by Philippa Kennealy MD MPH CPCC.

Coaching is the art of facilitating the performance, learning and development of another. Myles Downey 1999

The Traditional Authority

The day, in the mid-nineties, that I encountered my first patient armed with information obtained from the Internet about a not-yet-released drug, I knew that the practice of medicine was facing a profound shift. I recognized that our traditional physician authority was about to be challenged.

Well-trained doctors are experts. Immersed in technical training during medical school and residency, they emerge prepared to assess, diagnose and dispense. In prior generations, this formidable education engendered awe, respect and passive obedience in patients. It took little more than a physician's gentle admonition or kindly advice to prompt most health behavior changes.

No longer so. Global, inexpensive communication and mass media ensure greater availability of healthcare information. Patients are becoming informed consumers. Yet health behavior change seems harder to effect, possibly due to reduced physician-patient contact time, inadequate physician interpersonal skills or patients' lack of motivation.

Changing health behaviors.

Change is difficult for most of us, despite our best intentions. We resist others telling us what to do. Only when our motivation is high because we perceive the proposed change as important, or when we are somewhat confident in our ability to succeed and ready, can we take the steps towards a different outcome.1,2

To instigate change effectively, physicians need to acquire fresh skills. They must learn to be able to assess the importance of change to patients, as well as patients' confidence in their ability and readiness to alter their lifestyles or acquire new health behaviors. These are the skills used by coaches.

The Coaching Model

A relatively new profession, coaching clarifies the direction for change, helps remove obstacles and assists patients in getting to where they want to go3. The coaching process begins from the patient's perspective, rather than that of the doctor.
One of the business and personal coaching models, the Co-Active model, relies on interactive participation and collaboration between coach and client4. When adapted for healthcare, it rests upon four cornerstones:

• The patient's strengths
• The idea that the patient is whole and resourceful
• The patient's agenda
• A relationship explicitly designed between physician and patient

In this model, the doctor and patient articulate how their relationship will empower the patient. The physician:

• Explores the patient's vision of a successful outcome
• Clarifies what is most important to her in making the change
• Helps her identify meaningful goals and the steps to achieving them
• Champions her efforts.
  
  Typical results of the coaching process include:
  
  
• Motivating patients to get into action
• Achieving first small and then bigger goals
• Deepening the patient's learning and self-mastery

Coaching has been successful in producing specific clinical outcomes. In the multicenter Australian COACH randomized controlled trial, trained health coaches proved highly effective in improving the coronary risk factor status of patients with CHD5. They helped patients make lifestyle changes resulting in lower cholesterol levels, blood pressure, body weight and cardiac symptoms.

What are the coaching skills needed for this new paradigm?

Patient-centered reflective listening: Listen actively to discover the underlying meaning of the patient's words, and restate your interpretation to check for accuracy.

Curiosity: Ask simple but powerful open-ended questions such as "What do you mean?", "What are your other options?", "What are you willing to do?"

Summarizing: Capture the essence of the dialogue succinctly, using as many of the patient's words as possible.

Intuition: Trust your gut feeling, although it may not always seem logical, and test it out with the patient. Use phrases such as "I have a hunch that….." or "I wonder if….".

Self-management: Leave your expertise and coercion behind, and abandon your assumptions about the patient. Avoid terms such as "compliant" and "non-compliant" that originate from your perspective as a physician.

Negotiation and informed choice: Propose options and alternatives, educate the patient about the possible impact of choices, and negotiate a pathway to achieving a goal.

Cultural awareness: Be aware of and respect the cultural differences between you and your patient. What is observed and meaningful in one culture may be insignificant or a source of embarrassment, discomfort or ridicule in another.

What next?

Most physicians who have opted for their challenging and interesting professions are motivated by a desire to impact positively the health of their patients. It is time to recognize that the days of traditional medical authority and persuasion are numbered. In order to provide real value to patients and produce improved health behavior outcomes, physicians need to learn and adopt coaching techniques that honor patients' agendas and their motivation to change, and support them through a process that is designed to help them succeed.

References:
1. Rollnick, Stephen; Mason, Pip; Butler, Chris. "Health Behavior Change - A Guide for Practitioners". Churchill Livingstone 2000.
2. Prochaska, James O.; Norcross, John; DiClemente, Carlo. "Changing for Good". Avon, 1995.
3. Sandahl, Phil. "Coaching - An Empowering Choice". Choice 2003, Fall 2003 Premier Issue.
4. Whitworth, Laura; Kimsey-House, Henry; Sandahl, Phil. "Co-Active Coaching". Davies-Black Publishing, 1998.
5. Vale, Margarite J. "Coaching patients On Achieving Cardiovascular Health (COACH)." Archives of Internal Medicine 2003; 163:2775-2783.

Author Information:
Philippa Kennealy MD MPH CPCC.
Executive and Personal Coach.
President, Oya Consulting.
Contact information: pkennealy@oyaconsulting.com
www.oyaconsulting.com
(310) 476-6116

Dr. Kennealy has a passion for connecting you to your professional and personal potential. She created The Vision Realization Process to coach your growth and transformation towards your most fulfilling career and life. She is a Certified Coach as well as a board-certified Family Physician, formerly in private practice, with a Masters in Public Health in Health Services Management. She is also a mom, spouse and owner of her own business.