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Listening: more than what meets the ear.

* Les MacLeod, EdD, MPH, FACHE

In this article ...

Discover the differences between hearing and listening, and learn how to improve your listening skills.

"One of the greatest gifts you can give another is the purity of your attention."

--Richard Moss, MD

OVER THE PAST SEVERAL YEARS, TWO THINGS have appeared with regularity in the management literature that haven't made much sense. One has been the emphasis on understanding the difference between hearing and listening (often mistakenly used interchangeably) and the second being the repeated evidence that most of us are, in fact, poor listeners (averaging only about 25 percent efficiency).

Management notables such as Peter Drucker (The Effective Executive, 1966), Stephen Covey (Seven Habits of Highly Effective People, 1997), and Daniel Goleman (Primal Leadership, 2002), along with a host of other experts, clearly have demonstrated the importance of being a good listener. So why, then, does there continue to be such a disconnect? Does it really matter all that much for physician leaders; and what, if anything, should be done about it?


"The art of conversation lies in listening."

--Malcom Forbes

In their now classic article, "Listening to People," which appeared in a 1957 issue of Harvard Business Review (HBR), authors Ralph Nichols and Leonard Stevens could not have been more direct in asserting that, "It can be stated, with practically no qualification, that people in general do not know how to listen." (1)

Much has changed since then and now more than ever we run the risk and associated consequences of ineffective listening. Ever-present digital distractions, multitasking as the new workplace norm, constant exposure to information overload, and the use of multidiscipline teams are but a few of the newly emerging risk factors. As noted in a more recent HBR article, "Today we're locked into a mode of continuous partial attention." (2)

Add to this the fact that most of us are untrained listeners to begin with (only 2 percent of the population has received any formal listening training) and you have a ready-made prescription for conversational problems.

Speaking and listening now surpass writing and reading as the most common forms of workplace communication. This will necessitate an adjustment in leadership skill sets. "As organizations have become flatter, more virtual and increasingly far-flung, it has become axiomatic that effective leadership is predicated on effective communication and, in particular, on finely honed listening skills." (3)

It's not too surprising, then, that in a more complex and competitive environment, listening as a leadership skill has reemerged as a focus of executive development. "For leaders, listening is a central competence for success." Major corporations such as General Electric are redefining what they seek in their leaders, and now place "listening" among the most desirable traits in potential leaders. (4) Some have rated listening competence as the most important leadership skill.

For physician leaders, the challenge of effective listening especially is difficult in that they often find themselves walking a fine line between two distinct organizational cultures: clinical and non-clinical. Most physicians have had little or no formal training in communication skills.

As highly intelligent, hard-driving professionals without much interest in the "softer," less-scientific disciplines, they typically have more things to do than time to do them. Egocentricity is not that uncommon, nor is patience a typical virtue. ("Studies show that the average physician in a typical interaction will interrupt a patient within 17 seconds.") (5)

They are, for the most part, serious individuals tasked with serious responsibilities, without much in the way of spare time for drawn out conversation. When they do converse, they expect their physician leaders to listen with "clinical ears" and to view things through the same "clinical lens" as they do.

Managers aren't particularly good at listening, either. Human resource experts list, "Fail to listen to and help employees feel that their opinions are valued" as among the top 10 mistakes that managers routinely make. They tend to focus more on financial matters and expect physician leaders to prioritize the "no margin, no mission" mantra with a similar level of importance.

They have a much broader, longer-term institutional perspective, as opposed to the here-and-now, individual patient focus of busy physicians. They approach conversations from a business perspective with all its associated jargon, which they expect physician leaders to readily understand.

On the major issues of quality and costs, "hot-button" terms used by the two professions are seldom the same, and if not listened to carefully, much can get lost in the translation, leaving plenty of room for misunderstanding or misinterpretation that can (and often does) result in relationship-compromising consequences. Listening skills can be essential in avoiding such counterproductive and usually difficult-to-repair situations.


"Most people tend to be hard of 'listening' rather than hard of 'hearing.'"

--U. Minnesota

The term listening has been defined in a variety of ways, most of which derive from the one originally proposed by the International Listening Association (ILA). One widely used version defines listening as "the learned process of receiving, interpreting, recalling, evaluating and responding to verbal and nonverbal messages." According to this definition, it's clear that listening is an involved process encompassing cognitive, behavioral as well as relational elements.

Hearing, on the other hand, is simply defined as the faculty of perceiving sounds. It happens as a basic, physiological response to sound waves hitting the ear and is more physical than cognitive. Effective listening is just the opposite, involving considerably more than what meets the ear. It's something that has to be conscientiously engaged in, in order to accurately process the intended meaning.


Because of the survival-based way in which the brain evolved, humans instinctively listen at much faster rates than they talk. The average person talks at about 150 words per minute, but listens at nearly four times that rate and can think at rates up to 1,000 words per minute.

During normal conversation, this leaves lots of downtime during which a listener's mind can (and usually does) wander. Full concentration thus requires a deliberate override of the more natural tendency to process external stimuli at the fastest rate possible.

How one chooses to use the downtime determines the degree of comprehension that will take place. Full comprehension becomes a function of focus, otherwise the listener is simply unaware of things that might have been expressed, but didn't actually get through. Similarly, the speaker might assume, incorrectly, that the intended message was fully understood. In either case, the end result is the same: words were heard but the message missed.

In order to help avoid these kinds of communication gaps, theorists have posed a number of listening models. One of the more recognized models (in abbreviated form) includes:

* Hearing--receiving raw data.

* Selecting--choosing among the stimuli.

* Attending--focusing attention.

* Understanding--assigning meaning.

* Evaluating--analyzing and judging.

* Remembering--drawing on memory.

* Responding--giving feedback.

Each element is interrelated, meaning that if one is under-addressed or ignored entirely, the effectiveness of the entire process becomes compromised.

During interpersonal conversation, the importance of conveying the feeling that the speaker has been listened to cannot be overstated. It's a key element of what's called empathetic listening, and is one of the most effective ways of showing respect for what is being said.

"It all starts with actually caring about what other people have to say," argues Christine Riordan, provost and professor of management at the University of Kentucky. Listening with empathy consists of three specific sets of behaviors:

1. First, there's the actual intake of information--recognizing the verbal and nonverbal cues the other person is emitting.

2. Then there's processing, which is where we make sense of what the other person is saying.

3. Finally, there's responding. This is where you validate what they've said--and note that validating doesn't mean you have to agree with it--by nodding, playing back what you heard, or otherwise acknowledging that you're picking up what they're putting down." (6)

As listening theory has developed, a variety of forms have been described, each with its own situational relevance. Table I lists several of those most widely recognized.

Irrespective of the form, they all have one thing in common: the importance of distinguishing between passively hearing the words being spoken and actively listening to the entire message being communicated, both verbally and nonverbally. Table II lists some key differences between the two:

HEARING                           LISTENING

A passive process                 An active process

A physical sense                  A learned skill

Largely auditory                  Largely cognitive

Enlists only partial attention    Enlists full attention

An involuntary response           A deliberate choice

Nonverbal cues unimportant        Nonverbal cues very important

Requires minimal effort           Requires considerable effort


"Most of the successful people I've known are the ones who do more listening than talking."

--Bernard M. Baruch

Most of us take listening for granted and, although we agree that listening is one of our most frequent activities, we tend to overestimate our skill levels and thus don't feel much need to improve them. Some of the more common reasons for this include:

* Not viewing listening as a "legitimate" skill.

* Not acknowledging our listening deficits.

* Undervaluing the importance of effective listening.

* Being unfamiliar with listening-related research findings.

* Having little or no listening education or training.

* Being too busy.

We also live in a "sender-oriented" society. Speaking is prized, with entire courses being devoted to elocution and presentation skills. Listening has received much less attention even though studies show that we spend more time listening than on any of the major communication forms (writing 9 percent, reading 16 percent, speaking 30 percent, listening 45 percent). The amount of teaching emphasis, however, has traditionally been in the reverse order of what we actually use.

In organizational settings, the time spent listening is even more pronounced, with workers averaging 55 percent of their work time and managers 63 percent. As related specifically to health care, studies also have confirmed positive relationships between effective listening and both physician- and management-related outcomes. Table III lists several of these findings.


"Most people do not listen with the intent to understand; they listen with the intent to reply."

--Stephen R. Covey

Dealing with physician colleagues is not always easy. They're often overloaded with work, pressed for time and preoccupied. (7) As such, they tend to be in a state of unavoidable multitasking, which makes it difficult to get their undivided attention.

When you do get their attention, they expect to be heard and not to have to repeat themselves. Because their time is used taking care of patients, it's likely that they value their time over yours and will not take kindly to vague or ambiguous discussions.

They're frustrated by ever-increasing administrative demands and nearly half report being burned out (46 percent in a 2015 survey, up from 40 percent in 2013). (8) Add to this that administration is routinely viewed with a certain amount of suspicion, and it's clear that physician leaders have their work cut out for them in terms of agenda-free conversations.

Managers, on the other hand, tend to be less direct, leaving a fair amount of diplomatic wiggle room for interpretations. They draw from a separate non-clinical knowledge base with its own set of buzzwords.

When in discussions with physicians and managers, both sides look to the physician leader for a favorable interpretation of what is meant or implied, in addition to what is being stated verbally. Effective listening can lend objectivity to competing interpretations. It also can lessen the likelihood of professional posturing and become a means of turning tense conversation into useful collaboration. If left to its own, opportunities for cooperation can be missed, and the same old competitive relationships continued.

Positive listening habits are contagious. If managed properly, they can help to establish a cultural norm. However, it takes demonstrated leadership and an honest appreciation for its underlying value. People will follow behavior a lot more readily than advice.

Table IV lists some common modes of positive and negative listening.



"Wisdom is the reward you get for a lifetime of listening when you'd have preferred to talk."

--Doug Larson

Effective listening is first about attitude. Ideally, it should lead to learning. Much can be gleaned both from what is being said, as well as what is being implied "between the lines" or as Peter Drucker once put it, "hearing what isn't being said." However this seldom is as easy as it sounds. It's not difficult to listen to people you like or when the subject is interesting, or you're hearing welcomed remarks or information.

The challenge comes when the opposite is true. Then it requires much more in the way of patience and discipline. Those doing the speaking are keenly aware of the degree to which they have your attention, even though it might not be verbalized. Much of the listener's attention will be interpreted (correctly or incorrectly) from a variety of nonverbal indications.

One of the difficulties with nonverbal messages is that they are just that--nonverbal, and the sender has no idea as to how they are being interpreted. They can be intentional or unintentional, and can be sent consciously or unconsciously; either way, it represents upwards of two-thirds of all communication.

An inability to sense and decode nonverbal messages leaves much of what is being expressed unrecognized. Table V lists major nonverbal categories.

Here are several conversational do's and don'ts that are worth consideration. The list could be longer, but these are the ones that appear most frequently in the "becoming a better listener" literature.

It's also useful to do a candid self-assessment in terms of your own current "listener" status.

* Are you unknowingly a sentence-grabber, a sentence-completer, a conversational manipulator or dominator, or any number of other unfavorable qualities which can make you someone who is "difficult to talk with?"

* Do you follow the general rule of treading on no more than 25 percent of the speakers time (coincidently, an anagram for listen is silent)?

* And most important, do you in fact listen to learn?

An honest appraisal of listening deficits is the first place to start the skill-building process. More often than not, you'll find that the most effective way to get people's full attention is to give them yours.

Perhaps the greatest practical benefit of effective listening is its return on investment. Once a reasonable degree of listening skill is acquired, the potential gains in knowledge, understanding, cooperation, etc. far outweigh the effort. Plus, there are additional benefits of gaining the trust, respect and appreciation that result when someone genuinely feels that they've been listened to.

By the same token, failure to recognize one's listening deficits runs the risk of becoming the object of a listener's unspoken lament: "I don't think that he/she was listening" at best, or "That self-important, inconsiderate, so-and-so didn't hear a word I said" at worst--both of which can damage what otherwise could have been a more useful exchange.

Each listening experience is unique and it will be up to the listener to assess the speaker's intentions, credibility and sincerity, as well as the specific circumstances surrounding each conversation. Appropriate skills then can be used. Oddly enough, honing such skills not only helps in becoming a better listener, but having a better understanding of the listening process also will help in becoming a better speaker. (9)

In view of the many studies in support of a broader view of the listening process, it's interesting to note that for centuries the Chinese character for the verb "to listen" has included four distinct elements: ear, eyes, undivided attention and heart. Apparently much of what is now being learned is also a validation of some fairly basic, time-tested wisdom.

Les MacLeod, EdD, MPH, FACHE, is a professor of health management and policy at the University of New Hampshire in Durham, New Hampshire.


(1.) Nichols R. G., Stevens L.A. Listening to people. Harvard Business Review. Sep 1957.

(2.) Fryer B. Is Listening an endangered skill? Harvard Business Review. Nov 5, 2009.

(3.) Korn Ferry Briefings. The science of listening. The Korn Ferry Institute Magazine. Winter 2013.

(4.) Charan R. The discipline of listening. Harvard Business Review. Jun 21, 2012.

(5.) Cook, K. Improving physicians' communication skills. Hospitals & Health Networks Daily. May 28, 2015.

(6.) Green S. Everything you need to know about becoming a better listener. Harvard Business Review. Feb 6, 2015.

(7.) Mauksch LB et at. Relationship, communication, and efficiency in the medical encounter: creating a clinical model from a literature review. Archives of Internal Medicine. 168(13):1387-95, Jul 14, 2008.

(8.) Rappleye E. The most and least burned out physicians broken down by specialty. Becker's Hospital Review, Jan 27, 2015. http://www. specialty.html

(9.) Purdy M., Borisoff D. Listening in Everyday Life: A Personal and Professional Approach, 2nd ed. Lanham, MD: University Press of America, 1996.
FORM                    CHARACTERISTICS

Active listening        Giving full attention and listening with all
                        your senses

Comprehension           Listening for understanding

Critical listening      Listening to scrutinize and evaluate what is
                        being said

Dialogic listening      Listening to find shared meaning through

Empathetic listening    Listening to better understand the emotions
                        of the speaker

Informational           Listening to understand and learn new
listening               information

Naive listening         Listening without speaker/subject

Rapport listening       Listening to develop relationships and build

Therapeutic             Listening with a nonjudgmental, healing ear



Patient satisfaction with care      Leadership acceptance by staff

Patient treatment compliance        Staff job satisfaction

Patient trust in their physician    Staff productivity/goal

Patient adopting preventive         Manager problem solving

Physician-nurse relations           Manager likelihood of promotion

Fewer malpractice claims            Teamwork effectiveness




Appreciative      Listening for enjoyment

Efficient         Tuning out internal, external, and semantic

Reflective        Attempting to understand the speaker's points of

Discriminative    Differentiating subtle differences in sounds and

Humble            Listening on an equal footing with the speaker

Nondirective      Refraining from "firing back" one's own opinions

Deep              Listening to understand the speaker behind the

Comprehensive     Focusing on understanding and remembering



Biased            Listening with a preconceived agenda

Selective         Picking and choosing what one wishes to hear

Insulated         Focuses on screening out unfavorable messages

Disruptive        Persistently interrupting the speaker

Narcissistic      Being self-absorbed with one's own points of view

Defensive         Listening with a focus on self-protection

Pseudo            Pretending to listen

Face-value        Concerned only with the words being spoken



Chronomics      The use of time being late, hurried,
                dock-watching, etc.

Haptics         The use of touch hand shake, hand on shoulder,

Kinesics        The use of body language facial expressions,
                posture, etc.

Oculesics       The use of eyes contact, aversion, rolling,
                staring, etc.

Paralanguage    The use of voice tone, loudness, intonations,
                speech rate, pitch, etc.

Proximics       The use of space too close/distant, behind a desk,


LISTENING DO'S                       LISTENING DON'TS

Consciously prepare to listen        Take listening for granted

Try to put the speaker at ease       Be impatient/abrupt

Give the speaker your full           Be distracted/preoccupied

Show the speaker that you are        Be prematurely judgmental

Pay attention to the speaker's       Avoid reasonable eye contact
nonverbal cues

Try to understand the speaker's      Appear to be condescending
points of view

Refer to the speaker by his/her      Interrupt unnecessarily

Reflect on what is being said        Be passively unresponsive

Ask for clarification when needed    Appear disinterested

Summarize your understanding of      Maintain a defensive posture
what was said

Use occasion-specific listening      Be overly/unduly emotional

Listen as you would expect to be     Judge the person over the message
listened to
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Title Annotation:Management
Author:MacLeod, Les
Publication:Physician Leadership Journal
Geographic Code:1USA
Date:Jul 1, 2016
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