BTG: RESPONSE TO A LETTER TO THE EDITOR

A Discussion of Recency, Relevance, and Perspective

Dr. Gabrielle Fundaro, CISSN, CHC

Shannon Beer, LLB, MNU-Certified Nutritionist

Dan Feldman, MS, RDN

We emphasize the important roles of conscientiousness and collaboration in the attitude of Comprehensive Coaching © in order to promote careful, thoughtful, cooperative efforts with clients as well as other professionals in the field. Thus, we welcome constructive feedback and citiques from other practitioners who share our purpose of improving client care and the industry standards for coaching. Additionally, we value and apply empathy and understanding in our professional interactions regardless of the presence of opposing viewpoints. Recently, we received a letter that encouraged us to revisit our statements about the paradigm shift occurring in the medical field, specifically. This article serves to express our considerations and responses in order to establish a shared understanding and continued dialogue. You will see the original letter (unedited and presented in its written order) in italics, with our responses below each section. Additionally, we have provided the references included in the letter to the editor in a separate section as originally written, though we have also referenced those sources with in-text citations and footnotes to support our response.

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“The third article in the “Bridging the Gap” series starts off by identifying how the traditional model of coaching mirrors that of the traditional model of healthcare. This is followed by the idea that coaches are still operating under a paternalistic model, where the coach is the expert and tells the client what to do, leading to a one-sided relationship. As the third paragraph in the article briefly acknowledges a paradigm shift in healthcare towards a more client-centered, holistic practice before returning back to coaching examples, the article gives off the impression that paradigm shift towards a client-centered approach is a recent phenomenon. While this shift may be novel in the coaching world, the nature of the doctor-patient relationship evolving towards a patient-centered approach has been at the forefront of discussion for decades.”

We are certainly in agreement with the author of the letter regarding the importance and emergent nature of this evolution; it is one that has been a topic of discussion in the medical, allied health, and coaching fields for some time. Coaching approaches and client experiences vary greatly, and accrediting bodies continue to provide educational opportunities to learn about client-centered approaches. Research regarding client experiences and client-centered care in the medical field remains ongoing, as presented by the author and us in later sections.

Our article stated, “Fortunately, a paradigm shift is taking place across a variety of industries, from clinical healthcare practice to online coaching. The rise of health coaching and the establishment of accrediting bodies in fitness, health and wellness have shifted the traditional model toward a more client-centered, holistic practice.[1]” We realize that the timeline here may be open to interpretation, but the specific timing or recency was not intentionally implied. It seems that we are also in agreement that this has been, and still is, an invaluable topic of discussion.

“In 1956, Drs. Szasz and Hollender initially proposed three models of the doctor-physician relationship: activity-passivity, guidance-co-operation, and mutual participation. The mutual participation model requires that “the participants [doctor and patient] have equal power, be mutually interdependent, and engage in activity that will be in some ways satisfying to both.” This model was also endorsed by Michael Balint in 1964, a psychoanalyst who focused the majority of his work on building the doctor-patient relationship. It is through his work that the term “patient-centered medicine” was coined, which appeared in medical textbooks as early as 1972. “

We appreciate the additional insight into these pioneering practitioners. Upon reviewing the information in the reference provided by the author of the letter, we noted that the Balint training and credentialing became available as of 1993, which could be considered recent relative to the Institute of Medicine’s introduction of the definition of primary care practice in 1961 [2], [3]. It could also be considered very recent against the timeline of the history of medicine, dating back to 2600 B.C..[4] Additionally, in a 2017 article provided by the author of the letter, present-tense is used when stating, “As the popularity of patient- and family-centered health care increases, it is expected that patients will become more engaged and satisfied with the delivery of their care, and evidence of its clinical efficacy should continue to mount[5].” The author of the letter to the editor provided a link to the Family Practice Management Topic Collection: Patient Centered Care, which is an incredible resource, and also apparently somewhat recent with the earliest publication dated 1999[6]. Their references also included a 2007 article describing the evolution of the doctor-patient relationship which stated that the, “...asymmetrical or imbalanced interaction between doctor and patient...has been challenged during the last 20 years,” which does seem to imply a fairly recent and perhaps ongoing change[7].

We also wish to note that Dr. Szasz and Hollander’s Mutual Participation Model does make pioneering and beneficial contributions by stating the importance of identifying with the sick patient[8]. However, the principles outlined in our articles go much further and include some aspects lacking in their model, such as taking a non-judgemental approach, understanding the “why” and “how” of the formation of behaviors, and distinguishing “adherence” from “compliance.” Szacs and Hollander also state that “the model of mutual participation...is essentially foreign to medicine”. While Enid Balint did discuss the implications of training doctors in patient-centered care, the extent to which it’s actually being utilized by general practitioners is still unclear (and will be addressed in a later section).

Based on the recency of information provided by the author of the letter to the editor as well as present-tense voice used in all references utilized, it seems that this paradigm shift is ongoing and likely iterative. We feel that, timelines and recency aside, we are in agreement with the author of the letter to the editor that the idea of client-centered care is neither an entirely novel construct nor one that has reached its nadir.

“Since then, there are numerous articles defining patient centered care, discussing how to improve communication. Patient-centered communication is at the forefront of most, if not all, medical curriculum. This is also especially ingrained in primary care, and there are articles providing firm examples of how exactly to go about doing this, which are similar to the examples provided in the author’s social media post entitled “Providing Information in a client-centered paradigm.””

Current evidence illustrates a potential disconnect between the recommendations and education regarding client-centered care versus the practice. It is important to consider this shift not just from the perspective of educators and practitioners, but patients and clients[9]. A 2015 systematic review illustrated that, in addition to positive experiences such as relational communication skills, physician technical expertise, and a personally-tailored approach to care, clients also reported negative experiences such as disrespect, discrimination, time constraints, and exclusion of psychosocial aspects of care as well as helplessness. Compared to physician characteristics, however, patient characteristics may explain more of the variance in patient experience surveys in some settings, and large-scale data on patient experiences is difficult to aggregate. This further confounds any conclusion about the translation of education and discussion into practice[10]. Results from the Commonwealth Fund 2003 National Survey of Physicians and Quality of Care (published in 2006) reported that only 36% of the surveyed physicians received feedback from their patients regarding their experiences[11]. Their findings led the author to conclude that their results, “...point to a gap between knowledge and practice, between what physicians say they want to achieve (patient-centered practice attitudes) and what they are able to do (patient-centered practice adoption).” We are pleased to know that our recommendations are aligned with best-practices in the medical field and recognize the clear overlap with evidence-based recommendations in coaching.

“While this article makes strides to improve the coaching industry, using the medical field as a brief example without further mention of the history surrounding the doctor-patient relationship as a phenomenon that has evolved over the past few decades is short-sighted at best.”

We appreciate the recognition of our attempts to improve the dialogue and provide some guidance and structure to operationalize a client-centered approach. It is troubling to hear that our perspectives appear short-sighted, but we validate each reader’s evaluation of our content as the sum of their unique experiences, expertise and insights. We sincerely regret any affront to the medical community or the innumerable practitioners that embody this patient-centered care paradigm. It is never our intent to shame or ostracize, nor do we present our framework as a completely novel concept. Rather, we hope to unite and ally practitioners, coaches, patients, and clients through this amalgamation of best practices from complementary fields in order to bridge the gaps between them in continued collaboration. New practitioners benefit from continued discussion, novel applications specific to each field, and the experiences of other practitioners. We hope that this discourse highlights the importance of the discussion and operationalization of these best practices.

Reference List

[1] BRIDGING THE GAP PART III: A COACHING REVOLUTION – Vitamin (Ph)D: Evidence-Based Nutrition. (n.d.). Retrieved July 30, 2020, from https://vitaminphdnutrition.com/2020/05/29/bridging-the-gap-part-iii-a-coaching-revolution/

[2] Institute of Medicine (US) Committee on the Future of Primary Care; Donaldson MS, Yordy KD, Lohr KN, et al., editors. Primary Care: America's Health in a New Era. Washington (DC): National Academies Press (US); 1996. 2, Defining Primary Care. Available from: https://www.ncbi.nlm.nih.gov/books/NBK232631/

[3] The American Balint Society. https://www.americanbalintsociety.org/content.aspx?page_id=22&club_id=445043&module_id=261713. Accessed July 30, 2020

[4] Hajar R. (2015). History of medicine timeline. Heart views : the official journal of the Gulf Heart Association, 16(1), 43–45. https://doi.org/10.4103/1995-705x.153008

[5] NEJM Catalyst. What Is Patient Centered Care? https://catalyst.nejm.org/doi/full/10.1056/CAT.17.0559?fbclid=IwAR0pGnS_N3DId8OD4WybTQ2jhRIb_GJpjZVd_Q5hBTQV4UqPo4izGGdRhhQ . Accessed July 30, 2020.

[6] Family Practice Management Topic Collection: Patient Centered Care. https://www.aafp.org/fpm/topicModules/viewTopicModule.htm?topicModuleId=36 . Accessed July 30, 2020.

[7] Kaba R, Sooriakumaran P. The evolution of the doctor-patient relationship. Int J Surg. 2007;5(1):57-65. doi:10.1016/j.ijsu.2006.01.005

[8] Szasz TS, Hollender MH. A Contribution to the Philosophy of medicine: The Basic Models of the Doctor-Patient Relationship. AMA Arch Intern Med. 1956;97(5):585-592. doi:10.1001/archinte.1956.00250230079008

[9] Rocque R, Leanza Y (2015) A Systematic Review of Patients’ Experiences in Communicating with Primary Care Physicians: Intercultural Encounters and a Balance between Vulnerability and Integrity. PLOS ONE 10(10): e0139577. https://doi.org/10.1371/journal.pone.0139577

[10] Fenton, J.J., Jerant, A., Kravitz, R.L. et al. Reliability of Physician-Level Measures of Patient Experience in Primary Care. J GEN INTERN MED 32, 1323–1329 (2017). https://doi.org/10.1007/s11606-017-4175-y

[11] Audet AM, Davis K, Schoenbaum SC. Adoption of patient-centered care practices by physicians: results from a national survey. Arch Intern Med. 2006;166(7):754-759. doi:10.1001/archinte.166.7.754