The assessment of surgical skill is most often associated with the determination of competency, rather than performance improvement. Yet improved performance, especially for practicing surgeons, is actually a more worthwhile goal, and surgeons – like their colleagues in other fields – can benefit from coaching to improve their skills.
The role of a coach is to provide objective and constructive feedback on what he or she observes, helping the practitioner to recognize what is successful and what can be improved. Coaches do not judge or instruct; instead, they guide and facilitate. They act as collaborators and partners to assist practitioners to develop a better understanding of their own performance, and they help them to use their experience, knowledge, and abilities to provide the best care possible (Nursing Standard. 2009;23:48-55). The focus should always be on the surgeon and not what the coach would do in a similar situation.
Coaching can be valuable for surgeons at all stages of their career (J. Am. Coll. Surg. 2012;214:115-24). It is easy to imagine the role of a coach in smoothing the increasingly jarring transition from training to independent practice. But experience in other areas suggests that established practitioners can also benefit. As one develops expertise, actions become more automated and more experienced practitioners spend less time examining their approaches and actions (Fitts, P.M.; Posner, M.I.; Human Performance. Brooks/Cole Publishing Co.: Belmont, Calif., 1967; Work 2006;26:93-66). A coach can serve as a catalyst to jump-start introspection and further practice improvement.
The Importance of Adult Learning Theory
Until recently, medical education has not encompassed the proven principles by which adults learn. In 2007, Boonyasai and colleagues developed a list of adult learning principles based on the major educational theories that could be applied in medicine (JAMA 2007;298:1023-37):
• Enabling adult learners to be active participants.
• Providing content relating to the learner’s current experiences.
• Assessing learners’ needs and tailoring teaching to their past experience.
• Allowing learners to identify and pursue their own learning goals.
• Allowing learners to practice their learning.
• Supporting learners during self-directed learning.
• Providing feedback to learners.
• Facilitating learner self-reflection.
• Role-modeling behaviors.
A surgical coaching program would almost by definition include at least the first eight principles, so this list is likely to be a very effective approach for improving performance.
What Makes a Good Coach?
The best athletic coaches were not always the standout athletes. They did, however, almost always participate in the sport they coach at a very high level. This is because the characteristics of a good athletic coach to do not necessarily parallel the characteristics of a good athlete, but an intimate knowledge of the appropriate skill set is critical.
Similarly, the most experienced and skilled surgeons will not necessarily make the best coaches, but a surgical coach by definition must be a surgeon. A surgical coach must develop an easy rapport and a trusting relationship with each surgeon. The coach must be empathetic and tactful, but also flexible – able to ask probing questions and make constructive comments (Consulting Psychology Journal: Practice and Research; 2001;53:240-50). The best surgical coaches are likely to be experienced, thoughtful, inquisitive, nonjudgmental, and well respected by their colleagues.
The coach described by Atul Gawande in "Personal Best," his article on surgical coaching, embodied all of those qualities and excelled as a surgical coach (Gawande A. Personal Best. Top Athletes and Singers Have Coaches. Should You? New Yorker Oct. 3, 2011). When we questioned him about his deftness in this new role, he credited the light hand (socially) that he developed from years of intraoperative consults.
Coaches need time and flexibility in their schedule. For this reason, surgeons who are nearing retirement or who are newly retired may be good candidates to serve as coaches. Many of these surgeons are likely to have the experience and respect required for surgical coaching. The key is to ensure that they also have the flexibility, openness, and lack of judgment. Another potential pool of coaches may be surgeons who are interested in a more flexible lifestyle for personal reasons, such as childrearing or caregiving for an ill or elderly family member. Surgical coaching can provide a way to remain engaged in surgery and continue to contribute to the field without the same demands as a busy surgical practice.
Some Basic Principles
Jim Knight has developed a paradigm that he terms "partnership learning" to coach teachers (Knight, J. Instructional Coaching: A Partnership Approach to Improving Instruction. Corwin Press: Thousand Oaks, Calif., 2007). He contrasts this with the "dominator approach" upon which most traditional professional development is based – for example, the situation in which a person gives a PowerPoint presentation to convey an "expert opinion" to a roomful of people. Sound familiar?