In my role as both a family medicine physician and clinician coach, I am often asked, “Does coaching frontline physicians work?” The health care leaders who ask the question typically are thinking of the physician with recurrent patient complaints, the dedicated physician who struggles with patient satisfaction and doesn’t know why, or the high-revenue producer who is just rude. With transparency and consumerism rising steadily and the culture of organizations at stake, doing something to help and support these physicians has become more important than ever.
A Physician Coaching Journey
As a member of a large multi-specialty group, I was assigned the task of “coaching doctors” in 2002, during a time when our physicians were nestled in the bottom decile of the patient experience when compared with other large groups in a national database. Over the years, I had to figure out how to engage busy colleagues in efforts to improve patient-communication skills while maintaining the flow of their clinical work. Throughout this period, I shadowed clinicians, designed training approaches, and carefully reflected on the coaching techniques that worked in order to answer the question of “who gets better?” Over the initial 6 years, with coaching and skill-building as our principal efforts, the medical group physicians eclipsed the 90th percentile in that same patient-experience database.
During this process, in which both individual and group coaching approaches were used, several truths emerged. First, certain physicians were just more coachable than others, and a good coach needed to know how to assess and respond to a physician’s “coachability.” Second, there were specific coaching techniques that worked consistently to engage physician effort and commitment to change. Finally, and perhaps most notably, when physicians experienced the benefit of a new skill with patients, they not only continued to use that skill, but they would also proselytize that skill to their colleagues. The physician-to-physician skill exchange that followed coaching helped to spread skills and create an organizational culture of learning.
After working with our medical group, I have had the opportunity to work with organizations from across the country, building coaching approaches focused on helping physicians to develop communication skills that many simply have never learned. During this time, I have come to understand that the role of a physician coach is not just to guide physicians on how to improve communication skills, but to position them to rediscover the restorative power of connecting to patients. To that end, it is important to know which factors predict coaching success and which coaching techniques work best.
Predictors of Coaching Success
1. The response to coaching is better when physicians ask for help. One immediate pattern that emerged was the contrast between the responsiveness of physicians who requested help compared with those who received coaching in remediation. Both cohorts improved, but the rate and degree of improvement were clearly better among physicians who had requested assistance. When it comes to coaching physicians, “pull” seems to work better than “push.”
2. The physician coach believes that improvement is possible. One of the most important predictors of coaching success is a belief in the physicians who are being coached. Often, I have seen leaders give up on a physician, resigned that the physician’s longstanding behaviors will never get better. Over the years, I have seen a number of these physicians rise up and stun both leaders and colleagues by committing to simple skills in the exam room. The stories of these physician turnarounds, often related by the physicians themselves, can serve to validate the power of change, raise the visibility of coaching, and fuel the participation of others. I remind coaches of the Henry Ford quote, “Whether you think you can, or think you can’t — you are right.” As in most endeavors, hope and belief matter, and a good coach will bring both to the table.
3. The coached physician takes ownership of his or her own behavior. Ownership is a strong predictor of coachability. The highly coachable physician will say, “I’m not sure what it is exactly, but apparently I am doing something that is creating these results . . .” Conversely, when physicians blame others, dismantle the data, and take no ownership of their behavior, the response to coaching is low. For coaches, fostering coachability is an important skill. Techniques for encouraging ownership and self-reflection rarely emerge from turning up the volume on decile ranks or patient-satisfaction scores.
In my experience, the most reliable way to foster self-reflection among coached physicians is to simply share comments from patients. Comments such as “The doctor never even touched me . . . I don’t know how he came to my diagnosis, and I never filled my prescription” and “The doctor treated me like an idiot” have a deep impact on physicians and clarify the importance of communicating effectively with patients. I have found that when a physician listens to a story from a patient, it fundamentally shifts his or her receptiveness to new approaches.
4. The coached physician is willing to try a new skill. The willingness of the coached physician to try a new skill in the exam room is a strong predictor of coaching success. I frequently remind coaches that learning skills is easy, but using them is what matters. When physicians simply agree to try the skills that they have learned, results can quickly follow. Recently, I was coaching a group of ambulatory-care physicians. The new skill that we had worked on was narrating the physical exam to patients, framed around the phrase “Here is what I am looking for . . .” as a way to build patient confidence and convey thoroughness. Each of the coached physicians tried the new skill with patients and then conferred with each other in a debriefing session, during which they described the patient response as having been “overwhelming.” The practice of narrating the exam has now become a part of how these internists communicate with patients, with one of the coached physicians describing this single skill as a “career changer.”
Understanding the predictors of coaching success is an important foundation for an effective coaching approach. Equally important is knowing coaching techniques that will both create meaningful improvements in quantitative metrics and allow us to reconnect to the purpose of our work. Let’s take a look at some of the approaches that work best to move the needle.
Physician Coaching Techniques
1. Understand that issuing directives to improve patient satisfaction scores does not work. Physician coaching techniques are sometimes developed around what not to say to colleagues. Mandating improvement is tempting but is categorically ineffective. First, ineffective communication skills are never intentional. Second, physicians, like patients, do not respond well to being told what to do. Physician receptiveness to patient-experience data is fundamentally better when patient experience reporting is tightly coupled with simple techniques that can be immediately implemented. Helping beats nagging every time.
2. Encourage care team members to learn together. Although we have frequently used one-on-one physician coaching and shadowing to help and support physicians, some of our most successful coaching efforts have been those in which a room full of clinical team members (including physicians, nurses, and other members of the caregiving team) have committed to learning a particular technique together. Learning publicly builds a common approach, fosters synchronous effort, and creates the accountability that comes from a shared commitment while simultaneously increasing skill awareness, participation, and uptake.
3. Frame coaching around things that physicians care about. Effective coaching involves helping physicians to develop skills that generate meaningful outcomes consistent with our values as clinicians. For example, coaching efforts that are focused on helping physicians to create patient trust, instill patient confidence, and increase patient participation in care are far more compelling than those that are focused on improving low patient-satisfaction scores. Coaching simply for the purpose of improving scores undermines both the spirit and the intention of coaching and fails to honor the mastery ethic that is part of being a physician. Coaching efforts must be framed with language that connects with why we became physicians and our role as trusted caregivers.
4. Use the “Me Then Thee” approach. Coaches who simply tell physicians to try a new skill are not nearly as effective as those who actually share their own stories of what they have learned, tried, and discovered and then invite their colleagues to do the same. This “Me Then Thee” approach is reminiscent of the “see one, do one, teach one” model that guided so many of us through residency training and should be replicated when building an effective coaching approach.
Final Reflections on Making Coaching Go
Coaching is often viewed as a strategy to remediate physicians, improve performance, and raise scores. These views are not wrong, but they fall short of what coaching physicians is really about. The best of coaching is about clinicians helping clinicians and creating a caregiver community that learns and improves together. Above all else, coaching is about getting back to why we became physicians, reconnecting to our patients, and remembering that our best moments can still be found behind the exam room doors.