SURGICAL PERSPECTIVES
Surgical Coaching for Individual Performance Improvement Caprice C. Greenberg, MD, MPH,∗ † Hala N. Ghousseini, PhD,‡ Sudha R. Pavuluri Quamme, MD, MS,∗ Heather L. Beasley, BA,∗ and Douglas A. Wiegmann, PhD∗ †; for the Wisconsin Surgical Coaching Program
T
he technical skill of individual surgeons is an important determinant of surgical outcomes, at least for bariatric surgery. In a recent study in The New England Journal of Medicine, Birkmeyer and colleagues1 provide evidence that there is wide variation in technical skill among practicing surgeons and that this variation correlates with outcome. The authors conclude that new approaches to improving individual performance are needed and one-on-one coaching has potential to fill this role. The concept of coaching for performance improvement has been recently described in a variety of health care settings, but it is not well developed and experience is limited.2,3 Surgical coaching has the potential to address limitations in our current approach to continuing medical education, which does not incorporate the critical concepts of adult learning theory. Adults learn best as active participants in learning that builds on individual needs, is tailored to past experiences, and has direct applicability to their daily activities.4 Adult learners should participate in the identification of their own goals and have the opportunity to practice what is learned through self-reflection coupled with constructive feedback. The importance of self-reflection is emphasized by K. Anders Ericsson, who advocates for deliberate practice. Ericsson examines this concept for physicians, suggesting that most clinical practice does not include the critical aspects of deliberate practice, namely, the identification of areas for improvement by reflection on performance, followed by intentional adjustments in approach and evaluation of the resultant impact.5 This deficiency leads many practitioners to plateau in a state of proficiency. In contrast, professionals in other disciplines use coaches to facilitate deliberate practice and continued performance improvement, even among the most elite experts. To further develop the concept of surgical coaching, we examined features of coaching in other disciplines through literature review and observation and interviews of prominent coaches. In what follows, we outline main themes and provide a conceptual framework to synthesize the critical elements.
WHAT IS “COACHING”? The International Coach Federation defines coaching as a cooperative process between a coach and a coachee, which includes “providing objective and constructive feedback to help a [coachee] recognize what works and what can be improved” (http: //www.coachfederation.org/). Coaching has also been defined as
From the ∗ Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin, Madison, WI; †Department of Industrial and Systems Engineering, University of Wisconsin, Madison, WI; and ‡Department of Curriculum and Instruction, University of Wisconsin School of Education, Madison, WI. Disclosure: Supported by Wisconsin Partnership Program Grant to the Wisconsin Surgical Coaching Program at the University of Wisconsin School of Medicine and Public Health. The authors declare no conflicts of interest. Reprints: Caprice C. Greenberg, MD, MPH, Surgical Outcomes Research Program, University of Wisconsin Hospitals & Clinics, 600 Highland Ave K4/728, Madison, WI 53792. E-mail: [email protected]. C 2014 by Lippincott Williams & Wilkins Copyright ISSN: 0003-4932/14/26101-0032 DOI: 10.1097/SLA.0000000000000776
32 | www.annalsofsurgery.com
“ . . . helping someone else expand and apply his/her skills, knowledge, and abilities.”6 Coaching shares many similarities with activities in traditional medical education, such as teaching and mentoring, but is distinctive in its focus on the improvement and refinement of existing skills, goal of empowering coachees to become their own agents of change,2 and applicability throughout the career trajectory.
WHAT ARE THE CHARACTERISTICS OF AN EFFECTIVE COACH? The characteristics of a successful coach are similar across disciplines. Crucial among these are interpersonal skills, including the ability to effectively communicate using a cooperative communication style that emphasizes active and engaged listening to encourage and challenge the coachee.7,8 Successful coaches are masterful communicators and unsuccessful coaches often fail not because they lack knowledge of the sport but because of poor communication skills. (Athletic coach) . . . developing your coaching voice . . . not just how it sounds, but the actual art of coaching people, it takes some time and some people just don’t have a presence . . . . (Athletic coach) In addition, coaches in other disciplines assess the individualized needs and perspectives of each coachee and adapt their approach to the individual. Coaches of teachers, for instance, are encouraged to focus their first conversation on becoming familiarized with the teacher’s strengths and style and professional goals and philosophies.9 This is also true in athletics and music: You’ve got to study and analyze each individual and find out what makes them tick . . . . (Athletic coach) . . . the ability to adapt . . . is 95% of being a good coach. Reading the situation and figuring out what each person needs. (Music coach) Another critical characteristic of effective coaches is that they are highly respected within the field. This can help build rapport and gain the respect of individual coachee. Although a coach’s broad knowledge base and understanding of the fundamentals of the discipline are crucial, a more advanced skill set, such as technical skill mastery, can help engender this respect.
WHAT ARE THE COMPONENTS TO CONSIDER WHEN DESIGNING A COACHING PROGRAM? We propose the Wisconsin Surgical Coaching Framework as a systematic approach to the development of surgical coaching interventions and to guide future work in this field (Fig. 1). The activities of coaching can be divided into 3 domains: (1) setting goals, (2) encouraging and motivating, and (3) developing and guiding.6,7 A surgical coach must be able to recognize the ability and experience of the surgeon, build rapport and trust, and work as a partner to define goals that are specific, achievable, and appropriate.6 Together, the coach and the surgeon identify strategies to advance these goals. Although there may be situations where surgical coaching would be more top-down (eg, to aid transition to independent practice), coaching for practicing surgeons should be designed as peer coaching. In this context, the coach Annals of Surgery r Volume 261, Number 1, January 2015
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Annals of Surgery r Volume 261, Number 1, January 2015
Coaching to Improve Performance
FIGURE 1. The Wisconsin Surgical Coaching Framework. There are 3 distinct but interrelated activities of coaching: (1) setting goals, (2) encouraging and motivating, and (3) developing and guiding. Each of these concepts is developed and central to our framework for surgical coaching. These activities will be influenced by both mutable and static forces. Mutable characteristics that must be optimized in the design of any coaching activity include the traits of the coach including both technical and nontechnical knowledge and his or her disposition and inherent traits. The coaching context should be designed to facilitate the desired coaching activities. Activities must also consider the traits of the surgeon to be coached and the operative context in which he or she functions. Each surgeon will bring a particular skill level, set of experiences, interpersonal skills, and disposition that will make him or her more or less receptive and amenable to the coaching activities.
serves as facilitator to encourage the surgeon to examine his or her own performance and identify areas for improvement. This may be accomplished through active listening, affirmation of positive attributes, and explicitly challenging assumptions and approaches, among other strategies. The coach must also be able to ask probing questions to promote problem solving while maintaining cooperative communication. Coaching for surgeons can target performance improvement in 3 domains: (1) technical skill, (2) cognitive skill, and (3) nontechnical skill. In surgery, we tend to consider “technical” and “nontechnical” skills as exhaustive and mutually exclusive designations, with nontechnical including both cognitive skills, such as decision making, and interpersonal skills, such as leadership.10 However, some cognitive skills, such as judgment and decision making are more related to technical skill—the so-called motor-cognitive continuum of human performance—whereas others, such as situation awareness and mental readiness, are better conceptualized as nontechnical skill. We therefore include 3 distinct but interrelated domains of performance in our framework; coaching interventions may target any or all of these. A coaching program must be designed to optimize components that are controllable, such as selection of an effective coach as discussed earlier and optimal design of the coaching context. Decisions regarding the coaching context include the use of video-review versus live intraoperative coaching, peer versus expert coaching, and the setting from which coaches and surgeons will be identified. Each has advantages and disadvantages, and the coaching context may vary C 2014 Lippincott Williams & Wilkins
on the basis of the goals of an individual program. For example, video-based coaching will be significantly more efficient and less time consuming than live coaching, allow the full attention of both the coach and the coachee to be on performance by removing concurrent clinical responsibilities, and remove complexities related to credentialing and responsibility when compared with live coaching. However, video-based coaching has its own challenges. Videotaping can still make many operating room staff uncomfortable and raise concerns about discoverability, so local culture must be considered in the design of a program. Other components of a coaching program are not mutable but must be addressed in the design of the program. For example, coachees will vary in experience, skill level, dispositions, and interpersonal skills and coaches should be trained to interact effectively across this range. It is also critical to consider the types of operations, practice setting, and characteristics of the system in which the surgeon works and ensure that the coach is familiar with each.
FUTURE DIRECTIONS The concept of coaching for performance improvement in surgery is attracting increasing attention. Driving forces include a national focus on improving quality and safety and recognition of the limitations in our current approach to continuing medical education. Adapting principles from other disciplines, we have proposed a conceptual framework that summarizes the critical issues to www.annalsofsurgery.com | 33
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Greenberg et al
consider in designing a surgical coaching program. Many questions remain to be addressed, however, including (1) which surgical skills, if any, are amenable to coaching; (2) how best to identify and train effective coaches; (3) whether video-based or live coaching is better and under which conditions; and (4) if coaching can improve surgical performance, whether it translates into improved patient outcomes. Although the idea of coaching has face validity, significant research is still needed to evaluate its effectiveness. If surgical coaching does prove effective, translation into sustainable practice may also prove challenging. For example, it is unclear where ownership of surgical coaching programs would reside and how they would be financed. There is reason to think surgical coaching will have traction, however. The American Board of Surgery has included lifelong learning and self-assessment and evaluation of performance in practice as requirements for Maintenance of Certification. We believe that surgical coaching could offer a meaningful way to meet these requirements. In addition, numerous regional and national surgical quality collaboratives exist, providing a possible venue for both research and implementation of coaching programs. Several groups, including ours, have ongoing research and development projects related to surgical coaching, and excitement for the approach within the field is evident. We hope that the Wisconsin Surgical Coaching Framework can provide a conceptual basis for future program design and advance our understanding of performance improvement for practicing surgeons.
34 | www.annalsofsurgery.com
Annals of Surgery r Volume 261, Number 1, January 2015
ACKNOWLEDGMENTS The authors are grateful to the leadership and membership of the Wisconsin Surgical Society for their continued support and collaboration on this project.
REFERENCES 1. Birkmeyer JD, Finks JF, O’Reilly A, et al. Surgical skill and complication rates after bariatric surgery. N Engl J Med. 2013;369:1434–1442. 2. Grumbach K, Bainbridge E, Bodenheimer T. Facilitating improvement in primary care: the promise of practice coaching. Issue Brief (Commonw Fund). 2012;15:1–14. 3. Hu YY, Peyre SE, Arriaga AF, et al. Postgame analysis: using videobased coaching for continuous professional development. J Am Coll Surg. 2012;214:115–124. 4. Kaufman DM. Applying educational theory in practice. BMJ. 2003;326:213– 216. 5. Ericsson KA. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med. 2004;79:S70–S81. 6. Chen CW. Coaching Training. Alexandria, VA: ASTD; 2003. 7. Anderson EM, Shannon AL. Toward a conceptualization of mentoring. J Teach Educ. 1988;39:38–42. 8. Gallimore R, Tharp R. What a coach can teach a teacher, 1975–2004: reflections and reanalysis of John Wooden’s teaching practices. Sport Psychol. 2004;18:119–137. 9. Staub F, West L, Bickel D. What is content-focused coaching? In: Contentfocused Coaching. Portsmouth, NH: Heinemann; 2006:1–17. 10. Yule S, Flin R, Paterson-Brown S, et al. Non-technical skills for surgeons in the operating room: a review of the literature. Surgery. 2006;139:140–149.
C 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Surgical Coaching for Individual Performance Improvement Caprice C. Greenberg, MD, MPH,∗ † Hala N. Ghousseini, PhD,‡ Sudha R. Pavuluri Quamme, MD, MS,∗ Heather L. Beasley, BA,∗ and Douglas A. Wiegmann, PhD∗ †; for the Wisconsin Surgical Coaching Program
T
he technical skill of individual surgeons is an important determinant of surgical outcomes, at least for bariatric surgery. In a recent study in The New England Journal of Medicine, Birkmeyer and colleagues1 provide evidence that there is wide variation in technical skill among practicing surgeons and that this variation correlates with outcome. The authors conclude that new approaches to improving individual performance are needed and one-on-one coaching has potential to fill this role. The concept of coaching for performance improvement has been recently described in a variety of health care settings, but it is not well developed and experience is limited.2,3 Surgical coaching has the potential to address limitations in our current approach to continuing medical education, which does not incorporate the critical concepts of adult learning theory. Adults learn best as active participants in learning that builds on individual needs, is tailored to past experiences, and has direct applicability to their daily activities.4 Adult learners should participate in the identification of their own goals and have the opportunity to practice what is learned through self-reflection coupled with constructive feedback. The importance of self-reflection is emphasized by K. Anders Ericsson, who advocates for deliberate practice. Ericsson examines this concept for physicians, suggesting that most clinical practice does not include the critical aspects of deliberate practice, namely, the identification of areas for improvement by reflection on performance, followed by intentional adjustments in approach and evaluation of the resultant impact.5 This deficiency leads many practitioners to plateau in a state of proficiency. In contrast, professionals in other disciplines use coaches to facilitate deliberate practice and continued performance improvement, even among the most elite experts. To further develop the concept of surgical coaching, we examined features of coaching in other disciplines through literature review and observation and interviews of prominent coaches. In what follows, we outline main themes and provide a conceptual framework to synthesize the critical elements.
WHAT IS “COACHING”? The International Coach Federation defines coaching as a cooperative process between a coach and a coachee, which includes “providing objective and constructive feedback to help a [coachee] recognize what works and what can be improved” (http: //www.coachfederation.org/). Coaching has also been defined as
From the ∗ Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin, Madison, WI; †Department of Industrial and Systems Engineering, University of Wisconsin, Madison, WI; and ‡Department of Curriculum and Instruction, University of Wisconsin School of Education, Madison, WI. Disclosure: Supported by Wisconsin Partnership Program Grant to the Wisconsin Surgical Coaching Program at the University of Wisconsin School of Medicine and Public Health. The authors declare no conflicts of interest. Reprints: Caprice C. Greenberg, MD, MPH, Surgical Outcomes Research Program, University of Wisconsin Hospitals & Clinics, 600 Highland Ave K4/728, Madison, WI 53792. E-mail: [email protected]. C 2014 by Lippincott Williams & Wilkins Copyright ISSN: 0003-4932/14/26101-0032 DOI: 10.1097/SLA.0000000000000776
32 | www.annalsofsurgery.com
“ . . . helping someone else expand and apply his/her skills, knowledge, and abilities.”6 Coaching shares many similarities with activities in traditional medical education, such as teaching and mentoring, but is distinctive in its focus on the improvement and refinement of existing skills, goal of empowering coachees to become their own agents of change,2 and applicability throughout the career trajectory.
WHAT ARE THE CHARACTERISTICS OF AN EFFECTIVE COACH? The characteristics of a successful coach are similar across disciplines. Crucial among these are interpersonal skills, including the ability to effectively communicate using a cooperative communication style that emphasizes active and engaged listening to encourage and challenge the coachee.7,8 Successful coaches are masterful communicators and unsuccessful coaches often fail not because they lack knowledge of the sport but because of poor communication skills. (Athletic coach) . . . developing your coaching voice . . . not just how it sounds, but the actual art of coaching people, it takes some time and some people just don’t have a presence . . . . (Athletic coach) In addition, coaches in other disciplines assess the individualized needs and perspectives of each coachee and adapt their approach to the individual. Coaches of teachers, for instance, are encouraged to focus their first conversation on becoming familiarized with the teacher’s strengths and style and professional goals and philosophies.9 This is also true in athletics and music: You’ve got to study and analyze each individual and find out what makes them tick . . . . (Athletic coach) . . . the ability to adapt . . . is 95% of being a good coach. Reading the situation and figuring out what each person needs. (Music coach) Another critical characteristic of effective coaches is that they are highly respected within the field. This can help build rapport and gain the respect of individual coachee. Although a coach’s broad knowledge base and understanding of the fundamentals of the discipline are crucial, a more advanced skill set, such as technical skill mastery, can help engender this respect.
WHAT ARE THE COMPONENTS TO CONSIDER WHEN DESIGNING A COACHING PROGRAM? We propose the Wisconsin Surgical Coaching Framework as a systematic approach to the development of surgical coaching interventions and to guide future work in this field (Fig. 1). The activities of coaching can be divided into 3 domains: (1) setting goals, (2) encouraging and motivating, and (3) developing and guiding.6,7 A surgical coach must be able to recognize the ability and experience of the surgeon, build rapport and trust, and work as a partner to define goals that are specific, achievable, and appropriate.6 Together, the coach and the surgeon identify strategies to advance these goals. Although there may be situations where surgical coaching would be more top-down (eg, to aid transition to independent practice), coaching for practicing surgeons should be designed as peer coaching. In this context, the coach Annals of Surgery r Volume 261, Number 1, January 2015
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Annals of Surgery r Volume 261, Number 1, January 2015
Coaching to Improve Performance
FIGURE 1. The Wisconsin Surgical Coaching Framework. There are 3 distinct but interrelated activities of coaching: (1) setting goals, (2) encouraging and motivating, and (3) developing and guiding. Each of these concepts is developed and central to our framework for surgical coaching. These activities will be influenced by both mutable and static forces. Mutable characteristics that must be optimized in the design of any coaching activity include the traits of the coach including both technical and nontechnical knowledge and his or her disposition and inherent traits. The coaching context should be designed to facilitate the desired coaching activities. Activities must also consider the traits of the surgeon to be coached and the operative context in which he or she functions. Each surgeon will bring a particular skill level, set of experiences, interpersonal skills, and disposition that will make him or her more or less receptive and amenable to the coaching activities.
serves as facilitator to encourage the surgeon to examine his or her own performance and identify areas for improvement. This may be accomplished through active listening, affirmation of positive attributes, and explicitly challenging assumptions and approaches, among other strategies. The coach must also be able to ask probing questions to promote problem solving while maintaining cooperative communication. Coaching for surgeons can target performance improvement in 3 domains: (1) technical skill, (2) cognitive skill, and (3) nontechnical skill. In surgery, we tend to consider “technical” and “nontechnical” skills as exhaustive and mutually exclusive designations, with nontechnical including both cognitive skills, such as decision making, and interpersonal skills, such as leadership.10 However, some cognitive skills, such as judgment and decision making are more related to technical skill—the so-called motor-cognitive continuum of human performance—whereas others, such as situation awareness and mental readiness, are better conceptualized as nontechnical skill. We therefore include 3 distinct but interrelated domains of performance in our framework; coaching interventions may target any or all of these. A coaching program must be designed to optimize components that are controllable, such as selection of an effective coach as discussed earlier and optimal design of the coaching context. Decisions regarding the coaching context include the use of video-review versus live intraoperative coaching, peer versus expert coaching, and the setting from which coaches and surgeons will be identified. Each has advantages and disadvantages, and the coaching context may vary C 2014 Lippincott Williams & Wilkins
on the basis of the goals of an individual program. For example, video-based coaching will be significantly more efficient and less time consuming than live coaching, allow the full attention of both the coach and the coachee to be on performance by removing concurrent clinical responsibilities, and remove complexities related to credentialing and responsibility when compared with live coaching. However, video-based coaching has its own challenges. Videotaping can still make many operating room staff uncomfortable and raise concerns about discoverability, so local culture must be considered in the design of a program. Other components of a coaching program are not mutable but must be addressed in the design of the program. For example, coachees will vary in experience, skill level, dispositions, and interpersonal skills and coaches should be trained to interact effectively across this range. It is also critical to consider the types of operations, practice setting, and characteristics of the system in which the surgeon works and ensure that the coach is familiar with each.
FUTURE DIRECTIONS The concept of coaching for performance improvement in surgery is attracting increasing attention. Driving forces include a national focus on improving quality and safety and recognition of the limitations in our current approach to continuing medical education. Adapting principles from other disciplines, we have proposed a conceptual framework that summarizes the critical issues to www.annalsofsurgery.com | 33
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Greenberg et al
consider in designing a surgical coaching program. Many questions remain to be addressed, however, including (1) which surgical skills, if any, are amenable to coaching; (2) how best to identify and train effective coaches; (3) whether video-based or live coaching is better and under which conditions; and (4) if coaching can improve surgical performance, whether it translates into improved patient outcomes. Although the idea of coaching has face validity, significant research is still needed to evaluate its effectiveness. If surgical coaching does prove effective, translation into sustainable practice may also prove challenging. For example, it is unclear where ownership of surgical coaching programs would reside and how they would be financed. There is reason to think surgical coaching will have traction, however. The American Board of Surgery has included lifelong learning and self-assessment and evaluation of performance in practice as requirements for Maintenance of Certification. We believe that surgical coaching could offer a meaningful way to meet these requirements. In addition, numerous regional and national surgical quality collaboratives exist, providing a possible venue for both research and implementation of coaching programs. Several groups, including ours, have ongoing research and development projects related to surgical coaching, and excitement for the approach within the field is evident. We hope that the Wisconsin Surgical Coaching Framework can provide a conceptual basis for future program design and advance our understanding of performance improvement for practicing surgeons.
34 | www.annalsofsurgery.com
Annals of Surgery r Volume 261, Number 1, January 2015
ACKNOWLEDGMENTS The authors are grateful to the leadership and membership of the Wisconsin Surgical Society for their continued support and collaboration on this project.
REFERENCES 1. Birkmeyer JD, Finks JF, O’Reilly A, et al. Surgical skill and complication rates after bariatric surgery. N Engl J Med. 2013;369:1434–1442. 2. Grumbach K, Bainbridge E, Bodenheimer T. Facilitating improvement in primary care: the promise of practice coaching. Issue Brief (Commonw Fund). 2012;15:1–14. 3. Hu YY, Peyre SE, Arriaga AF, et al. Postgame analysis: using videobased coaching for continuous professional development. J Am Coll Surg. 2012;214:115–124. 4. Kaufman DM. Applying educational theory in practice. BMJ. 2003;326:213– 216. 5. Ericsson KA. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med. 2004;79:S70–S81. 6. Chen CW. Coaching Training. Alexandria, VA: ASTD; 2003. 7. Anderson EM, Shannon AL. Toward a conceptualization of mentoring. J Teach Educ. 1988;39:38–42. 8. Gallimore R, Tharp R. What a coach can teach a teacher, 1975–2004: reflections and reanalysis of John Wooden’s teaching practices. Sport Psychol. 2004;18:119–137. 9. Staub F, West L, Bickel D. What is content-focused coaching? In: Contentfocused Coaching. Portsmouth, NH: Heinemann; 2006:1–17. 10. Yule S, Flin R, Paterson-Brown S, et al. Non-technical skills for surgeons in the operating room: a review of the literature. Surgery. 2006;139:140–149.
C 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
