Coaches are allied with a performer with the goal of helping the performer achieve the best performance possible. That said, there are numerous types and definitions of coaching.2 Regardless of the specific model, several unifying themes emerge: (1) the critical importance of establishing an effective coach-coachee relationship, (2) attention to enhancing personal awareness and reflective capacity, (3) exploration of the coachee’s goals, (4) a sober assessment of the coachee’s current reality, and (5) enhancement of the coachee’s self-sufficiency and will to grow. Professional coaching is a hot area these days and typically refers to a process whereby the coach uses powerful questions and other tools to enhance an individual’s self-awareness and self-efficacy. With this sort of coaching, the coach does not provide content expertise to solve the coachee’s problems but instead provides a structure and process by which clients come up with their own solutions. An emphasis is often placed on getting the client to focus on the future rather than on the past and, when contemplating the past, to focus on experiences of success that might reveal keys to succeeding in the future. In contrast, coaches in sports and the arts are expected to have high levels of content expertise and to be able to teach the content to players and performers. When professional tennis players hire a coach, they expect the coach to be deeply knowledgeable about both coaching and tennis. Communication skills coaching requires, in our view, a blend of these two types of coaching, whereby we leverage what the coachees already know, cultivate enhanced self-awareness, and facilitate the development of their own solutions, while also providing content expertise where needed.
An example of a common coaching model is G.R.O.W., which stands for identifying and developing coachee Goals; clearly assessing the coachee’s current Reality; considering the coachee’s Options for trying to achieve the identified goals; and Wrapping up by developing a strong action plan that takes into account practicality and obstacles.3 Other similar models describe this as:
Imagining the ideal
Making a clear-eyed assessment of current reality
Developing a plan to close the gap between the current reality and the ideal
Articulating short-term plans that are specific, measurable, achievable, relevant to the longer-term goal of moving toward the ideal, and time-bound
Implementing the plans
Assessing their effectiveness
In a sense, then, coaching aims to bring a clear structure and accountability to the process of living one’s life, a process that most of us conduct in an often disorganized, impulsive fashion if no one is there to provide a framework and hold us accountable.
Communication skills coaching adds some specific agenda items to this generic framework, and the items are grounded in our prioritization of building and attending to interpersonal relationships:
Perception/observation skills. We emphasize the importance of noticing and being able to name personality and behavioral cues so that the clinician can respond to the emotional state of the patient and colleagues. How, we need to ask ourselves, does this person before me seem to be feeling? What kind of day is he having? What can I learn about him simply by watching and listening?
Rapport-building skills. How do you make someone feel welcome? How do you make someone feel important? How do you establish trust? How do you start to make a connection?
Empathic skills. How do you let someone know that you care? How do you make her feel cared for? How can you begin to imagine what it would be like to be in the other person’s situation? What are effective ways to respond to strong emotions? What does someone who is suffering experience as helpful?
Listening skills. How can you elicit the other person’s story and perspective effectively? How can you listen so as to maximize the likelihood of accurately understanding what the other person is trying to say? How can you listen without hijacking or dominating the conversation?
Explanatory skills. How do you convey information in such a manner that it can be understood and remembered? How do you assess understanding?
Negotiating and conflict-resolution skills. What are your options for how to respond when conflict emerges? What are the pros and cons of these different options? How can you address conflict without escalating it? How can you use conflict as a path to a stronger relationship?
As noted earlier, our vision of communication and interpersonal skills coaching blends different coaching models in a way that some would call a combination of coaching and mentoring. We brought content expertise and thought that we were going to be most effective when we could facilitate a process by which the clinicians being coached arrived at their own solutions to the extent that they could. While in some coaching models the ideal is to have the coachees arrive at their own answers, coachees struggling with communication skills often benefit from examples of things to say and specific strategies to use. For example, one of the most powerful tools that our communication skills training participants tell us about is the “power of the pause,” by which they mean waiting for the other person to speak or taking time to carefully formulate one’s response. One coachee who was creating discord on teams by saying inflammatory things took to carrying a beverage around so that when tempted to respond in the heat of the moment, he could take a sip to prevent himself from speaking until he could consider his words more carefully.
Often it is more effective for us to learn what the other person has to say than for him or her to learn what we have to say.
As we developed our approach to coaching, we were conscientious about linking it to the R.E.D.E. model and focusing on relational skills. In our communication courses, a key point of emphasis is attending to relationships. Entering an exam room to see a patient, the first priority for the clinician, barring a medical emergency, is the relationship. In coaching, the first priority for the coach is the relationship with the coachee because the work takes place in the context of that relationship. And when coaching, the most valuable help we can provide is to help the coachee develop more effective relational skills. Just as we want clinicians in our course to think about how to establish, develop, and engage in relationships with patients, so in coaching we want coachees to think about how to establish, develop, and engage in relationships in a variety of work settings.
Thus, the coaching process could be envisioned as moving through three stages: (1) establishing a connection with the person and negotiating an agenda; (2) developing the relationship by skillfully listening and asking powerful questions with the goal of enhancing both the coach’s and the coachee’s understanding of the coachee’s goals and current reality; and (3) engaging the relationship by negotiating a plan of action and expectations of accountability. In the coaching setting, R.E.D.E. looks like the progression shown in Table 7.1.
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TABLE 7.1 R.E.D.E. to Coach
Phase
Skill
With Patients
With Coachee
Phase I: Establishment
Convey value and respect with welcome
Collaboratively set agenda
Convey empathy with S.A.V.E.
Hi, I’m Dr. Gilligan. I’m glad to see you. Thanks for coming to see me. How are you today?
I’d like to get a list of your concerns that you want to address today.
You sound frustrated
Hi, I’m Dr. Gilligan. I’m glad we were able to meet today, and I look forward to getting to know you.
I’d like to get a list of the different concerns that you are hoping to address with me.
It’s hard to practice the way you want to sometimes.
Phase II: Development
Elicit narrative
V.I.E.W. questions
Tell me about your headaches from when they first started.
How are your headaches affecting your life?
What ideas do you have about what’s wrong? Have you read about headaches on the Internet?
What are you hoping that I’ll be able to do for you?
What are you most worried about?
Help me understand how you ended up engaging in coaching?
How are the problems you discussed affecting your life?
What ideas do you have about what the problems are?
What are you hoping to get out of our work together?
What are you most worried about?
Phase III: Engagement
Share diagnosis and information
Collaboratively develop a plan
It looks like you are suffering from cluster headaches. Has anyone else ever suggested that to you?
What do you know about treatments for headaches?
It sounds like you would like your patients to experience you as more caring than they do now.
What would that look like? What can you do to help them know that you care about them?
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R.E.D.E. in Coaching for Communication
We typically begin by meeting the coachee to start building a relationship. Often, this is done over coffee, breakfast, or lunch. Before tackling the issues at hand, we aim to learn who coachees are and how they ended up where they are. We also aim to help them understand what coaching is and what we have to offer. In the development phase, we explore their goals. What do they aspire to? What does success look like to them? When have they succeeded in the past? What strengths or assets did they use? What is their current reality? What do they like and dislike about it? What would they like to continue, and what would they like to change? Where are they succeeding, and where are they getting stuck? The engagement stage involves developing a plan for moving from the current reality toward the imagined ideal. What would it take to move in such a direction? What skills or assets could they deploy that would help them? What barriers do they foresee? What do they have to gain if they succeed? If their goal is for patients to feel fortunate to have them involved in their medical care and the reality is that their patient satisfaction scores are low, can they imagine what it would look or feel like to be a clinician who was beloved by his or her patients? How would such a clinician behave? How is that different from their current behavior? Although it may sound absurdly simple, applying the discipline to think about such matters systematically and without emotion or defensiveness can be powerful and transformative. Bolstering this process are the following key elements: the relationship, reflective capacity, external perspective, content expertise, and accountability.
The relationship
We strongly subscribe to the belief that effective coaching depends upon a trusting relationship with the person being coached. Entering into the coaching relationships with a sincere interest in and curiosity about who the people are, why they went into healthcare for a career, what they like and dislike about their work life, what they value, how they define success, what they are hoping for, and how they view their current struggles is important. On such a journey, it’s important to trust your travel companion. The coach’s goal is to help the coachee. Judging, criticizing, rehabilitating, reforming, and remediating are not the coach’s responsibility or task assignment. If remediation is needed, and it often is, coaching can help individuals remediate their performance, but it is the individual’s responsibility, not the coach’s. The coach is there to support and to provide a structure and process, not to fix. The coach must also want the individual to succeed, and the coachee should feel this.
Coaching is, in a sense, an invitation to imagine a better future and then work toward it.
Reflective capacity
Developing reflective capacity enables people to assess their own performance more accurately and to understand better both their impact on others and others’ impact on them. We hope that clinicians will become more aware of how their specific behaviors affect other people and why they react the way they do to the behavior of others. How does it feel to an obese middle-aged woman dressed in her underwear to have a slim, athletic male physician tell her that she is fat? How does it feel to a doctor fiercely committed to improving the health of his patients when patients come in day after day with ever-increasing body mass indices and never-ending reasons why they haven’t improved their diet, stopped smoking, or started an exercise regimen? In these instances, there are both cognitive and emotional frameworks underlying the logic of the interaction, and becoming more aware of the emotional elements is critical.
One day I saw a clinician treating a first-grade child who had tears streaming down her face in the middle of what the clinician expected to be a relatively painless procedure. The clinician said to the child, “Don’t cry. Smile. It’s not so bad.” In a span of seven words, there were three statements that negated the emotion the child was feeling. Beyond that, the words communicated to the child not to feel what she was feeling. Later, when we debriefed, I recounted the incident to the clinician, who was surprised that he had said what he did. He reflected on it. “I think that when a patient is reacting to a procedure as if it’s much more painful than I think it should be, I get angry at the patient.” He recognized that the anger was inappropriate, and it was empowering for him to be able to name it. Armed with this insight, we brainstormed ways to manage his anger and develop language that was more attuned to the needs of the patient.
There is another reason that developing reflective capacity deserves prioritization: it is more effective to empower people to develop their own insights, goals, and solutions than to provide them with other people’s insights, goals, and solutions. Sound familiar? We know that patients are more engaged in decisions that they are a part of making. Everyone is. If coachees depend on the coach’s ideas, then how will they function when the coach isn’t there to help? Coaching aims to enhance self-sufficiency and problem solving. Enhanced self-awareness combined with an ability to assess one’s performance accurately through reflective processes helps achieve this aim.
External perspective
When a tennis coach watches someone serve or hit a backhand, she can see things that the player cannot see. We all tend to have both good and bad habits of which we are partly or entirely unaware. By shadowing or videotaping clinicians in action, performing 360-degree evaluations, and doing role-play exercises in which the clinician plays the role of the patient or colleague and hears her own words spoken to her, we can help individuals gain an external perspective on their behaviors and thus become more self-aware. As described by Windover in Chapter 5, external observation of their behavior or skill can move people from a place of unconscious incompetence to a place of conscious incompetence: now you know what you don’t know. It is also the moment in one’s learning process when skill building or training is useful because people are aware of areas they need to work on.
Only with awareness can someone make real changes to his or her behavior.
In our coaching, we largely depend on shadowing and/or videotaping to gain insight into these issues, although often much can be learned simply by listening and observing carefully. One physician we coached had colleagues complain that he made them feel stupid. When the coach sat down to talk with him, get to know him, and plan a coaching agenda, it struck him that the picture the coachee had drawn of the people he worked with was that they were not very good at their jobs and not very bright. Part of the behavior that was getting him into trouble was apparent if we watched for it and assessed our own response to his narrative. This makes it easier to start a conversation about his current reality and what a different reality might look like.
In today’s world, we don’t just have the external perspective of a coach; we have the external perspectives of the patients we serve. Comments on patient satisfaction surveys and patient complaints and compliments about a given provider to the ombudsman’s office provide a wealth of information, and themes can emerge. Transparently highlighting these to providers can provide contextual information about potential blind spots and lead to a discussion of how the provider interprets these. How does feedback from patients compare to feedback from colleagues and coworkers? Most clinicians b
elieve there is something unique about their patient population, and in some ways, this is undeniably true for everyone. And yet, unless they are planning on making a major professional change so that they see a completely different patient population, their patients are a reality in their world. We want to focus on how to work more effectively within that reality. An isolated complaint does not necessarily have much meaning, but where there are clear patterns and recurring themes, it is important to seek the meaning of the feedback.
Foundational knowledge about key communication skills
Content expertise is important because many useful skills and tools have been developed that are widely applicable and relatively easily applied. Clinicians need to be competent in a variety of communication tasks: listening and eliciting the patient’s complaints and history; responding when a patient displays strong emotions; delivering bad news; educating patients about diagnoses and treatments in a manner that they can understand and retain the information; motivating patients to adopt healthy behaviors. The process of mastering these skills is often aided by providing learners with specific examples of what they might say that can be adapted by the individual and coach to fit more authentically with his or her personality and communication style.
Although we don’t expect our clinicians to be experts in communication and the evidence surrounding it, we do want to build an expectation that core communication skills are important to their practice. Not all clinicians can generate the right words at the right time on their own. The benefit of working with a coach in a safe, private venue is that clinicians can be supported in developing their own language and approach. Not only are the core concepts in communication important, but how they are presented may also hold value. Given that all of our physicians have been required to undergo fundamental communication skills training, we aim in coaching to reinforce and build upon the skills taught in the R.E.D.E.-based courses. This maximizes the potential for encoding and recall.
Communication the Cleveland Clinic Way Page 14