Moving Us Closer To Osler
A Miller Coulson Academy of Clinical Excellence Initiative

The Role of Visual Thinking Strategies Coaching in Clinical Excellence

"Chrysantheme und Biene." Hokusai, K. (ca. 1832). Public domain, Wikimedia.


Take an appreciative approach when giving feedback to learners. It will not only build clinical skills, but will also foster a healthy community of learning and practice.

Role modeling and coaching are the two main methods I use to teach medical students and residents how to be clinically excellent at the bedside. Observing a learner and giving feedback on a specific clinical skill she is mastering is an integral part of coaching. I’ve taken many faculty development courses that have included or even focused on how to give feedback; programs like the Harvard Macy Institute Program for Educators in Health Professions and the Johns Hopkins Longitudinal Program in Teaching Skills I & II Teaching Skills—both fantastic programs from which I learned a lot about how to teach.


But for me to really learn a teaching skill and get it to stick with me, it has to tie into a passion. And, as much as I love teaching learning, what I’m most passionate about is art, and particularly the use of visual art in medical education.


In learning how to facilitate open-ended discussions of works of art with medical learners, I’ve taken a couple of Visual Thinking Strategies (VTS) practicum programs, as well as course called VTS@Work, and I am now certified as a VTS facilitator. The next step along that training program is to become certified as a VTS coach of beginning VTS facilitators.


What does all this have to do with clinical excellence? Well, it’s from the VTS coaching workshop— which tied into my love of teaching and the passion I have for art—that it all finally clicked for me. From that workshop, I not only learned a method of coaching someone who is learning the skill of facilitating a VTS discussion, but I learned a method of coaching medical learners in clinical examination skills and of coaching patients in health behaviors. In fact, the VTS coaching workshop changed the way I teach (and practice) in a way that no course—however absolutely fabulous they are—did.


I want to share this coaching method with you because—if you’re clinically excellent—you’re most likely doing some teaching and a lot of patient care. I’ve now used this method with medical students, residents, colleagues, and patients at Hopkins around all sorts of skills and practices. I’ll give you an overview of the coaching method by way of a couple of examples of how I’ve used it with a group of learners and with individual patients.


Part of my job is attending on the psychiatric inpatient service at Johns Hopkins Bayview Medical Center, where I provide clinical supervision and teaching for teams comprised of two first year psychiatry residents and, often, a couple of medical students. One of the foundational skills that new interns and medical students need to master early on is performing a comprehensive psychiatric examination, which includes a detailed history and a systematic mental status examination.


So, in April and June 2020, this is what I did. I told my groups of learners I was going to provide daily coaching for at least one of them in a group setting on morning bedside rounds. Before we entered a patient’s room, I asked that day’s designated learner (or ‘coachee’) what skill she is working on. For example, did she want to focus on making sure she remembered to ask all the questions in the mental status examination or making the standardized examination more conversational or another examination skill? So that’s the first step of this coaching method—asking for focus questions before you begin: What are you working on?


And then we entered the patient’s room, where the learner performed the mental status examination. After finishing our bedside rounding on that patient, the formal coaching session began with the question posed to the ‘coachee’, What did you learn from that and/or how did you feel about that? Next, I asked each team member, “What did you appreciate about her examination?” so that everyone—including myself—could share their observations about what she did well. I then asked everyone, including the ‘coachee’, “What were your surprises? and some people shared reflections like “I was surprised how comfortable the patient was in answering that question about his sex drive.” And then I asked of everyone, “Are there any questions for her?” which gave team members to ask a question like “Why didn’t you ask the patient about suicide?”  If no one asked any questions or I wanted to build on a question, I always had a more detailed question at hand like, “I noticed that you didn’t ask about suicide. While it may feel unnatural at first, we’re trained to perform the mental status examination in a particular order. What may be the benefit of asking the MSE of every patient in a particular order? And the coaching session always ended with the ‘coachee’ having the last word, as I ask them, “What do you want to work on?” or “What are your takeaways?


So that’s an example of how I used the group coaching method I learned in the Visual Thinking Strategies workshop with medical learners. The coaching didn’t take up a lot of time and I didn’t do it with every learner every day of course, but each learner received coaching at least once a week.


One of the medical students on a team said:

“[This] coaching method empowered me to actively observe each member of the team in order to share my appreciation and feedback. [It] laid the framework for creating a safe, supportive environment where each team member played an important role in every other team member’s education.”


Another medical student commented:

“The coaching method made me feel valued as a learner. On other rotations, I often am not sure what I am doing well and what I could be doing better until later on in the clerkship. Getting daily feedback allowed me to adapt and grow on a frequent basis, which was incredibly valuable. It also made me feel much more integrated into the team and patient care.”


All three psychiatry residents found the coaching experience useful. One reflected:

“The thing I most appreciated about the way we completed feedback was that it allowed us to give feedback detached from personal judgments of someone’s performance. I sometimes find feedback challenging in that I am commenting on someone’s performance, which is inherently personal. This method allowed for similar feedback content, but with the focus switched more to the clinical situation (rather than the learner), the feedback was easier to give and receive.”


Another said:

“I really loved the non-confrontational approach to feedback that didn’t go into the duality of ‘what you did well’ vs. ‘what you need to work on.’ By focusing on simply stating what we saw, what surprised us, and what questions we had, it allowed both the feedback giver and receiver to collaboratively work together on addressing the encounter constructively.”


And another noted:

“Surprises help us focus on the less-expected responses – doors to open further as we learn more about the patient, and potentially illuminate new aspects important for formulation. Questions allow us to consider new hypotheses for the patient, to examine learners’ understanding, and to absorb from the more experienced members of a team. Finally, things we notice provide an opportunity to appreciate and discuss particular elements of the exchange as a whole – chosen language, but also style, body language, nuance, and nimbleness of interaction.”


I also learned a one-on-one version of the coaching method, which I’ve used with learners and with patients. I’m a psychiatrist, but it can be used by other practitioners as well. For instance, if you have a patient who has diabetes, you could ask him at the beginning of a visit, “What are you working on?” with regard to his diabetes care, which will become the focus of coaching. If he says he’s been trying to take his insulin three times a day, you could ask him “How do you feel that’s been going?” You can then say some things you appreciate about how he’s been managing his diabetes, followed by, “Were you surprised by anything?” and/or “Do you have any questions for me?” He may say, for instance, that he was surprised how hard it was to take the insulin three times a day or he may ask if you have any suggestions for how he can remember to take it as prescribed, after which you could say:


Specific Observation: “I noticed that it’s been really challenging to remember to take your fast-acting insulin three times a day, like it is for a lot of patients.”


Clarify Method: “While it may be really hard at first to take a medication three times a day, as you know that kind of insulin really does need to be taken three times a day to keep your blood sugar under control.”


Possible Questions: “I wonder what tools you may have to remind you to take that insulin? “


This kind of coaching will motivate the patient to come up on his own with a personalized way to remind himself to take his insulin, like by setting an alarm on his smartphone. At the end of the coaching session, you can then ask him specifically, “What do you want to work on for next time?” and “How are you going to do that?”


I’ve found that coaching is critical. As part of lifelong learning, it’s something we all need and it’s something we can provide (and model) for our learners so we can all be better clinicians. Coaching is also a technique we can use to build health-promoting skills in our patients.






This piece expresses the views solely of the author. It does not represent the views of any organization, including Johns Hopkins Medicine.