Lon Setnik, MD FACEP, MHPE 2022-02-23 %% #moc/publish # MOC Concept Why do I want to make this MOC? MOC Process: > - _**Cluster**_ ideas/notes together. > - Add lines between clusters (add the gaps). > - _**Chart**_ the empty spaces between clusters (map the gaps). > - _**Create**_ a new “thing” note. > - _**Create**_ a new “statement” note. > - _**Collide**_ your ideas. > - _**Clarify**_ your note titles. > - _**Connect**_ your notes. > - _**Cut up**_ a note into two. > - _**Combine**_ two notes into one. > - _**Cast aside**_ notes that are no longer relevant. > - _**Categorize**_ the notes in the MOC. _Mapping Concepts_ includes mostly creating links to other ideas. It is a higher order of note making. Creating Maps of concepts include finding the [[emergence]] and [[Convergence]]. This is an inherently [[Constructivism]] way of creating knowledge and storing ideas. It mirrors the way our brain works. It is a way of organizing and [[dealing with complexity]] [[Knowledge Value Making]] allows us to keep each note small, but to create meaning in and between each note. ```toc style: number min_depth: 2 max_depth: 6 ``` %% ## What's the big idea here? [[listening is a conversational procedure]], a complex task with social, cultural (_Why Conversations Go Wrong with Deborah Tannen | Hidden Brain Media_, 2022) physiological, environmental, and learned behavioral attributes. Listening is done in every patient interaction and in many other critical moments in our lives, like when we are acting as a [[failure friend]] or when we are [[The Workshop/coaching]]. Listening is not well researched, reported or described in the EM literature. Learning a skill is best accomplished with [[Deliberate Practice]] which requires a target of success and a method of feedback. A challenge with learning how to listen is the lack of a clear target of success. Hearing the person you are listening to exclaim [[That's exactly right]] can provide a target of success to improve the skill of [[Listening to Understand]]. Here is the approach I will lead you through: - Discover what type of listener you are in different circumstances - Focus on listening to understand - Create a target to have the patient exclaim, "That's exactly right" - Model vulnerability, seek opportunities to be corrected - Separate collection of ideas from judgment of ideas. - Close both loops, the reason the person came from their perspective, and the likely dangerous conditions that might be related to their signs and symptoms. #### Background: Listening is incredibly under-valued in Emergency Medicine, and in our current world. Yet, listening is the core skill of providing compassion and “the most commonly cited factor contributing to positive experience [was] compassionate care (27.8%)” (Sonis et al., 2016, p. S8). There is a gap in how we think about listening as it applies to many of our situations. We consider ourselves teachers, which means we have information to transmit. We believe if people only had our information they would see the world the way we do, a phenomenon called [[Naive Realism]]. If we can begin to see most of our interactions as a form of negotiation, we can work to optimize by exposing those different world views. To negotiate to optimize, we also have to be willing to be changed. We need to approach our patient conversations with blissful awareness of our ignorance of what caused the patient to come to the ER. We need to discover and acknowledge their unique drivers, and do it with humility. Once they have been heard, as witnessed by them declaring spontaneously "that's exactly right," we can move onto the part where we address both their concerns, and what might be actually going on, which are often not the same thing. We pay so little attention to why patients come to the ER. Recently there was a study asking for *the first time* why patients came to the ER with back pain, "Yet no study has specifically examined patient priorities in the ED setting." (Kim et al., 2023) It turned out that "(1) the decision to seek emergency care for low back pain is motivated by severe pain, resulting disability, and fears about a catastrophic diagnosis, (2) participants sought various goals from their ED visit but emphasized the primacy of pain control, (3) participants were reluctant to use pain medications but also acknowledged their benefit" CDC states 131 million ED visits each year, **Chest** **pain** is the second most common complaint, accounting for approximately 7.6 million annual visits to emergency departments (ED) in the United States. Searching Annals of EM for "Chest Pain" includes 4,840 articles and 1,616 research articles (on March 9, 2023).![[Search for Chest Pain.jpg]] Searching or "Listening" which is involved in 100% of the 131 million ER visits per year reveals 512 results, with only 1/4 of these being even research articles. ![[search for listening 1.jpg]] Listening is not we researched, reported or described in the EM literature and conversations. ## Step 1: What circumstances lead you to listen to win? There are multiple self assessment tests that can be done to assess your style of listening, and multiple ways of describing listening styles. We develop our listening style like how we develop other communication styles, through learning from watching others and with our own set-point and style. We often haven't had specific training in listening. Additionally, our environment influences our behavior. We come into an ER visit with emotionally activated minds, complex social dynamics, and destructive soundscapes. Patients come with anxiety anxiety and frustration. So, we need to create the mindset that will create the conditions for us to get to understanding. For the purpose of this conversation I'm going to generalize listening to two concepts: listening to understand and listening to win. ### Some questions to ask yourself: _These behaviors may be situational, ask yourself about what you do in the ED or Urgent Care? How about if a friend was giving you bad news about their health, what would you do naturally?_ - Do you frequently interrupt a speaker asking for clarification or to correct a pronunciation? (Listening to win) - If you feel you know more about a topic then a speaker, do you let them finish and pause for a few seconds before speaking? (Listening to understand) - Do you think about what you are going to say next when listening? (Listening to win) - Does your mind wander when you are listening to a topic that doesn't really interest you? (Listening to win) - Do you look at the speaker's body language for cues about their emotional state when listening? (Listening to understand) - Do you clarify your understanding by paraphrasing what you thought you heard? (Listening to understand) - Do you get your eyes below theirs, lean forward, and make eye contact? (Listening to understand) - Do you stand back, cross your arms, lean against something? (Listening to win) What can we learn from this exercise? For me it is the idea that we are influenced by our framing of the situation in terms of how we approach listening. ![[Minehart - Listening Styles Quiz 2pg.pdf]] ## Step 2: What is the purpose of this conversation? If the conversation is to transmit a process that you need to learn, it might make sense to listen to win. You need the details, you need your ideas to be clarified or even corrected. If someone is teaching you, you need to ensure you heard them correctly, you need your questions to be answered. If the purpose of the conversation is to learn something about the other person, about their experience, or if you need to create a shared [[Mental Model]], then you need to understand. ### Can listening be assessed? [[Assessing]] listening has been studied in multiple dimensions: ![[CleanShot 2023-03-31 at 07.43.41.jpg]] None of these fully accounts for the comprehension of the act, so they provide different lenses to view listening as a procedure. (Shields et al., 2022) ![[CleanShot 2023-03-31 at 07.38.11.jpg]] ### Types of Listening In order to achieve the proper type of listening, you need [[awareness]] of how you are listening. #### [[Listening to Understand]]: The goal here is [[Teaming by Amy Edmondson]] around solving a problem together, create a dynamic of paired responsibility, you need to listen to them and they need to listen to you. [[listen for what's right instead of for what's wrong]]. Our process should be [[empathic listening]], which requires that your active listening technique for both content and emotion. %% - [[relational listening]]: goal is building connection - [[analytical listening]]: goal is solving a problem together %% #### [[listening to win]] ((Coughlin, 2023): The goal here is to give the special information that only you have to the other person, to improve their thinking, to change their point of view. The problem with listening to win is that it results in [[reactance]], the idea that people feel when you're pushing, and it creates an equal and opposite or even stronger push against you. %% - [[critical listening]]: goal is judging the content and reliability of the speaker - [[task focused listening]]: goal is transferring information %% ## Step 3: How do you know when you understand? In a listening to understand conversation, you can have a target of understanding, which is the speaker replying to you, "[[That's exactly right]]." This is different than how we usually approach these conversations, in which we assume we understand. However, we should be considered innocent of understanding until we are proven guilty of understanding. The judge of our our understanding can only be the speaker. _"The Biggest Problem in Communication Is the Illusion That It Has Taken Place"_ Generally attributed to George Bernard Shaw with apparently [limited evidence](https://quoteinvestigator.com/2014/08/31/illusion/) Usually this means just being a little more active than you usually are. When you listen, wait till the speaker is done, and instead of saying, "Uhuh" and asking your own questions, say, "I want to make sure I heard you, what I think I'm hearing is ..." and speak only in your own words, none of the words that they said. If you **do not** hear the response, "That's right" or even better, "That's exactly right" then you didn't understand. If they clarify, that's great, now you can try to get to "That's exactly right" again. Don't try for "Yes," yes is low enthusiasm, and the speaker just expects the conversation to end. If you try 3 times and it feels like the goalposts keep moving on your understanding attempt, you need to step back and be curious about what's going on. "I feel like I'm trying to listen and I'm not hearing what you're saying, or the goalposts are changing a little, is there something else going on that we should talk about?" [[name it to tame it]], try to get at what else is going on. Here you are naming not understanding. The goal is to keep your [[curiosity]], recognizing that they have information you don't about the situation. ### Being open to being changed In power differentials, the lower status person doesn't do what they hear, they do what they see being done. Your job is actively [[modeling vulnerability]] which allows the lower status person to open their mind. This relates to the conversations we have at work because we represent the hierarchy of healthcare. We hold the prescription pad. Our vulnerability to being open can only be felt by the other person if we take specific steps to demonstrate it. Generally, this means finding an opportunity to be corrected. When you make an attempt at active listening, and they correct you, this is a good thing. Thank them for speaking up and helping you understand. You leaning forward into changing your thinking helps them be open to changing theirs. ### Being present Being present is the key to opening the feeling of mutual respect, awareness of how you are being present, and what conditions you require to become present, will be the first step in being a successful listener. [[inverse charisma]] is what we are going for here. Try not to try to listen, instead presence is the goal. A key question is in complex systems we cannot just want to do something to make it happen, instead we create the conditions that make it likely (Dierickx, 2020). So, how do we create the conditions for us being present, just for a couple of minutes, even in the context of hallway patients, waiting room evaluations, etc? ## What are the jobs we are hired for? A key problem we face is misunderstanding the job we are being hired for (Christiansen, 2012). His example, when we get home from work and our partner has been with the kids all day, and we jump in and start cooking dinner and cleaning the dishes from the day, we misunderstand that what our partner needs is actually a grownup to talk to. We think we are being helpful because we are taking action, what they really need is presence. When patients come to the ER, I will argue, we have two jobs. - One job is listening to understand so their concerns are aired, so they can let go of that worry, if possible. - The other job is taking reasonable steps to make sure they are safe, and that we have something close enough to the diagnosis that they are safe moving to the next step. Instead, we think we are supposed to classify them into a group such as "chest pain," and then be perfect in getting the diagnosis, or at least rule out all the bad things. The problem with this approach is we often classify them into a group too early, as humans we are [[satisficers]], not seeking the best answer, but seeking the first answer that gets close enough. - Our nature leads us to over-test for concerns that aren't important, and then when our tests are negative we are reassured, but we didn't ever address why they actually came. We didn't care for them in a way which aligns with their values, so we aren't sharing enough of the responsibility with them. This is a form of learned paternalism. ## Step 4: Identify and Leverage Strong Emotion Emotions are practical elements of our lives. They gives us important data about what we care about. Strong [[emotion changes the world we are in]], it changes our ability to see and think clearly. We see feedback as criticism, data as an attack on our identity. One key technique is [[naming emotion decreases activation]], so we can make the same guess at the emotional drivers. If we are wrong, it is ok, we can be corrected. When people are upset about something, it means they care about it. This is good data for us, it doesn't mean they are mad at us, it means they care about the topic and haven't yet had that need met. Reframe from an attack on us to a sign that this is a topic they care about and they have an emotion that needs to be named. This process is similar to [[emergency empathy]] from [[🐓 Idea Farm/Deadfall/For myself only/Readwise/Books/Nonviolent Communication]](Rosenberg, 2015), but includes giving the option to explore. ### Don't answer feelings with facts When strong emotion comes up, resist the temptation to subdue those emotions with your doctor facts. This unintentionally makes the person feel not listened to. Instead, GIVE towards the emotion. When you see strong emotion, consider the GIVE pneumonic (BMJ, 2020) ![[CleanShot 2023-03-17 at 13.10.37.jpg]] ### Listening Across Cultures Cultural humility ![[Intercultural Communication Self-Check.pdf]] ## Sources: _7 Types of Listening: How Listening Styles Help You Communicate - 2023_. . MasterClass. Retrieved March 11, 2023, from [https://www.masterclass.com/articles/how-listening-styles-help-you-communicate](https://www.masterclass.com/articles/how-listening-styles-help-you-communicate) Aubrey Marcus (Director). (2022, April 13). _Deep Listening Technique So POWERFUL It Is Psychedelic | Guy Sengstock on Aubrey Marcus Podcast_. [https://www.youtube.com/watch?v=flashHPvoQY](https://www.youtube.com/watch?v=flashHPvoQY) BMJ. (2020, April 13). _Laura K Rock: Don’t answer feelings with facts_. The BMJ. [https://blogs.bmj.com/bmj/2020/04/13/laura-k-rock-dont-answer-feelings-with-facts/](https://blogs.bmj.com/bmj/2020/04/13/laura-k-rock-dont-answer-feelings-with-facts/) Coughlin, C. (2023, Jan 24). _Become A Better Listener_ (No. 157). Retrieved March 1, 2023, from [https://youtu.be/TNyaaUF0hwE](https://youtu.be/TNyaaUF0hwE) Christensen, C. M., Allworth, J., & Dillon, K. (2012). _How will you measure your life?_ (1st ed). Harper Business. Dupuis, D. (2020, September 17). _What are the Four Listening Styles?_ Mandel Communications. [https://www.mandel.com/blog/what-are-the-four-listening-styles](https://www.mandel.com/blog/what-are-the-four-listening-styles) Dierickx, C. (2020, July 27). _How To Create The Conditions To Optimize Your Success | LinkedIn_. [https://www.linkedin.com/pulse/how-create-conditions-optimize-your-success-constance-dierickx/](https://www.linkedin.com/pulse/how-create-conditions-optimize-your-success-constance-dierickx/) Kim, H. S., Strickland, K. J., Seitz, A. L., & McCarthy, D. M. (2023). Patient Perspectives on Seeking Emergency Care for Acute Low Back Pain and Access to Physical Therapy in the Emergency Department. _Annals of Emergency Medicine_, S0196064422014032. [https://doi.org/10.1016/j.annemergmed.2022.12.028](https://doi.org/10.1016/j.annemergmed.2022.12.028) Minehart, R., Symon, Benjamin, & Rock, Laura. (2022). What’s Your Listening Style? _Harvard Business Review_, _5_. [https://hbr.org/2022/05/whats-your-listening-style?ab=hero-main-text](https://hbr.org/2022/05/whats-your-listening-style?ab=hero-main-text) Listening Styles. (2016). _4.2 Listening Styles_. [https://open.lib.umn.edu/publicspeaking/chapter/4-2-listening-styles/](https://open.lib.umn.edu/publicspeaking/chapter/4-2-listening-styles/) Rosenberg, M. B. (2015). _Nonviolent communication: A language of life_ (3rd edition). PuddleDancer Press. Shields, C., Willis, H., Nichani, J., Sladen, M., & Kluk-de Kort, K. (2022). Listening effort: _WHAT_ is it, _HOW_ is it measured and _WHY_ is it important? _Cochlear Implants International_, _23_(2), 114–117. [https://doi.org/10.1080/14670100.2021.1992941](https://doi.org/10.1080/14670100.2021.1992941) Sonis, J., Mort, E., Natsui, S., Goldsmith, A., Joseph, T., White, B., Raja, A., & Aaronson, E. (2016). 18 Listening to Our Patients’ Concerns: A Call to Focus Experience Efforts on Communication and Compassion. _Annals of Emergency Medicine_, _68_(4), S8. [https://doi.org/10.1016/j.annemergmed.2016.08.028](https://doi.org/10.1016/j.annemergmed.2016.08.028) Staff, A. (2017, January 17). 7 Types of Listening Styles and How to Approach Them. _Elite Learning_. [https://www.elitelearning.com/resource-center/laboratory/7-types-of-listening-styles-and-how-to-approach-them/](https://www.elitelearning.com/resource-center/laboratory/7-types-of-listening-styles-and-how-to-approach-them/) _Why Conversations Go Wrong with Deborah Tannen | Hidden Brain Media_. (2022, March 1). [https://hiddenbrain.org/podcast/why-conversations-go-wrong/](https://hiddenbrain.org/podcast/why-conversations-go-wrong/) %% ## Unrequited notes (by link) _update when creating MOC to point to this note_ These notes point directly to this note. But this note doesn't point back. ```dataview table file.mtime.year + "-" + file.mtime.month + "-" + file.mtime.day as Modified from [[listening]] and !outgoing([[listening]]) sort file.mtime desc ``` ## Associated notes (by tag) _Update when creating MOC to point to this tag_ These notes have this associated tag: `#MOC Template`. ```dataview table file.mtime.year + "-" + file.mtime.month + "-" + file.mtime.day as Modified from #on/listening and !outgoing([[listening]]) sort file.mtime desc ``` %%