Coaching competencies for physicians: listening at the next level
Nancy M. Merrow, MD
In this second of a series of articles on coaching competencies, the focus is on developing the skill of listening. Most physicians have been trained in “active listening,” using brief encouraging sounds and gestures, paraphrasing, summarizing, reflecting, and probing for additional detail. However, by looking further into the composition of a powerful and transformative listening encounter, we can learn to listen at the next level.
When using the coach approach, we co-create a relationship within which questions can be asked that provoke the coachee into new insights about the issue, their options, and their willingness to act.1 The coach holds the coachee 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 coachee, which may be holding them back from committing to what they say they want.
Listening as a specific skill
Levels of listening have been described by various authors. One influential writer is Ralph G. Nichols, PhD, who famously said, “The most basic of all human needs is the need to understand and be understood. The best way to understand people is to listen to them.”2 Before his death at age 96, Dr. Nichols was recognized with the Lifetime Achievement Award by the International Listening Society. The art and science of listening has flourished since he published his studies as a professor of psychology at the University of Minnesota over his 40-year career.
Traditional medical training has included basic training in “active listening” and most physicians are familiar with how to demonstrate it by using brief encouraging sounds and gestures, paraphrasing, summarizing, reflecting, and probing for additional detail. By looking further into the composition of a powerful and transformative listening encounter, we can learn to listen at the next level.
Modes and levels of listening
Note: The following material has been adapted from E. Cox,3 Kimsey-House et al.,4 pages 34-9, and Hawkins and Schwenk.5
Internal listening — Internal listening is about what is going on for the listener. We have a need for information or understanding about how a situation may affect us or decisions we must make. When listening internally, we are trying to figure out things: Am I ready for this? How long might this take? Where do I have to be next? Will we need to follow up on this? What needs to happen next? When listening internally, we are not yet working on what matters to the person who is trying to communicate with us. Most conversations begin with a brief period of internal listening so that we can set our own goals and boundaries on the rest of the encounter.
If internal listening identifies critical issues and the opportunity for a good conversation is limited, the encounter may have to start with planning a better time to talk. For example, if, as the conversation starts, you are feeling some urgency to reach a conclusion because of competing priorities, your ability to listen effectively may be limited.
Focused listening — When we shift our focus from what we need to what is going on for the other person, more noticing occurs. We start making observations about the other person’s posture, gestures, energy level, tone, and pace of speech. The content of the conversation is attended to, as well as the emotions. We start using techniques, such as paraphrasing, reflecting, summarizing, and probing. Generally, a person will feel well heard during and after a focused listening experience.
Global listening — At some point in a productive relationship that involves listening, we begin to consider what is going on between and around the listener and the speaker. Global listening considers the quality of the relationship between the parties and the circumstances that impact the progress of their communication. This is how we identify and manage differentials in authority, power, culture, knowledge, beliefs, and assumptions to understand the challenges in communication. The more complex the issues and the higher the stakes, the more global listening will help to remove barriers to progress. When listening at this level, we explore how the people and the situation came to the place we are at. We go beyond what we think to why and how we think. Top
Generative listening — At this level, we achieve fascinating, fun, and unexpected insights in conversation. Suddenly, we both know something neither of us knew before. It results from the genuine non-judgemental and curious stance taken by people who are committed to hearing each other and moving forward in a positive direction. Generative listening leads to creative partnerships and initiatives with deep understanding of unique perspectives.
Authentic listening — Calling out the multiple factors that affect how well we can listen to each other is an advanced technique in listening. When we enter the mode of authentic listening, we openly explore and have a dialogue about what is making it difficult to listen. There may be unresolved issues, prejudices, biases, confusion, or values conflict within or between the parties that must be recognized and processed if they are barriers to listening. When the relationship has not matured to this point, the listener may discuss the barriers identified during authentic listening with a trusted colleague.
The role of the listener (physician, teacher, supervisor, mentor, leader) and the relationship with the person being listened to (hierarchical, peer, direct report) help to define the level and mode of listening that will be most impactful in a positive way. We offer this discussion to invite reflection on how and when you need to listen and what benefit enhanced listening skills might offer. Top
Components of the listening competency: quick reference tool
Prepare for impactful conversations by bringing your awareness to the present moment. Focus on your breath for a minute. Move around to release some kinetic energy before you begin. Notice when your awareness is drifting, and use subtle tactics to draw yourself back to the present moment. Quietly tap your toe, touch your tongue to the roof of your mouth, or otherwise silently and invisibly signal to yourself that you are back. Top
Find an appropriate setting for the encounter. Silence any devices and set them aside. Give the person your full attention by using body language, eye contact, and brief, timely verbal responses and gestures. If you lose attention, ask a clarifying question to get back on track. People know when you are not paying attention. You are human, so just admit that you lost focus and ask them to back up the discussion a bit. Your clarifying question tells them you were with them up until that point.
Who you are speaking with and your roles and the relationship frame the conversation. How you look, talk, smile, move, shake hands, and occupy space has an impact on the other person. Your choice of language and use of humour, as well as the pace, tone, volume, and habits of speech that you use all reveal how committed you are to hearing and understanding. Manage your presence with intent and purpose.
Suspending judgement and using open-ended questions demonstrate genuine curiosity about the other person’s issues and views. Hold your opinions, values, experiences, history, and advice aside unless the person asks for your perspective. The person will feel more deeply listened to when you ask questions to clarify what is happening for them, not what you would like to know. Top
Authentic listening goes beyond non-judgemental curiosity and allows biases and lack of understanding to surface. When you are reacting to a person in a way that is interrupting your ability to listen, call it out and talk about it. Explore your assumptions and any differences in values, perspectives, and beliefs for greater understanding.
Use paraphrasing and reflection to check understanding. Acknowledge feelings that surface during the conversation. Offer and accept feedback on how the encounter unfolded. Have a trusted mentor or coach to debrief intense interactions for ongoing learning and development.
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 depend on the patient or person making choices, decisions, and changes. The goals and the solutions are theirs. By acting as a coach when people bring you problems that are within their control, not yours, 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. Top
There are related competencies in the field of medical practice that do not need to be duplicated in a coaching model. In upcoming issues of CJPL, I will adapt the core competencies of the coach approach for physicians and medical leaders and discuss the specific skills that comprise each. My next article will be about enquiry. We will examine the art of the open-ended question and how to choose exactly the right next question that moves the conversation forward in an impactful way.
3.Cox E. Coaching understood: a pragmatic inquiry into the coaching process. Los Angeles: Sage Publications; 2013.
4.Kimsey-House H, Kimsey-House K, Sandahl P, Whitworth L. Co-active coaching: changing business transforming lives (2nd ed.). Boston: Nicholas Brealey Publishing; 2007.
5.Hawkins P, Schwenk G. The interpersonal relationship in the training and supervision of coaches. In Palmer S, Mcdowall A (editors). The coaching relationship: putting people first. London: Routledge; 2010. pp. 203-21.
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.