Dec 09, 2020
This is a no-brainer. Why wouldn’t surgeons have a coach?
When I talk with friends outside of healthcare about what the Academy for Surgical Coaching does, this quote summarizes their unanimous reaction. They don’t need a randomized controlled trial to know that parachutes save lives when jumping out of an airplane. The Academy connects surgeons with trained Surgical Coaches to improve intraoperative performance — a concept with strong face validity.
When I talk with colleagues in surgery about surgical coaching, the responses are a bit more skeptical. “Show me the evidence that it works” is a common reaction. Another is, “Surgeons might not buy into this.” I’ve also had surgeons tell me, “I already get better every day” or “I already coach students and residents every day.” At times, the resistance is palpable for introducing coaching to the field of surgery.
In this brief report, I’ll review the rationale for coaching in surgery and summarize new evidence to support its implementation. We’ll cover the training of surgeons to become coaches, the implementation of surgical coaching programs, and the results of coaching programs for surgeons’ continuing professional development.
Why do surgeons need surgical coaching anyway?
Like professional athletes, musicians, business executives, and others who routinely work with a coach, surgeons are highly trained professionals who perform specialized skills. What separates surgeons from other professionals are the higher stakes of the job — patients’ lives and well-being — and the fact that surgeons have to perform on a near daily basis with few opportunities for ongoing practice and feedback.
Achieving meaningful performance improvement is a major challenge for surgeons in practice. Although surgical trainees are immersed in an environment that supports the continual development of surgical knowledge and skills, this environment largely disappears once surgeons enter professional practice. With medical knowledge and technology advancing at a blistering pace, how can any surgeon be expected to keep up on their own for 30 years of professional practice after formal training?
Surgical coaching has emerged as an effective process for surgeons’ continuing professional development. In a surgical coaching partnership, a surgeon undergoes structured one-on-one reflections with a trained Surgical Coach to focus on individualized performance improvement efforts with longitudinal follow-up. Coaching embraces adult learning principles and is distinguished by a non-hierarchical relationship between the surgeon and the coach, which are especially welcomed features for surgeons in practice.
Stated simply, there are two major reasons why we need surgical coaching. The first is to avoid plateauing throughout long surgical careers. The second is to incorporate new procedures and technology safely into practice. From years of training to perform complex tasks during surgery, we develop routines to simplify our cognitive load — this is a normal human behavioral tendency. But continual improvement is difficult once these routines are established. Even the most famous surgeons risk plateauing once they hit a sweet spot midway in their careers. Surgical coaching provides valuable external perspective to enable us to maximize performance potential in a respectful manner for highly skilled professionals like surgeons.
Beyond merely keeping existing skills sharp, surgical coaching can improve the way we adopt new surgical techniques and technology. The field is always advancing, and surgeons need a better way to incorporate surgical innovations safely into practice. Previously, we surveyed 150 surgeons at 2 academic medical centers on their preferred methods for learning new skills in practice. Surgeons reported an interesting disconnect between the most effective methods for acquiring new skills and the methods they commonly chose to use. Specifically, while scrubbing into an expert’s case or doing self-study were most often used, few surgeons believed these to be the most effective way for them to adopt a new procedure or technology. This is a critical gap that surgical coaching can fill.
So, it makes intuitive sense that surgical coaching can help practicing surgeons perform better. But I know you still want to see the evidence. Fortunately, several recently published studies lend scientific credibility to the process by which the Academy for Surgical Coaching does coaching with surgeons.
How do you train surgeons to be Surgical Coaches?
A series of recent papers from the Harvard / Ariadne Labs Surgical Coaching for Operative Performance Enhancement (SCOPE) program fill in major evidence gaps for how to conduct surgical coaching effectively. These three articles report lessons from a formal surgical coaching program involving 46 practicing surgeons from multiple specialties within four Harvard-affiliated hospitals.
The first study, published in Annals of Surgery in July 2020, investigated how surgeons train to become a Surgical Coach and how they apply newly learned coaching techniques in real life. For all participants — including both the coaches and the surgeons receiving coaching — the Ariadne Labs team conducted 3-hour, in-person Surgical Coaching Workshops led by surgeons, a behavioral scientist, and an expert professional coach. The training curriculum published alongside this study was based on the Wisconsin Surgical Coaching Framework.
Coach training enables surgeons to adopt the mindset, core principles, and key skills of coaching (Figure 1), which contrasts with many of our experiences in traditional surgical training. Fundamentally, this training progresses from:
- how to approach surgical coaching (the coaching mindset), to
- how to be a surgical coach (the core principles), to
- what to do as a surgical coach (the key skills).
In the Harvard program, 90% of the participants who responded rated the training “good” or “excellent.” (This was in the context of an 82% response rate.)
The core principles that Surgical Coaches must enact are goal setting, guided inquiry, constructive feedback, and action planning. When we studied audio recordings of surgeons and Surgical Coaches in real coaching sessions, we saw that coach training works. In a historical cohort of surgeons who did not receive dedicated coach training, surgeons demonstrated only two of the four core coaching techniques. With dedicated coach training, the current cohort exhibited all four core coaching principles. For surgeons looking for real-life examples of coaching techniques that Surgical Coaches have used with peer surgeons, check out Tables 2-4.
Participants received a Coach Playbook, and weekly email reminders kept coaching tips readily available for the new coaches. Although the core principles of coaching could clash with traditional surgical culture, this study showed that many surgeons are open to using non-hierarchical coaching techniques with surgeon colleagues. At the Academy for Surgical Coaching, we engage new coaches with this approach during our Surgical Coach Training courses.
How do you run a surgical coaching program? Ask the surgeons who experienced it.
Although the enthusiasm is high for surgical coaching, the existing literature offers little guidance for how a surgical coaching program should be run. The second paper from the Harvard SCOPE program, published in JAMA Surgery in October 2020, was an implementation study designed to address this evidence gap. Earlier, I mentioned cultural pushback about coaching for surgeons. Given those concerns, it was necessary to consider the nuances of surgical culture when instituting a surgical coaching program.
Specifically for this study, we sought to identify implementation recommendations from the surgeons and coaches who actually participated in the SCOPE program. Who better to know how to improve the program than the participants themselves?
We interviewed 23 of the 46 participants and analyzed their interview transcripts for common themes. We also asked participants to rate their coaching sessions using the Net Promoter Score, a 1-question rating used in business to measure customer experience and predict company growth. To interpret the surgeons’ implementation recommendations in the appropriate context, we compared interview responses from surgeons who gave high ratings (“Promoters”) with those who gave low ratings (“Detractors”) of their coaching sessions.
Interestingly, both coaches and surgeons receiving coaching generally agreed on key implementation factors for surgical coaching programs. These factors included how to optimize coach-surgeon relationships, how to facilitate productive coaching sessions, and how to do so in a way that respects surgeons’ culture of autonomy. What differed among participants was the ratings they gave their coaching sessions.
Promoters (those who gave high ratings) tended to experience the program aligned with how they would recommend the program be run. Detractors, on the other hand, had the same recommendations but personally did not experience the program as such. The biggest implementation takeaways are summarized in Figure 2.
From interviewing surgeons who participated in a peer surgical coaching program, we learned that the first coaching session is critical. Although coach-surgeon pairs can improve at coaching over time, stellar first sessions really set the tone for a positive experience in subsequent coaching sessions.
Surgeons emphasized how important it was for the coach-surgeon match to be a great fit. The first priority was establishing trust and mutual respect. Transparency about each other’s goals in the program were important to hash out before diving into coaching sessions. And in the early stages of surgical coaching, surgeons reported a better experience when the coach and surgeon were from similar clinical specialties.
Institutional leaders have an important role in optimizing surgical coaching for their surgeon colleagues by creating an environment that encourages coaching. This includes normalizing coaching activities among OR staff to negate the false perception that only “bad” surgeons need coaching.
With these surgeon-informed experiential recommendations, the Academy for Surgical Coaching incorporates evidence-based best practices for implementing surgical coaching programs. Health care institutions and organizations benefit from the Academy team’s extensive experience running formalized coaching programs. This way, surgeons can receive the most effective intraoperative coaching experience available without reinventing the wheel.
New evidence that coaching works for surgeons
Despite the growing popularity of surgical coaching, many still want to see evidence of downstream benefits for practicing surgeons. The third paper from the Harvard SCOPE program studied just that. To do so, we aimed to measure surgeons’ technical and non-technical skills. We also asked participants how they believed that surgical coaching affected their practice and well-being.
For the quantitative analysis of surgeons’ intraoperative skills, surgeons submitted self-assessments, and the coach submitted their own assessment of the surgeon’s technical and non-technical skills. Technical skills were assessed with a modified version of Objective Structured Assessment of Technical Skills (OSATS), and for non-technical skills the Non-Technical Skills for Surgeons (NOTSS) framework was used.
In this study we were unable to detect quantitative changes in surgeons’ technical or non-technical skill ratings over three coaching sessions. However, the ratings were subject to bias from the social and unblinded nature of the coaching relationships. This was evident from the average skill ratings that clustered at the maxima of the scales. The skills analysis was also underpowered and limited by missing data. A more objective measurement strategy — such as by using blinded video review — may have allowed us to detect quantitative improvements in surgeons’ skills.
To supplement the quantitative findings, we interviewed surgeons about their perceptions of how coaching affected their performance. Surgeons reported positive changes to their teamwork and communication skills, situation and self-awareness, and well-being. One surgeon reflected on how their relationship with the OR team improved, saying “I think my mindset has changed because it’s very obvious when someone’s watching that they’re paying attention to everything I’m saying.”
The coaches also felt like they improved their skills, even though the program was focused on surgeons receiving coaching. One coach said, “So I think in my mind a little bit before I speak, what’s the better way of using words like, ‘What did you think? … or, What went through your mind when you saw this?’ as opposed to ‘Why did you make something bleed?’”
Participants also recognized the potential for coaching to improve burnout due to reduced stress in the OR and improved camaraderie. Importantly, they also said if coaching were implemented poorly (such as if it were mandated), it could worsen burnout by adding to chronic work overload.
These findings show important benefits for surgeons who participate willingly in surgical coaching. While research studies have yet to quantify improvements in surgical skill or patient outcomes, early surgical coaching programs have captured surgeons’ perception that coaching can change their practice for the better. The Academy for Surgical Coaching exists to deliver these benefits directly to surgeons.
How you can get involved in surgical coaching
- If you want to personally engage with surgical coaching, you can contact us to get a Surgical Coach or to be trained as a Surgical Coach.
- If you want to start a surgical coaching program within your organization, you can leverage our experience and expertise to get your program off the ground!
- If you want to stay in touch, add yourself to our email list for periodic updates on the Academy’s major moves and upcoming events.
If you are not quite ready to engage with the Academy directly, we encourage you to keep surgical coaching on your radar by following us on social media:
Contact us to learn more! We look forward to working with you.
Jason C. Pradarelli, MD, MS
Medical Director | Academy for Surgical Coaching
Formerly a Safe Surgery Fellow | Ariadne Labs