Approach to teaching active listening in the age of artificial intelligence

Verbal and nonverbal communication

Aizuchi originally referred to the alternating strikes of hammers on hot iron by an expert sword maker and their apprentice.⁵ It has come to mean the frequent short interjections or sounds that a Japanese listener makes to show they are paying attention. Simple aizuchi translations include words such as yeah, uh-huh, and oh (Table 1).

However, aizuchi is not only a verbal phenomenon. Nodding is also a form of aizuchi. Much of Japanese communication is nonverbal, and short utterances are also mirrored with engaged facial expressions and well-timed nods. In linguistics this is referred to as back channelling.⁶ Back channelling is how we interject to show understanding and attention rather than to convey new information. These are not so much questions but rather facilitating remarks to encourage the speaker to continue.

Lastly, aizuchi can also take on the form of short echo statements; for example, when a patient says, “I have been hacking up phlegm for the past week,” the doctor replies, “You have a terrible cough.” Here the listener creates a short synthesis or semantic transformation of what the speaker has just said. This interjection is short enough to be timed like an echoing hammer strike.

These 3 components of aizuchi—short acknowledgment sounds, nods, and echo statements or questions—mesh nicely with Western forms of active listening, as linguistic back channelling is universally common, independent of culture.

Presence in the moment

The origin of the term implies you must have your eyes and ears on the hammer so you can time your interjection with the “strike” of the patient. It therefore implies the learner must be in the moment and present with the patient. This is best encapsulated in the term used at Japanese tea ceremonies, ichi-go ichi-e, which translates to “one time, one meeting,” “for this time only,” or “once in a lifetime.”⁷ The sentiment of this 4-word or 4-character phrase is complex and has multiple other translations. One interpretation of this term is that time never repeats itself and every encounter has its own uniqueness that can be perceived and appreciated only when one is mindful. The concept of ichi-go ichi-e greatly facilitates authentic aizuchi.

Computers can easily take us away from awareness of the moment. Imagine someone typing during a Japanese tea ceremony—it would take the Zen out of the moment! Likewise, when our eyes are on screens, we are less able to cherish the uniqueness of the current moment of clinical practice.

Our eyes can break from the screen to check a laboratory test result or imaging report the same way an athlete’s eyes can look down to a ball, but our focus should largely be on our interaction with the patient.

Documentation challenges

One of the biggest threats to the practice of aizuchi and mindful active listening is the need for clear electronic documentation. Learners face challenges with both underdocumentation and, more commonly, overdocumentation.⁸ Many learners are worried they will not remember details or capture the full information correctly. Inherent to helping the learner make eye contact with their patient is teaching the learner to trust their ability to perceive and synthesize information during the encounter. The more present they are during the encounter, the easier it is for them to synthesize both verbal and nonverbal information afterward. Teachers can highlight this paradox and provide gentle encouragement to shift the bulk of documentation to a moment immediately after the encounter. This also involves giving the learner permission to practise aizuchi while writing shorter notes that focus on what was important rather than on exhaustive detail.

The time needed for documentation after an encounter is a frequent source of stress, and it is unclear whether being more present will ensure clearer and faster formulations or if it will cause cumbersome delays. However, the ever increasing use of AI scribes over the past year may eventually shift learners’ clinics to use objective structured clinical examination–style encounters rather than the parallel exercise of interviewing and note writing. In the future learners may have opportunities to interact with patients with fewer distractions from a screen, but it is possible their note-writing skills will develop less.