Friday, September 30, 2011

The Surgical Coach

By now, most medical people have read or heard about Dr. Atul Gawande’s latest New Yorker piece. After taking a tennis lesson which improved his game, he decided to see if acquiring a “surgical coach” would improve his “surgical game." He wanted to continue to reduce his—[self-described] already lower than the national average but level for a few years—complication rate. He enlisted a retired surgeon, who was a mentor during his residency training, as a “coach,” and his complication rate is falling again.

I was asked to comment by Dan Diamond, Managing Editor of The Advisory Board’s Daily Briefing. He quoted me in his commentary on Gawande’s concept: 

But not all think that Gawande's article heralds a viable model.

The blogger known as Skeptical Scalpel—a longtime surgeon and former surgical department chair who writes under a pseudonym—told the Briefing that he's, well, skeptical about the ideas that Gawande raises.

"I would accept a coach but doubt I could find one," according to Skeptical Scalpel, particularly a coach as talented, experienced, and available as Osteen. He adds that surgeons often are challenged by issues outside of the operating room, such as in areas like diagnosis, communication, and bedside manner. Skeptical Scalpel also wonders whether the coach would be liable if the patient experienced complications and elected to sue.

Medicine's cultural barriers may present the most significant barrier. As Gawande acknowledges, many surgeons are happy to prescribe a coach for others—but few would acknowledge the benefits of finding a coach of their own. Skeptical Scalpel told the Briefing that a successful surgeon needs a healthy ego; "most of us feel we are the best surgeon we know. If you didn’t feel that way, you probably can’t do some of the things we do."

I’d like to further explore my issues with Gawande’s surgical coach.

Where would the average surgeon find a suitable coach? There aren’t many retired surgeons who would have the necessary skills, the time or the motivation to do it. Gawande practices in a major teaching hospital in Boston. Very few surgeons would have access to people like the coach he chose.

The coach is apparently only involved with what goes on in the OR. Many complications arise due to patient co-morbidities, timing of the operation, postoperative care, supervision of residents and many other factors. Should the coach make floor rounds or see patients in the surgeon’s office too?

The liability question is real. You can bet that if a patient has a serious complication or dies in the OR, everyone in the room, including the coach, will be sued. And the coach, a retired surgeon, is not likely to have malpractice insurance. 

The patient has a right to know who is in the operating room. How does one explain the presence of a coach to the patient? At the end of his article, Gawande shares a vignette depicting his rather awkward attempt to introduce his coach to a patient on the operating room table:

“He’s a colleague,” I said. “I asked him along to observe and see if he saw things I could improve.”
The patient gave me a look that was somewhere between puzzlement and alarm.
“He’s like a coach,” I finally said.
She did not seem reassured. 

That is not surprising since only the most enlightened patient would see the value of a coach in that situation. I think a more typical reaction would be to think, “Maybe the coach should operate on me instead of the trainee.”

From an ivory tower in Boston, the idea of a surgical coach is a lovely one. Too bad it has little to do with the average surgeon in the United States.

12 comments:

fraz said...

Perhaps this article is the opening salvo to discuss the cultural issues around coaching in medicine?

Not too long ago, a patient may have been aghast that a surgeon required a checklist to keep things straight.

Skeptical Scalpel said...

Good point, fraz. But as I said, I don't know where you would find enough qualified and willing coaches.

Anonymous said...

I guess I'm confused -- as an academic physician myself, why doesn't the department chairperson serve as the coach? Isn't that, in part, the job of the chairperson -- to mentor the members of his or her department, identify issues that are relevant to their skills and the care of the patients, and bring into place interventions to make the surgical care better?

//.amanda.eleven. said...

I did [naively] believe that Dr. Gawande's article seemed like a valid approach to improving outcomes, but completely see where it could be unrealistic. This being said, I still wonder if slowly, but surely, some kind of surgical advisor could be implemented -- what if certain surgeries you wanted to improve your outcomes on were recorded and then you met with someone who viewed it to discuss where you could improve your technique? Obviously it's not the same as being in the OR, but it would lessen the liability issue.

Aside: By the way, I asked a number of physicians I have been interacting with in my area and they have all said that they tell strangers their profession. Maybe it depends on the region?

Skeptical Scalpel said...

@Anonymous

Brilliant comment. I am bummed that I didn't think of it myself.

@Amanda

Good thoughts re the coach. I'm kind of surprised about the MDs telling strangers their profession. Are you in a small town?

//.amanda.eleven. said...

Well, I'm in suburbia/metro-Detroit. Maybe it's a big city thing?

Skeptical Scalpel said...

Or a Midwestern thing?

XOXO Dr. Kay Elizabeth said...

Maybe it is a Midwest thing. Most of the doctors I know aren't afraid to say they are doctors, it sort of like a badge to the people I've come into contact with, not to mention all of my friends who are also practicing physicians.

Norman Briffa said...

This debate Is a really interesting one. In the UK , the number of hours and years surgeons spent in training has fallen dramatically over the past ten years. As the number of hours fall, the quality and nature of training had to change if we did not want to face a deterioration in standards. A new measure that has been introduced for trainees is the work based assessment. There is no reason why something similar could not be introduced in the appraisal and re-licensure of established practitioners. Professional bodies such as college of surgeons or other societies could organise the process. Good debate.

Skeptical Scalpel said...

Dr. Briffa,

Thanks for commenting.I had not heard of work based assessment. It sounds like something our Joint Commission has mandated for hospital credentialing.

hope said...

Just did a search of the blog to see if you'd commented on surgical coaching (I knew you would have!). Just had the pleasure of hearing a wonderful talk by Dr. Caprice Greenberg, a surgeon at the University of Wisconsin who just received an RO-1 grant to study the utility of coaching within a fast-paced surgical environment. She actually outlined quite a practical and easily-implementable plan to study the effects of coaching on surgeons in academic and private practice. I see your points (it being nicer in theory than in practice), but she did have fairly strong rebuttals to them. I do think, at the very least, surgical education (and continuing education) could benefit a great deal from some thoughtful and pointed comments regarding technique and performance. My old violin teacher's comments about my bow hold were far more helpful than my of my attending's comments (virtually zero) on my grip of the Castro. Another final point -- Dr. Greenberg stressed that one area that coaching would be extremely helpful is for surgeons who do fewer numbers of open procedures; ie a gastric bypass surgeon who is doing an open hernia repair. A coaching session may focus specifically on a video of this procedure and discuss technical points that may be helpful given the smaller number of cases this surgeon may be performing.

Skeptical Scalpel said...

Gawande's article involved a coach present in the OR. I take it that this coaching would be via video. Just a few questions. How many surgeons would be coached or coaches? Will those being coached volunteer or be coerced? How many surgeons would be involved? Maybe someone who only does gastric bypasses shouldn't do open hernias. And how do you get video of an open hernia repair? Google glass?

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