American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Featured Commentary

Our online subscription format, SRGS Connect, features 10 commentaries on recently published articles in top medical journals with each new edition. The commentaries are by practicing surgeons and focus on the strengths and weaknesses of the research and its contribution to advancing the field of surgery.

Below is a sample of one of the commentaries published in the current edition of SRGS Connect, What You Should Know.

Bonrath EM, Dedy NJ, Gordon LE, Grantcharov TP. Comprehensive Surgical Coaching Enhances Surgical Skill in the Operating Room: A Randomized Controlled Trial. Ann Surg. 2015;262(2):205-212.

Mutabdzic D, Mylopoulos M, Murnaghan ML, et al. Coaching Surgeons: Is Culture Limiting Our Ability to Improve? Ann Surg. 2015;262(2):213-216.

Greenberg CC, Klingensmith ME. The Continuum of Coaching: Opportunities for Surgical Improvement at All Levels. Ann Surg. 2015;262(2):217-219.

Commentary by: Karen Deveney, MD, FACS

The concept of coaching for groups other than athletic teams or elite musicians is a recent addition to American society. It has pervaded almost every walk of life as emphasis on mastery of a subject, rather than simply an average degree of accomplishment, has become commonplace. The value of coaching to improve performance has been the subject of surgical research in recent years, particularly at one of the centers of research in surgical education, the University of Toronto. Two articles that appeared in Annals of Surgery, 2015, concern coaching to improve surgical performance: one a randomized controlled trial (RCT) with surgical residents as its subjects, and the other a study that involved semi-structured interviews with practicing surgeons to explore their attitudes towards coaching and provide insight into barriers that might exist for practicing surgeons to accepting the value of coaching in their own practices. Finally, in a third article in the same issue, well-known surgical educators offered a commentary about these articles and reinforced the potential value of coaching for surgeons at every stage of their career.

The study by Bonrath and coauthors was an IRB-approved RCT, with nine surgical residents in each group that was conducted in 2013–2014 at the University of Toronto. The structure for the control group was the usual instructional approach on their two-month minimally invasive rotation. The experimental group participated in a thorough analysis of the steps and conduct of the procedure and comprehensive surgical coaching during the procedure with emphasis on residents developing expertise in self-assessment of their performance so that continued improvement could be built into their future practices. Assessment of the actual performance of the residents was via standardized, validated instruments. Not surprisingly, the intensively coached residents improved their technical performance to a significantly greater degree than did the control group on most measures, and also demonstrated better accuracy in assessing their own performance. The authors compare the effect of coaching in surgical skill acquisition to that seen in other high-performance fields, with common features being a systematic process, personalized attention, feedback through listening and question, and goal-oriented structure. The study integrated the instructional strategies of debriefing, feedback, and behavior modelling that are features of Kolb's framework of experiential learning. The one- and one-half-hour coaching sessions occurred every other week for two months and were well-received by participants. The authors concluded that such structured experiential learning in the OR not only improves technical skills and reduces errors, but also enhances the residents' ability to assess their own performance.

The article by Mutabdzic and coauthors explored the concept of coaching as a potential method to achieve effective continuing professional development, a mandate of governing bodies in many professional fields, including surgery. It has been recognized that traditional continuing medical education activities most frequently do not achieve the desired goal of performance improvement. Based on information from other fields of endeavor, such as athletics, the authors utilized semi-structured interviews with 14 volunteer surgical faculty of varying specialties and years of experience to investigate their perceptions and attitudes towards coaching in the operating room, using a qualitative grounded theory approach that analyzed transcripts of the interviews to identify common themes expressed by interviewees. None of those interviewed had previously participated in formal coaching. These surgeons demonstrated a spectrum of attitudes about coaching, but were generally skeptical of its potential value in improving their operative skills; in fact, they doubted whether increased operative skill was important or valued in their career settings, once a sufficient degree of mastery had been achieved. Several expressed the concern that the presence of a coach in the operating room would negatively affect their image and identify them as somehow deficient; the image of competence was clearly important to them. Some suggested that having the coaches review videos of their operations in private would be more acceptable than open critique in the OR. They also expressed a concern about loss of self-regulation of their learning goals if a coach were present. Preservation of their autonomy was an additional important concern.

This study did not support the view that surgeons would embrace the concept of coaching as a method to improve their technical performance or even that all surgeons are motivated to improve technically to the point of true expertise. The authors acknowledged that surgical expertise is more complex than simple technical skill and involves multiple other domains, such as leadership, and that their interviewees worried that the presence of a coach in the operating room would scar their image, portray them as incompetent, and cause them to lose their autonomy.

In the third article by Greenburg and Klingensmith, a commentary on the above two articles, the authors described the conceptual framework and findings of the two studies and presented arguments for the value of coaching at all stages of a surgeon's career. They explained the differences between expert coaching for developing a new skill or procedure and peer coaching for performance improvement of surgeons in practice. They emphasized the importance of residents' learning analytic reflection to improve self-assessment via a structured approach of facilitated analysis, feedback, and debriefing. The authors also offered approaches to coaching experienced surgeons that might overcome the barriers identified in Mutabdzic's study by correcting misconceptions expressed by the interviewees. They suggested that coaching need not threaten the surgeon's autonomy, as the areas needing improvement are best defined by the surgeon him or herself; the learners defined their own learning goals and objectives. The coaching need not occur in the operating room, but can be done later in private by the use of videotapes.

It is clear that formalized coaching will be accepted and even welcomed by trainees who are, by nature, highly motivated to proceed through the stages of technical skill acquisition from novice to accomplished surgeon. Surgeons already in practice, however, tend to feel that they have already achieved technical skill and they do not recognize inherent value in formal coaching. Most surgeons in practice have not received the benefit, however, of such highly-refined, formalized, and effective experiential learning methods as those described by Bonroth and coauthorsduring their training, since such methods are only now being implemented. It is entirely possible, and even likely, that current trainees who have been exposed to the positive aspects of such methods will bring to their future practices a different attitude towards coaching than the surgeons already in practice, for whom such methods are entirely foreign and, therefore, suspect. As new surgical techniques, procedures, and devices continue to proliferate in our surgical environments, those who fail to keep learning will face early extinction.

Surgeons who demonstrate an openness to accepting such helpful methods as coaching, which have shown in Bonrath's article the potential to improve operative performance as well as surgeons' ability to assess their performance, will be more likely to survive and thrive in their surgical practices.