models also emphasise spotting and responding to patients’ cues in order to listen during interactions (verbal and non-verbal signals,⁷ picking up and checking out cues⁸). In this first Section, I explore GPs’ perceptions concerning listening in their everyday work, both initiating listening and choosing not to listen during interactions.

The value of listening

The role of the GP as someone who is easily available for talking, offering time and listening within the community is a major theme for these doctors. There is good evidence that this is also valued by patients.^9,10,11 Listening is important as:

‘Part of our global approach, social factors, physical factors, psychological factors.’ (Matt)

‘I just let her sit and talk. You’ve got to set aside time to listen. I think that’s part of the importance of being a GP, providing a great big ear sometimes, and nothing more, for patients to talk into. … no matter how awkward it is or difficult, I think you’ve just got to take it on board and sit and listen.’ (Steve)

‘Her husband suddenly had a massive stroke, so she stopped work to look after him. She finds it very hard and she’s very bitter about it. She feels guilty and she off-loaded all this to me and I spent most of the consultation listening. She seemed to feel a bit happier at the end of it, somebody actually taking an interest in it really. I think listening is a big important part of the job. I think we achieve something every time she comes.’ (Alex)

‘A familiar face that she knows, just to talk about it.’ (Ben)

In addition to accessibility, the GP may be the only person to whom patients feel they can turn:

‘She just really had nobody else at all to talk to. I had to listen long and I had to listen hard. It all poured out and poured out. I said very little. I see it as within my remit to try and help.’ (Chris)

Another, more pragmatic, valuing of listening is that:

‘If you don’t get to the bottom of why a patient has come to see you, then they just keep coming back.’ (Ben)

It is desperately important to sit there and let them tell the whole story because if you cut them too soon, you will miss vital things. If you actually take the time to listen instead of jumping in and thinking “for heaven’s sake, why have they troubled me with this?”, you will find out exactly why they are there, because great granny has died or their friend’s got this or that.’ (Phil)

In other words, listening is essential and ‘if you listen for long enough, you will find out the real reason why the patient has attended’ (Phil). Another reason for investing time in listening is the long-term effect that it may have on the relationship:

‘Patients with demanding multiple trivial complaints. I have had occasions when appropriate listening time has been very relevant for them, probably at some cost to myself. I think those are very draining consultations. Occasionally they’ve created a very different relationship afterwards. It may just be the opener for many subsequent consultations or it may move the rest of the relationship on to a totally new level.’ (Lew)

Time spent listening now is thought to reap rewards in the future and alter the balance of the doctor–patient relationship. Listening is also seen as therapeutic in itself:

‘One thing I have realised is how therapeutic listening can be. Just sitting and listening to somebody who comes along with a crisis situation, you might not necessarily think you’re the most appropriate person. What you do is you sit and listen for a while and you maybe see them once again afterwards and they’re sorting it out. You realise that you’ve actually done a fair bit of good in quite a short space of time.’ (Rick)

There is general agreement that listening is appropriate, important and a good use of time:

‘Giving space and listening is what makes me a GP.’ (Sam)

‘We are there to listen.’ (Tim)

The idealising tone of these responses contrasts with the similar consensus that spending time listening can be hard and frustrating, and may produce problems:

‘It’s much easier to give a prescription than it is to actually listen to people.’ (Pete)

‘We don‘t always have the answers.’ (Ed)

‘I would say 50% of consultations need some exploration away from the purely physical. … as important as handing them a prescription. The problem is, it’s very time-consuming but it’s quite satisfying so I do quite a lot of it.’ (Sam)

Finding the time for listening and the limits these doctors establish will be explored later in this section.

When discussing listening, the themes explored were not around specific skills but about aspects of relationship and knowing patients in a wider sense:

‘I think good listening skills are about risking something in a relationship to become more involved.’ (Lew)

‘Where I come from people regard their doctor as, not threatening, but somebody on a completely different level to you, and I think maybe find it hard to go to the doctor and actually communicate effectively with them – in awe of them. So I thought “If you‘re trying to be a good doctor, you‘ve got to try and be approachable and reassuring to people that what they‘re telling you isn‘t ridiculous, and they can feel able to just tell you whatever they want”.’ (Vic)

‘So I just sat back and let it all come at me for a while and let her get it off her chest. I was quite pleased that she could feel that kind of anger.’ (Rick)

‘In general practice you interact really, you live in the locality, work in the locality and I think just getting the listening skills – the verbal clues – ask another question … ask “what’s going on at home, what’s going on with your children, what’s going on at work?” and be prepared, once you‘ve asked that question, just to sit back in your chair and listen.’ (Matt)

Recognising that listening is needed

For these GPs, recognising that someone needs listening and attention, in the form of time to talk during the consultation in the middle of a busy surgery, is part of day-to-day life and work. How this recognition of need actually occurs varies from doctor to doctor, from patient to patient and from context to context. Sometimes the doctor may simply ‘realise’ that listening is needed:

‘You‘ll start off, someone will come in with something quite straightforward and all of a sudden will say something and you’ll realise that that’s not really the problem. That’s a starter for ten sort of thing and then if they’re feeling confident with you and relaxed and maybe you’ve demonstrated some listening skills, they will then tell you what the real problem is.’ (Vic)

Recognition may be a natural consequence of a consultation about a physical problem:

‘A lady came in really requesting a repeat prescription for omeprazole and to ask about gastroscopy. She then got on to her holiday and that in turn led to how she’d met someone, which in turn led to her ongoing problems with bereavement. She lost her son a long time ago.’ (Pat)

From Pat’s account, it seems that there was a progression from present and physical issues to longstanding and underlying issues. The common ground and ongoing relationship already established in previous consultations, and the safety of having started with a physical issue, appear to have given space and confidence within the consultation for a longstanding and deep problem to be aired. In contrast, the situation is seen as different with a patient not previousl...

Table of contents

• Cover
• Title Page
• Copyright Page
• Table of Contents
• Foreword
• Preface
• Acknowledgements
• How to use this book
• About the author
• Dedication
• Introduction
• Section 1 Choices in listening
• Section 2 Listening work and relationships
• Section 3 Boundaries and self in listening work
• Postscript: ‘I just listened’
• Epilogue
• Appendix I Methodology
• Index