Can Physician Self-care Enhance Patient-centered Healthcare? Qualitative Findings from a Physician Wellbeing Coaching Program

Abstract

Introduction: While physicians promote the health and well-being of their patients, they often carry a burden of responsibility that is detrimental to their own health and well-being. Physician burnout and compromised patient care are well-known results. Yet, few interventions focused on physician well-being have been reported.

Objective: This article reports on findings from qualitative interviews with participants of a pilot Physician Well-being Coaching program at Duke University. It draws from perspectives of participants and coaches to explore how Physician Well-being Coaching this coaching approach may influence physician self-care and by extension, affect patient care.

Methods: Twenty-five physicians in four medical departments completed between three and eight individual coaching sessions. Eleven physicians and three coaches participated in a qualitative interview focused on three main areas: life context, impacts of coaching and coaching process. We conducted qualitative content analysis of interviews to elicit patterns and themes within these three interview areas.

Results: This study suggests that physician well-being coaching can help raise participant self-awareness, increase the value placed on self-care and allow for new perspectives and approaches for increasing well-being. Physicians reported that coaching positively influenced the way they related to their patients and brought about greater compassion and empathy.

Discussion: Medical institutions have long promoted a culture of selfsacrifice and self-denial that has undermined physician wellness. Interventions that recognize the value of self-care are needed along with more robust mentorship structures, integrated and accessible stress-management programs and accelerated efforts to reduce the stigma for seeking help.

Keywords: Physician health and well-being; Health coaching; Health care; Burnout; Self-care; Resilience

Introduction

Physicians hold important positions as leaders in the healthcare arena. Yet, while promoting the health and well-being of their patients, they often carry a burden of responsibility that is detrimental to their own health and well-being. Despite the stress, fatigue and distress that often accompanies such heavy demands and pressures, physicians tend to make little space for their own self-care. Physician burnout and compromised patient care are well-known results.

A Physician Well-being Coaching Program was implemented within Duke University to support physicians in building self-care, coping, and stress management skills. We conducted qualitative interviews with a sample of Physician well-being Coaching participants and their coaches to evaluate the perceived impacts of the program. This article draws from perspectives of participants and coaches to explore how this coaching approach may influence physician self-care and subsequently, affect patient care.

While work demands may prevent physicians from investing in adequate self-care, they may also be learning behaviors, beginning in medical school, that discourage setting boundaries and allocating time towards their own health and well-being. The stresses of medical training and practice may also create indifference to the physician’s own inner life and undermine their empathy for others. Medical culture implicitly reinforces the idea that professional development and patient care can happen in the absence of personal well-being. Yet, research suggests something quite different: many physicians are increasingly isolated, have difficulty responding to their own needs, and suffer from psychological distress [1, 2].

The increasing rate of physician burnout is considered a public health crisis. Physicians experience high rates of depression and alcoholism on account of burnout and many view suicide as a major occupational hazard for this population [2-5]. In some estimates, suicide rates for physicians are six times higher than in the general population [6]. Such serious distress inevitably affects quality of care and patient safety [7, 8].

Despite the alarm bells sounding for physician burnout, few research studies evaluate intervention programs that prevent burnout and promote well-being [6, 9-11]. For example, in a review of the literature on stress management in medical education, Shapiro et al. [12] found over 600 studies that addressed stress in medical education, but only 24 of the studies reported on some form of intervention. The range of interventions described in the literature – including mindfulness-based stress reduction programs, narrative medicine, appreciative inquiry based dialogues, and counseling– have not been implemented with any regularity nor have they been sufficiently evaluated in relation to physician burnout [1, 2].

Qualitative research suggests that physicians share a common set of strategies that help them cope with stress. A study by the Association of Professors of Medicine [9] describes five wellness strategies that physicians most commonly rely on: protecting time for relationships; nurturing religious/spiritual beliefs and practices; finding meaning in work; cultivating self-care practices including seeking professional help as needed; and incorporating a positive outlook, values and balance. Shanafelt et al. [13] found that physicianresident participants in their study most often rated their family and colleague relationships as “significant” or “essential” for managing stress. Similarly, Wallace et al. [6] and Jensen et al. [14] found that physicians who have supportive relationships are more successful in achieving wellness. Studies have consistently found that investing in self-care, nurturing personal values and maintaining personal and professional relationships provide a basis for resiliency [1].

In recognition of this evidence, a pilot Physician Well-being Coaching program was implemented within the Duke Department of Family Medicine in 2012. Coaching is generally described as a method used to help individuals “improve, develop [and] learn new skills, find personal success, achieve aims and manage life change and personal challenges such as work-related stress and achieving work/ life balance” [15, 16]. Health and well-being coaching can target a variety of outcomes which can include chronic disease management, physical activity, tobacco use, distress management and burnout [17, 18].

Physician-directed coaching interventions typically aim to improve work skills such as leadership training, self-directed learning for residents and executive coaching for practice management, communication and patient care [16, 19 – 22]. Few physician coaching programs, however, directly address physician self-care and wellness and little is known about the efficacy of such programs.

Methods

The intervention

A Physician Well-being Coaching pilot was developed in collaboration with the Gold Foundation in the Spring of 2012. Funds were provided by the Gold Foundation to elaborate and field test a coaching program with the aim of “increasing humanism in medicine.” The program was offered in four medical departments at Duke University (Family Medicine, Psychiatry, Peiatrics and Opthamology).

The Physician Well-being Coaching pilot was adapted from Duke Integrative Medicine’s Integrative Health Coaching (IHC) model [23]. The IHC model supports individuals in identifying and implementing health behavior changes that are connected to intrinsic values and a vision for optimal health and well-being. Health is defined broadly within this model, encompassing many areas of life that contribute to overall well-being. Coaching focuses attention on seven domains of self-care: nutrition; movement, exercise and rest; personal and professional development; physical environment; relationships and communication; spirituality and mind-body connection, as well as prevention and professional intervention. Clients assess themselves along each of these domains and develop a personalized health plan which orients their coaching sessions.

The Physician Well-being Coaching model follows Duke’s IHC approach, while bringing focused attention to stress-management, coping and resilience strategies. It emphasizes the importance of a coaching partnership that is co-created by coach and client. As the Duke IHC Professional Training manual describes, “The coaching partnership develops out of genuine curiosity, a willingness to learn, a profound respect for every individual and trust in both the client and the change process. The coach and client act as a team working towards a common goal: the client’s optimal health and well-being, one focus and one action step at a time” [24].

The coaching relationship is based on a partnership of equals with shared responsibilities. While the coach holds expertise in guiding the behavior change process, clients are recognized as the experts in the content of their lives as well as their values, behaviors and goals. This focus on partnership differs from traditional therapy, counseling and education approaches in that there is no expert-based hierarchy. Instead, there is a “deep respect for the autonomy of the client and an understanding that the health goals and action steps will be chosen by the client according to their needs and values” [24].

The Physician Well-being Coaching model draws heavily on Motivational Interviewing (MI), an approach that emphasizes the collaborative partnership between the practitioner and client [25]. MI takes an active interest in understanding the perspective of clients, recognizing their absolute worth as human beings and their right to make independent choices. Within this respectful and collaborative relationship, coaches guide individuals through a process of articulating a vision for optimal health and well-being, identifying values that undergird their vision, assessing their current state of health and well-being, exploring readiness to change and setting goals and action steps. Coaches draw on skills such as other-focused listening, reflections, inquiry and acknowledgement to guide the process of self-discovery and awareness as their clients consider their options (and ambivalence) for seeking health-enhancing changes.

Participants

Three coaches, all female, participated in the Physician Well-being Coaching Program. All of the coaches were medical faculty trained in Integrative Health Coaching. They were selected from the Spring 2012 coaching cohort trained by Duke Integrative Medicine. They included two primary care physicians and one clinical psychologist who had worked with resident and faculty physicians within an academic medical center for almost 30 years.

Physician participants were identified through talks on physician burnout and resilience given to several departments in Duke University. Twenty-eight physicians in the departments of Family Medicine, Psychiatry, Pediatrics and Ophthalmology expressed interest in participating in the coaching project. Between October 2012 and May 2013, 25 physicians (12 residents and 13 attending physicians) completed between three and eight individual coaching sessions.

The majority of the sessions (78%) took place in an office setting and the remainder (22%) took place over the phone. The focus of the sessions was determined by the physician being coached. Approximately half of the coaching sessions focused on work-life balance. Other focus areas for coaching included stress management, self-care, navigating work politics and professional goals clarification.

Data collection

In June 2013, all physician participants were contacted by their coach with information about the qualitative study, which was approved by the Duke University Institutional Review Board (IRB). Eleven physicians agreed to participate in the study and completed an individual telephone interview conducted by a research team member unaffiliated with the Physician Well-being Coaching Program. The physicians who did not participate in the study noted that time was their principal barrier.

The study participants who completed the interviews included five residents and six attending physicians. The five residents were affiliated with the Department of Family Medicine and the six attending physicians were affiliated with Family Medicine (3), Opthamology, (2) and Psychiatry (1). One attending physician was a residency director; three were core faculty for a residency and two were clinician faculty. Participants ranged in age from 36 to 59 years old; six were men and five were women.

The interviews were based on a semi-structured interview guide developed by the research team and approved by the IRB. This guide was designed to query the physician coaching participants on three main areas, 1) Life context: professional and personal experiences that contribute to stress or burnout, 2) Impacts of coaching: focus areas, insights and changes achieved through coaching; and 3) Coaching process: relationship with the coach, elements of the coaching process that were helpful and aspects that were not helpful. The interviews lasted from 12 to 48 minutes with an average length of 26 minutes.

The three coaches in the pilot were interviewed using a separate semi-structured interview guide approved by the IRB. These interviews were conducted face-to-face by a different research team member who was not affiliated with the Physician Well-being Coaching Program. The interview guide was designed to capture coach perspectives on the three areas listed above: physician life context, impacts of coaching, and coaching process. The three coach interviews lasted an average of 53 minutes.

Data analysis

All physician and coach interviews were tape-recorded, transcribed and de-identified. Two members of the research team assigned a series of provisional codes to the transcribed interviews. Interview data were entered and coding was refined using Atlas. Ti (qualitative data analysis and research software). Output reports were generated for participant and coach data. These reports were read and re-read to identify important themes.

Content analysis continued in several steps. We populated data charts with blocks of text (quotations and summaries) organized by theme, maintaining separate charts for participant and coach interviews. These charts were reviewed for patterns and trends across cases. The patterns were the basis for further classification into higherlevel charts. Finally, we compared participant and coach data charts to elicit shared or divergent understandings of the effects of coaching.

Study Results

Space to get unstuck

The physicians in our study represented a wide professional development spectrum from first year-residents to physicians in latter career stages with leadership roles. Regardless of specialty or career stage, they all described their careers as deeply meaningful, particularly in relation to patient care. They enjoyed working with “bright and interesting people” and appreciated intellectual challenges associated with working in academic medicine. Yet, given their high level of responsibility and demanding schedules, participants most often reported experiencing stress related to time pressure, “unachievable” work demands, competing academic requirements that distract from patient care (feeling “pulled in multiple directions”) and difficulty achieving work-life balance. Because of time pressures, these physicians reported little leisure time and few outlets for stress relief and self-care.

The coaches in this study described their physician-clients as feeling “burdened and stuck.” They suggested that coaching sessions helped to provide physicians with insight on their “condition” and to help them get unstuck.

I think the coaching process really lends itself to identifying barriers that keep people stuck. So once you understand what the barriers are, you can then problem solve and you are more likely to move past the barrier than if you just feel stuck but you don’t know why.

In almost every single person I coached, there was a shift towards being more in this moment, like ‘I can take a moment and explore what choices I have.’ The coaching process developed that new habit, of being curious again, about their own lives, instead of just feeling burdened and stuck.

From the perspective of physician-participants, feeling “burdened and stuck” resulted from what they perceived to be unrealistic expectations and feeling pulled in too many directions. As we have reported elsewhere [26], many participants focused on boundary setting and prioritization as part of their health coaching process and as a form of self-care. Examining priorities required space – space to be heard, space to explore their options and space to make changes. When asked about the most helpful elements of the coaching process, physicians most commonly mentioned simply carving out time for them to reflect and being heard and acknowledged by their coaches. As one physician noted, “I think just even having this session… every few weeks, and just knowing there was a time that I was going to stop everything and focus inward.” Other participants shared why this time was so important to them:

It’s a luxury to be able to have that time, just blocked away, to talk about where you are, thoughts and ideas and aspirations. Because you’ve talked it through with a coach, you know that those places in your mind exist and you can explore them as you move forward.

I was generally scheduled for coaching right after I’d had a really busy morning, so I would sit down and feel what it was like to be tired, to be frazzled and it helped me just to be more observant of that.

Because of ever-present time pressures that many physicians experienced, the opportunity to “check in” and “observe” oneself was sometimes described as a “luxury.” Participants often used the concept of “space” in their interviews to describe various positive attributes of coaching – from the environment of safety (“safe space”) that was cultivated by the coach to the “pause” from busyness that coaching enabled. Coaching was viewed as a space to “bring whatever I wanted to bring,” to “think creatively,” and to “have someone to bounce ideas off of.” One physician used the word space to describe what she left with after a coaching session – “a kind of capaciousness, a sense of space that I hadn’t always come in with and that was helpful.” Participants referred to the “breathing room” they received via coaching in regards to the space that was opened up to consider their own needs. As participants reported, the coaching relationship – and the trust they felt with their coach– enabled these spaces to be cultivated.

Space for self-care

Participants indicated that their coaches’ collaborative, nonjudgmental approach created a safe space through which selfexploration was possible. They trusted their coaches in part because their professional backgrounds were similar and their experiences gave them credibility. As one respondent explained, “[My coach] was somebody that I quickly respected…knowing that she was wellqualified, had a lot of life experiences and was very approachable. I think that was the thing that [was] most important.’

The majority of participants knew of their coach or had developed a relationship with their coach prior to receiving coaching. This was perceived as a positive element of the coaching experience:

She was my sounding board in some respects before coaching… and so I suppose that by the end of it our relationship was improved or enhanced by the fact that we’d gone through coaching, so I used her as more of a resource than I did previously.

While most of the participants described a trusting relationship with their coaches, many resident-physicians referred to their coaches as “mentors,” suggesting a gap that their partnership filled. However, it wasn’t only the coaches’ credentials or the perception of mentorship that enabled a nurturing space. Many participants were surprised by how powerful it was to be listened to, understood and validated. As one physician explained, “It was just very lovely to be listened to and have someone acknowledge that you’re a whole person and that there are all these different parts of your life that are meaningful and that interplay together.” Participants mentioned various instances in which their coaches effectively helped them reframe their thinking, offered new perspectives, challenged them and held them accountable. One physician noted how effective it was that her coach simply “let more silence into the conversation.”

Within this trusting and reflective space, the coaching process helped physicians acknowledge the importance of their own selfcare, which they suggested was rarely something they had previously thought about.

As one coach described: One thing the coaching helped to clarify is that without good personal care their work actually suffered. For many of them it really was the first time in years or the first time ever in their adult life someone gave them permission and support for self-care.

Similarly, in their exploration of physician resilience, Epstein and Krasner [1] found that “physicians needed – but found it difficult – to give themselves permission to engage in activities that would improve their self-awareness and self-care, despite recognizing that these qualities enhanced their own resilience and their capacity to provide the kind of patient care they and their patients value” (p. 303). For many physicians in our study, the coaching partnership opened up space for them to examine what they needed to gain a healthier worklife balance. It offered them “permission” to set boundaries and to make health-promoting changes. As one coach explained, “I’d say what they’re really learning was how to be supportive of themselves and to believe in themselves, you know. to be a friend to themselves, to shift from feeling victimized.”One participant noted:

It’s definitely just a way for us to click the pause button and maybe rewind or redo our habits and our routines, see where we can make small changes that make us happier or change the path and do something completely different. So no matter what the long term outcome is, it’s a process that’s invaluable for people in stressful vocations.

While physicians consistently agreed that the coaching process helped them move towards greater balance, their biggest challenge was making space for their sessions. One coach described how none of her coaching clients finished all of the sessions. She explained that “this is a symptom of the time pressures. There was something about the face to face that they really wanted but couldn’t figure out how to make it happen consistently.”

While busy schedules are partly to blame, the interviews suggest that “guilt” was another barrier. For some, coaching felt too much like a “luxury” or “indulgence.” As one physician remarked, focusing on himself was difficult because “it is still time you’re taking away from the other work that you need to do.” In other words, the very process that was intended to help physicians decrease their stress, sometimes felt like yet another stressor.

Trickle down effects

When participants were able to overcome barriers of time and guilt, they consistently reported that the coaching program helped to make them better doctors. This was, in part, because it helped them recognize the value of deep listening. As one physician explained:

(You get) a real sense of how powerful it is to have someone pay attention and listen to you. I think that that’s helped me as a clinician, too. You know, when I’m with a patient, to recognize that by being there and listening to them, it’s like doing something for them therapeutically.

Another reason participants mentioned that coaching helped them as clinicians was that they simply were able to reframe and reorganize their work lives in a way that helped quell some anxiety. For example, one participant described how coaching gave her the opportunity to “take the weight off my mind during my residency period, which as a secondary effect has allowed me to become a better doctor, to be more personal, more open and more humanistic with my patients.”

Additionally, the coaches described how physicians’ own struggles with behavior change through the coaching process helped them see their patients’ struggles in a different light. This enhanced their compassion and their patience, as noted by one of the coaches. I think the self-awareness, you know for them realizing how many barriers there are – you know they want to exercise, they want to sleep better, but how hard it is to do that themselves – and I think it provides a more patient response to a patient who is trying to do that.

Physicians did not only gain perspective on the difficulties that their patients might be experiencing in seeking health. They were also reminded of the therapeutic nature of clinical skills like empathy, deep listening and reflecting back what their patients are saying, that may have diminished over time in their practice. For many participants, coaching awakened these skills and reminded them of how they intended to be with their patients when they entered the profession of medicine. From one coach’s perspective, these physicians could be more empathetic with their patients when they too were grappling with the challenges of making self-care a priority. As she notes:

If physicians understand how to better take care of themselves, when they are counseling patients on behavior change, they’re coming from a more genuine place of understanding that fosters compassion because they know how hard it is.

Discussion

Participant interviews indicated that the coaching partnership cultivated a safe space for reflection. This helped physicians to “pause” long enough to think “creatively” about what they needed to bring better balance to their lives and work. This study suggests that physician well-being coaching can help raise self-awareness, increase the value placed on self-care, and allow for new perspectives, options and approaches for increasing well-being. It can remind physicians of what it is like to be listened to, how it is to struggle with behavior change and how they want to be as doctors. As a result, these experiences can have an impact on their clinical approach and may serve as building blocks to more compassionate and humanistic health care.

One coach summarized the trickle-down effect of physicians’ increased self-awareness in this way:

I think the important concept is that when people learn to take care of themselves they have more energy to offer someone else. I think if they have thought about all areas of their lives…then they’re realizing, well when I work with a patient, it’s not just a patient with lung disease, it’s a patient with all of these same dimensions of their life that I have. So I think it just broadens their own focus of how they see wellness.

Yet, the culture of medicine has long undermined physician wellness. As Shapiro et al. [12] suggest, “one unintended and unfortunate side effect of medical training is that it produces physicians who believe that self-denial is valuable and necessary and that living under stress is normal” (p. 757). Furthermore, while physician education rewards individual achievement, self-reliance, independent judgment and self-sacrifice, the culture of medicine deters physicians from seeking help [6].

The Physician Well-being Coaching model calls these long standing values into question. It emphasizes the concept of “maximizing wellness,” opens space for exploring new options and opportunities for optimizing health and offers physicians a partnership in support of their self-identified goals and actions. It supports the well-being of the whole individual rather than separating their personal and professional life or privileging the professional over the personal. This coaching model rein forces the words we hear over the airplane speaker as we prepare for takeoff: adults are to put their oxygen masks on first before placing masks on their children. It refutes the idea widely accepted in our culture, that self-care is selfish. Instead this coaching model posits that self-care can be selfless when viewed within the larger context of our influence over the well-being of others.

For the selfish to selfless reframe to take root, physicians need to be supported by a culture that recognizes the value of wellness and they need to see others modeling this behavior. They also need support and mentorship in reaching for goals that bring about greater health and balance while pursuing their professional goals. Institutionally supported programs that offer protected time for coaching is one small step towards this end. More robust mentorship structures, integrated and accessible stress-management programs and accelerated efforts to reduce the stigma for seeking help all seem critical for supporting physician well-being.

Conclusions

The founder of the Institute for Mindful Leadership, Janice Marturano [27], noticed that while leaders effectively perform and meet their quarterly goals, most “do not feel they are living their best lives – at work or at home” (p. 9). When she explored what these leaders felt was missing, the response was surprising. Leaders said they need – and do not have - “space.” As she explains “we often simply do not have the space, the breathing room, necessary to be clear and focused and to listen deeply to ourselves and to others” (p. 10).

Our pilot study suggests that coaching offers this space to physicians; it reminds them to pause, listen and then proceed. It also appears to influence the value that physicians place on self-care as well as the way they approach patient care. Opening up new avenues of compassion and empathy, coaching can help physicians acknowledge their patients as whole individuals rather than parts and pathologies. The strengths-based approach on which coaching is based may have much to offer medicine. Its focus on wellness is a timely antidote to our costly disease-based model that has given us little opportunity for hope in a healtheir future.

Health and well-being coaching interventions for patients are increasingly integrated into clinics and hospitals throughout the U.S. They offer patients a valuable bridge between self-care and healthcare. Despite marked increases in demands and pressures on physicians, similar interventions are rarely offered to them. Making such interventions more accessible for physicians requires working upstream, but the benefits of better supporting health providers can pay dividends for generations to come. Cultivating a culture of selfcare and compassion in medicine seems to be a vital place to start.

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