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Clinical skills have traditionally been taught in a master-apprentice relationship with all of its usual assumptions. So long as we provide the student with access to a qualified practitioner, the argument goes, we can assume that sooner or later the necessary skills will be acquired. The student will learn by example how to become a good clinician, armed with his supervisor's wisdom and a handful of aphorisms culled from the literature.
Many good clinicians have developed from such a system and its partial success has blinded us to its obvious faults. Take clinical listening as a case in point. It seems indisputable that specific kinds of listening are needed to decode the latent content of a patient's statements, yet in how many cases is the student given specific training in this technique? Moreover, how many clinicians under stand the way in which they themselves listen, to the extent that they can explain it to someone else? As in many kinds of complex skills, we rely on the master-apprentice mode of teaching because we have nothing else to offer; too little is known about specifics to set up a formal course of training.
Two dimensions of clinical listening can be isolated at the outset-mode and content. By mode we refer to the size of the unit being considered-does the clinician pay attention to every word or only to certain underlying themes? By content we refer to the specific sets of meanings-words or themes-that are considered important. The two dimensions can vary independently; thus, we can listen to a specific theme (e.g., birth fantasies) as it is expressed in the total sweep of the material, or as it appears in discrete words. In the latter case, we would be alerted to specific words, such as delivery, term, issue, etc., even when the