CHAPTER 11
Appreciative Coaching: “I Want to Be Known as the Clinician Who …”
In his New Yorker article “Personal Best,” surgeon and author Dr. Atul Gawande describes his experience with coaching after he asked a colleague to observe his surgical technique.1 Any physician—or anyone who knows a physician—recognizes that this is a highly uncommon and unusually humble thing for a practicing physician to do. As physicians, we are trained to appear confident at all times and to never admit errors. Why would we need coaching?
Dr. Gawande notes that because of his Yoda-esque mentor’s observations, he made important adjustments for procedures with which Dr. Gawande was already highly familiar. Though his mentor had no training in Dr. Gawande’s specialty, he offered some very useful insights into the process of setting up a case, ensuring an optimal surgical environment, and avoiding common pitfalls. Dr. Gawande concludes that “coaching done well may be the most effective intervention designed for human performance.” If an experienced surgeon can learn new strategies from a coach for further improvement, imagine what could happen if all clinicians were equally open to feedback. Let’s talk about the most common activity in medicine: communication with patients. Although communication happens all the time across every medical specialty, many of us don’t give our communications skills or strategies much thought. When we become willing to be coached in better communication practices, everyone benefits.
Core Requirements for a Coach
Some of the most successful coaches in history have not been the most renowned performers. In 2016, Joe Maddon managed the Chicago Cubs to their first World Series victory in 108 years. With a combination of strategic fielding decisions and wacky team-building stunts like making players wear pajamas on airplanes, he pushed them out of their comfort zones and won accolades for his genius and skill. Yet he never made it to the major league as a player.2
Similarly, coaches for clinicians in healthcare do not necessarily need to undergo training as clinicians themselves. Mr. Maddon shows us that knowledge, observational ability, and motivational skills can inspire high performers toward even higher accomplishments. Coaches who lack medical training bring a valuable perspective to the table—the patient’s perspective. This can be highly beneficial as long as coaches remember that all patients won’t necessarily have the same needs and wants as they do.
The recipe for the most effective healthcare communication coaches calls for several important ingredients:
• Empathy and ability to modulate one’s own emotions
• Familiarity with organizational change management
• A framework for appreciative coaching
Before we jump right into the framework, let’s start with the first two elements.
Empathy and the Ability to Modulate One’s Own Emotions
In my (Maysel Kemp White’s) training as a family therapist, I learned that I did not have to love the people that I was counseling, some of whom were abusing their children. What I did need to do was develop empathy for them. Over time, I came to believe that people are always doing the best they can with their current resources and limitations. I had to suspend my personal judgments of their behavior, be present for the person who was seeking my guidance, and validate his or her experience. The same is true for those I coach; in order to be effective, I must be present for each learner.
In decades of working with clinicians, coaches have found that essentially all of us as medical professionals hope to be known for our caring toward our patients. We want to do the right thing at the right time. After all, these traits are what drew many of us to healthcare in the first place. When it seems that we are falling short of these objectives, telling us that it seems like we don’t care only invites defenses. Coaches need to honor our attempts, while helping us gain the skills to adjust our behavior so that we can effectively express our caring. There may be times when a coach observes a behavior in someone he or she is coaching that feels startlingly unexpected. For example, a coach may notice that a clinician is blithely and unwittingly sharing information with a patient’s family without noticing the family’s clear evidence of distress. Coaches are most effective when they are able first to understand their own reactions to what occurred, and then share their emotions and perspective afterward in an evenhanded way.
Familiarity with Organizational Change Management
A coach’s ability to succeed also depends on the ability of the consulting organization to express its commitment to improvement in a growth-oriented, rather than punitive, way. Few of us are as courageous as Dr. Gawande, who sought his own coach. Healthcare systems commonly send clinicians to a coach when their patient experience scores fall below the institution’s average. Even though the intent is to help struggling clinicians, when we are told that we need to be coached, we often feel that we are failing and must improve or lose our jobs.
Therefore, as brilliant as a coach may be, initial discussion and investment from leadership are critical to effectiveness. Many well-meaning projects have gone awry because of poor strategic communication. Imagine if an organization sent the message that it was committed to the success of clinicians and their relationships with patients, and in this spirit, the organization was hiring coaches to invest in its clinicians. It may be a similar strategic approach but a vastly different message than “your scores are low and you need to report for remediation.” (We will see more about the importance of institutional investment in Chapter 18.)
A Framework for Appreciative Coaching
Coaching techniques can reflect either a growth-oriented or a punitive approach. We advocate a method of appreciative coaching, first conceived by Dr. David Cooperrider, because it assumes the best in everyone and taps into internal motivation.3 This three-stage approach marries the fundamental communication skills (see Chapters 3–5) with the approach to feedback (see Chapter 10):
• Stage 1: Pre-briefing—building rapport, discovering strengths, and dreaming of the ideal
• Stage 2: Setting up and managing live observation or skills practice
• Stage 3: Debriefing and next steps
The most effective coaches use these fundamental communication skills to demonstrate the strategies that they want to support. Let’s say, for example, that you are in a Thai cooking class where you are assigned to cut carrots into a flower garnish. Even if you are a good cook, unless you have specific training in vegetable carving, you can destroy a lot of carrots before getting one that looks even semi-presentable. Effective coaches must make room for learners to make mistakes and go through all the awkwardness of learning a new skill before learners can achieve mastery.
STAGE 1: PRE-BRIEFING—BUILDING RAPPORT, DISCOVERING STRENGTHS, AND DREAMING OF THE IDEAL
An initial encounter with a coach is similar to the beginning of a clinical encounter. The coach must first build rapport and create an environment in which trust can grow. Coaches will accomplish these goals through greeting and introduction, small talk before big talk, and addressing communication barriers (see Chapter 3). In a coaching encounter, the coach will also need to discuss the agenda and its rationale, clarify time limits, and review how to manage introductions to patients during observations. These steps will take just a couple of minutes; in coaching as in clinical work, that small investment of time will pay big dividends later.
Imagine that you are a low-performing clinician who has been referred to a coach. You’re being told that you’re bad at what you do, which challenges a professional identity that you have worked hard for a long time to attain. At the very least, you will be wary of this coach. Imagine that this coach says to you, “I have a list here of all the things you need to do better. I’m here to make sure that you do them, or you’re out of here.” That coach might as well make you drop to the floor and do burpees to the quick rhythm of a whistle. Even for that small minority of you that loves burpees, the whistle and the punitive tone don’t exactly make you feel inspired or motivated to take action.
Now imagine instead that the coach meets you with a warm handshake, a brief introduction of what is going to happen in the relationship, and a short period of small talk to get to know you better. You may still be somewhat suspicious, especially because you might recognize some of these tools from reading Chapter 3, but at least you’re not doing burpees.
Then the coach asks you some questions:
1. When did you know you wanted to be a clinician? What led you to making that final decision?
2. What do you perceive to be your greatest strengths as a clinician?
3. If your patients are having a meal with friends and family, what do you hope they are saying about you and the kind of care you provided them? If members of your interprofessional team are talking among themselves about you, what do you hope they are saying about the kind of care and collaboration you provide?
4. If you have been coached in the past, what worked in helping you change behaviors?
This initial investment in the relationship is critical to building the first tendrils of trust that can develop into successful practice. Take a bit of time to answer one of these questions for yourself. What feelings come up for you? It’s likely that other clinicians who are being coached will also have emotions come up as they answer. A coach’s empathy can create a connection that will facilitate change.
The answers to these strength-finding questions lead into a phase of dreaming of the ideal. Essentially, we can make progress toward reaching our own dreams when we imagine that they have already come true. After a coach asks learners how they wish to be known, he or she can say, “If that were true today, what exactly would you look like, sound like, and be doing? What would make you stand out as exceptional?” This gives clinicians the chance to envision themselves as already successful. It might sound like a hokey exercise, but it is remarkable how this visioning process can enable us to pursue our goals with renewed inspiration.
Here is a tangible example of how this process might go. I (MKW) was coaching Dr. Harris, a hospitalist and the first woman physician in her family’s four generations of clinicians. She identified several areas as strengths: noticing when patients appear worried and taking time to explore why, asking about barriers to following therapeutic plans and problem-solving, and advocating with specialists on behalf of patients. After I asked these questions, I noticed an easing of her initial suspicion and a shift in her guarded tone of voice. Her answers to question three were telling: she teared up a little when she said she hoped that patients and colleagues viewed her as compassionate, caring, competent, and respectful of autonomy. I told her that I noticed how fervently she wanted to connect with her patients, and that it must feel quite disappointing to get scores that didn’t reflect that dream. She looked at me with a mixed expression of sadness and anger. I said to her, “I’m going to do everything I can to get you where you want to be.” She reached out, grasped my hand firmly, and quietly said, “Thank you.”
STAGE 2: SETTING UP AND MANAGING LIVE OBSERVATION OR SKILLS PRACTICE
With a firm understanding of the clinicians’ strengths and an inspirational ideal of what they could potentially achieve, coaches can design a plan for achieving the dream. As first mentioned in Chapter 1, we know that better communication skills lead to better patient outcomes, increased clinician job satisfaction, decreased burnout, and benefits to the institution in which they work. It follows that focusing on developing those communication skills can lead to rewards for the clinician and the institution, now and in the future. To set up for success, one can’t try to improve all the skills all at once. In the same way that baseball players don’t do batting practice simultaneously with fielding practice, coaches are more likely to succeed if they work on one skill set at a time.
Coaches must have data to help them choose the relevant skill to start with. Data may include the clinician’s reflections about learning goals, his or her observations prior to the design plan, patient experience scores and narratives, and anonymous focus group surveys of patients, among other possibilities. We know that some of this information is more easily accessible, so it may be attractive for coaches to use the most expedient approach. At the same time, the approach must feel relevant to the learner in order to instill a sense of motivation. The coach should strengthen the fundamental skills of the clinician that are consistent with his or her vision or dream. The scores will follow.
I shadowed Dr. Harris on her usual inpatient rounds during a typical hospitalist shift. After observing her interact with three hospitalized patients, it was clear to me that she intended to be, and indeed thought that she was, listening and showing empathy. Unfortunately, she didn’t often express that empathy with reflection or PEARLS statements (see Chapter 4). I noticed that she frequently downloaded a lot of information without checking with the patient.
During this stage of coaching, the coach needs to balance the clinician’s own reflections on performance with discussion and specific behavioral feedback (see Chapter 10). Coaches generally start by asking clinicians to reflect on what they did effectively and how close the actual behaviors were to their dreams. The coach then reports what was observed, attending to the learner’s emotional cues, followed by specific behavioral feedback. The coach and learner can then work together to strategize on how to help the clinician get closer to the ideal self.
Dr. Harris thought that she had validated one patient’s frustration, which was accurate. I reinforced that she had used one clear partnership statement and that the patient appeared to respond positively. I then asked what she did to accomplish her dream of being seen as compassionate. Dr. Harris said that she expressed her compassion by giving patients lots of information. As we talked, she realized that patients might not view this information download as compassionate. As a result, she resolved to talk less and listen more, and to look for and respond to emotional cues from patients. I agreed that she could increase her receptivity to emotion. We reviewed PEARLS together, and she took the initiative to try to use statements of emotion and legitimization during the next encounter.
My second observation with Dr. Harris was like rounding with a different clinician. She paused to hear the patient tell the whole story, and rather than immediately telling the patient what was going to happen for the day, she said, “It’s completely natural to worry that you’re never going to improve. I’m here to give you the best treatments we have to make your shortness of breath better.” When we debriefed, she was very happy about the way the encounter went, and even more inspired when I shared with her the exact words she’d said to the patient, and reminded her of the patient’s expression of gratitude.
STAGE 3: DEBRIEFING AND NEXT STEPS
When coaches conclude their observations, it can be very helpful when they recap the entire experience. Using the ART (Ask, Respond, Tell) technique (see Chapter 5), we ask learners to reflect on which behaviors demonstrated their strengths and which skills need more work. We then summarize our own perspective and identify a few specific things that we believe the learner can do to improve the patient or family experience. Finally, we ask the learner to commit to working on one or two specific skills.
We generally follow up coaching visits with a phone call or e-mail including a written summary of our observations. We attach relevant literature discussing the behaviors the learner committed to practice, and reinforce use of a skills card that outlines all the behaviors we were looking for during our observations.
Conclusion
Experienced clinicians are going to view fundamental skills as routine. When someone tells us we need to improve, it is natural to feel defensive and resistant. When we don’t understand or believe in the coaching process, it is even harder to be emotionally on board with the process. We have outlined three coaching domains that will maximize success: strong empathy and emotion modulation skills, familiarity with organizational change management, and a robust and appreciative approach to the actual coaching process. We have also shown how the process itself is a series of applications of the fundamental communication skills (see Chapters 3–5) and requires facility with giving effective feedback (see Chapter 10). We have found coaching to be one of our most fulfilling tasks, as the benefits accrue to improved patient-clinician relationships as well as clinician well-being.