Help me, or fix me? The power of generative listening in the GP consultation

Published by Peter Devlin


I love it when I can make a connection between theory and lived experience.

I have often wondered in my clinical practice what it is that I do that sometimes means that a consultation goes really poorly, and why, just very occasionally, a consultation really fizzes. In the former, “patient” and “doctor” come out the other end feeling variously disappointed, short-changed, cross, frustrated. In the latter, both feel a real sense of connection, a coming together which creates possibility for a different future.

There are places in between, in which most consultations sit, intuitively adjusted to suit the situation, and most of the time that seemed to me, for many years, to be ok.

Okay that is until I started becoming immersed in both the theory and practice of something called “systems thinking”, a discipline that challenges me to examine what I and the system that I work in actually delivers from an outside-in perspective. What is it actually like to be a customer, client, patient on the receiving end of the services I provide?

What this tells me is that sometimes it is ok, and a lot of the time it isn’t good enough. Too often my patients don’t get access to what really matters, or the journey is hugely complicated, with too many hurdles to overcome, blind alleys to back out of, and fraught with delays, confusion and wasteful expense.

Fix me, or help me?

I have a friend who has just had an endoscopy investigation. Her experience was uniformly positive. The purpose was clear – “I want to be reassured that I don’t have cancer”, and she was treated efficiently and courteously by staff who all introduced themselves with “hello, my name is”. At the end of the investigation, her endoscopist explained the reassuring findings, and she left with her needs fully met.

In the patient stories we have studied (case studies of over fifty people using services we partner to deliver), with complex, chronic, long term and generally “incurable” problems of physical, mental, and social disability, the experience is rarely so positive. At best, much of what we do for these people adds no value to their lives, and at worst, and far too often for comfort, actually causes harm.

I have noticed that I and other clinicians often only hear requests to “fix me”. Fix me is usually relatively easy – the clinical pathways for a broken bone, or peritonitis, or chickenpox are straight forward, time limited, and the options are to do nothing or do treatment x.  My friend’s endoscopy sits firmly within the fix me group.

For most patients, and certainly all of those in our case studies, fix me, is not an option. It is not even what is being asked of us. Most people know when fix me is a fantasy, and what they are really asking is “help me”. Help me to live my life a bit better, help my breathing to be a bit better, help me to get out a bit more, help me to feel less anxious, help me to feel less lonely.

What is it about help me that is so difficult, why is it that clinicians so often don’t even hear the help me, and seek out only the fix me questions?

Listening on another level

This is where theory and practice really connect, through the work of American academic Otto Scharmer, and his analysis of the four levels of listening we do.

Level one is downloading – where listening is simply checking for the facts that reinforce what we are already thinking. This type of listening is often at the heart of a dysfunctional consultation.

Level two is factual – listening out for new facts that help to shape or change our hypothesis. This works in simple encounters – “I’ve got a sore throat …….have you got a fever?”

Level three is empathic – putting oneself in the other person’s shoes, and trying to understand the world from that person’s perspective. This type of consultation has a sense of personal and emotional connection, and enables the listener to begin to manage complexity and uncertainty.

Level four is generative – moving beyond the empathetic to a space of co-creation and possibility. In this level, both listener and speaker are able to step out of their inner thoughts and move into the space between themselves.

Everyone can think of occasions when this has happened, in our work or in our personal relationships, and can remember the pure energy, joy and optimism of these moments. In clinical practice, a generative conversation gets to the heart of what matters to the patient, and enables her to choose the options that are most likely to work, to take back control, and to create solutions that neither of you had previously imagined as possible.

It is increasingly clear to me that the combining of generative listening with systems thinking really opens the door to new ways of working, that through this it is possible to do the right thing, first time, every time; and spend far less time doing things that add no value to a person’s wellbeing.

Peter Devlin is Director of Clinical Leadership at Here. Care unbound. To create more possibilities for care in every moment. 

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