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.