The real secret to better health

Most of us can see a doctor. But what if what we really need is a coach?

Two years ago, just shy of my fortieth birthday, my body started doing strange things. One morning I woke up with a rash on my face in the shape of a butterfly, its body on the bridge of my nose, its wings spread symmetrically across both of my cheeks. I was tired and, inexplicably, my joints were sore.

I waited. And then I did what doctors are loath to do: I visited a doctor. 

Tests showed I had no acute infection, but my immune system was revved up anyway, acting of its own accord. My doctor told me it was possible, even likely, that this would happen to me on occasion. He said there was medicine I could take. He also said that to prevent future flare ups I needed to eat better, sleep better, and exercise regularly—and while I was at it, try to manage my stress.

I had always taken good health for granted. To push through the strenuous 24 hour-long hospital shifts of medical training, doctors are given the mantra, “eat when you can, sleep when you can.” So, for most of my career, I measured my fitness in terms of my ability to handle minimal sustenance and sleep, while maintaining high performance. Who had time for exercise? I had places to be, patients to treat, and papers to write. 

Deep down I knew, of course, I would be well-served by taking better care of myself. It’s just common sense. But the obviousness doesn’t lessen the difficulty.  And wise though he was, my doctor had fulfilled his obligation to me with his stern admonition to change my lifestyle. To break decades of bad habits, I would need a different kind of help.

What’s in a coach?

No matter the circumstance, going from unhealthy to healthy requires radical reorganization of schedules and routines. Everything from grocery lists to bedtimes become subject to modification. While doctors are trained to provide prescriptions, they are seldom prepared to support behavior change at this level. Enter, the coach.

The term “coach” originates from nineteenth century slang. It was how students at Oxford referred to the private tutors who would carry them (as if in a horse-drawn carriage) across their exam period. The reference started in jest but it contained a foundational insight—to truly improve, they needed practical help beyond the classroom. 

Decades later the term was widely adopted for sports. Today there are coaches for just about everything: athletic coaches, career coaches, relationship coaches, even life coaches. From Ted Lasso to Brene Brown, coaches are inescapable. Yet most people don’t have one.

This may be because the utility of coaching is so obvious that it is at once taken for granted and misunderstood. My mentor Dr. Atul Gawande once reflected that the concept of a coach is “slippery.” He points out, “Coaches are not teachers, but they teach. They’re not your boss—in professional tennis, golf, and skating, the athlete hires and fires the coach—but they can be bossy. Mainly, they observe, they judge, and they guide.” It also turns out that to be a great coach you don’t even need deep expertise of the subject matter. 

Bonnie Stoll, a professional racquetball player with minimal experience as a swimmer, is a case in point. From August 31 to September 2, 2013 she coached Diana Nyad, age 64, to complete an astonishing 110 mile swim across the hazardous Florida Straits. Nyad was already a uniquely motivated person. But Stoll’s history-making talent was drawing out Nyad’s motivation even further. For every stroke of her 53-hour swim from Havana to Key West, Nyad breathed to her left—keeping Stoll, her coach, in direct sightline.

Learning from the best–and drawing from science

The last time I had my own coach was also poolside, on my high school swim team. In the years that followed, swimming continued to be my preferred method of exercise, but I struggled with the motivation to go to the pool on a dark Boston morning and hop into cold water. Once I was in, there was always an excuse to hop out early. 

Armed with a mandate to get healthy, but no clear steps, my wife nudged me to join a swim team again. And so, a solid 25 years after high school, I found Coach Bill.

Bill Paine lives a few blocks away from me. He’s been coaching my local recreational adult swim team for well over two decades, showing up six days a week and rarely missing a practice. When I asked him why he does it, he shrugged.

“I like the camaraderie. And it’s always possible to improve,” he told me.

That’s it. If Coach Bill was going to show up, I needed to show up too. With his encouragement, I set a stretch goal to complete my first open water swim this summer (only two miles versus Nyad’s feat of 110). To my surprise, burning more calories each morning meant eating differently. Eating differently meant sleeping better. Sleeping better meant less stress. Bill was right—there’s always room to do better. But without a coach in my life I would, unquestionably, be doing worse.

The psychology of coaching rests on two competing approaches: Positive Psychology, which refers to active and empathic questioning; and Cognitive Behavioral Therapy, which refers to goal-setting and outcomes. The tension between these approaches lies in the push and pull between intrinsic motivation (Nyad’s need to prove she could accomplish what experts previously deemed impossible), and extrinsic motivation (a jolting health event and the nudge from my wife to get back in the pool). Both forms of motivation are important, but the ideal balance appears highly specific to the relationship between a person and their coach–and the goal, and the context. This complexity makes the science of coaching necessarily imprecise. Maybe that’s ok.

Here’s what we know: neurologically, the brain’s frontal pole cortex (FPC) determines much of individual goal-achievement. The presence of a coach, specifically a coach trained to break up big goals into smaller goals, has been linked to structural changes in the FPC. While drugs can make certain parts of the brain temporarily light up, they rarely by themselve change the structure of our brains. Somewhat uniquely, coaching appears to make us more neurologically persistent and resilient. 

In high performance professions, from business to surgery, coaching has been shown to improve technical skills, and soft skills; reduce burnout and foster personal development. Yet crucially, coaching is also highly effective for more routine acts of daily living, including those that promote personal health. While we often associate coaching with supernatural victories, it might be best poised to help with tasks that seem quotidian—but are actually herculean.

Coaching for those trying, and trying again 

Medicine centers on advice-giving. But medical advice is rarely tailored to an individual patient’s personal goals or capacity for change. Several studies suggest that health coaching has the potential to fill that crucial gap in care between the doctor’s office, and the contemplative drive home. 

Health coaching has been shown to help optimize blood sugar control for people with diabetes; to reduce hospital admissions in those with chronic lung disease; and, in a randomized control trial of people with multiple, poorly controlled chronic conditions, to improve medication adherence—in person and virtually.

The potential to help with even the most fundamental of needs led our team at Maven to extend coaching to a previously untested domain: people who are trying to conceive. While few might think to ask for it, we found that 85% of families opt in when it is offered. 

Imagine: if you’re a person trying to have a baby and you visit your primary doctor, among the panoply of other advice, they will very likely add in the exact same things I was told: to eat well, sleep well, exercise, and manage your stress. And then, as you walk to the door, they’ll tell you to check back in after a year. If you still aren’t pregnant then, we can refer you to a fertility doctor, they’ll say.

That’s the set up for those who even get a preconception visit. Nearly 90% of couples will just try without medical counsel, and many will struggle. Maven’s Care Coaches impart knowledge for getting pregnant, but most critically, they support people to form healthy habits that optimize their chances, and motivate them to stick with those habits when the going gets tough. Some work with their coach to adjust their nutrition; others to track their ovulation with precision. So far, among our Fertility members struggling to conceive (many of whom might otherwise have gone directly to IVF) 30% conceive naturally.

I believe coaching can solve a persisting conundrum—that medicine prioritizes intensive treatment over affirming guidance, even though only some people need the former, and all benefit from the latter. I also believe that digital health companies have an important role to play in making coaches more accessible, in discovering new use cases, and in measuring our progress. 

All in, today there are only 71,000 professional coaches worldwide for a population of 8.1 billion. Only a small percentage of them are trained for health care. So I’d love to know—what could you use a coach for?

What my team is reading, thinking, and building against:

• Two weeks ago, on April 11, the world lost the ultimate coach: Penny Simkin. She founded the modern doula movement, proliferating coaches for birthing people across the globe, and daring to reimagine the care that they deserve. I was honored to contribute to her obituary in the New York Times here. 

• Shameless plug: the details of my open water swim on July 13 are here, two miles (assuming I swim straight) in the choppy Atlantic. The cause is protecting and preserving a section of the Ocean State that means a lot to me: the Narragansett Bay. I've told everyone I know that I'm doing this so I've got to do it now! Any support is deeply appreciated.

• To understand what it would take to swim to Cuba in your sixties, and what it would be like to love someone determined to do so, highly recommend this profile of Diana Nyad in The New Yorker. Or the corresponding biopic Nyad that came out last year, earning best actress and best supporting actress nominations for Annette Bening and Jodie Foster at the Oscars.  (Countless physicians told Nyad that her swim was not physiologically possible, especially at her age—Nyad’s response was to inform them that the human spirit was not physiologically measurable).

• Atul Gawande’s meditation on coaching is a reminder that no individual is above improvement, and great performance comes from support. Plus, you’ll learn quite a bit about classical music. 

• For anyone who followed college basketball this season, the South Carolina Gamecocks claimed their third national title, and their coach Dawn Staley was celebrated as one of the most successful coaches of all time. She is the first Black coach in Division I history to lead a team to an undefeated season, and a beacon of light in a notoriously discriminatory industry. Staley’s superpower appears to be an intuitive understanding of the delicate balance between intrinsic and extrinsic motivation. She drives her players for rigid performance, while listening to discern their individual skills and aspirations. She told the Players Tribune, “This isn’t just about the four years they spend with me…This is about their whole lives.”