When I say … listening

Listening is a word that appears constantly in medical education. We urge learners to ‘listen to patients’, praise clinicians who are ‘good listeners’ and critique encounters in which listening appears absent. Despite its ubiquity, the term itself is rarely defined. More often, listening is treated as self-evident or folded loosely into broader ideas about communication, empathy or professionalism. In educational contexts, listening is commonly understood as a behavioural posture: maintaining eye contact, allowing silence, avoiding interruption and responding with appropriate verbal cues. In this framing, listening is largely receptive and interpersonal, a complement to speaking well. These elements matter. But they capture only a narrow version of what listening actually does in clinical practice. When I say listening, I do not mean politeness, passivity or simply allowing someone else to speak. I mean the interpretive work through which clinicians recognise and determine what counts as meaningful in patients' and families' words. Listening does not simply transmit information; it determines what clinicians recognise as clinically meaningful.1 What clinicians hear is filtered through professional training, diagnostic categories, institutional routines and the expectation that conversations should move towards decisions. This distinction became visible to me not primarily as an educator but as a family member. My father had terminal lung cancer. Near the end of his life, our family was navigating decisions that were neither urgent nor settled, including whether to pursue a CT scan that might clarify remaining options. We were unsure whether we were fully transitioning to hospice or continuing palliative care with some openness to intervention. We were not asking for a specific outcome so much as time: time to understand what the options might mean and time, still, with my father. During one visit, a member of our family used the word ‘hospice’. The internal medicine physician responded immediately: ‘Oh, we don't need that test then’. In that moment, the conversation narrowed. What struck me was not cruelty but compression. Our uncertainty, grief and deliberation were collapsed into a single category. Hospice had been named and with it the field of what could be heard seemed to close. A clinician listening interpretively might instead pause and ask, ‘When you say hospice, what are you hoping for right now?’ Such a question would not delay care. It would reopen the conversation and widen what can be heard, allowing uncertainty, fear and the desire for time to become part of what the clinician hears not as obstacles to a decision but as the meaning the family was attempting to communicate. In medical education, communication is often taught as a set of observable competencies. Learners are trained to deliver information clearly, structure difficult conversations, maintain eye contact, avoid interruption and demonstrate empathic responses through appropriate phrasing or reflective statements.2 These skills are valuable and rightly emphasised. Yet, they frame listening primarily as a behavioural posture that accompanies speaking well. What receives far less attention is how clinicians interpret what they hear. Behavioural listening is not the same as interpretive listening. The latter involves recognising meaning within what patients and families say, including meaning that is uncertain, evolving or not yet fully formed. That interpretive process is shaped by diagnostic frameworks, prognostic expectations, institutional routines and the practical demands of clinical decision making. Interpretive listening therefore does not sit outside clinical reasoning. It shapes the very data from which clinical reasoning proceeds. Clinicians are therefore trained to listen for information that helps define a problem and move towards resolution. Expressions that clarify symptoms, identify risk factors or signal preferences for treatment readily register as clinically relevant. Other forms of communication, such as uncertainty, ambivalence, grief or the desire to slow decision making, can be harder to recognise because they do not immediately advance a solvable problem. Seen in this light, the moment with my father's physician becomes easier to understand. When the word ‘hospice’ entered the conversation, it activated a familiar clinical pathway. Within that framework, a CT scan appeared unnecessary. The physician's response was not primarily a failure of empathy or concern. It reflected a form of behavioral listening oriented towards categorising the situation and determining the appropriate course of action, listening that, in its own terms, was working exactly as it had been trained to. Many communication tools used in clinical training reinforce this orientation. Teach-back, for example, asks clinicians to confirm that patients understand the information they have been given.3 While valuable for improving comprehension, the method centres the clinician as the primary source of meaning and rarely asks whether clinicians have fully understood what patients or families are attempting to communicate, particularly when those communications take the form of uncertainty or evolving preferences rather than clear decisions about what should happen next. This distinction matters because many of the clinical situations most valued in contemporary medicine, including end-of-life care, chronic illness management and shared decision making, unfold precisely in moments when meaning is still forming. Narrative medicine has long argued that attending carefully to patients' stories is not supplemental to clinical care but constitutive of it.4, 5 Patients and families may be working through grief, testing possibilities, or searching for time before committing to a course of action. In such moments, interpretive listening requires more than identifying the next step in a treatment pathway. It requires the capacity to recognise hesitation, ambiguity and silence as meaningful elements of the clinical encounter. Medical education rarely asks learners to examine how strongly their training shapes what they are able to hear.6 Clinicians do not listen from a neutral position. They listen through professional frameworks that reward efficiency, closure and action. When interpretive listening is understood as a clinical and ethical competency, shaped by training rather than temperament, missed meaning becomes less mysterious. The problem is not simply that clinicians fail to listen. It is that they have been trained to hear selectively and to overlook forms of meaning that do not yet appear actionable. My father died not long after that visit. We did transition to hospice. What remains with me is not the decision itself but how easily complexity was flattened before it could be heard. When I say listening, I mean the trained capacity to recognise uncertainty, hesitation and silence as clinically and ethically meaningful data, even when they do not immediately advance a solution. Medicine fails patients and families not only when it cannot tolerate uncertainty but also when it cannot make space to listen beyond the imperative to fix. Until medical education takes interpretive listening seriously in this sense, we will continue to misunderstand what patients and families are trying to say, especially in the moments when meaning is still taking shape. Brian Tuohy: Conceptualization; writing – original draft; investigation; writing – review and editing; formal analysis. Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.