Krishna Naineni is a GP Partner at Wealden Ridge Medical Partnership and an Educational Supervisor for the KSS Deanery. An ECHO-certified listening practitioner, he served as President of the International Listening Association (2024/25), focusing on listening-centered communication skills for healthcare professionals.
Margarete Imhof is professor of psychology in education at Johannes Gutenberg University, Mainz, Germany. Her research focused on the cognitive psychology of listening, teaching of listening and effective use of listening in communication. In 2007 she served as President of the International Listening Association.
As a GP, every time I call a patient, I face a silent choice: “Will I meet a story… or just a symptom?”
As a GP, I prefer the story. Between the rising complexity of care and the relentless demands of documentation, a GP’s cognitive bandwidth is often stretched to its limit.1 This isn’t a failure of empathy, but a predictable response to overload. As the digitalised consultation demands the GP’s attention, the patient’s voice can easily get lost in the noise.2
Between the rising complexity of care and the relentless demands of documentation, a GP’s cognitive bandwidth is often stretched to its limit. This isn’t a failure of empathy, but a predictable response to overload.
Additionally, there is a “communication paradox”: On the one hand, the GP has complex medical information to convey. On the other hand, the patient has limited capacity to absorb it. With worries and concerns racing through a patient’s mind during the consultation, there is less space than usual for the information the GP has for the patient.
To focus on what GPs can control, we propose the L₂O framework, a synthesis of Listening, Listenability, and Observation to structure the communication in the consultation so that everyone gets more out of the 10 minutes. Here is how:
L – Listening (IN)
The Goal: Shift to precision inquiry. Listening is complex cognitive work.3 Under overload, the mind defaults to “downloading”—hearing what confirms preconceived assumptions. Use questions that create space for the patient’s narrative.
What to do:
“Launch” Question: Avoid the checklist. Start with a high-yield opener that invites the timeline: “Take me back to when this first started…”
“Safety” Pause: When they finish a sentence, wait. This patience acts as a nudge; the silence signals safety, often prompting the patient to reveal the hidden concern without being asked.
Context Scan: Before they enter, glance at the notes. Where is this story happening? Is it the start of a new illness, or a plot twist in a chronic one?
When to Pivot:
“Interruption Itch”: You feel a physical urge to cut them off.
“Premature lock”: You decide the diagnosis in the first 10 seconds and stop hearing new data.
Action: Drop your shoulders, exhale, and ask one more open question.
L – Listenability4 (OUT)
The Goal: Tailor your output to the patient’s narrowed bandwidth. Translate your message into their language. Reduce the cognitive effort required to process the message and make your message listenable.
What to do:
Listening is complex cognitive work.3 Under overload, the mind defaults to “downloading”—hearing what confirms preconceived assumptions. Use questions that create space for the patient’s narrative.
Reincorporation:5 Deliberately reuse the patient’s own metaphors. If they say their pain is “vice-like,” use that exact phrase in your explanation. It validates them and reduces the translation load.
Advance Organisers: Help the patient predict what is coming. “I want to cover three things: what this is, how we treat it, and when to worry.” This structure reliefs cognitive load.
Personalise Data: Use personal pronouns rather than clinical terms. Rather than saying, “Anti-inflammatories reduce swelling,” say, “This medication will help you bring your swelling down.” This shift to personal language fosters a more conversational dynamic and increases patient engagement.
When to Pivot:
Vacant Nod: The patient is nodding rhythmically, but their eyes are glazed or looking past you.
Loop: You find yourself explaining the same concept for the third time.
Action: Stop – shift modes. Draw a diagram or use a metaphor instead.
O – Observation (ABOVE)
The Goal: Monitor the interaction. Move from “controlling” the consult to “witnessing” the interaction, allowing you to spot patterns before they become conflicts.
What to do:
Closure Check: When you feel certain of the diagnosis early on, challenge it. Ask: “Have I stopped listening because I think I know the answer?”
“Focus” Snap: If your mind drifts to the backlog/admin, use a physical trigger (e.g., touching the keyboard) to snap back: “Be here.”
Physiological Reset: If you feel tension, do a “Jaw Drop”—consciously unclamp your jaw. It signals your parasympathetic system to reset.
When to Pivot:
“Overtalking”: You notice you are talking over the patient or interrupting their rhythm. This is a primary sign of lost connection.
“Time Panic”: You are looking at the clock more often than at the patient.
Action: Acknowledge the feeling (“I am stressed”), exhale, and re-engage.
Following L2O helps GPs both to tailor their messages to the patient’s needs and to base their decisions on more solid and relevant information.
Just as human bodies need H₂O to function, professional well-being as clinicians needs L₂O. To begin implementing this, we invite you to try one micro-technique from the L₂O framework and checklist in your next clinic consultation. For a quick version, we offer the pocket mnemonic:
IN – listen, don’t collect
OUT – speak so it’s easy to understand
ABOVE – manage yourself
References
- Young JQ, Van Merrienboer J, Durning S, Ten Cate O. Cognitive Load Theory: implications for medical education: AMEE Guide No. 86. Med Teach. 2014 May;36(5):371-84. doi: 10.3109/0142159X.2014.889290. Epub 2014 Mar 4. PMID: 24593808.
- Swinglehurst D, Roberts C, The role of the electronic patient record in the clinical consultation, February 2014, In book: The Routledge Handbook of Language and Health Communication, Chapter: 30, Routledge, Eds: Heidi Hamilton, Sylvia Wen-ying Chou, https://www.taylorfrancis.com/chapters/edit/10.4324/9781315856971-34/role-electronic-patient-record-clinical-consultation-deborah-swinglehurst-celia-roberts
- Wolvin AD (Ed) Listening and Human Communication in the 21st Century, 3 February 2010, Blackwell Publishing Ltd, ISBN:9781405181655 DOI:10.1002/9781444314908
- Rubin DL. Listenability as a tool for advancing health literacy. J Health Commun. 2012;17 Suppl 3:176-90. doi: 10.1080/10810730.2012.712622. PMID: 23030569.
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Pynton R, Do Conversation: There is no such thing as small talk. 7th March 2024, ISBN 978-1-914168-27-7
https://thedobook.co/products/do-conversation-there-is-no-such-thing-as-small-talk?Format=Paperback [accessed 26/2/26]
Featured photo by Nathan Dumlao on Unsplash
