Are policy makers really listening?BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d3218 (Published 02 June 2011) Cite this as: BMJ 2011;342:d3218
- Iona Heath, president, Royal College of General Practitioners
The quality of healthcare has always depended on the quality of listening: intimate, attentive listening shared between the patient and the doctor or nurse. Now, suddenly, there is much talk of listening at the much less tangible level of policy making. The word “listen” is a beautiful and ancient one, thought to be first recorded in written English in the Lindisfarne Gospels of ad 950. The complementary verb “to hear” is equally ancient and makes its first appearance in the same exquisite text.
Words are precious and dictionaries the treasure chests within which the history of each word’s usage is stored. According to the complete Oxford English Dictionary, to listen means “to hear attentively; to give ear to; to pay attention to.” The marvellously idiosyncratic Samuel Johnson, in his great Dictionary of the English Language, published in 1755, defined to listen as “to hearken, to give attention.” The inclusion of the notion of giving in both definitions suggests the moral content of listening. Doctors have a grave responsibility to listen to their patients, politicians to their citizens. The BBC’s Skillswise website (www.bbc.co.uk/skillswise) is designed to help people wishing to improve their literacy and numeracy, but many of those already skilled in these areas might do well to consider the suggestions that are given in relation to listening: “Listening is a form of communication and is an active process. When you listen you must get meaning from what is being said before you can respond.” And: “Often, you may hear what you expect to hear, not what is actually said. Everyone brings past experience to a communication situation, even without intending to. Pressure of time and work increases the risk of doing so.”
All of us listen selectively and have to do so because of the intensity and complexity of auditory sensation. It is all too easy to listen without hearing, and, when preoccupied by other thoughts, all of us have had the experience of losing the track of our listening. Music is perhaps the best test of true listening. How long can we listen and really hear the music before our brains begin to whirr again and the music recedes into the background of our more immediate and mundane thoughts?
Listening without hearing can also be a little more sinister. Somerville and colleagues have shown the extent to which doctors working in rapid access chest pain clinics allow themselves to hear only those parts of the patient’s account that can be used to confirm or refute a possible diagnosis of cardiac ischaemia, while ignoring aspects of the story that are clearly of great significance to the patient (Social Science and Medicine 2008;66:1497-508, doi:10.1016/j.socscimed.2007.12.010). Doctors working in this way are using listening instrumentally: not as an end in itself but as the means to a diagnosis. As the psychotherapist Paul Gordon puts it, in his book The Hope of Therapy: “The problem is not trying to make sense of things but that a search for understanding, for comprehension, can too often get in the way of a real attunement, a real listening. Instead, we end up hearing what we think we ought to hear . . . what fits into our preconceptions.” If it is easy for doctors and other healthcare professionals working in pressured clinical situations to fall into this trap, how much easier must it be for policy makers, who all too often have a predetermined agenda of their own and are listening at a distance far from the intimacy and immediacy of the clinical encounter.
George Steiner, in his book Heidegger, writes, “The vital relation of otherness is not, as for Cartesian and positivist rationalism, one of ‘grasping’ and pragmatic use. It is a relation of audition . . . It is, or ought to be, a relation of extreme responsibility, custodianship, answerability to and for.” It seems that far too much of what passes for listening at every level of the health service has this “grasping” instrumental quality and that we all need to test our own listening against these standards of responsibility, custodianship, and answerability to and for.
It is in all our interests to try to ensure that listening is genuine and is linked to both hearing and understanding. Words are precious—and, somehow, the more ancient they are, the more precious. But there is a long history of the distortion of words in the interests of those seeking to exercise power. There seems a definite possibility that listening will shortly be added to the ever lengthening list of words that have become corrupted in this way; recent additions already include words such as reform, quality, choice, and care.
The Oxford English Dictionary illustrates the use of the word “listening” with a quotation from John Milton’s essay, “The Reason of Church-Government Urged against Prelaty”: “It were a folly to commit any thing elaborately compos’d to the careless and interrupted listening of these tumultuous times.” This warning seems only too appropriate to our own tumultuous times, but we must continue to hope that this perception is mistaken. Samuel Johnson had chosen to exemplify the noun “listener” through an almost diametrically opposed figure. Roger L’Estrange (1616-1704) was a belligerent Tory, a staunch royalist, and a political pamphleteer and journalist. He attacked other writers who displayed any trace of dissension or radicalism, including John Milton. The quotation chosen by Johnson reads: “Listeners never hear well of themselves.” Perhaps the degree to which this is true makes genuine listening by those reliant on political power and popularity all but impossible.
Cite this as: BMJ 2011;342:d3218
IH, though president of the Royal College of General Practitioners, writes in the BMJ in her personal capacity.