In most areas of our lives, we are collaborating with other people. Whether it be driving a car, buying groceries, selling products, seeing patients in an office, defending a client in court, working in an assembly line, leading an organization, or teaching in a classroom, individuals are connected to other people, and they rely on their skills of communication, cooperation, negotiation, and listening to accomplish goals. At the core of these collaboration skills are foundational attitudes, beliefs, and feelings, including trust, respect, and empathy.

The word collaborate is a derivative of the Latin word collaborare meaning to labor together. Webster’s New Collegiate Dictionary defines collaboration as “to work jointly with others especially in an intellectual endeavor” and “to cooperate with an agency or instrumentality with which one is not immediately connected.” [1] On the surface, to collaborate appears relatively easy and straightforward to do. But, all too often, this verb is dismissed and replaced with more self-serving verbs including demand, threaten, persuade, and argue which often leads to disagreement, discourse, rebellion and chaos.

One of our basic human needs is connection. We are wired to connect. From birth, we bond with our mothers, and throughout life we continue to bond with others. Even ten thousand years ago, humans lived in nomadic groups as hunter-gatherers and relied on each other for survival. Collaboration has been an essential ability since the beginning of time.

Seventy years ago, Abraham Maslow highlighted our need for connection in his hierarchy of needs [2]. The third level of his original five-tiered pyramid is “love and belonging.” Maslow described the first needs as our physiologic needs, and our second needs as our safety and shelter needs. Right after that comes love and belonging or connection. After this level comes self-esteem and finally self-actualization. See Figure 1.

Figure 1: A Schematic Pyramid Representing Abraham Maslow’s Hierarchy of Needs

Thirty years after Maslow, Edward Deci, PhD and Richard Ryan, PhD emphasized the importance of connection in their Self Determination Theory, a theory of motivation. According to Deci and Ryan, humans need to feel competence, autonomy, and relatedness in order to feed their volitional motivation [3]. Relatedness is similar to connection. In the Theory of Self Determination, connection or relatedness is recognized as a one of three psychological needs for motivation and for best possible performance, creativity, and perseverance. If any one of these three needs is unfulfilled or obstructed, then it is unlikely that the person will reach their full potential or optimal level of wellness. See Figure 2.

Figure 2: A Schematic Representing the Theory of Self Determination by Edward Deci, PhD and Richard Ryan, PhD with three basic psychological needs for motivation.

Deci’s and Ryan’s theory brings up the important point of autonomy or independence, the feeling that an individual wants to do it his way and he has the right to act on his own accord. It is this autonomy that makes collaboration a challenge because if individuals do not respect the autonomy of others, collaboration is not possible. Thus, we long for connection and need cooperation for survival. Yet, at critical times, when there is stress, difficulty, or potential danger, individuals tend to abandon the essential collaboration foundational attitudes, beliefs, and feelings, including trust, respect, and empathy. When this happens, the collaboration skills of communication, cooperation, negotiation, and listening disintegrate. So, the question is how do people work towards collaboration in challenging times?

Lifestyle Medicine is a burgeoning field of medicine that focuses on decreasing the morbidity and mortality from lifestyle related diseases such as heart disease, stroke, diabetes, obesity, metabolic syndrome, and cancer through lifestyle interventions including exercise prescriptions, nutrition prescriptions, smoking cessations programs, and encouraging limiting alcohol consumption. The American College of Lifestyle Medicine was founded in 2006 and has grown tremendously over the past nine years. There is European Society of Lifestyle Medicine and many other colleges of lifestyle medicine being created in a number of different countries all over the world. Medical schools are starting to embrace lifestyle medicine. Harvard Medical School has a Lifestyle Medicine Interest Group that has been in existence since 2009, and other medical schools are developing similar programs. More and more practicing physicians are looking for training in exercise prescription, nutrition basics, motivational interviewing, behavior change, and weight management because these subjects were not stressed and often not even taught in medical schools, even ten years ago. Due to the nation’s obesity and diabetes epidemics, there is a push to include these important topics in US medical schools, not just in the form of interest groups which are optional activities but also including it in the required curriculum.

Since the seminal work of McGinnis and Foege on Actual Causes of Death in the United States, published in the Journal of the American Medical Association in 1993, we have known that approximately 40% of actual causes of death in the US are due to lifestyle, specifically physical inactivity, poor diet, smoking, and alcohol consumption [4]. Approximately ten years later another research article was published on the topic that revealed not much had changed; still roughly 40% of deaths were due to the same lifestyle behaviors, physical inactivity, poor diet, smoking, and alcohol consumption [5]. In 2002, there was a landmark study published in the New England Journal of Medicine. This research article reported on a study that compared a lifestyle intervention to a popular diabetes drug on a population of patients that were pre-diabetic. It was a randomized controlled trial, the gold standard in medicine. The results showed that after 2.8 years, the subjects that were in the lifestyle intervention had a significantly lower rate of converting from pre-diabetes to diabetes compared to the drug. The lifestyle intervention reduced the incidence by 58% and the drug reduced the incidence by 31%. The difference was statistically significant. The lifestyle intervention involved striving for the goals of at least a 7% weight loss and achieving at least 150 minutes of physical activity per week [6]. Slowly but surely, physicians and health care providers are starting to pay attention to these findings and heed the call for lifestyle medicine counseling and behavior change collaboration.

A desperate need for lifestyle medicine counseling surfaced fifteen years ago, in 2000. According to the results of the Behavioral Risk Factor Surveillance System, only 3% of adults surveyed follow all four of the healthy lifestyle behaviors that were recommended [7]. The four behaviors were and still are

• Not smoking

• Maintaining a normal body mass index

• Consuming five or more fruits and vegetable servings a day

• Regular physical activity

More recent reports indicate that these unhealthy patterns have not improved. In the US, 38% of adults reported eating fruit less than once a day and 28% of adults reported eating vegetables less than once a day [8]. In another study, fifty-two percent of all people in the US did not meet the requirements for physical activity and 76% did not meet the guidelines for strength training activities [9]. Also, it has been estimated that one out of five people in the US smokes [10]. As far as maintaining a normal body weight, in the year 2011-2012, it was reported that 35.1% of people in the US were obese [11].

There are many reasons for a lack of adherence to healthy lifestyles, and it is multi factorial. One important part of the equation lies in the physician’s office. Less than 50% of patients report being counseled on one or more of the following strategies, the benefits of regular physical activity, weight reduction, and smoking cessation, in order to reduce risk of lifestyle related diseases during their most recent visit to the physician [12,13] Why don’t physicians counsel on these healthy lifestyles? The answer is because they do not learn about them in medical school [14,15]. Thus, they are not confidant or comfortable counseling on these topics. In addition, there is evidence that physicians preach what they practice and practice what they preach. For example, if physicians do not strength train, they are not likely to counsel on strength training. However, if physicians do strength train and engage in regular aerobic activity, they are more likely to counsel on both of these activities [16]. This reminds us that physicians are also patients. They fall into the same risk factors and statistic charts along with everyone else.

Apart from increasing the knowledge base of physicians in the topics of exercise, nutrition, weight management, and smoking cessation, there is also a need to change the counseling style of physicians from a demanding and authoritarian style to a collaborating and partnership style. In other words, the physician must take off the expert hat and put on the coach hat. The physician with the expert hat knows all the answers, shares the information freely without checking in with the patient, asks primarily closed ended questions to remain in control of the interview and follow his own medical agenda. With the expert hat on, the physician listens only long enough to find out key pieces of information, looks for red flag symptoms, and takes full responsibility for the treatment plan. This is something that an expert does to someone with little interaction or connection required. The physician with the coach hat on knows that the patient sitting in front of him is creative and whole and may well have many answers to problems as that person is the expert of his own life, experiences and motivations. With the coach hat on, the physician shares information after checking in with the patient, asks primarily open ended questions to try to learn more about the patient’s needs, desires, strengths, and attitudes. He listens intently not only to the words but also to the tone of voice, facial expressions, and body language of the patient, and shares responsibility with the patient for behavior change, as the patient spends the majority of the time outside the clinician’s room. Switching from the expert hat to the coaching hat is the essence of the coach approach in behavior change and lifestyle medicine [17].

In order for more Americans to adopt healthy habits, physicians and health care providers need to start collaborating with their patients and really connecting on these topics. Patients want to keep their autonomy, as it is one of the three basic psychological needs for volitional motivation according to Deci and Ryan’s Self Determination Theory. Also, patients want to connect, another motivational need in their theory as well as a basic need in Maslow’s hierarchy of needs. The coach approach allows for both this desired connection as well as the maintenance of autonomy. Whereas the expert approach often alienates patients and strips them of their autonomy because they are being told exactly what to do and how to do it with no choices allowed. There is evidence in the literature that using the coach approach in medicine allows for improved clinical outcomes [18,19].

Given my experience in medicine, health and wellness coaching, and behavior change, I developed a tool for physicians and other health care providers to help them enjoy successful collaborations with patients. The cycle is based on the essential skills of collaboration including, communication, cooperation, negotiation, and listening as well as the foundational attitudes, beliefs, and feelings of collaboration, including trust, respect, and empathy. There are five steps in the collaboration cycle: 1) Communication, 2) Empathy, 3) Respect, 4) Mutual Goals, and 5) Mutual Trust

The first step is communication, and this starts the process of connecting, a basic human need. With open communication, the partnership can begin. This step is not labeled talking because talking only involves one person, and communication involves two people. One person is expressing words and the other person is receiving those words or listening. Both talking and listening need to occur together for communication to be successful Figure 3.

Figure 3:The Five Step Collaboration Cycle.

The second step is empathy. Empathy is the defined as the capacity for participation in another’s feelings or ideas [1]. Empathy is a necessary component of any collaboration. Two people must fully understand each other and be able to “walk in the shoes” of the other. Empathy requires listening and understanding the ideas, concerns, feelings, and thoughts of the other person. Feeling empathy and showing empathy are not the same. If someone does not express his empathy, the other person may not feel it or appreciate it. To express empathy, one can reflect back what he heard. A simple reflection goes a long way. Reflections are one of the core skills in motivational interviewing [20]. And, empathy has been shown to effect outcomes in the doctor’s office [21].

In a study, of 891 diabetic patients from different primary care physician offices, the influence of the physician’s level of empathy was compared to the patients’ biomarkers. The Jefferson Scale of Empathy was used to rate the empathy of the physicians, and the biomarkers evaluated included hemoglobin A1c (a test to check for glucose control in diabetic patients) and LDL cholesterol (the bad cholesterol that works to create atherosclerotic plaques). The results of this study showed that physicians with the highest levels of empathy had patients with lower hemoglobin A1c levels and lower LDL levels indicating they had better control of both their diabetes and their bad cholesterol, respectively [21]. This study looked at empathy alone. When combined with the other steps of the collaboration cycle empathy is even more powerful and can help propel patients into action. People want to feel understood. Once they feel acknowledged, affirmed and appreciated for who they really are and where they are in their stage of change, they are ready for powerful connections and collaborations.

The patient needs to feel the empathy of the physician. However, the patient also needs to give empathy to the physician. Knowing that most physicians are over-worked, fighting insurance companies, and filling out reams of extra paper work each day is important for patients to know and appreciate. This is why physicians are often running late and might on occasion be distracted by a beeper indicating there is an emergency in the ER or another extremely sick patient that needs to be seen right away. Physicians do not intend to run late and annoy patients. It happens as a consequence of busy schedules, multiple responsibilities at the same time, and health care system inefficiencies. When the physician feels understood and appreciated, he or she is able to connect at a deeper level without feeling the need to protect him or herself. Mutual empathy is a gateway for a transformative connection.

After empathy comes respect. This respect also needs to be mutual. Respect is defined as to consider worthy of high regard [1]. The physician must respect the patient as the expert in his own life, experiences, and motivations. The patient needs to respect the physician as an expert in the functioning of the human body and how to treat disease. Both patient and physician deserve respect. In the collaboration cycle, the patient and the physician are regarded as worthy and whole. Without respect, the collaboration quickly breaks down. In addition, in my experience without mutual respect and empathy, the level of activation by the patient and the health care provider will be dramatically less.

Mutual goals come after respect. The word mutual is inserted in this particular step, even though it is implied in the steps of empathy, respect, and trust. It is emphasized here because the physician often has many different medical goals for the patient, and she desperately wants the patient to meet those goals, especially because they are goals that will reduce health risks and increase longevity. The physician’s goals cannot be the goals that are part of the collaboration cycle unless the patient agrees to these goals. This agreement is a critical factor in behavior change counseling. In fact, there are five As of behavior change counseling: ask, advise, agree, assist, and arrange [22]. At one point, there were 4 As without the agree, but counseling strategists realized that without the agree, the model would not be effective. Mutual goals are goals that are agreed on by both the physician and the patient. When two people are working towards the same goal together, there is a greater likelihood that the goal will be met. Moreover, if the physician selects the goal, and the patient does not like that goal, then the patient is not likely to pursue it. Instead, he will find a goal on his own and satisfy his need for autonomy. Agreeing on a goal allows the patient to decide whether or not he wants to consent to that particular goal. So, he still has a choice and has autonomy to make that decision. By agreeing on a goal, the physician and patient are using their collective wisdom to co-create a compelling goal.

After mutual goals are set forth, trust enters the five step collaboration cycle. Trust is defined as assured reliance on the character, ability, strength, or truth of someone or something [1]. The physician trusts that the person will follow through and is committed to the goal. The patient has to trust that the goal is a good one for him and that the physician supplied him with good advice as well as solid guidance based on research, science, and the latest medical information. The physician and patient need to trust the relationship and partnership they have created. If things do not go well and the patient is unable to meet the goals, the patient must be able to trust that the physician will communicate openly with him, listen to him, and treat him with empathy. The physician needs to trust that the patient will do everything in his power to accomplish the goals and if he does not, then the physician needs to trust himself to react with empathy and strive to help the patient to use a growth mindset to learn from his missteps, mistakes and failures. Trust grows with time and experience. Trust, the last step in the cycle, keeps the cycle going around and around. When trust breaks down, the cycle stops.

A successful collaboration is often akin to symbiosis. Symbiosis is defined as the intimate living together of two dissimilar organisms in a mutually beneficial relationship [1]. This is not to imply that the physician and patient become intimate or literally move in together. It means that the two realize that together they can achieve more than they could individually. In other words, if the physician just prescribes a blood pressure lowering pill and tells the patient to take it everyday, that is not enough to solve the patient’s blood pressure problem, even if he selected the best and most effective blood pressure medicine for the patient. The patient must fill the prescription at the pharmacy, return home, remember to take the medication, and continue to take it. Both physician and patient need to do their part. In lifestyle medicine, this translates to a slightly different situation. If the physician tells the patient to walk for 60 minutes, six to seven days a week, to lose weight, he will have done his part. However, the patient actually has to plan for and complete these recommendations in order to see the weight come off and the goal of losing weight actualized. The physician cannot go to the patient’s house everyday, lace up the patient’s sneakers and go for a walk with the patient. Thus, with each of them fulfilling their roles, the physician guiding and the patient doing, together they accomplish the desired goal of losing weight. It is possible that the patient could just do this alone, but the physician provides the added benefit of accountability and long term follow up which is essential for behavior change to last. The benefit to the physician is the reward of a healthy patient and fewer emergencies to handle. The benefit to the patient is achieving health and wellness, which translates to less hassles, less visits to the doctor, and more time for enjoying life and fulfilling his potential. The symbiosis occurs after a few times through the cycle with rewarding experiences for both physician and patient.

In this five step collaboration cycle, the physician and patient continue to meet back at step one, communication. One cycle could take weeks or months depending on the frequency of the communication. Together, they continue to cycle through all five steps with a new interaction, a new goal, renewed trust, and underlying empathy and respect built into each interaction. This type of collaboration is inspirational and can be life changing—lifestyle changing.

Millions of people in American are dying to collaborate with someone to help them adopt healthy habits. Behavior change is complicated. It requires attention and great care. This five step collaboration cycle is one method of putting on the coach hat in order to educate, motivate, and facilitate with the goal of empowering patients to sustain a healthy lifestyle for a lifetime. This cycle can be a tool that clinicians use each time they enter a patient’s room. Start with open communication, express empathy, remind yourself of all the reasons this person is worthy of respect, co-create a plan that fits your mutual goals, trust each other and the process, do your work and follow through until you meet again and start the visit with open communication. It is a road map for creating a powerful collaboration with another person, a connection that creates new opportunities, that provides support to people, that is rewarding, that fosters growth and development, and that feeds the basic human need to connect.