Health Coaching: An Essential Communication Skill
By Shelley Simon, RN, DC, MPH, EdD
If you have been reading my column since it debuted at the beginning of this year, then you know that I often write about the importance of developing and using good communication skills. The reason for this is simple: Practices succeed or fail based on the practitioner's ability to communicate effectively with prospective and active patients, staff, colleagues and business associates. In this article, we explore how chiropractors can use coaching as an essential communication skill to support patients in achieving their health goals.
The terms coaching, wellness coaching, and health coaching are now used so frequently in chiropractic circles that it makes one wonder whether the concept will turn out to be a passing fad or have staying power. I believe that whether or not the terms remain in vogue, having the ability to effectively engage in health coaching serves both chiropractors and their patients well and will continue to do so for years to come. Learning the language of coaching requires effort, but chiropractors who put in the time to become competent in this area and do so for the right reasons (i.e., to help patients achieve their health goals) will be rewarded for their investment.
Teach, Advise or Coach?
It is imperative for chiropractors to have the ability to identify which essential communication skill will be most helpful with a patient at any given time. There is a time to teach, a time to give advice and instructions, and a time to coach. Knowing which of these to choose comes with experience and is much easier when you learn to listen to both the patient and your own intuition. Listening carefully and staying fully present during each patient encounter will help you in determining whether it's time to teach, advise or coach. All of these skills fall under the umbrella of "communication and interpersonal intelligence," and successful chiropractors never stop working on improving their competence in all three areas.
Even chiropractors who have a keen sense of what is needed must take into account what is wanted by a patient. They sometimes want facts and advice, pure and simple. Or they want information to help them better understand their problem, coupled with clear instructions about what they can do to feel better. Many patients view their chiropractor as the expert and want to be told exactly what to do and how to do it, and they're perfectly happy to follow directions. For individuals who want a more collaborative doctor-patient relationship, however, and for those who have their own ideas about how to manage their health, coaching may be more effective than educating or advising.
In an article in the March/April 2008 issue of EXPLORE: The Journal of Science and Healing, Kreitzer, et al., state that health coaching "differs from health education and case management in that the focus is on helping clients make choices and behavior changes that will promote their overall health and well-being."
Coaching involves guiding patients to develop a vision of their preferred future related to their health (e.g., "I want my pain controlled to the degree that I can go back to my job full-time"), allowing the patient to come up with some of their own solutions and plans to achieve their vision, helping them sort out what is most likely to be successful, working through assumptions and obstacles, supporting them through times of resistance or frustration, and holding them accountable to reach the health goals they say are most important to them.
Setting Aside Judgment and Biases
As the health coach, your role is to make it clear that you are willing and able to be a member of the patient's support team and that you stand ready to work with them toward success. The first step in supporting patients to achieve their health goals is trusting that they know what they want. A patient's desire to achieve immediate pain relief instead of addressing the underlying cause of the pain may seem shortsighted to you. But being free of pain may be the only thing that matters to the patient, at least for the moment. Coaching involves honoring that patients understand not what's "best" for them, but what is important to them. Setting aside judgment and bias requires being curious about what a patient wants, what they are and aren't willing to do to improve their own health, and what their beliefs and preferences are as well.
When it comes to helping patients reach their health goals, practitioners can borrow a page from the world of professional coaching. When coaching a patient, the focus should stay on the needs, desires and goals of the individual being coached. As chiropractor/coach, your job is to set aside judgment and help your patient achieve whatever it is that they want, even if you don't necessarily agree with their goal. For example, you have a patient who is 40 pounds overweight and suffers from chronic low back pain. In your professional judgment, they should lose the excess weight as part of a comprehensive plan to improve their back pain. You've mentioned this to them, but for reasons that are unclear to you, losing weight is simply not a priority for this individual. What he has clearly stated, however, is a desire to get back out on the golf course. Instead of spending time and energy and annoying the patient by harping him about his ample belly, focus your attention on the patient's primary goal: playing golf.
Coach, Don't Advise
Coaching patients, as opposed to advising them, isn't easy when you are in the expert position and posses information that would make a difference in your patients' lives, if only they would listen, take your suggestions and accept what you say as fact. Staying with a patient's agenda and keeping the focus on their goals sometimes requires restraint. The best way to illustrate the difference between coaching and advising (or telling) is by example:
Patient states: I know I should keep my appointments, but I get busy and then just wait until the pain gets bad again.
Advising: We've discussed this before. You know that keeping on schedule is the only way to prevent these problems from recurring.
Coaching: You've said your goal is to be able to count on your back to be stable so that you can do the activities you enjoy. Given that, what would help you to be more consistent with keeping your appointments? (Note: This question helps the patient refocus on their goals and connect achieving those goals with the benefits of treatment.)
Patient states: I don't have time to exercise. I know that I should, but I have three kids and a job.
Advising: I hear you. I have two little ones myself. Here's what I do: Just get up an hour earlier and get in your workout before anyone else wakes up.
Coaching: Most of my patients have a hard time making time for exercise. If you were to make it a priority, what would be the most likely time of day that you could fit it into your schedule on a reasonably regular basis? (Note: This question is designed to help the patient see new possibilities and tap into their own creativity and ideas for solving the problem of not enough time.)
Patient states: I know I should take my supplements every day, but I forget or get lazy and don't do it.
Advising: Put your supplements in one of those day-of-the-week type boxes and keep a log to bring in for your next appointment.
Coaching: What do you understand about the benefits of taking these particular supplements? (Note: This question should reveal whether the patient even sees the value of taking supplements or if they simply need a better system or routine for taking them.)
Patient states: I don't want any X-rays. I'm afraid of the radiation, and I don't have insurance to cover this.
Advising: I can't properly diagnose you without an X-ray. The radiation is minimal so you shouldn't worry about that.
Coaching: What is your main concern about X-rays? Is it the cost or the radiation exposure? Is there anything else that concerns you? (Note: This question will uncover more detail about a patient's assumptions or bias.)
Having illustrated the importance of staying focused on the patient's vision for themselves by coaching rather than advising, it must be said that the coach/chiropractor's role is also to help the patient embrace a vision for themselves that may be larger than what they can see in the immediate future. An example of this might be the patient who has a short-term goal of just being well enough to get back to work. Certainly, this is a worthy goal and one that you would support. It also might be useful to ask about other meaningful goals that the patient might have as a strategy to help them see even greater possibilities.
Dealing With Resistance
It's not uncommon for patients to get excited about achieving a health goal only to face internal resistance when it comes right down to working toward achieving the goal. The patient who stands in your office and commits to a home-exercise program will come back at the next visit saying that they're too busy or that they've decided the exercise program is not important to them after all. Dealing with resistance in a patient requires very simply going back to the beginning of the process by asking patient-focused questions: What do you want? Why is that important to you? What would be the benefit of working through this? What could you do? What will you do?
Remember that you can't force or cajole a patient into doing anything they don't want to do. It's human nature that we all think our own ideas are the best ones. We like to be right, and we tend to act on and follow through with our own ideas more readily than on the ideas of others. Let the patient come around to deciding whether or not they want to recommit to a goal, modify the goal to be more achievable, or abandon the goal altogether. (For an in-depth discussion on how to manage resistance on the part of patients, refer to my article "How to Diagnose and Manage Resistance in Others," in the April 8, 2008 issue of DC: www.dynamicchiropractic.com/mpacms/dc/article.php?id=53165).
Developing Coaching Competence
You do not have to drop what you are doing and go back to school to become a full-fledged coach in order to develop many of the competencies associated with quality coaching. On the other hand, just saying that you are a "wellness coach" or adding it to your Web site and brochure as a new service does not necessarily mean that you possess the necessary skills to effectively coach patients.
The International Coach Federation (ICF) certifies both coach training organizations and coaches. The core coaching competencies put forth by the ICF include creating a foundation for the coaching relationship, establishing trust, being present, effectively communicating with active listening and powerful questioning, designing action plans and setting goals, and establishing accountability. If you are interested, you can read about these competencies in greater detail at www.coachfederation.org.
Good coaching requires being fully present and curious, asking meaningful questions, staying focused on the goals of the patient, and being careful not to let your own biases cloud the encounter. Coaching can be learned by regularly engaging in patient-focused dialogue, through structured independent study, and by working with your own coach to hone your skills.
Good for the Patient, Good for the Practice
Patients clearly stand to benefit greatly from achieving their goals in terms of better health. But there is also a clear advantage to the practitioner who helps patients achieve their important goals - it's a practice builder.
In 2005, the Institute for Alternative Futures (www.altfutures.com) published The Future of Chiropractic Revisited: 2005 to 2015. Their report stated, "Lifestyle approaches are often the most effective way to prevent disease or to reverse it in its early stages. A 'healthy life' is viewed as powerful medicine and many types of providers ... commit to build practices as 'healthy life doctors.'" With this in mind, and factoring in the aging baby boomers (arguably the first generation to take preventive care and wellness seriously and to take charge of their own health care), chiropractors would do well to consider the possibility of including health coaching as a primary communication strategy to help patients achieve their goals.
You may be the best clinician in your community, but most patients have no way to measure your technical or clinical ability. What they can measure - and what they talk about - is how much they feel cared for. Becoming genuinely interested in helping patients achieve goals that are important to them demonstrates a level of caring that goes far beyond what most patients expect. And exceeding expectations is an excellent marketing tool.
If you can get your chubby, golf-loving patient with low back pain back out on his favorite course, he will have achieved his goal and will sing your praises to his golf buddies on every other hole. Help a grandmother experience the joy of being able to pick up her grandchildren without pain, and her friends and family will be sure to hear about it. Partner with a patient to help her regain her ability to teach yoga and you'll likely find yourself with a few new yogis and yoginis in your practice. Consider how you might help your patients achieve these kinds of results through health coaching.
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