The respiratory tract

November 2012


A is for aphorism

The power of silence

Volume 41, No.11, November 2012 Pages 909-909

Sanne Kreijkamp-Kaspers

Paul Glasziou

‘All you have to do is listen’ is the title of Rob Kapilow’s delightful book on classical music;1 but he could equally have been talking about general practice consultations. Listening requires several skills including attention, echoing and body language, but begins with silence. Well timed silences, used judiciously, can allow the patient adequate space to express symptoms and concerns, while allowing the general practitioner more time for attention, comprehension and synthesis.

Listening without interrupting the patient sounds like a recipe for running late. But the research provides some surprises: patients don’t generally speak for very long and not interrupting initially does not lengthen the consultation. Without good training in listening skills, clinicians tend to interrupt very early into the consultation. Studies suggest a range of 12–23 seconds that patients are allowed to speak before the first interruption. Less than one in 3 patients are allowed to complete their opening statement.2,3 This disruption or redirection by clinicians can mean missing information or other issues that are re-introduced later and in the end, saves no time.

This problem was confirmed in a study using audiotaped family practice consultations. When a patient was allowed to complete the opening statement the average consultation time was 14 minutes and 52 seconds versus 15 minutes and 18 seconds when the patient was interrupted,4 and although not statistically significant, the trend was toward saving time. A study in Israel5 videotaped primary care doctors’ consultations for 2 days. On the second day they were handed a note saying ‘When the patient starts speaking, please do not interrupt him or her until you are satisfied that he or she has finished’. The median time for the initial statement increased from 15–21 seconds, but the consultations were no longer (again, the trend was to be slightly shorter). However, the videotapes showed that 65% of patients were still interrupted before completing their initial statements. It seems that doctors are not used to being silent. The instruction note in the previous study was minimal ‘training’. A study in Basle6 gave doctors 1 hour of coaching in the basic elements of active listening: waiting, nodding, echoing and using facilitators such as ‘umm-hmm’. Mean time to first interruption was still only 92 seconds, and 78% of patients completed their initial statement in less than 2 minutes. Unfortunately, there was no control period or group to assess the impact on total consultation time, but the average should be no more than 77 seconds extra (92 minus the usual 15), and the previous studies suggest it might actually save time.

Most evidence on silence relates to the initial part of the consultation. But silence can be used elsewhere: when a new topic is introduced, or pausing when strong emotions appear in the patient’s voice, face or posture. A surprise to many clinicians is that we can even begin the consultation with silence. In his book on consulting styles in general practice, Roger Neighbour7 suggests remaining silent for several seconds after the patient sits down while waiting to see whether they commence the consultation without prompting. They usually do. This short period of silence allows the GP time for attention to the patient’s appearance, posture, breathing and voice, which can all provide clues to the patient’s problem or their degree of concern about it. The power of silence deserves to be used more frequently in general practice, but it is a skilled art that requires practise and patience.

Conflict of interest: none declared.


  1. Kapilow R. All you have to do is listen: music from the inside out. Hoboken: John Wiley & Sons, 2008.
  2. Rhodes KV, Vieth T, He T, et al. Resuscitating the physician-patient relationship: emergency department communication in an academic medical center. Ann Emerg Med 2004;44:262–7.
  3. Beckman HB, Frankel RM. The effect of physician behavior on the collection of data. Ann Intern Med 1984;101:692–6.
  4. Marvel MK, Epstein RM, Flowers K, Beckman HB. Soliciting the patient’s agenda: have we improved? JAMA 1999;281:283–7.
  5. Rabinowitz I, Luzzati R, Tamir A, Reis S. Length of patient’s monologue, rate of completion, and relation to other components of the clinical encounter: observational intervention study in primary care. BMJ 2004;328:501–2.
  6. Langewitz W, Denz M, Keller A, Kiss A, Ruttimann S, Wossmer B. Spontaneous talking time at start of consultation in outpatient clinic: cohort study. BMJ 2002;325:682–3.
  7. Neighbour R. The inner consultation: how to develop an effective and intuitive consulting style. 2nd edn: Abingdon: Radcliffe Publishing Ltd, 2004.


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Medical aphorisms