The Clinical COACH: How to Enable Your Learners to Own Their Learning

The ultimate goal of medical education is for learners to become competent physicians who identify learning needs from patient encounters, from system issues, and even from mistakes, and proactively develop educational plans to fill those needs. With this article, we continue the Council on Medical Student Education in Pediatrics series about the skills and strategies of great clinical teachers by illuminating the coaching role teachers can play in developing lifelong learners.Clinical teachers supervise clinical learners as they jointly provide medical care to patients. A key role is to provide feedback to learners; however, this can be a struggle because most clinical teachers have received little instruction in giving feedback.1 Clinical teachers also may believe providing constructive feedback is often done in vain, because of a lack of resources to help the learner improve.1 Teachers may worry about damaging their relationship with learners or about hurting the learners’ self-esteem.2 Learners contribute to the challenges within this teacher-learner feedback relationship, because they often avoid asking for feedback for fear it will be critical and may become defensive when offered corrective feedback, particularly if they worry about feedback hurting their grades.3Feedback and coaching are different. The focus of “feedback” is often on the tasks that teachers do (how to deliver feedback, when to have such conversations, etc) to direct the construction of a learning plan. Often, feedback is given about something decided on by the teacher rather than that requested by the learner. There are other ways to help students develop. Advising and mentoring are also directed by the preceptor, and his or her role is to provide advice or guidance over a short- or long-term period, respectively. On the other hand, the key features of “coaching” are that the coach encourages the learner to reflect, gain insight, address and solve problems, and take responsibility for his or her own learning and growth.4,5Whitmore’s6 general coaching model, not specific to medical education, describes the following 4 steps for effective coaching: help the learner articulate Goals, reflect on Reality or current abilities, describe Options for learning, and decide on a plan (What they want to do/are going to do). The resulting acronym “GROW” is meant as a general coaching framework for helping someone get to an “inspirational” or “stretch” goal over a substantial period of time.6 The R2C2 model7 describes 4 phases for assessment discussions with medical learners: (1) develop Rapport and relationship, (2) explore the trainee’s Reactions to the feedback, (3) assist in understanding Content of feedback, and (4) Coach to identify performance or knowledge gaps, then set goals and plans.7 The authors of the R2C2 model note a key limitation is the time required to conduct an R2C2 session, which may limit its use in some circumstances in busy clinical settings.7Adding coaching sessions into a clinical teacher’s schedule may seem daunting. Coachable moments can be identified and efficiently acted on, however, during clinical encounters. We have drawn from key literature about orientation,8 learning environments,9 coaching,4–7 and closed-loop communication10 to create a 4-step model for coaching in the moment called the Clinical COACH. The key actions for each step of this model (contact, optimize, act, check-in) make up the mnemonic COACH. Table 1 describes each of the 4 steps of this model, along with potential sentences and questions appropriate for teachers to use. Figure 1 provides a quick overview of the Clinical COACH model.Orienting learners to a clinical environment assists in the creation of good clinical learning environments.8 During orientation, the teacher works with the learner to create a shared understanding of their coaching relationship. This conversation includes sharing and exploring the learner’s goals and the roles each will have as coach and learner.The teacher explores and implements ways to optimize his or her ability to coach, by being in the right places at the right times to identify moments when coaching can be helpful. Examples include having an extra stool in the examination room to facilitate in-room observation, extra paper or a white board readily available to provide visual aids, or extra examination equipment available for demonstration and practice. The learner should be empowered to ask the teacher to observe activities around which they desire coaching. The teacher should also seek out feedback from patients, families, and others in the health care environment, to identify potential areas for coaching.The teacher coaches his or her learner in the moment around a recently observed action or behavior. The key roles of the coach in this phase are to see if the learner is (1) aware of the performance issue, (2) has an appropriate goal for performance improvement, and (3) has a good plan to reach that goal. The teacher may help the learner gain awareness by encouraging self-reflection. Some examples could include asking, “I noticed you struggled during the difficult conversation. How did you feel your encounter with the parent went?” Once the learner has reflected and gained awareness of the performance issue, teachers can help the learner identify a goal. For example, “How skilled do you think you should be in holding goals of care conversations?” Once the performance goal has been identified, the teacher will coach the learner to create a plan to achieve it. “Have you thought of ways to develop the skills needed for you to hold goals of care conversations?”Teachers check in at the end of each in-the-moment coaching session to ensure the learner has understood the feedback and continues to be receptive to further coaching. Ideally, a coaching relationship will be longitudinal, and teachers should check in intermittently to ensure the relationship is going well. The teacher can invite suggestions from the learner on how to improve the relationship by asking, “How can we make our coaching relationship better?” Additionally, teachers in the check-in phase can reflect on their own role in the relationship. Questions such as “How am I doing?,” “What can I change for future learners?,” and “Do I need to alter the physical layout of the clinical space?” can guide self-reflection.Effective coaching has the potential to enable learners to increase their clinical skills and lifelong learning strategies. When done well, coaching can help learners to reflect, gain insight, address and solve problems, and take responsibility for their own learning, which are skills that are not necessarily nurtured in traditional feedback models. With competency-based medical education emerging as an important model for physician training, clinical teachers will need to equip themselves with tools to foster learner-driven education. The Clinical COACH model can help great clinical teachers to succeed in accomplishing this.

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