How doctors and others who listen with a “third ear” can help us connect
We talk about ourselves and others to ourselves and others — to connect and reject, teach and learn, plan and breakup, diagnose and oppose, manipulate and ingratiate, dominate and pacify, and support and deny. This is how we evolve as beings, families, communities, and societies.
Yet, as children, we are often just told to listen but never taught how. Nor are we in school and college or as families and couples. We often tune out those we love or think we know what they will say or why, but get emotionally engaging content that triggers our curiosity even if hurtful (e. g., what high school peers or perfect strangers on social media think of us).
So listening on command and with intent is a skill that needs to be trained and maintained as practice. A world pushing for more diversity, equity, and inclusion requires listening to more and more different voices, and, as life and business increasingly take place in and out of the office, across different types of media.
With such greater complexity came higher expectations of bosses, in particular. Managers are told to do much more to make their employees feel heard. Doing so might promote engagement and adherence to company policies and strategy. Feeling heard is an essential element of relatedness in a dyad or team. it is part of the perceived quality of a relationship and is indicative of an individual’s motivation to remain engaged in that relationship.
And even though listening is a core management skill, most managers are not taught to listen, either, even those who go to business schools — although the case method, based on participant-centered learning, rewards productive listening behavior. We assume that listening is a skill that good managers, teams, and employees have or will develop.
Very few professionals are formally taught to listen as doctors are. So an MBA and a behavioral neurologist wondered: What can we learn from their process to improve communication and well-being at work? How do they distinguish symptoms from signs to diagnose and prescribe? And more generally, what can we learn from other professions to help listeners and speakers reach their goals?
From imperative to skill: Listening To, For, and From
In this post, we suggest that we can improve outcomes by being more explicit about three dimensions:
a) What is the listener listening to (which characterizes and interprets the nature or purpose of the message’s intentions)?
b) What is the listener listening for (which characterizes and interprets component elements of the message itself)?
c) Where is the listener listening from (which processes the incoming information through multiple filters)?
The first two are inherently influenced by the listener’s perceived role in the dialogue and the goals such a role should entail (which may not be at all what the speaker needs or expects of the listener). Simply put, the listener should be conscious of the nature of the intention. Why one is paying attention will determine how one pays attention and what one is paying attention to. The third shapes the filtering.
Before we get to the process used by physicians, we provide a brief overview of the science of hearing works and the art of listening.
The Science of Hearing
We distinguish listening from hearing by defining hearing as the condition manifested out of the bottom-up sensory apparatus for receptive communication. Its capacities and constraints are biologically, anatomically, or environmentally facilitated and imposed on the information imparted by the speaker.
Sounds and behavior start to be connected in utero. Fetuses seem to start hearing sounds (like the mom’s heartbeat) around 18 weeks of pregnancy. Ten weeks or so later, they perceive external sounds, like the mom’s voice, albeit quieter and at a lower pitch. Full-term babies hear like adults. Hearing a mother reading aloud, a study showed, quieted the fetus — it moved less than when the mother is silent.
Then, once babies are born, parents across centuries and geographies soothe them with lullabies that are repetitive and rhythmic. A researcher found that they are usually in triple meter or 6/8 time, which evokes a swinging or rocking motion, which seems to be soothing.
Even the sounds that dolphins make to communicate with their calves follow a rhythmic pattern an uses a higher pitch. And vocalization is central to play in the animal kingdom.
Hearing, therefore, is more a matter of identifying a signal from noise, and the signal in question is meaningful content for the listener’s interpretation, followed by response and reaction.
Adult ears process sound differently. A message that goes ‘In one ear and out the other’ might depend upon the ear it enters. The left responds better to emotion and music and might be better at intuiting issues from a person’s speech (for processing in the right hemisphere). The right ear seems to respond more to logic and speech (for processing in the left hemisphere of the brain). As a result, individuals with damage to the left ear have a harder time understanding friends (perhaps becoming literally tone-deaf); things are harder to sort out for people who experience damage to the right ear. In addition, most of us hear from both ears differently.
In elder adults, loss of hearing is connected to decreased connection and, in some cases social isolation, depression, and cognitive decline. Sadly, more and more young people are impacted, with an estimated 1 billion experiencing hearing loss because of unsafe listening practices. We are increasingly less able to hear in an ever-nosier world.
The Art of Listening
Listening is the top-down conscious and unconscious executive and salience-making processes that filter, focus, and frame meaningful content. The act of listening is not passive but active by its inherently interpretive nature, and it is by listening that the preparation is made for response and reaction to the listener’s response. That response and reaction can vary widely, and should, hopefully, be congruent to the contract between the speaker’s and the listener’s goals of the communicative transaction.
Listener and speaker typically denote an acoustic platform, but we would like to believe that the nature of these roles translates in any communicative medium of similar participation. Thus, whether performed with speech, sign language, or epistolary — we designate the producer of the message as the speaker and the receiver of the message as the listener. Metacognitive monitoring of a listener (listening to yourself) would treat the listener’s internal monologue or listen to the responses a listener makes toward a speaker as placing the internal monolog or response as a speaker (or speaker role) and the self-monitoring as a listener role.
The Nature of the Dialogue
Dialogue is not an individual sport. In essence, a dialogue can be perceived as a pitcher-catcher relationship. You need both roles to play the game meaningfully. The same goes for communication. A speaker needs to relay certain information to the listener to achieve the desired outcome to model this relationship simplistically. If the listener only hears but does not process this information, its presence is irrelevant to the desired outcome.
Our experience and background impact how the information is perceived, what is “heard” / considered versus what is “omitted” (subconsciously or consciously, the thought might be, “oh, this is just crazy stuff, I’ll ignore it”). For both the speaker and the listener, it is important to be cognizant of these prior experiences, and how they’re shaping our listening process.
Dialogue is a co-creationary activity. A successful, productive dialogue will be through meeting goals. Those goals may be held by both speaker and listener, or they may be different — but the more they are complementary the more likely the dialogue will be successful or productive. The context of speaking and listening, then, can be crucial in making explicit the goals because often context defines specific roles for Speaker and Listener, and roles have inherent goals. But so much of our world does not have such a standardized context. Therefore, a more explicit delineation of goals by the speaker and listener may be necessary. Otherwise, the listener can fall prey to any number of cognitive traps.
To add a bit more complexity, communication between human beings is not just about exchanging information, but also about emotional engagement. An emotionally engaging speech mobilizes armies and negotiates peace treaties. At the same time, voicing how we feel and what we need at a certain moment, helps us deal with our own emotions. Likewise, we can sympathize to provide comfort in distress.
There are many types of listening: for love, comfort, and connection (for example, listening to your child or partner, even when they drone on about something that might bore); safety (listening to warnings); domination and manipulation (pollsters, employee surveys, demagogues, social media platform); sympathy and empathy (to act and support, “we hear you”); discovery and co-creation (like a doctor or manager or coach); action (training); pleasure (music, sex); investigation, inconsistencies, and lies (detectives and lawyers); and many other ways and reasons.
The Medical Conversation
In a medical consultation, there are specific forms of listening. For the clinician, these variable forms share in common the features of intentionality and modular structure. It is said doctors ‘take’ histories; patients do not ‘give’ them. The pejorative often seen in charts that a patient was ‘a poor historian,’ is as foolish as it is seeking exculpation. Patients chronicle their experiences. It is the doctor who plays the historian. Shifting the burden to the patient fundamentally misunderstands the active and intentional process of a doctor’s listening.
Taking the “History of Present Illness”
The goal of listening to the patient is to extract from a patient’s account of his experience of symptoms the nonaccidental elements of the illness's course and qualities in order to render these elements into a synthetic category called ‘disease.’ This hypothesized disease then can be explored with confirmatory tests to uncover a specific pathology, and, hopefully, if both patient and doctor are lucky, we can treat the pathology from which the disease arrives, ultimately relieving the patient’s suffering.
The goal of listening is to delineate the patient’s understanding of their illness, its source, its effect on his life, and its therapeutic options (an ecological view of illness) because these elements will organize the therapeutic approach and, depending on the patient’s appreciation of the situation, determine what strategy is tenable.
The doctor is listening to the patient but also listening to herself. Based on that self-monitoring, she permutes the formula of questions to redirect the inquiry. Sometimes she reshapes it to be more explicit or more specific (e.g. yes-no answers only, leading questions), and sometimes purposely vague (open-ended questions to reduce influencing the response, or tangential questions to reduce the chance the patient can anticipate where the inquiry is pointing to). Sometimes the doctor will pause this diagnostic inquiry and utilize a more appreciative form of listening (no less active, simply with the goal of being therapeutic rather than diagnostic).
The doctor might follow one of the mnemonics in medicine, such as “Old Carts,” making sure to enquire about the Onset, Location, Duration, Character, Aggravated or/ Associated factors, Relieving factors, Timing, and Severity. The use of this or other devices implies there is a formal structure to a doctor’s listening, and that structure enables a function (diagnosis and treatment).
All conversations have a structure, but we’re often not considering consciously how aligned the intents, objectives, and methods of the speaker and the listener are in the conversation.
Ideally, the patient is also listening to the doctor and to himself. He adjusts what he says in response to the doctor’s questions and their perceived connotations and implications. Sometimes in listening to himself, he discovers a previously unacknowledged feature of his experience. Other realizations come from this new self-discovery. Together, through speaking and listening, the history of present illness is defined. It is a narrative written up in a special kind of script, a script encoded with actionable information.
The history of present illness will relay the symptoms shared by the patient. Symptoms are sensations or feelings reported by the patient. What the doctor sees are signs — observable characteristics. The symptom is what a patient reports: “I have a headache.” To the physician, a sign is what she observes: “The patient presents with a nail sticking in her head.”
How doctors make these distinctions is described next.
Performing an Examination
The goal of an examination is to disclose and confirm signs that are beneath the surface of the narrative that can now be found in the body itself. It’s not a direct examination (there’s no surgery), so it’s still information once removed (hence being a sign). One part of the examination is a practice called “Auscultation.” Auscultation is the medical act of listening, in this case not to the person but to their internal organs (e.g. lungs, intestines, hearts).
Like history-taking, the doctor’s listening in auscultation is structured and intentional. Structured in that there are only certain places to be listened to and in a certain order that yields useful information. Intentional in that one is paying attention to specific forms which carry specific meanings. If the doctor is worried about a particular heart condition, he may try to accentuate a noise by asking the patient to engage in a particular behavior during the examination (unconsciously, but voluntarily for sure). It’s no different, really, than how the doctor was listening out in the patient’s narrative of experience, only this time, it’s a bodily narrative.
The patient is also listening at this time. They are looking at the doctor’s face as she examines him, searching for signs the doctor is surprised or concerned or satisfied, or confident. The doctor does not tell the patient these things, they come from the patient’s observations and listening for changes in the doctor’s tone of voice. This can lead to misdiagnosis of the doctor’s intent — a scrunched-up face could come from abdominal gas pain.
Finally, both parties have their own goals in the interaction. A doctor wants to find a problem or get the patient out efficiently. The patient might have a primary reason for coming in to be seen but also working toward a secondary gain — perhaps a note to get the next day off. So the physician might also be listening for what ELSE else her interlocutor might seek.
A managerial derivation
As we saw, the doctor is using an approach that, generally speaking, is for a consultation and carefully distinguishes between what is said and observed. This approach is relevant to any consultant of any field approaching a client’s question. Consultation can be loosely defined. A supervisor listening to the concern of a subordinate or a junior colleague trying to understand the demands of a senior manager can and does use some of this approach. Namely, when listening for anything other than pleasure, a person should listen with intention and structure.
The listener should be conscious of the nature of the intention, as why one is paying attention will determine how one pays attention and what one is paying attention to. The listener should be conscious of the structure of reception and interpretation of the speaker’s response. A doctor’s structure is different than an attorney’s and different from a pastor’s, and different from an architect, etc., but they have a structure, and they deploy that structure in listening.
Mort Adler’s classic, “How to Speak, How to Listen,” provided a general set of rules that can be a useful structure for anyone engaged in a productive, transactional dialogue (of which consultation is just one form).
The other form of listening (what was previously described as therapeutic), is equally important in a consultation, regardless of the field. This is not just letting one’s client talk. It’s using your response to signal that their appreciation of the situation is being appreciated in turn by the consultant. Being listened to is being known, which goes a long way toward developing an alliance.
If leaders think of listening as a systemic — rather than only an interpersonal — activity, they might use their power to further psychological safety. They might want to ask themselves if they have created and fostered the conditions in their team/company/government that enable them and others to be exposed to a robust variety of viewpoints. They can also consider and encourage others to consider what biases and default modes of engagement they are bringing to difficult workplace interactions.
Sadly, despite the costs of miscommunication, poor worker engagement and disconnection, most of us in business seem to have no concerns about these skills. An Accenture survey in 2015 found that 96% of the 3,500 professionals they surveyed thought they were good listeners. About 98% of them, however, also spent their days multitasking. Add to this another puzzle: the average person listens at only about 25% efficiency. While most people agree that listening effectively is a very important skill, most people don’t feel a strong need to improve their own skill level.
Learn from each other
It is not all about leaders, however. Not only are we not taught to listen, but we also don’t teach ourselves. Yes, we come into contact with people in very different occupations, and if we don’t, we should make more of a concerted effort to learn from others.
One way to learn is to develop the intellectual and emotional courage to consciously expose ourselves to ideas with which we disagree. In this piece, mediation expert Eugene B. Kogan shares some approaches from his field to practice seeking out differences in our radically polarized times.
Another avenue for exploration is occupation. Do different occupations listen differently, and in what ways? Occupations, by their nature, have specified outputs, whether a good or a service, and the ways someone functions as a Listener during career-context communication, in turn, might influence what they are listening to and listening for. In other words, a butcher, a baker, and a candlestick-maker might have different strategies for Listening, and whether or not you yourself or a butcher, baker, or a candlestick-maker, their strategies might prove an adaptable strategy in your own transactions. How would knowledge of these occupational listening strategies circumvent or resolve cognitive traps?
Next time you have a chance to interact with a professional, consider the parameters of “listening to, for, and from” across disciplines, professions, careers (an athletic coach and a professional coach; a politician and a schoolteacher), but also in those occupational roles that interplay (a doctor, a nurse, and a patient; a 911 dispatcher and a policeman; musicians and conductors). In this practice, we might also identify certain dynamic communicative alignments in goals that, again, if identified in analogous transactions, could prove useful strategies to surmount impasses or troubleshoot breakdowns in negotiation or inquiry, or advice-giving.
Listening with a Third Ear
In the 1940s, psychoanalyst Theodor Reik wrote a book by this title. A family institute describes this ear as being able to hear beyond the surface words to the underpinning emotions: “With our Third Ear we’re like an audience listening while staying in our seats, never climbing onto the stage to join the drama.” Below we explore how a coach, a law enforcement officer, and a mediator use their three ears to perform their duties.
A coach on active listening and validation
A coach listens using active listening, a holistic way of seeing, hearing, and feeling their clients. Coaches notice whether a client flushes or covers their mouth during a particular share. They listen to tone but also silences and hesitations, and to the things that have not been said, as well as the sequence in which things are stated.
A coach will practice active listening, making sure to be able to reformulate what a client might say. They also reflect what they hear to clarify, challenge, and, most importantly, validate their clients. Listening is a conscious act that requires muting judgment when listening to another person. To gain trust, the coach will tend to mimic the client’s gesticulation and casualness, smiling more or less on reflection and command, for example. The speaker here should own 80% of the airtime. But the coach is by no means passive –sharing observations or offering shifts in perspective by asking the client to substitute “can” for “might” or “should” and asking the client to share how that felt.
“My job is to offer a mirror to my clients, to ensure that they feel totally heard and validated in the time they have with me,” notes Sylvie Maury from Self -Path Coaching. “It is rare that we have someone listen to us so intently for a sustained amount of time. This means exercising tremendous restraints — not to interrupt, reach conclusions, and solve problems. Only the client can do that.”
A law enforcement officer and providing safety, not just physical
Law enforcement is not just about public safety and rules. As a District Attorney told us, “As an elected official, my job is to listen — that is part of my service. Solving the problem is not just what I do. Most of the time, within a few minutes of a conversation, I know what should happen next. But some people want eyeballs and earlobes on them — even if it takes 100 minutes. But it took me a while, much too long actually, to understand that and only did after my mother, who is a psychologist, told me I was doing my job all wrong. This changed my life and that of my constituents.”
A mediator and the difference between a position and an interest
In the world of mediation, empathy is important. Its objective is to demonstrate dispassionate engagement (shorn of any indication of agreement or alignment) with the ideas and experiences of others. For example, Kogan explains in a book, “we train mediators to demonstrate empathy — equally — vis-à-vis all parties at the table, but be prepared to be assertive in knocking down any suggestion that this engagement is tantamount to agreement (because the moment party A perceives that the mediator is comforting party B, party A is bound to lose faith in the mediator’s impartiality).”
Getting to Yes emphasizes the importance of listening for the underlying interests of parties in deal-making in order to understand whether there are creative solutions to be found to the topic being negotiated. Take, for instance, an example of a manager who hears an employee’s request: “I want a 5% increase in my salary.” A 5% income bump is not an “interest,” but a “position” — the statement reflects what the person wants, not why she wants it. The latter is the interest for which the manager needs to inquire, listen actively, and discern. This interview showcases “strategic listening” in negotiation, illustrating the passage with the perceptive comments by Francois de Callieres, the 18th-century French diplomat who wrote one of the foundational books on negotiation in 1716, Manière de négocier avec les souverains (“On negotiating with rulers”).
They know what they are listening to and for. Do you?
Towards Empathetic Listening
No matter the context and skill level, listening, for our purposes, is performed by humans coming to the task with all their frailties and impacted by a general loss of trust in experts, scientists, managers, doctors, and politicians, or anyone whose opinions diverge from ours.
Along with learning to listen, we can also become more aware of what impedes our performance and progress. These range from expediency (for a doctor, it might be to get to a diagnosis and send the patient along or for a DA to get a protective order) and dopamine (from the thrill of having “solved a problem” and checked off a box), to the traps of assumptions (we tend to reach conclusions about others that get in the way of our actually listening to them… “so and so is a grouch,” ”here goes Chicken Little,” or “patients always lie”), distraction (and the siren songs of the cell phone; boredom, and the Tik Tok brain), and self-deprecation (listening to the voices about ourselves in our heads, “management does not understand me” or “my patients don’t respect me because I look so young”).
Stephen Covey’s book The 7 Habits of Highly Effective People explains that to be a good communicator one has to be a great listener. We tend to listen to reply instead of listening to understand. He advocates the use of empathetic listening, which goes beyond active listening. Both encourage you to repeat what you heard — the former encourages you to relay what emotions you might have felt. This means bringing an open mindset to understand the needs, goals, pressures, and feelings of your interlocutor. What might you be listening to and for — in spoken and body language.
Then it evolves resisting the urge to evaluate, scold, fix, and be nosy. Consider this sample scenario. You tell a colleague your parent passed died afer a long and difficult illness. An empathetic answer might be, “thank you for letting me know. I am very sorry to hear this. Please let me know how the team and I can support you and your loved ones at this moment.”
A default mode has us using our own experiences as a base instead. So we might be evaluating (“your mom was ill and it was hard on you, this is a relief”), and probing, not because it is helpful to the interlocutor, but because we are curious about the facts and details so that we can opine about them (“will she be cremated?”).
Then comes advising and giving counsel (“whatever you do, don’t…”). The listener has decided what the speaker’s challenge and wants to solve it. However, often the listener does not know what the speaker is struggling with. This also happens with interpreting (“you must feel so sad”).
If we can listen for greater connection and to the entirety of our interlocutor, we can connect, heal and rebuild. When paged to help deal with a patient who allegedly was delirious and not making any sense, Michael took a pause to listen — and realize that the patient was communicating by quoting Shakespeare. In his distress, the man could finally be heard because Michael knew what he was listening to and for. He listened, felt, and paused before fixing.
This requires discipline, time, practice, and investment. It involves the eyes, ears, mind, and heart. And if managers emulated President John F. Kennedy below, employees might engage more in creating a joint future.
“‘One of the things which struck me most forcibly,’ Isaiah Berlin recalled about JFK, ‘was that I’ve never known a man who listened to every single word that was uttered more attentively. His eye protruded slightly, he leaned forward towards one, and one was made to feel nervous and responsible by the fact that obviously every single word registered. … He really listened to what one said and answered that.’”
Source: Robert Dallek, Camelot’s Court: Inside the Kennedy White House (New York: HarperCollins, 2013), pp. 187–188.
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Authors
Michael P.H. Stanley, MD, is a neurology fellow, Brigham and Women's Hospital. He currently serves as the director of outreach and engagement for the Boston Society of Neurology, Neurosurgery, and Psychiatry, as well as the director of the Young Oslerian Group within the American Osler Society. In addition to his clinical duties, he is a frequent contributor of essays and articles on the intersection of medicine and society, writing for the Wall Street Journal, National Review, and Portland Press Herald, among others. Follow him @Mphstanley on Twitter.
Carin-Isabel Knoop founded and leads the 20-member case writing team at Harvard Business School. Learning about managers’ challenges pushed her to make their lives better, which lead to the publication of Compassionate Management of Mental Health at Work with Professor John A Quelch (Springer, 2018). She also co-founded HSIO (Human Sustainability Inside Out), a provider of mental health support materials and educational programs, and speaks and publishes about mental health in the U.S., French, and Spanish-language spheres. She enjoys soft-serve ice cream, pragmatic idealists, and postcard writing.
We are indebted to the contributions of many in our learning journey.
One standout is Antonio Sadaric, an aesthetic storytelling fan and artist at heart who advocates for the humanization of organizational development. He also authored the Capt. Bossman’s Workplace Stories.
Another is Eugene B. Kogan, Ph.D., a Harvard negotiation strategist, executive coach, and thought leader. He has 15+ years of experience enabling over 2,000 international executives and their teams to successfully navigate ambiguity and stress. He co-authored “Mediation: Negotiation by Other Moves” (Wiley 2021) and teaches Advanced Negotiations programs for Harvard’s Division of Continuing Education.
