ADVICE: Coaching competencies for physicians: the artful question
Nancy M. Merrow, MD
In this series of articles on coaching competencies, we have been exploring how the coach approach fits into medical practice and leadership. Whenever you are faced with a person or group of people who want things to change, there is an opportunity for coaching. In coaching, artful questions and deep listening skills are used to identify the person’s goals, intentions, and inner resources that will be drawn upon to move forward. We propose that the coaching style of conversation is one tool that can be very useful once the physician has explored the utility and circumstances that make it powerful.
KEY WORDS: coaching competencies, questioning, deep listening
When using the coach approach, we co-create a relationship within which questions can be asked that provoke the person into new insights about an issue, the options, and their willingness to act. The coach holds the person accountable for their stated intentions. The coach uses deep listening skills to formulate the questions that move the conversation into action. By listening with intent and purpose, the coach will identify beliefs, thought patterns, and assumptions that are held by the person and may be holding them back from committing to what they say they want. Top
In our first article,1 we introduced the parallels between a traditional medical encounter and one using a coach approach. We adapted the SOAP model (subjective, objective, assessment, plan) and switched the physician role from the expert providing the right answer, to a coach asking the right question that unlocks the person’s expertise in their own life. The coach approach shifts the responsibility for insight and action to the person with the issue. The coach holds the person accountable for their intentions.
The first specific competency we looked at was listening.2 Whatever kind of helping encounter you may be in — whether you are treating patients, teaching, mentoring, or leading — better listening can be expected to lead to better understanding. When we are listening well with intent and purpose, we start to design questions from what we hear. The more deeply and deliberately we listen, the more incisive the questions become. Truly artful questions arise from what the other person is saying, and from what you hear. Using your careful and fulsome attention and observations, you will pick up nuances that bring the next great question to your mind. You will know that your question is sparking an insight when the person reacts with a pause and a comment, such as, “What a great question” or “Let me think about that for a bit” or “I am not sure how to answer that.” Top
Practice sitting quietly with your full attention on the person while they process your question. Resist peppering them with another question. Manage your own feelings of curiosity or impatience and notice when you are getting ahead of the person with a pre-judged notion of what they will think or say. The best next question can only come from what you hear from the other person. When your listening skills are attuned, when you suspend your judgement, when you hold the person completely capable of getting to their own solution, the questions will flow. Top
Artful questions are open ended. In general, we start with “what” or “how” and, rarely, “why.” A question beginning with “what” or “how” opens possibilities. A “why” question can sound challenging or judgemental, as it may require the person to justify something they think or do. “When” questions are useful for helping the person formulate their next steps and to hold them accountable for moving their intention into an action. Using a coach approach will be most useful when helping an individual or a group to change their issue into a goal and to decide about steps to take. A coaching encounter will generally not be effective if the person cannot get to the point of putting a goal into words. If they can, the coach’s questions will start to pull out what they want, what is getting in the way, what strengths they can draw upon, and what they are prepared to do by when to move toward their goal.
If you have a relationship of trust with the person being coached, questions can become deeper and more challenging. Always remember that many issues are intensely personal for the person, and they may feel vulnerable opening up to you, even though they have sought your help. Where there is a power differential between you and the coachee or where you may be responsible for their performance review, you may not be the best coach, although you can listen to them and help them consider options for support. In any event, kindness and compassion are well placed in these situations. Top
The artful question in practice
Let’s look at a scenario I have anonymized from one of my coaching encounters.
I was approached by a colleague (C) who was facing some conflict in the workplace. He was frustrated and had started to think about leaving the hospital he had been at for many years. He had heard that I was doing some coaching and was curious about the approach. He called me and, after a brief chat, we booked an hour together and met near his office. After a brief introduction to the process, I asked him what he hoped our conversation would achieve. Top
“If we spend an hour talking about this, what will have made it a good use of your time?” He was a bit stumped at first, and this is a key point. Sometimes, we invest a lot of time thinking and talking about our issues, without any plan or idea about whether the time was well spent. We go around and around on the vexing parts of the problem without formulating any specific goal or action. This is where using a coach approach can get people unstuck or help shift their perspective and open new options to move forward.
I nudged him a bit: “When you were making your way over here just now, what were you hoping would come out of the conversation?”
C: “I need to decide whether I can stay at my current hospital.”
M: “So, the goal of our coaching session is for you to make a decision about where to work?” I asked, seeking clarity.
C: “Uh, no I don’t really want to leave where I am now.”
M: “Okay, what would you say is really the decision you are trying to make?”
C: “I just can’t stay there the way things are.”
M: “You need something to change so that you can keep practising where you are.” I paraphrased. He nodded. “All right, so we are going to talk about changing something about your current work that would make it possible for you to stay there.” I thought this was about as close to a goal as we could get for the moment.
C: “Yes, that’s it.”
Until there is a goal for the conversation, you may be listening and trying to help, but you are not coaching. It can take several minutes to get clear on what to spend the rest of the time talking about, so stay with it. Top
The next challenge when using the coach approach is to manage your own curiosity and need to know what the situation is. What needs to emerge is what is making the situation so difficult for the person. In coach mode, you are not problem solving and you do not “need to know” the details of the experience they are having. Subject matter expertise is not necessarily part of what the coach brings to the relationship.
Remember, the core tenet of coaching is that the coach believes that the person is competent in their own life and can make decisions and act on their own behalf. When you step into advice giving and problem solving, there is a risk that their capacity for managing themselves and their life is diminished rather than expanded. We all know of people who are overly dependent on others for various reasons. When the situation is such that you are faced with a competent person who is asking for help, and they agree to have some coaching about the issue, the opportunity is there to reinforce and build their skills to be better at turning a problem into a goal, moving intentions into actions, and being held accountable to their stated next steps. Top
The conversation with my colleague about his work went on.
M: “What would make the biggest difference for you at work right now?” Note, I did not ask him what the problem was.
C: “I feel like I am doing more than my fair share of the work and the call, and I’m fed up.”
M: “How could you go about asking for fairness?” I did not ask how much call he was doing, how many in the group, etc. As much as I might like to form my own opinion about what he is doing and whether it is appropriate in a group, those details are not relevant to what he can do about the problem. I picked up on his use of the word “fair” which may be related to his sense of values and principles, not necessarily an amount or number, and used it in my question.
C: “I can’t ask the chief; we don’t see eye to eye.” I’m super curious now, but I hold it. He did not answer my question, so I simply acknowledge that I heard him, and ask it again.
M: “You don’t feel you can go to the chief, so how could you go about asking for fairness?”
C: “I guess I could meet with the scheduler. She is working on the next block this week.”
M: “How could you get ready for that conversation?” In a higher stakes conversation this might lead to a role play and prep session.
C: “I have the schedules for the last three-month block. It shows how many clinics and call days we each have.”
M: “What other information might be helpful about the fairness of the schedule?”
C: “I think there is something in our division rules about it, but I’m not sure.” He hasn’t done all his homework yet for a successful conversation about how work is shared in the group.
M: “When do you think you could be ready for this conversation with the scheduler?”
C: “I could review the rules tonight and give her a call tomorrow.” He is not committed with “I could.”
M: “So what is your plan?” I could assume that he will do what he says, or restate what he told me, but he will own the plan if he puts it together himself in a statement back to me.
C: “Tonight, I’m pulling out the last three months of schedules and reviewing the division rules. Tomorrow, I will call the scheduler and ask for a meeting.”
M: “How does that feel for an action plan?”
C: “Better. I was just so angry and tired that I couldn’t get my next step straight. Thanks.”
M: “Would you like to give me a call or text and let me know how it goes?” Offering to hold him accountable.
C: “Yeah, I will. That will close the loop for me.” Top
It seemed to me that there were likely a lot of other issues for this physician in his group, but the one he brought to the coaching encounter was fairness of work assignments, so that is what we focused on. This conversation was very focused once we established his goal to get treated fairly in the clinic and call schedule.
I have simplified the scenario and the coaching process to introduce the rhythm of a coaching encounter. In a longer coaching engagement, it would be up to the coachee to open different and deeper conversations about his conflict with the chief of his department, whether it is difficult for him to stand up for himself, where his value of fairness is rooted, and how he let himself get so far down the road of considering a job change without taking some straightforward steps to improve his situation. Although this example may seem like a relatively simple issue to an experienced physician, for him it was weighing heavily, so I met him where he was at. Top
More on core competencies for using the coach approach
Our adaptation of coaching competencies to the clinical setting and medical leadership has a place in your toolkit of behaviour modification techniques, in the management of situations that are dependent on the patient or person making choices, decisions, and changes. The defined questions, goals, and solutions are theirs. By acting as a coach when people bring you problems that are within their control, you build their capacity for problem solving. Further, the relationship is clarified and strengthened, whether it is doctor–patient, teacher–student, or leader–team member.
In upcoming issues of CJPL, I will continue to adapt the core competencies for the coach approach for physicians and medical leaders (see diagram) and discuss the specific skills that comprise each. My next article will be about “goals, values and beliefs.” We will explore how listening skills and artful questions can be used to uncover what may be either empowering or getting in the way of a person’s ability to move forward on important issues. Top
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Nancy M. Merrow, MD, CCFP(PC), FCFP, G(CEC), Certified Executive Coach, is Chief of Staff and VP Medical Affairs at the Orillia Soldiers’ Memorial Hospital in Orillia, Ontario.
This article has been peer reviewed.