00:00 Dr Krishna Naineni
This is my deepest fear. I fear that they stop sharing the real concern with me. Maybe I then base my diagnosis based on incomplete story that they have shared with me because I stopped listening, they perceived that I’m not interested, and they didn’t share the story which they really wanted to share or which I wanted to hear.

00:56 Oscar Trimboli
Dr. Krishna Naineni works as a general practitioner in England. He’s a member of the Royal College of General Practitioners and is a faculty at Brighton and Sussex Medical School. He’s passionate about listening education, research, and practice. He’s delivered structured and evidence-based listening education programs in the UK and in India to hundreds of healthcare professionals with practical strategies and the knowledge needed to enhance the way they engage with their patients through their listening practice.

He has co-founded Glocal Academy, which has been instrumental in delivering custom-made clinical communication skills training programs to healthcare professionals and organizations across India and the United Kingdom. The academy delivered its first ever clinical communication skills training program in 2015 to healthcare professionals in India. He enjoys a long distance running and he hates cooking, but he loves eating food. During this discussion, Dr. Naineni change my mind about the impact of the environment in which you listen , education and your mindset, particularly in healthcare, but equally in workplaces all around the world.

While you’re listening today, reflect on the question about what does your physical or virtual environment contribute or detract from the effectiveness of your listening?

I’d love to hear your answers, and for the first five people who send an email to podcast@oscartrimboli.com with a subject line environment with an answer to these questions:

1. How does this conversation increase your awareness about the impact of your environment?
2. How does this play out in face-to-face environments?
3. How does it play out in virtual environments,
4. and what change will you make as a result of listening to this conversation?

We’ll send you a paperback copy of the award-winning book, how to Listen: Discover the Hidden Key to Better Communication, the most comprehensive book about listening in the workplace, and we’ll send it in the post for you.

03:34 What’s the cost of not listening?

03:36 Dr Krishna Naineni
Cost of not listening is immense in healthcare and in medical training. I’ll answer the question from a healthcare point of view first, because I’ve got two roles. I’m a medical educator and a clinician.

I would say poor satisfaction from patient’s point of view and from a clinician point of view, lack of adherence to management plans that we carefully design, and lack of trust.

Lack of trust is very significant because we need trust to establish this humane connection with patients. Not only do you establish, to sustain them. When there is no trust, then it’s very difficult for you to manage or maybe for patients they find it very difficult to believe in what you said or what you are giving them, and most of all, respect. They come to the clinic, they come to you to share their narrative.

When you are not listening for whatever reason that may be, or when they perceive that you’re not listening, then you’re just being disrespectful as humans, as a basic courtesy.

There is a question that I use a lot in my clinical communication courses, which is clinician equals human first, then professional.

To be an effective clinician, we need to always remember that we are human first. We got to respect each other. Then, the professional comes into being, so that’s why it’s very important for me, those three elements.

Respect, trust, and satisfaction.

05:29 Oscar Trimboli
When a clinician is not creating a environment of trust, what are they doing or not doing to contribute to that?

05:39 Dr Krishna Naineni
Sometimes, I forget to inform patients that I need to really look at their notes when they’re narrating the story, and they share something and,I want to check against my knowledge of them in the notes.

If I spend too much time looking at the computer and not looking at the patient, they perceive that I’ve stopped listening because I’ve listened for some time and then I started looking at the computer more than they want me to look out, more than I wanted to look.

If many a times I signpost to them, okay, I may have to look at the computer briefly. But sometimes, in the heat of the moment, you forget and then you’re carried away in looking at the computer and typing away.

I really get annoyed with myself, because as an educator and as a clinician, you’re not only practising but you’re also teaching that don’t look at the computer, it’s the patient first.

However, sometimes, it happens and it happens so fast that maybe it’ll be too late before you recognize that it has happened. So, that is one thing that people might perceive that you’re not listening, and therefore, I fear, this is my deepest fear. I fear that they stop sharing their real concern with me.

Maybe I then base my diagnosis based on incomplete story that they have shared with me, because I stopped listening. They perceive that I’m not interested, and they didn’t share the story which they really wanted to share or which I wanted to hear.

07:24 Oscar Trimboli
Doctor, if we follow your formula of human first, practitioner second, what would the human do in that moment when they’re being seduced by the computer?

07:34 Dr Krishna Naineni
Accept that it happens and apologize to the person in front of you that I didn’t mean to do that. “I’m here now. I promise you that I’m not going to look at this again, so could you please share the story? The last I heard was this.”

Maybe when you say the last I heard was this is – maybe you are giving the impression that actually you did hear.

07:58 Oscar Trimboli
I’m guilty of it also, and I think to be human is to be fallible, to be honest, and to show respect. That is what the last thing I heard.

I’m curious to explore a principle from design where design defines performance, and I want to zoom into the rooms. Some people call it the treatment rooms, some call it the office, some call it the practice.

What would you call where you see your patients?

08:35 Dr Krishna Naineni
I call them as a consulting room.

08:38 Oscar Trimboli
We zoom into the consulting room, draw us a little picture

08:44 Dr Krishna Naineni
On my door, it’s from Parker J. Palmer, “Courage to Teach.” I loved this concept of welcoming. On the door, I wrote, “Welcome.” When I asked my manager to print that one, they said, “Krishna, are you sure?” She said, “Why?” “You are writing welcome on your door. How much time do you think you have to welcome patients into your room?”

And then Padma, my wife, she said, “You must be mad to write welcome on your door. Really? You want people to keep walking into your room because you write welcome?”

Then I had to say that my intention is when they see that under my name, when they enter the consulting room, they want to actually feel that, okay, welcome. Oh, that’s a nice gesture. So, it’s sending out a message before they enter the room.

09:42 Oscar Trimboli
How long into your practice did you make that change?

09:47 Dr Krishna Naineni
As a GP, I’ve been practising for just over 10 years. Five years into being a GP, we are busy. Healthcare professionals are busy for obvious reasons. People are busy, and suddenly what I felt was they should not feel that I don’t have time and I’m busy before they walk into the room. If they come into my consulting room, assuming that I don’t have time for them because I’m busy and I’ve got so many things to do, I fear that they might rush through their narrative. I don’t have any research to back it up. This is just purely based on my assumption and fear, and one of the stories which a patient narrated to me.

“Dr. Naineni, I don’t feel that you give an impression that you are rushed for time.”

I said, “How could you tell?”

“Just from walking from the waiting room into your clinical room? I walked behind many clinicians in my time. You are the only one where you slow down and you slow my pace down before you enter into the clinic room. Many a times, the clinicians, they walk fast and I get a feeling that they’re already walking fast, which means they’re hurrying me up already,”

which also implies that people are observing every little thing that you do from the way you walk, from the way you sit, or maybe from the way you talk. That’s an interesting observation I had to say to him.

11:37 Oscar Trimboli
So we step through the welcome door.

11:43 Dr Krishna Naineni
As you enter to the room, the first thing which the people see is, “Do the things that make you happy, do more of what makes you happy, and live the life that you would like.”

And as I sit, as I’m seeing the person in front of me, behind him on the door, I have got these two words, “Be present.”

When I look at the patient, I’m also looking at those two words. What the patient would see as he is looking at the wall is, “What does it mean to be present?”

They see that question. For me, it’s me to be present and for them it’s what does it mean to be present.

As I look at the computer between the patient and the computer, I have this, “We are going on a bear hunt,” song. Do you know that song, Oscar? We are going on a bear hunt. Don’t go over it. Don’t go under it. We have to go through it.

It reminds me that don’t take shortcuts.

You have to go through, that they go through the challenges. You need to learn to go through. It’s a gentle reminder for me that, okay, I’ve got challenges ahead. I will have challenges ahead. However, I need to find a way to go through them.

The way my desk is arranged is not in between.

The computer is on the desk, the patient is sitting next to the desk. We are almost facing each other with only a small amount of the desk coming in between our way. I am facing the patient and there is only the corner part of the desk that is between me, and as if I’m just placing my hand on the desk but most of me and the patient are in contact with each other.

I have a cricket bat on my left side of the room. On the cricket bat, it says, “Look, listen, and respect.”

The three words. Look at the patient, listen to the patient, and respect what they’re saying.

14:15 Oscar Trimboli
My father had his second stroke and it was a much more significant stroke than the one he had seven years earlier.

For two and a half weeks, he lost the function of his tongue. He couldn’t speak and communicate, and he struggled to swallow whether that’s solids or liquids.

I want to talk to you about my experience as the person supporting the patient.

At first, I’m in a stroke unit, so everybody fully has this context and doesn’t judge anybody in this story, particularly the medical professionals, whether they’re nurses, neurologists, speech pathologists. Everybody was doing their best.

The hospital had huge COVID issues and a lot of staff were moved from the stroke unit into the COVID units. As a result, a typical ratio for a nurse was one to four, or four patients for one nurse.

When my dad arrived in the stroke unit, it was 20 to one, 20 patients or one nurse.

One thing I noticed consistently was when I was present to my dad and when he was receiving a consultation in the stroke unit, the medical staff were directing their communication to me, and I had to move my body and sit next to my dad on the bed.

Otherwise, they would just keep talking over the top of my dad as if he wasn’t there. Is this common?

15:57 Dr Krishna Naineni
Firstly, Oscar, I’m sorry to hear that your father had such a… The second stroke was impactful on his overall health.

To answer your question, the people who are caring for such patients, they may be at various levels of the training. Speaking from a UK perspective, I’m not sure about the layout and the perspective of the Australia healthcare system, but in the UK, I think at any given time, you have nurses who have been doing the job in the same country for many years, and you may also have the nurse who has just come to the country in the last year from India or from other countries and come on practice.

The training with which they receive and the things they observe and they try to practice may be different from person to person. In a way, it’s not uncommon what you have observed, that the conversation direct at the person sitting next to the bed.

It could be that they have assumed that the person, I’m using the word person, not your dad because we’re talking generally, they might assume that the person can no longer communicate.

Maybe you have got the answers and his best interest at heart, so you could communicate. However, they don’t realize that suddenly you’re putting too much pressure on the person sitting next to their loved one to makemake decisions further for them.

Suddenly they don’t… If people like you, you feel like,

“Why am I making decisions for my father?” Who, from your point of view, can communicate, can share their decisions , if you spend quality time with him.

Again, there, the equation of 20 to one might come into being so they don’t have that time that you expect them to spend. They might want to move on to the next person or the patient because they are pressured for time, and they’re approaching you to have a dialogue about the patient care and the decisions.

As a medical educator, our default or automatic reaction is to phrase the sentence or a question in such a way that you would say,

“Oh, Oscar, what do you think? What is the best thing to do for your dad?”

So, the onus is on the person and they might feel that,

“Oh my god, I had to make decisions for my loved one. What if I get it wrong? What if I get it right? What might my sister think of my decision?” So, they are in a different world when they hear such a question. When the intention of the healthcare professional was,

“What is the best thing to do here?” But the way they phrase the question might come across differently. Hence, it’s very important to be mindful of everything and hear the phrasing of the questions.

19:15 Oscar Trimboli
By the second day in the stroke unit, I communicated to the head of the nursing area and left a note for the consulting physicians that when I’m present, they should look at my father in the eye, even if they’re talking to me because he can hear completely fine. He can understand everything that’s being said.

It’s just his struggles with his yes and no. We worked out a code, so it was fine. It was one squeeze on my hand for no, and two squeezes on my hand for yes. It was a very simple system to do that.

The reason I was being deliberate is not that I was concerned about the questions that were being asked. I fully accepted my responsibility in that moment to act in my father’s best interest as he did when I was born and growing up and throughout my life.

What I wanted the medical staff to be conscious of is to bring my dad along in the journey of moving him on from someone who’s had a stroke to somebody who’s leading a life after a stroke.

Now, we’re 12 months down the track.

My dad is back at home. He’s got some extra care. He’s unable to drive. He uses a walking stick.

Yet, only three months ago, we went to see the consulting neurologist in their offices, in their consulting rooms.

My dad, I made sure, sat as close as possible to the treating neurologist, and yet the whole conversation, they kept talking to me.

“Gee, your dad’s doing so well.”

My dad can talk . For two and a half weeks, he didn’t have full functional use of his tongue. It took him the best part of six weeks to regain that through wonderful speech therapy and exercises.

For me, yes, there was a moment where the ratios were completely out of balance. But when I zoomed in, and that’s why I was asking you all the questions about the consulting room, because I was fascinated about how that drives a dialogue, a narrative, a listening conversation, or just a one-way conversation.

For me, it was how do I make my dad part of his recovery rather than something that’s being done to him.

I’m curious, as you hear that, what’s going through your mind as an educator?

21:55 Dr Krishna Naineni
I just did a session 10 days ago, Emotion in the Clinical Encounter, fascinating book, in that the author makes a very powerful simple model about how emotion can influence person’s presentation.

Let me read those two questions which might explain what you’re saying. I think she says this one,

“Do you want us to do X for your mother?

Do you want us to be looking at you and saying, ‘Do you want us to do X for your mother,’ is a fundamentally different question than,

‘Would your mother have wanted us to do X? Would your mother wanted?'” So then, shifting the emphasis onto differently.

Coming back to what you were saying, the healthcare professionals, we should focus on the person with the problem and help them maintain their independence and support them.

They may not be able to do all the things that they were doing before they had their illness.

However, we need to learn about what are the things they can still do and what are the things that they wish to continue to do, and if so, how can we support them.

In that dialogue, together, you and the person with the problem and the family member realize that, okay, these are the things they can still do and these are the things in which they need some support, and these are the things that they can’t do.

That’s where they might need more time to come to terms with. I’m not sure how important driving was for your dad. For some people it is, and you need to allow time for them to come to their own understanding and in their own time to say, “Okay. I can see why it’s difficult for me to continue driving, or do X, Y, and Z because of the impact of the problem on me.”

24:10 Oscar Trimboli
I’m curious, who’s doing this really well globally in the medical profession?

24:17 Dr Krishna Naineni
Speaking from healthcare organization’s point of view, they have one thing in common which is the patient care.

If you design the service in the reverse way, what does the patient in my culture want?

What does the patient in my community want? Or better, what does the people in my community want when they become unwell?

What does the people in my community want when they develop life-threatening illness or the conditions that are going to make them disabled or not able to do things?

If we ask those questions, or the organizations or institutions who ask those questions, then they can design the services that can support that community better, because the needs vary from community to community.

Needs vary from culture to culture, and we can’t parachute the services that are working well in one organization into the other country because the cultural values and the cultural practices come into being.

If I may, when we started off the conversation, I said, “What is not listening? What’s the impact of not listening?” I said at the beginning of the conversation that I would answer it from a clinician and a medical educator.

Because we built a story on a clinician about what the impact of not listening, it’s going to be such a challenging thing because when people come to educational sessions, they come with…

26:08 I think this is my assumption. They come with various mindsets. Some with curiosity to learn more about the subject, and some they come for what the course gives to them, i.e., a certificate.

I think when you’re investing time and coming to the sessions, when you’re blocking one hour away, I request them to be there, walk with me, walk with the learners and participants in the room, and the magic will happen.

You might learn new things not listening, which means that you haven’t done anything to your existing knowledge and when clinicians or clinicians in the making don’t invest quality time in listening in educational sessions, ultimately, they need to acknowledge and remember that the patient is going to suffer, because our ultimate objective to our learning and our practices to deliver high-quality patient care.

27: 22 Oscar Trimboli
What’s the one question I should have asked that I haven’t?

27:26 Dr Krishna Naineni
That’s a good question. Maybe we could have asked what are the Five I WILL principles that we integrate in our educational sessions.

The five principles are Intentional presence. I think very important to be present with an intention to pay attention to what the other person is sharing with you and have a welcoming attitude.

The second principle is Welcome.

Welcome the patient, irrespective of their culture, beliefs, religion, socioeconomic status, educational status, sexual orientation. Irrespective of who they are, you welcome them, and you welcome them to share their narrative by giving them time and space.

I is for introduction.

Many a times, we forget to introduce ourselves. It’s very important we say to introduce by including three elements, name, role, and purpose.

“Hi, I am Dr. Naineni, I’m the GP. How can I help you today?” Or, “I would like to have a conversation with you today.” Or, “I’m here to perform X today.”

So, it’s very important to outline the purpose. We also talk about when you are introducing, when you are with the patient, you’re also introducing who you are. By the way you are standing, sitting, or by the way, you have your room layout so you’re introducing yourself.

Be cautious about what are you introducing to the other person, because they’re observing you. They’re observing you how fast you walk into the room, how you’re sitting, where you’re looking. So, be mindful of what you’re introducing to the other person.

The first L of I WILL is Listening intelligence.

As clinicians, educators, you cater for people with various learning needs. You cater for people with various health needs, and you’ve got many roles to play. So how well, how flexible you are in reading the situation and adapting your listening style to match the person in front of you, how well do you own that responsibility and read the situation and keep on adapting to the other person’s needs.

The last principle, L is for Language matters.

The principle says it on, it’s our responsibility as a clinician and educator to design the material or to design the clinical information in such a way that the person who is sitting in front of you, in that moment of time, understands.

The learner who is sitting in your class in that moment understands.

It’s your responsibility to read the person who is sharing information with you. And when you are listening to them, you’re also listening to what language they’re using, what metaphors they’re using, what images they’re using, and reuse them, recycle them, so that you connect with better, and reduce the amount of medical jargon that you are using. Reduce, avoid.

People say avoid, however avoiding can be challenging. Reduce it to start with, it works.

Those are the five principles. Intentional presence, welcome, introduction, listening intelligence, and language matters.

31:01 Oscar Trimboli
I wonder what you took away from this discussion.

What I took away from the discussion is Dr. Naineni is about care, intention, respect, thoughtfulness, and a holistic perspective of listening across culture and many other nuanced contexts.

His focus around listening is care filled and careful. I wonder what you took away from the discussion. I’d love to hear your answers.

For the first five people who send an email to podcast@oscartrimboli.com, with the subject line Environment, and answer these questions.

1. How did Dr. Naineni increase your awareness about the impact of the environment you’re in around listening?
2. How does it play out in face-to-face meetings for you? How does it play out in virtual environments?
3. And what will you change as a result of listening to this discussion?

I’ll send you a paperback copy of the award-winning book, how to listen: discover the hidden key to better communication, the most comprehensive book about listening in the workplace via post for the first five people who respond to those questions.

As a bonus for listening this far, you can listen to Dr. Naineni debrief me about how I was listening and how I can improve the process for next time.

I’m Oscar Trimboli, and along with the Deep Listening Ambassadors, we’re on a quest to create a hundred million deep listeners in the world, and you’ve given us the greatest gift of all. You’ve listened to us.

Thanks for listening.

33:28 How are we going with this conversation?

33:31 Dr Krishna Naineni
One of the thing that I teach in the science and art of asking questions, I say to my learners, I would say, is be mindful of where the questions are coming from. Are the questions coming from the patient’s narrative, or are the questions coming from your agenda, from your checklist? I’m very happy that all the questions that you’re asking are coming from my narrative.

33:55 Oscar Trimboli
What have you noticed about how I’m listening?

33:58 Dr Krishna Naineni
That you don’t have any agenda, you are more interested in what I am sharing and narrating, and you are expanding on the things that I’m sharing with you.