How surgical coaching helps performance, outcomes

Washington-Surgical coaching is a collaborative way for surgeons to improve their performance-and consequently, the outcomes of their patients, according to a keynote address at the Society of Urologic Oncology annual meeting in Washington, by Caprice C. Greenberg, MD, MPH.

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“Coaching is about unlocking a person’s potential to maximize their own performance. It is helping them to learn rather than teaching them. It is providing objective and constructive feedback to help someone recognize what works and what can be improved, and inspire them to maximize their potential,” explained Dr. Greenberg, professor of surgery at the University of Wisconsin, Madison.

Dr. Greenberg made the case that technical skill in the operating room is associated with postoperative outcomes. She pointed to a statewide collaborative effort of 20 bariatric surgeons led by the University of Michigan, Ann Arbor, in which each surgeon submitted a tape of himself or herself performing surgery (N Engl J Med 2013; 369:1434-42). Each tape was analyzed by other surgeons and rated based on technical skill.

The study concluded that technical skill of bariatric surgeons varied widely, and greater skill was associated with fewer postoperative complications.

“This is something that we all have intuitively known for a long time, but this is the first time that it was empirically… shown that what we do in the OR as surgeons, technically, directly influences how our patients do,” Dr. Greenberg noted.

Pointing to data from the University of Michigan study, she argued that complications are not the result of surgeons doing operations they shouldn’t be doing.

“Most often, it’s everyday surgeons doing what they do every day, but under uncommon circumstances,” Dr. Greenberg said.

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She demonstrated concern that much of the recent effort to improve quality and performance in the operating room-including regionalization, selective referral, increased specialization, and fellowship training-are not targeting the most important determinants of surgical outcomes.

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Dr. Greenberg argued that the concept of coaching has been effective in other domains as a means of improving performance throughout the entire duration of one’s career. She distinguished surgical coaching from surgical education by the collaborative relationship of the participants, the self-directed nature of learning, and the fact that the trainee can develop the capacity of self-monitoring their own progress.

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“This is about getting each other to pay a little bit more attention to how we continue to improve,” Dr. Greenberg said. “The goal of coaching is to promote a conversation between peers; it’s not about teaching someone.”

To skeptics who believe that expert surgeons have little room for further improvement, Dr. Greenberg pointed to work by K. Anders Ericsson, PhD, a psychologist, who argues that medical professionals reach a proficiency plateau that falls short of mastery, and that clinical practice is not the same as deliberate practice (Acad Med 2004; 79:S70-81).

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“We need to provide a space where we can transition from experts back into a learner mode. This applies to both the coach and coachee, because the model is based on co-learning, where both parties wonder about answers, show openness, wonder about beliefs, and continuously test competence, accept discomfort, and tolerate conflict,” said Dr. Greenberg.

Next: The Wisconsin Surgical Coaching Program

At the University of Wisconsin, Dr. Greenberg and colleagues have developed the Wisconsin Surgical Coaching Program, which has demonstrated feasibility of implementing video-based surgical coaching into practice. She prefers a video-based approach because it allows surgeons to view their own performance, confers a time savings, mitigates medicolegal and credentialing complexities, and has been shown to be most successful in sustaining behavior change over time. Dr. Greenberg then reviewed existing evidence that supports the effectiveness of video-based coaching to improve surgical technique in both medical students and resident trainees (Ann Surg 2015; 26:862-9; Ann Surg 2015; 26:205-12).

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Dr. Greenberg said she is optimistic about the future of surgical coaching and is currently collaborating with the University of Michigan to assess the effectiveness of a video-based coaching program in improving surgical outcomes. With an increased national focus on quality, safety, and transparency, she has witnessed increased interest in surgical coaching by professional organizations.

“As long as we stay in charge of this, I think we can really do this in a way that is going to improve care,” Dr. Greenberg concluded.

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