Richard Smith: Coaching—an essential skill in modern health practice

richard_smith_2014If you have meningitis how well you do depends on the medical team, whereas if you have diabetes it depends mainly on you, the patient. These days most of healthcare is about patients with long term conditions, usually multiple conditions. So the old style of healthcare when sick patients could be rapidly cured, which many healthcare professionals found deeply satisfying, has been largely replaced by a more complex kind of healthcare that depends on forming a strong, supportive relationship with patients.

Jenny Rogers and Arti Maini call this coaching, and in their new book Coaching For Health: Why It Works And How To Do It they spell out in practical detail how to coach effectively. Some professionals might find this kind of healthcare less satisfying, and more frustrating, than the largely extinct curative form, but the book shows how it can be equally and even more satisfying.

Coaching is more a mindset and collection of values than a series of techniques, and some of the values, although simple, may prove challenging. The starting assumption is that every patient, no matter how seemingly helpless, can make rational choices and that patients are the experts on themselves. The implication is that patients may make choices very different from those their clinicians would make. The choices may even seem irrational to the clinicians. Even more challenging to some clinicians is that “in a true coaching exchange, the outcome is unknown.” It might be the opposite of what clinicians have aimed for.

One reason that the outcome is uncertain is because coaching is a conversation between equals. Clinicians, bristling with degrees and used to exercising authority, must recognise that they are the equals of patients who may have very little education and find it hard to express themselves. And perhaps most challenging of all is the idea that the clinicians may be affected more than the patients by the interaction.

It’s very tempting and at first thought quicker to tell patients what to do. This might have worked better in the age of deference, but it probably didn’t work well even then. We’ve long known that many prescriptions are not even taken to the chemist and that adherence rarely rises above 50%. Rogers and Maini quote Angela Coulter, a long term student of clinician-patient interactions, when saying that traditional styles of practice “create dependency, discourage self care, ignore patient preferences, undermine patient confidence, do not lead to healthy behaviours, and ultimately lead to fragmented care.” What was poor practice in the age of acute, potentially curable disease is disastrous in the age of long term conditions and multimorbidity.

Rogers and Maini are explicit that you cannot learn coaching from a book alone, and it seems to me an activity that can never be perfected: you will keep learning. But the book is full of practical, actionable information.

One of the core skills of coaching is to create the right first impression. As Daniel Kahneman showed in Thinking, Fast and Slow we are hardwired to make almost immediate judgments on people. Clinicians who arrive late, don’t smile, don’t introduce themselves, and don’t look at the patients have a long way to go to build equal, coaching relationships with patients. They start by going backwards.

I much enjoyed the “Rapport checklist” provided by Rogers and Maini: smile; pay close attention to where you place yourself in the room; avoid writing and not looking at the patient; remember non-verbal cues that you are listening, like nodding; use the power of touch judiciously; pay close attention to unspoken nuances in the conversation; and avoid carping and grumbling. We can all benefit from this list in our everyday lives, but the therapeutic power of rapport (“the doctor as drug”) should not be underestimated. It’s probably one of the reasons that patients are so attracted to complementary practitioners. As Rogers and Maini write: “It is unusual to be offered 100 per cent attention and care by another human being, and it’s enormously validating when we do receive it.”

The book explores topics where coaching may be especially valuable or particularly difficult or both. Can coaching help people change their behaviours, something that traditionally clinicians do poorly? How can it be useful with disempowered patients, those whom it might be most tempting to tell but who most need a sense that they can control their lives? What are the special aspects of coaching people with mental health problems?

One part of coaching is to identify barriers that patients might feel and experience, and Rogers and Maini end their book by answering the questions that they know clinicians will ask, possibly as a means to resist change. Lack of time is our favourite universal excuse for not doing something, although really it’s just saying that the something is not a priority. Will clinicians, particularly GPs with their 10 minute consultations, have time for coaching?

Rogers and Maini’s answers are that using some of the basic techniques of coaching are timesaving—like setting the agenda for the consultation, asking patients what they hope to achieve, and summarising what is happening. But they might have answered that the old styles are failing; telling the patient what to do might get them out of the door quickly but will usually not result in improvement. Worse, they may create dependency and undermine self-sufficiency, meaning that the patients may be back soon and often.

After reading the book I was left knowing that I would buy a copy for my daughter who hopes to train as either a doctor or clinical psychologist. Whatever she becomes this book will be useful to her.

Richard Smith was the editor of The BMJ until 2004. 

Competing interest: This blog is a foreword to the book. I was not paid for writing the foreword but was given a free copy of the book, which I gave to my daughter.