Abstract
In our training and growth as health care professionals, we look to our instructors an d others as coaches, people who help us learn not only concrete skills but also ways to solve complex problems and form meaningful and productive relationships with patients and colleagues. In this article, I outline how I became my own coach by reflecting and building on my experience as student, teacher, and physician, and how I help others do the same.
The Story
I'll start with a story.
At about 5 p.m. one afternoon during my internship year at Minneapolis General Hospital (now Hennepin County General Hospital) a long time ago, I rode the ambulance to the scene of a one-car accident. The policeman at the scene led me to the car, smashed head-on against a tree. The driver, conscious but behaving wildly and speaking incoherently was seated in the car and handcuffed to the steering wheel. “When I arrived, Doc,” the policeman told me, “he came out swinging, and so I had to subdue and 'cuff him.” I was about to inject the man with a sedative so that we could transport him to the hospital, when one of my teachers, a physician who lived in the neighborhood, strolled by surveyed the scene, and reflected aloud, “I wonder if he's having an insulin reaction.” And so, instead of injecting the sedative, I substituted intravenous 50% glucose. In just a few moments, the man calmed down and spoke, making sense.
Students worry all the time about doing well and not making a mistake. I tell them that one of the purposes of professional training is to lessen the likelihood of mistakes. Yet there are so many different situations, combinations of problems, patients ‘personalities and cultural backgrounds, and ways they tell their stories— what is said and what is left unsaid—that the opportunities to err are immense. The chance appearance of my teacher gave him the opportunity to coach me and teach me important lessons. But how many times will we have a teacher by our side to coach us as we confront a new problem? Ultimately we need to become our own coaches.
How many times will we have a teacher by our side to coach us as we confront a new problem?
What did I Learn?
My students and advisees know that my favorite question of them is “What did you learn?” What did you learn from today's class (readings, lessons, encounter with a patient or physician who was a class guest, etc.)? What did you learn from your experience in the lab (as a waitress, as a nursing home volunteer) that would be of use in your career as a physician (nurse, therapist, etc.)? In essence I am asking them to internalize the question, build on their own experience, and become their own coaches.
I used this question every day, after every patient, to teach and coach myself. Here are some examples:
In caring for a patient with abdominal pain and weight loss, I learned the following:
Single problems can be multidetermined, and unless all the contributing causes are identified, the problem may be incompletely solved.
Patients may panic when their medical care is so divided among various professionals that no one seems to be in charge. One person needs to coordinate care and present a consistent message.
In caring for a combative patient with fever and diabetes, I learned the following:
Among the causes of fever are the common ones, like pneumonia and urinary tract infection, and those one might not first think of, like pulmonary embolus.
Beyond the technical tasks of managing each of this patient's illnesses, named and yet to be named, is recognizing that “combativeness” is itself a problem that needs to be more clearly defined.
In caring for a patient with congestive heart failure and a pelvic cancer, who had taken the nonsteroidal anti-inflammatory drug indomethacin, I learned the following:
Much illness is drug- or treatment-induced. When a new medicine or treatment is prescribed or stopped, we need to anticipate all the possible effects of the change. Indomethacin can precipitate congestive heart failure. 1
From many other patients, I learned the following:
In solving a clinical problem, it's important to name the problem. The problem statement can be the name of a specific disease, like appendicitis or acute myocardial infarction; a symptom, like chest pain or shortness of breath; or a physical sign or abnormal test result, like abdominal mass or anemia. Name the problem as precisely as you can, no more and no less. 2
Never hesitate to turn to others if you don't know what to do. Medicine and nursing are collaborative professions.
Regardless of how sure you are of your diagnosis and plans for therapy, ask, “Is there yet another way of looking at this?”
When one is dealing with a “difficult patient”—that is, one whose diagnosis is elusive, who is recovering more slowly than predicted from an illness, or one with whom rapport is difficult to establish—consider psychosocial issues. Often the patient is depressed or has other distressing things going on in his or her life. 3
In relating these reflections to students, my intentions are deliberate: Not only am I helping them learn self-coaching techniques, but I am also transmitting knowledge that may be new to them.
Beyond specific concrete skills, a good coach teaches transferable skills, methods of approaching a new situation using what one has learned from experience and techniques of reasoning.
Coaches teach skills. Those skills can be specific: how to punt or how to field a ground ball, if you're an athlete; how to insert an IV, decide how sick a patient is, or treat a heart attack, if you're a nurse or physician. Beyond specific concrete skills, a good coach teaches transferable skills, methods of approaching a new situation using what one has learned from experience and techniques of reasoning. Among the most sophisticated of these skills is
[the] ability to listen to a patient's story, integrate it with information from the physical examination and tests, and then to make a decision about diagnosis and treatment…. The “intellectual capacity to do the work of a physician [and nurse]”… does not require genius, but rather a creative and open mind and the ability to look at complex and difficult problems in new and creative ways.
4
I tell students how I learned people skills, listening and teaching skills, and efficiency in thinking and reasoning, from experience outside of medicine. From working as a salesperson in my father's jewelry story, I learned not to make the choice of a wristwatch overly complex for a customer by providing too many alternatives, to simplify when you can. From my work as a busboy and waiter in Catskill Mountain resorts, I learned not to go into the kitchen empty-handed, to save steps, to work efficiently. Each of these lessons transferred well to my work as a physician.
In my role as coach, I start where the students are and encourage them to build on their own experience. I ask my students, What have you done outside the classroom, during the school year and on vacations, for pay or as a volunteer? What did you learn from what you have done that you could use in your a career in medicine (nursing, etc.)?
If the advisee has done research, I say, “Tell me about what you have done— not the details of the research, but lessons from the process that could be transferable to a career in medicine.” I'm interested in their insights about what one does when the experiment doesn't turn out the way it was expected; how one needs to re-examine the hypotheses, the processes, and the techniques; and when one turns to the professional literature and to colleagues. Like research, medical diagnosis and treatment sometimes doesn't turn out in the predicted way. Like research, medicine is collaborative.
If the advisee has tutored third-graders, I make similar inquiries. Different people learn in different ways, some advisees will tell me, an important insight in instructing and advising patients. 5
If the advisee has been a resident dormitory advisor, I ask her to reflect on the role of the relationship in being an effective advisor. Like being a resident advisor or a third-grade tutor, becoming a good nurse or physician depends on one's ability to form a relationship of reciprocal trust, honesty, and respect.
And for the first assignment in my class, “The Human Side of Medicine,” I ask students to tell a story about their own illness, or that of a family member or friend, and to reflect on the best and worst parts of the experience, with particular attention to the roles of physicians and nurses.
The Good Coach
Coaching involves teaching and advising but also modeling for the student, the goal of all of which is to improve performance and lessen the chance of making a mistake. Coaching involves not only transfer of knowledge, but also the transfer of the ability to apply knowledge with wisdom and judgment. More specifically, it involves how to:
appreciate, and make use of, relationships with patients and with colleagues;
discriminate that which is important from a lot of other information;
think and act efficiently;
be precise in making a diagnosis or judgment and choosing the best treatment from many options;
see patterns among data; and
take what one has already learned and apply it to new situations.
Coaching involves not only transfer of knowledge, but also the transfer of the ability to apply knowledge with wisdom and judgment.
I am fascinated by Princeton University English professor Elaine Showalter's approach to teaching literature: “On the whole when we teach reading literature as a craft, rather than as a body of isolated information, we want students to learn the following competencies and skills ” (italics mine). 6 In another example of transferable skills, I have adapted her list to apply to the nursing and medical professions:
How to recognize subtle and complex differences between patients with the same or similar diagnoses.
How to seek out further knowledge about a specific illness or problem.
How to think creatively about problems and combinations of problems.
How to listen closely to a patient, with attention to what is said and the body language and emotions with which it is said.
How to work and learn with others.
How to defend one's own decisions against the informed opinions of others.
There's a lesson here: Even a subject as distant from science as English literature can provide a good background for a career in health care.
Some years ago, I was a guest in a class of adult students of a world-renowned biblical scholar.
When they asked him to eulogize a recently deceased colleague, equally well-known, they expected high praise. Instead he was critical. “He didn't leave even one person to carry on his work,” he said. “He created a private language that was not transferable. It was opaque and so it was not useful to others. Transparent knowledge can be used by others and can be transmitted. There are those who do what they do well but it is not teachable. He gave solutions but not formulas, and formulas can be used by others.” 7
In other words, he was a scholar and teacher, but not a coach.
In contrast, on the radio program From the Top, I once heard Isaac Stern, one of the world's premier violinists—and a master coach—illustrate that a good coach teaches the student to become his or her own coach. After hearing a teenage violinist play a difficult piece, he asked her to play a short phrase from the piece once more. When she had finished, he said to her, “Now tell me what you are doing that you would like to do better.” In this extraordinary moment, he not only coached her, but gave her a technique for self-coaching. The lessons are many: to be effective, coaching has to be nonthreatening, and the coach needs to start where the student is. Often the student already knows what she can do better and simply needs to draw on that internal wisdom. In other words, the answers are already in her, but she may not yet have the confidence or clarity of mind to find them on her own. 8 Stern's goal—and the goal of all of us who coach—was for the student to become her own coach; his technique was a step in that direction.
Self-Coaching Techniques: Coaching and Teaching at the Same Time
From so many experiences, then, I have become my own coach. Here are two of my self-coaching techniques, which I pass on to those whom I teach and advise about a career in health care.
In a stepwise approach to considering any clinical problem, ask:
What's the story? And when did it really start?
What are the issues, the questions that need to be addressed? They may include one or more of the following: diagnosis, treatment, prognosis, and psychosocial issues (see item 2 below).
What's the role of the relationship between the professional and the patient in enhancing the accuracy of the story, the diagnosis, the treatment choice, and the effectiveness of the treatment?
What did I learn?
In solving a clinical problem, the important steps are:
Name the problem.
Place it in clinical context by constructing a problem list of all the patient's problems.
Scan the problem list and ask, Is the new problem related to any of the other problems, or to the treatment of any other problems?
Construct a differential diagnosis, a list of all the reasonable diagnostic choices.
Make a diagnosis (the diagnostic solution).
Implement therapy (the therapeutic solution). 9
Evaluate the results. 10
The ultimate goal is for one to become one's own teacher and coach.
The most important element in both of these outlined approaches is asking, “What did I learn?” That question stimulates personal and professional growth. The question also stimulates one to reflect and to integrate the elements of what one has read, heard and experienced, in order to become a creative thinker, a key element in any career in health care. Asking, “What did I learn?” allows insight and discovery. It is the way we learn from experience. The ultimate goal is for one to become one's own teacher and coach. What one has learned can be at different levels: the more specific (e.g., “I learned that right lower abdominal pain can be caused by appendicitis”) or the more reflective (e.g., “I learned that patients can handle uncertainty, and bad news”). In addition, one can reflect: “From what I learned, I have been stimulated to consider these additional questions… .”
Back to the Story
Now look back to the story of the car accident.
The story really started before the accident. Here's what had happened: The man had type I diabetes, had taken his usual dose of insulin at the usual time that morning, but had delayed his meals because of an upper gastrointestinal x-ray. The intermediate-acting insulin had its peak action while he was driving home, and he became hypoglycemic and lost control of the car, causing the accident. If not for the presence of my teacher, I would have made the wrong diagnosis, treated his change in mental status incorrectly, delayed his recovery, and possibly compromised the outcome.
Here's what I learned from this single event:
Don't jump to conclusions. Without thinking it through, I went from the poorly defined problem, “behaving wildly,” to the treatment, “give sedative.” A better name for the problem would have been “change in mental status,” which would have quickly led me to consider alternative diagnoses.
One important cause of the problem, “change in mental status,” is insulin-induced hypoglycemia, which can occur at any time, but especially in the afternoon if the patient uses intermediate-acting insulin.
Ask, “When did this story really start? At the time of the accident? Before that?” And if the answer is unclear, think of various scenarios, including the one that occurred in this case. Build on experience.
For patients taking insulin or any other drugs for diabetes, adjust the dose appropriately on the day their meal schedule is altered for a test or other reason.
And, once again, even when you have made what you consider a firm decision, ask yourself, “Is there yet another way to look at this?”
I never forgot these lessons and this story, and in subsequent years I have passed them on to nurses and physicians, those experienced and in training, as we have shared other stories from our collective experience about the many subtle manifestations of insulin reactions. In addition, I often expand the discussion into a larger teachable moment by asking, “What are causes of ‘change in mental status ‘other than hypoglycemia?”
We have to become our own coaches, to develop reproducible techniques of addressing new problems and variations on old problems.
Conclusion
Early in any career, we need coaches like Isaac Stern to teach us and help us learn from our experiences and mistakes. But one can't always be as fortunate as I was when, as a young intern, I came upon the man with the unrecognized insulin reaction. And so we have to become our own coaches, to develop reproducible techniques of addressing new problems and variations on old problems. At our best, we ask, “If my coach was at my side right now, what would she suggest I do? And why?” As we mature as professionals, we skip that step, for the wisdom of our coaches becomes internalized. These are worthy goals in preparation for, and commitment to, lifelong learning in any career in health care.
Footnotes
1.
Laurence A. Savett, The Human Side of Medicine: Learning What It's Like to Be a Patient and What It's Like to Be a Physician (Westport, CT: Greenwood Publishing Group, 2002). These three case summaries are adapted from Chapter 22, “Another Look at a Day in the Life of a Physician,” pp. 188–189, 192–194.
2.
Naming the problem is a key step in the problem-oriented system of medical decision-making and reasoning. See L. L. Weed, “Medical Records That Guide And Teach,” New England Journal of Medicine 256 (1978): pp. 593–600 (part 1), pp. 652–657 (part 2).
3.
For a more complete discussion of the so-called difficult patient, see Laurence A. Savett, “Honest Reflections About ‘Difficult Patients,” ‘in Relationship-Based Care: Visions, Strategies, Tools and Exemplars for Transforming Practice, eds. Mary Koloroutis, Jane A. Felgen, Colleen Person, and Susan Wessel (Minneapolis, MN: Creative Health Care Management, 2007), pp. 361–365.
4.
Laurence A. Savett, “Pre-Med Advising: The Case for an Early Extended Interview. An Opportunity to Establish a Relationship, Explore and Listen, Teach, Guide and Coach, and Model the Doctor-Patient Relationship,” The Advisor 28 (2008), pp. 8–14.
5.
Ibid. These first two examples are drawn from the above article.
6.
This list is adapted from Elaine Showalter, Teaching Literature (Malden, MA: Blackwell Publishing, 2003), pp. 26–27.
7
Savett, The Human Side of Medicine, pp. xv–xvi.
8.
Thanks to Mariella Mecozzi for this helpful statement.
9.
For a more complete exposition of these approaches, see Savett, The Human Side of Medicine, chapter 1, “Medical Care Starts with the Patient's Story,” pp. 11–12; and chapter 10, “Diagnosis: How Physicians Reason,” pp. 81–92.
10.
Thanks to Susan Lampe, who reminded me of this step, a key part of the nursing process, and so critical to all we do.
Acknowledgments
Many thanks to Mariella Mecozzi, a prehealth professions advisor at the University of Michigan; Susan Lampe, a nurse-educator, Minneapolis; and Umesh Rao, who oversees a program of spiritual counseling and support at a large referral hospital in Bangalore, India. They generously provided a careful reading of an earlier dra.., suggestions for sharpening some of my observations, helpful additions, and validating comments.
Laurence A. Savett, MD, FACP, author of The Human Side of Medicine: Learning What It's Like to Be a Patient and What It's Like to Be a Physician and a member of the editorial board of Creative Nursing, practiced internal medicine for 30 years. He has taught and advised medical students at the University of Minnesota, and prehealth professions students and alumni at University of St. Thomas, and Macalester College in St. Paul, Minnesota.