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In Tibet we say that many illnesses can be cured by the one medicine of love and compassion. These qualities are the ultimate source of human happiness, and need for them lies at the very core of our being. Unfortunately, love and compassion have been omitted from too many spheres of social interaction for too long. Usually confined to family and home, their practice in public life is considered impractical, even naive. This is tragic. In my view point, the practice of compassion is not just a symptom of unrealistic idealism but the most effective way to pursue the best interest of others as well as our own. (HH 14th Dalai Lama)

The Backstory

I (Sara Miller) have coached physicians since 2003. About half of my clients are surgeons or anesthesiologist between the ages of 40 and 65 years old, who are labeled as having disruptive behavior. Typical referrals come from chief medical officers, human resources, or in-house medical peer review boards.

About 25% of the clients I coach are recent MDs or students who are in their third or fourth year of residency. This is the stage in their medical training where many are starting to experience firsthand the harsh realities of working in medicine. This can be a time of great disillusionment for some. For example, a fourth-year resident sought out coaching after a negative patient outcome. His mentor insisted he must emotionally detach from his patients and any negative outcomes. Even though he was at the end of many long years of medical training, he was seriously considering leaving the profession.

The last group of clients I see are those who were skilled clinicians promoted to medical director positions. Accustomed to soaring in the clinical arena, they are now faced with leadership challenges and oftentimes feel incompetent and discouraged. Physicians who are disruptive, discouraged, disillusioned, disengaged, disappointed, and despaired all have one thing in common—they are dispirited. For many physicians, they went into medicine because it felt like a calling. Sadly, for some, their calling has become more like a dreadful duty.

I met Geshe Dorjee, in 2010, when I attended my first dharma lesson at a sanghas in Fayetteville, Arkansas. Geshe comes from Tibet and is trained to the highest level with a lineage of impressive teachers. He is known as an accomplished professor on campus, a compassionate and wise advisor to new faculty, and a beloved teacher by his sanghas. Over time, we shared several conversations about the suffering in health care. As the conversations continued, so did our desire and commitment to make a meaningful contribution to making deep, long-lasting transformation in health care. Together, we created the life and liberation coaching process which integrates the second-century Tibetan philosophy with current coaching processes. The intention of this chapter is to share with you what went into the making of the process. It is in its most early stages, yet with time and refinement, we hope to offer this as an effective coaching process and model, for authentic, long-lasting transformation.

We chose to work with physicians first since they can be key change agents within the health-care system because of their position to influence team morale. The benefits of a transformed physician to the entire institution are great. When a person is relieved of stress, their clarity and stability improve, which can affect his or her own morale. Raised morale promotes team cohesiveness and work engagement. All of this helps the bottom line of the hospital by creating a culture desirable to work in, which will then attract quality professionals and encourage retention. Lawsuits are reduced, patient satisfaction is increased, and, the ultimate goal of all, patient safety is increased. Additionally, we believe a transforming intervention aimed at physicians is especially critical now due to low physician morale and a projected physician shortage.

Physician Morale and Impending Shortage in the USA

A survey of physician morale, the first of its kind, conducted by the American College of Physician Executives (Silbaugh 2011), indicates morale is at an all-time low. The results of the survey show doctors are experiencing extreme stress that can lead to fatigue, marital and family discord, depression, and burnout. Almost 60% of the survey participants indicate they have considered leaving the practice of medicine altogether. Many physicians are unhappy with their work, and their original expectations of what work would be, are much higher that the reality of their work. Malpractice suits are expected to happen for many medical professionals. Many feel a disconnect from colleagues. They experience tensions with administrators and support staff and therefore feel as if they lack control of their work environment. Over three-quarters of the respondents said they have suffered fatigue as a result of their work, and 67% said they had experienced “emotional burnout.” Interestingly, only 26% of the respondents sought personal counseling, and 4% of physicians said they have suicidal thoughts.

The sad news is that, overall, the situation is not improving. In May 2011, Dr. Barry Silbaugh, CEO of the American College of Physician Executives (ACPE), stated, “Despite the best efforts our profession is still plagued by doctors acting in a way that is disrespectful, unprofessional and toxic to the workplace.” (Silbaugh 2011)

Projection of a physician shortage by the year 2015 is 63,000 in the USA. Workplace chronic stress is causing physicians to rethink and re-craft their careers (Frellick 2011). Because of the short supply, the health care in the future will look different than today. Currently, most expect their primary care provider (PCP) to have a medical degree (MD). In the future, PCPs may be a nurse practitioner, a physician assistant, doctors of osteopathy (DO), and graduates of medical schools outside of the USA (Sheldon 2007).

Key Design Principles Based upon Ancient Philosophy

In designing the life and liberation coaching process, the high dissatisfaction and low morale among physicians were carefully considered. The program needed to be “user friendly” while following best practices for learning. In considering the key principles of Buddhist philosophy to include, we often looked to the 14th Dalai Lama. Below are the design principles, along with the most salient teachings, many from the 14th Dalai Lama.

  1. 1.

    The purpose of the program is self-transformation, not religious recruitment.

    Buddhism is divided into three categories, Buddhist science, Buddhist philosophy and Buddhist religion. Buddhist religion is the business of Buddhists; however Buddhist philosophy and science have universal application. (The 14th Dalai Lama)

  2. 2.

    A self-transformational philosophy is a critical foundation to effecting real change. The individual himself/herself must experience authentic change which is deep and long lasting.

    On the other hand, if humankind continues to approach its problems considering only temporary expediency, future generations will have to face tremendous difficulties. (The 14th Dalai Lama)

  3. 3.

    Ancient Tibetan philosophical teachings complemented with coaching principles can be used to effect positive, long-term change.

    Integration of both philosophical and theoretical knowledge base of eastern and western traditions to explore grounds for unity … could be avenues for the emergence of a new discipline of what is called “science of human nature” or “study of well-being”. (The 14th Dalai Lama)

  4. 4.

    The teacher and coach must be qualified and competent and use skillful means.

    Buddhist practice is to coach others to what they need, not to what the client may want. Another way to say this is that the coach considers the long-term view rather than the short-term view. We will use skillful methods to help our clients transform their self-destruction and low morale. It is the roots, not the symptoms that are coached to. (Geshe Thupten Dorjee 2011)

  5. 5.

    Contemplative work, such as meditation and journaling, will be essential aspects to bringing about change.

    At the heart of these meditation practices lie two key techniques, the refinement of attention and its sustained application on the one hand, and the regulation and transformation of emotions on the other. In both of these cases, I feel, there might be great potential for collaborative research between the Buddhist contemplative tradition and neuroscience. (The 14th Dalai Lama)

  6. 6.

    Buddhist-based contemplative practices are used to refine awareness and to regulate emotions, leading to self-examination and self-correction.

    Buddhism has long argued for the tremendous potential for transformation that exists naturally in the human mind. To this end, the tradition has developed a wide range of contemplative techniques, or meditation practices, aimed specifically at two principal objectives—the cultivation of a compassionate heart and the cultivation of deep insights into the nature of reality, which are referred to as the union of compassion and wisdom. (The 14th Dalai Lama)

  7. 7.

    The coach views the client as whole and resourceful. The coach’s focus is on the client’s strengths as opposed to his or her weaknesses.

    Human potential is the same for all, your feeling, “I am of no value,” is wrong. You are deceiving yourself. We all have the power of thought—so what are you lacking? If you have will power, then you can do anything. It is usually said that you are your own master. (The 14th Dalai Lama)

  8. 8.

    We coexist interdependently with others. These philosophical teachings spread throughout the community when others observe the transformation in individuals.

    If one assumes a humble attitude, one’s own good qualities will increase. Whereas if one is proud, one will become jealous of others, one will look down on others, and due to that there will be unhappiness in society. (The 14th Dalai Lama)

Integrating Coaching with Buddhist Philosophy to Create a Coaching Process

There are many coaching programs, models, and theories these days, yet most can be distilled down to the very basics: there is a coach, a client, and the coaching relationship. The most basic of coaching stages are (1) evaluation, (2) goals, and (3) action. It is under this framework that we took and integrated ancient Tibetan philosophy.

The Coach

International Coach Federation (ICF)-credentialed coaches have passed an exam demonstrating competency in working with clients in the areas of developing trust and intimacy, active listening, asking powerful questions, developing smart goals, and action planning.

Ancient Tibetan philosophy sites four specific criteria one must have to draw the student to learning. They are (1) compassionate intention, (2) pleasing speech, (3) skillful means, and (4) congruence between the teacher’s actions and what he or she is asking of the student.

The life and liberation coaching process begins with the coach’s intention. The coach engages in the relationship with the intention of giving his or her time and efforts generously and wisely to help relieve the suffering of another human being. Integrity, ethics, and morality are also necessary coach characteristics.

Evaluation

During the evaluation phase in the coaching process, the client is learning more about him or herself. The coach uses deep curiosity to learn about the client’s strengths, learning style, patterns, habits, level of self-awareness, and true nature.

Oftentimes, a formal assessment tool is used to bring awareness to the forefront. An assessment that is popular with our physician clients is the StrengthsFinder, from the (Buckingham and Clifton 2001). This assessment identifies an individual’s five signature strengths salient in the workplace. Knowledge from this assessment encourages the client to focus on strengths, instead of trying to remediate weakness. Knowing and calling upon one’s strength are also useful during stressful times. Here is a client example; a brilliant, yet extremely shy, pediatric anesthesiologist sought coaching after being terminated for the fourth time in his career. He was perplexed by his stream of terminations, for he, a top graduate from John Hopkins, did his due diligence at work and took his work seriously. His current termination made him anxious about his pending financial depletion. He was a pillar of financial support for his family and elderly parents. One of his signature strengths was “belief”—which is basically saying, “You have certain core values which are enduring. Consistency is a theme.” His use of this strength helped him in this unsettling transition phase. Eventually, he accepted a position in one of the top ten teaching hospitals in the USA. He continues to work at that hospital, and in the past eight years, he has had two significant promotions.

In addition, making use of many valid assessments available today, the life and liberation coaching process also uses an ancient process to discern the internal and external strength of the client. There are four possible outcomes: (1) internally strong/externally strong, (2) internally strong/externally weak, (3) internally weak/externally strong, and (4) internally weak/externally weak. Here is a client example; a third-year female resident sought coaching because she felt ganged up on by several females on the nursing team. During the work day, she appeared strong on the outside. She dressed professional, gave accurate and quick diagnoses, and spoke intelligently and authoritatively. Yet after work, the moment she stepped into her home, she would begin to cry, feel depressed, and “zone out for the evening with TV and sleep medication.” This is an example of someone who was internally weak and externally strong. In this example, the coaching process might focus on developing her internal mental strength.

Goals

The process of goal setting is important in the coaching process. It helps the client clarify what they need and want to get out of coaching and directs attention on one’s behavior. In coaching, the more explicit and measurable the goals are, the more likely they are to change behavior. Also goals are based upon client’s strengths and cause the client to stretch therefore being more motivational and increasing improved behavior. The best goals are worked out between client and coach.

When incorporating a Buddhist perspective into setting goals, three realms are considered. They are the realms of mind, body, and speech. In the Buddhist mind-set, the mind and body are connected, and our mental factors directly relate to our body’s state, for example, agitation and high blood pressure. Mind is internal and goals may include contemplative practices to calm the mind, and goals for the physical improvement of the body, such as nutrition and exercise, are considered. The coach and client might also explore areas related to the realm of speech, such as the use of divisive speech or malicious gossip.

Actions

In coaching there is a popular saying, “The real coaching happens in-between sessions.” It is outside the sessions where the client must work with real-world situations and put goals into practice. Action planning is directly linked to goal setting, and by continually practicing new behaviors, they can become a new habit.

From the Buddhist philosophical perspective, actions are deeds. In the life and liberation coaching process, the client would be asked to become aware of and contemplate on how his or her thoughts are put into deeds. The framework for this practice comes from the Buddhist teachings of the six paramitas. Each of the paramitas is a virtuous quality that when perfected represents our true nature. To bring these qualities into expression requires discipline, practice, and sincere cultivation. The six paramitas are (1) generosity, (2) morality, (3) patience or tolerance, (4) enthusiasm, (5) concentration, and (6) wisdom.

In Conclusion

Health care is in crisis. Physicians are experiencing an all-time low in morale, and a physician shortage is impending. Something must be done to transform health care. We believe the combination of ancient and timeless wisdom combined with current coaching processes can bring about the changes so greatly needed.