In this issue of the Journal of Graduate Medical Education, Lockyer et al describe a new spin to the previously published R2C2 (Relationship–Reaction–Content–Coaching) model for giving feedback that will be of keen interest to educators.1 The authors build on their established R2C2 model, which has shown success in assisting educational leaders, such as program directors, to frame feedback conversations with learners. In their new work, they have interviewed supervisors who have used the existing model and describe their method of incorporating that information into the modification of the tool. Now, this version of the R2C2 framework is easier to apply in the context of in-the-moment feedback.
The inclusion of coaching in the framework ensures that conversations are rooted in positive psychology and goal orientation. With this new model described in the article, the R2C2 tool is now relevant for any supervisor or preceptor, as it does not necessarily require a long-term relationship or longitudinal exposure to the resident, or to a suite of assessment data. The new R2C2 creates the possibility to apply the technique in exciting novel ways, such as with faculty who may only interact with the resident once or twice. This model also appears to be easy to teach to clinical faculty who may not be core educators.
The work that Lockyer et al have done to extend the application of R2C2 will play an important role in making coaching techniques, in a coaching framework, available to more supervisors and more learners. Much of the recent literature on coaching in medical education focuses on larger-scale coaching programs, yet anyone can use coaching techniques in their conversations with trainees. Based on the authors' work in this article, it may not be necessary to be a certified, or even self-identified, “Coach” to be able to coach for change.
This extended R2C2 model allows the supervisor-learner dyad to use a shared experience as the springboard for the feedback conversation and debrief, which surely must add credibility to the interaction from the perspective of the resident. This benefit is underemphasized in the article. Discussing a shared experience also paves the way for supervisors to share their own experiences—and this vulnerability can enhance the relationship building as well.
With this new model, the authors continue to underscore the foundation of relationship building to the coaching or larger feedback relationship. When used in the context of in-the-moment feedback, this building must be very explicit and intentional. The examples given by the authors, from their supervisors' quotes, are illustrative and show that even in this seasoned group, it may feel like a stretch to create a relationship de novo. Yet we know the “educational alliance” is key to the feedback dynamic.2 I appreciate the article's emphasis on using the interaction to reassure the resident that the supervisor is acting in the learner's best interest; this is also emphasized in the provided trifold outline. While a relationship may not form instantaneously, the interaction can be the first step in a longer-term relationship, or at least a “micro-relationship” for the purposes of the feedback interaction.
While I am optimistic that anyone can successfully use coaching techniques “in the moment” with this framework, I think that a future addition to the toolkit could be a more explicit description of how coaching is different from other forms of support, such as teaching, mentoring, or advising.3 In my experience, preceptors who are new to coaching tend to default into these more traditional roles and neglect to spend most of the conversation asking, rather than telling. Calling attention to this temptation could improve supervisor self-awareness and likelihood of actually using appreciative inquiry techniques to explore Reactions and Content in these 2 key middle steps of the R2C2 process.
The work by Lockyer et al can inform future studies in several ways beyond those that the authors suggest. I agree that the learner's perspective and experience are critical to understand. We will also want to better understand the objectives and desired outcomes of the coaching conversation and develop processes to measure whether the R2C2 conversations are helping to reach those goals. Some potentially fertile areas for research could be tracking if learner goals are met more quickly when composed using the R2C2 conversations or whether being coached using R2C2 improves lifelong or self-regulated learning traits. Coaching in medical education is relatively new to the literature4 and more work on its impact would be welcomed by the community.
In addition to providing a new use for the R2C2 framework, the article also role models how educators can use a structured approach to modify existing educational tools and instruments for their own unique purposes or environments. The semistructured interview process can be an accessible way to generate feedback data. While the team's expertise was deep and their qualitative methods were strong, many educators could replicate parts of this process in order to fit instruments to their own needs without extensive qualitative research training.
Lockyer et al's new spin on the R2C2 model shows promise to expand the reach of coaching and feedback to more learners by offering a straightforward framework that faculty can use, regardless of how long they have worked with the trainee. I look forward to its uptake and dissemination.