If you want to succeed at handling sudden injuries, it's not enough to become highly skilled. You need to review the “reiterated experiment” of your approach under the gaze of expert colleagues, said John Jones, MD, who was fresh from the battlegrounds of the French and Indian War when he proffered that advice, eventually compiling it into a textbook in the 1770s.
Today he is known as the father of surgery, but it could be argued that Dr. Jones was also America's first standard-bearer for urgent care medicine. His writings principally address treating trauma, and though he calls it by other names, perhaps most notably “the practice of attention,” Dr. Jones also seems to have been an early passionate advocate of clinical coaching.
Continuously be curious to learn new methods, he urged his peers, right along with recommending shoemaker's thread for ligature, which could compress tissue without cutting it. (See FastLinks.)
Now, some two centuries and two score later, as Dr. Jones might have phrased it, clinical coaching is being reconsidered as one of the ways in which emergency physicians can keep improving their performance.
“My personal feeling is that if we want to keep growing in medicine, if we want to keep people at their best, we need to institute some kind of coaching program,” said Rita Cydulka MD, a professor of emergency medicine at Case Western Reserve University and the co-author of several publications on medical education. After all, the era of “see one, do one, teach one” is coming to a close, and is being replaced by simulation exercises in which emergency physicians are videotaped, then critiqued, as part of their training.
Surgeon Atul Gawande, MD, posed a similar question last October in TheNew Yorker: if elite athletes and famous musicians need coaches, why don't doctors? And why didn't he, himself, have one, someone who would come in the operating room to coach him on his surgical technique? In fact, the coaching experience Dr. Gawande successfully sought became the basis of his article. He recounts how he coaxed his former mentor out of retirement to return to the surgical suite to do just that, scribbling tips and observations “on a notepad dense in small print” to help Dr. Gawande spring from his self-described surgical plateau.
“Coaching like that, in a non-threatening environment, would be wonderful,” Dr. Cydulka said. But it is likely to be resisted because physicians already are getting so many “report cards” now, from patient satisfaction surveys to practice outcomes data, she said. On the other hand, “I think most of us who have felt this kind of growth consider it a wonderful feeling.”
She said she asked for informal coaching frequently over the years, often after she has encountered a challenge and then sees a colleague who makes it look easy. “So I just ask them, ‘How did you do that, to make it look so simple?’”
Clinical coaching has taken on some new definitions in the wake of the Patient Protection and Affordable Health Care Act, in programs like Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) that are becoming a way of life in some emergency departments. The genesis of increased emphasis on clinical coaching is often attributed to the Institute of Medicine report of 1999, “To Err is Human,” but controlled trial of EDs also showed promising results. Teams trained in one large study reduced errors substantially. (Health Serv Res 2002;37:1553.) This special team training by EDs somewhat paralleled the evolution of TeamSTEPPS, a method of cross-coaching developed by the Department of Defense and the Agency for Healthcare Research and Quality. Both put a new kind of collaboration into practice, and it has been adopted by many EDs, including small, rural ones (See FastLinks).
Clinical coaching does have its problems, and it isn't just that this kind of oversight can make physicians feel too vulnerable, a common complaint. For emergency physicians, in particular, it can be difficult to decipher who has the expertise to do the coaching. This is a specialty with so many different processes — some of them wholly cognitive ones, others procedure-based — that it is a challenge just to decide who might be the expert capable of watching as others perform the usual duties in a busy ED. At least, that is way that E. Anders Ericsson, PhD, sees it, who has more than a dozen publications looking specifically at performance and its measures.
“Our work is based on studying the structure and acquisition of those performers who are able to perform at a very high level, such as elite athletes, musicians, ballet dancers, and chess players, where objective performance criteria can be applied,” said Dr. Ericsson. “Surgery is one of those domains where outcomes are often immediately available,” he said.
But it can be problematic to generalize across specialties, said Dr. Ericsson, a professor of psychology at Florida State University in Tallahassee. Even great teachers may not necessarily be the best clinical coaches.
“A key point is that social criteria for expertise often do not correlate with performance,” he pointed out. A great reputation and rapport with residents does not always equal the highest performer.
“Outcomes are needed” to establish that, said Dr. Ericsson. Real expertise must pass three tests: it must lead to performance that is consistently superior to that of the expert's peers, it must produce concrete results, and it must be able to be replicated. Yet studies of expert performers that show superior performance in clinical medical settings by such objective measures are rare. (Med Educ 2007;41:1124.)
Faculty members at Case Western, which was one of several medical centers that pioneered direct observation of residents, watch new doctors at work without interrupting them while recording their observations using a checklist of procedures as a guide. Those observations are discussed later, Dr. Cydulka said. Two key factors enhance this kind of learning: recognition of what is being done right, which is affirmed and reinforces good skills, and identification of areas that need to be done differently, with strategies for improvement.
That is a more comfortable way to undergo coaching, said Louise B. Andrew, MD, JD, a litigation stress counselor and the principal consultant at MDMentor.com. But, in fact, physician training focuses on learning “to do things like our professors do them” to avoid errors and achieve top performance.
And this may build a barrier to the kind of clinical coaching described by Dr. Gawande. “Physicians are taught explicitly and by example that we are supposed to be perfect,” she said. “So for generations many of us have gone out into the real world after training believing that this is the best, if not the only protection, and that no other preparation or protection is necessary.”
“We are supposed to be perfect already, and forever, and not to be inferior beings who might occasionally need a counselor, physician, coach, or mentor,” Dr. Andrew added. The fear of “not being seen as who we wanted to be, namely perfect,” is the main reason physicians can be so reluctant to admit mistakes, Dr. Andrew said. Few are likely to ever have had a senior person admit to one, she noted, recalling just such an example.
She felt “fully competent in matters medical,” but not trauma surgery when she was a young physician. Residents in those days were essentially in charge unless they called for help, and she informed the surgical chief resident that she had little experience in trauma management. “I told him that I would appreciate his input,” she said. She followed all the steps she had been taught when an elderly man who had been hit by a car was brought in alert but with falling blood pressure, the only mark on him a quarter-sized bruise on his inner thigh.
“Along with all the other trauma assessment techniques I had been taught, I pressed on his pelvis with all of my weight. I couldn't elicit any complaint of pain or any other clue to the reason for his hypotension,” Dr. Andrew said. “I called in [that] chief resident, and explained that I had done everything I could in terms of examination, and I could not explain his falling blood pressure.” The remaining possibility was a pelvic fracture, which could be spilling blood into the belly, she proposed.
The chief resident, irritated that he had been called, pressed on the pelvis and growled: “He doesn't have a pelvic fracture. Get him into x-ray and find out what's wrong with him!” The radiography equipment was nearby, but the man's blood pressure continued to plummet while he was on the table for imaging, and he could not be resuscitated. That experience “certainly left a mark on me, and I suspect that I am not the only one who has experienced such a situation,” Dr. Andrew stressed.
So how is clinical coaching likely to be seen in EDs, given this entrenched cultural history? It rests on the individual, said Janet Bickel, a leadership and career development coach in Falls Church, VA. The article by Dr. Gawande reflects the same kind of “openness, courage, and self-awareness” exhibited by many individuals who seek such coaching, she said.
Ms. Bickel has helped coach physicians who feel they have hit the kind of plateau Dr. Gawande described in his article, and her role is to help them find the means to do so. “It really doesn't come naturally [to many doctors] to say, ‘I think I need some help,’” she said. Some may, in fact, prefer the plateau.
Professional aspiration also spurs the desire for coaching, she said, sometimes because it has become obvious to a person who wants to achieve more that he lacks a necessary skill set. Other times it is because he has been identified by an institution as showing promise, and has been advised to engage a coach, Ms. Bickel added.
“Increasingly, it seems, academic centers and hospitals value offering people this resource,” she said. “It is more accepted now and likely to be built in more” at such institutions in the future. No universal, direct relationship exists between acquiring the attributes coaching can provide and ascending to higher rungs of authority, however. “There are a lot of individuals who don't get coaching who do get power,” she stressed.
“I could imagine myself asking for coaching but with some reservations,” said Bryan Ward, MD, a fourth-year resident in otolaryngology-head and neck surgery who currently is a research fellow at the National Institutes of Health.
“The coaching approach is similar to how we surgeons are trained in surgical technique. As you progress technically, [you] are provided more independence. We have assessment forms on surgical technique that we review with our attending surgeons after the case,” he said, adding that such assessments highlight the key moves involved in the surgery and their ability to navigate them appropriately.
Such conversations are similar to the ones that Dr. Gawande suggests in his article, he said. “The key difference is that his approach is for attending surgeons after attaining independence,” Dr. Ward pointed out. “As a resident, his solution seems logical, since it's what we're trained to do.” An abrupt change in responsibility occurs when surgeons become attendings, he observed. “Suddenly, no one is looking over your shoulder, and you are making all the decisions.”
Physicians adapt quickly to that newfound autonomy, he said, and asking those past residency to revisit the resident training approach “may be difficult for attendings once they've become comfortable with their independence,” Dr. Ward said.
“It is difficult to put yourself in the vulnerable position of being critiqued by your peers,” he said. Even in surgery, residents see a variety of technical approaches used for the same surgical problem, depending on the attending physician, he said. “Their techniques are usually the ones they've learned in their training and are trying to bestow to us,” he said.
“As residents, we decide which ones make the most sense — as little of this is studied — and propagate those techniques,” Dr. Ward added, allowing that, for some, it might be easy to get “stuck in one's ways.”
“I think this trap is where a coach would be highly effective,” he said. But even Dr. Ward, not yet out of residency, acknowledged that “the further away from residency I become, the more challenging that thought may be.”
Click and Connect!Access the links in EMN by reading this issue on our website or in our iPad app, both available onwww.EM-News.com.
- Read Dr. John Jones' book, Plain Concise Practical Remarks on the Treatment of Wounds and Fractures, from the National Library of Medicine archives at http://bit.ly/TbuSxC.
- More information about TeamSTEPPS is available at http://teamstepps.ahrq.gov/.
- Read more about the use of TeamSTEPPS in a rural ED at http://1.usa.gov/10iOJIx.
- Comments about this article? Write to EMN at [email protected].