While only 38% of orthopaedic surgeons self-reported feeling burned out in the latest survey conducted by Medscape, even that number seems way too high for those health care professionals who take on the responsibility of taking care of others.1 The debate, conversation, and research have also been all over the place regarding whether to measure burnout, resilience, well-being, moral injury, or something else. Although there are some common elements to career satisfaction and the drivers of burnout, even here the most scientific scrutiny has tended to stay away from more personal questions that might also play a role in or protect against burnout. Most orthopaedic organizations have not even taken on the task of measuring any of these parameters, even though this collection of data might provide valuable benchmarking and knowledge to its members.
In addition, physicians remain reluctant to seek professional assistance for burnout or mental health conditions. This is a real problem, especially among orthopaedic surgeons, because only 22% were likely to seek professional help for burnout or depression.1 In many wellness communities and among many coaches, some believe that these have even worsened the problem: (1) burnout even implies an individual weakness to stay lit; (2) burnout being recently defined by the World Health Organization as an illness implies an affliction to be remedied; (3) the Canary versus the Coal Mine debate which chooses to assign blame to the system or the lack of resilience of the physician. There are more reasons, but what is important to know is that, in my opinion, burnout is not something to be ashamed of—nor is it a mental health issue. Even performance concerns may not arise unless there are certain predisposing factors or the dose of mental health abuse is exceedingly high. Most burnout is a mix of all the issues being discussed, including the normal human response to acute or chronic stress and moral injury to a physician’s purpose in their life and career. Certainly, physicians can be predisposed to burnout due to prior life experiences and internal traits such as guilt, self-denial, and imposter syndrome. Our medical training, while largely the envy of the world, is also known to emphasize medical knowledge and skills, breed perfectionism, encourage competition and individualism, inhibit us from speaking up, worsen the symptoms of burnout, and contribute in many other ways to unsustainable strategies of performance improvement.
Although the data will be helpful to better understand all of these issues surrounding burnout, we are smart enough to start working on solutions now. Coaching and peer support are not novel concepts. Through coaching, which has long been used in the business world and other fields, we can provide a stigma-free method to address physician burnout. Coaching can help enhance self-awareness by drawing on a surgeon’s individual strengths, questioning self-doubt or overconfidence, focusing on new areas and aligning personal values with their professional duties. Coaching can potentially help physicians alter the pattern of devaluing self-care while prioritizing the care of others with skill development and increased self-awareness.2
Coaching has also proven effective at improving surgeon’s technical ability in the operating room. Surgeons primarily improve surgical technique with graduated responsibility in the operating room with their surgeon teachers, as an apprentice, and flippantly described as “See one. Do one. Teach one.” We supplement our live training with hands-on skill laboratories with models, cadavers, simulators, and even virtual reality. The missing element with most of these is that they do not seem real. Coaching can use video review and/or mental reflection on actual surgeries that have taken place to review what could have been done better, even when “replay or game review” shows that it went well. There are almost always learning opportunities with skills, decision making, team management, and so much more.
Although coaching is fairly new to the application of health care professional wellness, burnout prevention, and all these various subtopics, I shared some of my personal experiences receiving and then providing coaching to surgeons. We have all demonstrated the strengths and skills to reach the highly competitive milestone of becoming an orthopaedic surgeon. Further growth, and in particular sustainability, requires adding to these strengths and addressing those skills and traits that might be limiting.
My story begins in the present. I love being a surgeon. However, it was not that long ago that I did not love what I spent much of my life becoming. I love being a coach. Whether I am coaching other surgeons or being a surgeon, I have recovered my growth mindset from being coached by others to practice my best. My first 5 years in an academic practice and the following 10 years in private practice as an orthopaedic traumatologist were successful in many ways. I work in 3 trauma centers providing excellent care to many patients. I am the fellowship director for the San Diego Orthopaedic Trauma Fellowship and chairman of Unite Orthopaedics Foundation a 501(c)3 which manages the fellowship. However, beyond my title as a surgeon and employer, I am also a parent, husband, brother, and friend, among many other roles.
When I was experiencing my own signals of burnout, I found an exit strategy in becoming a certified professional coach. While learning about and receiving coaching, I discovered how profoundly this started to impact my own well-being, decreasing my emotional exhaustion and depersonalization, and reinvigorating my sense of professional accomplishment from being a surgeon. Realizing how impactful this was to my career and well-being, I invested the majority of my “spare time” researching the characteristics of highly successful surgeons and building a business surrounding physician coaching. Whether I am guiding a patient or a surgeon, I get tremendous satisfaction from assisting them in learning new skills or recovering old ones.
Through coaching, I discovered my passion for making a major positive impact on other people’s lives. By blending my experiences as a surgeon and researching the habits of highly successful surgeons, I developed a methodology for performance improvement for surgeons that I call the 8 Practices of Highly Successful Surgeons. One can use these 8 critical habits: (1) as a checklist to see that all these habits are growing and/or receiving deliberate practice; (2) as a guide for self-reflection or postgame and pregame analysis to see where there are barriers, strengths, or weaknesses that can be leveraged for performance improvement; (3) as a guide for creating a growth mindset and preventing burnout; (4) as a full cycle of positive energy production that creates the necessary passion for additional performance improvement; and (5) as an endless list of coaching opportunities.
Physician and surgeon coaching are akin to executive coaching. According to the Coaches Training Institute, coaching is a powerful alliance designed to enhance the lifelong process of human learning, effectiveness, and fulfillment. Coaching is an inherently creative activity of bringing forth knowledge, wisdom, and insight through: asking questions, listening deeply, keenly observing, dedication to self-awareness, and commitment to learning.3 Top athletes and professionals of all kinds benefit from the coaching and deliberate practice process. Coaching has also been defined as partnering with clients in a thought-provoking and creative process that inspires them to maximize their personal and professional potential.4 Coaching is most successful when one emotionally connects their inner purpose and passion to outer goals and strategies to bring extraordinary and sustainable results.5 Each of these could simply summarize surgeon coaching as a process that helps bring out the best in you.
Coaching can be the act of a professional coach, or it can be a skill applied by a leader, manager, or even a peer. The Wisconsin Surgical Coaching Program is one example of using peer-coaching to improve technical surgical skills, intraoperative decision making, and ultimately surgical outcomes. Their process uses surgical videos to allow peers who are often at a similar level of knowledge to engage in an equal, noncompetitive relationship that involves the establishment of goals, observation of a task, self-evaluation, and coach feedback. Their studies have shown that these processes can all help to improve task performance and support the implementation of changes.6 Their program highlights the following objectives that coaches and coachees can perform in the postgame video analysis.
This manuscript was written based on various outside sources and my own opinions. My surgeon coaching methods include a mix of expert opinions and literature review. I also researched various philosophies outside of medicine that have been extensively studied in human beings and behaviors. Although these have not necessarily been conducted on doctors, they are proven results.
Whether recovering from burnout, building resilience, healing moral injury, creating wellness, or improving at anything, applying the 8 practices is how we grow and get better.
- Passion for performance improvement.
- Reciprocity of roles and relationships.
- Attitude resilience.
- Communication with mutual understanding.
- Time/life management using rhythm.
- Inspiring to shared goals.
- Complex problem solving through simplicity.
- Energy for personal and practice wellness.
It is not important that one use my methodology. It is important that you develop or use a methodology that is based upon research, performance driven, reliable, and adaptable.
When you begin to explore why one would consider surgeon coaching, think about how many surgeons you know who are not—at least initially—very performance driven. Like high performers in other disciplines such as music, sports, and business, highly successful surgeons have a passion for performance improvement. So how do high performers get better? They train. They practice. In fact, most high performers use coaches at various points throughout their careers. Recently a study from the Mayo Clinic demonstrates coaching can also have a positive impact on surgeons in a number of important domains, including surgical outcomes, patient safety, and wellbeing.7 We need to fill our gaps of empirical evidence, especially in the application of coaching in physicians and surgeons, whereas even without academic support in music, sports, and business, coaching is readily accepted as a means for expert improvement and leadership training.
When asked, “Why do high performers then use coaches?” responses typically include: to get to the next level of success, to receive another professional’s perspective, to address challenges or a decline in performance, to achieve goals and identify potential actions, and because it works. Having developed a highly specialized skill set that few possess, high performers must seek elite performance through incremental change and deliberate practice.8
What if coaching is the “secret” to reaching your goals or working through your challenges? Through coaching, you can receive constructive feedback and challenge your thinking by providing you with someone who can be objective and detached from your own experience. Coaching also offers confidentiality and less judgement. Coaches should demonstrate care, compassion, and empathy to your challenges. A coach will focus on your development without any alternative agendas and ideally would not tell you what to do. Instead, coaches help to guide, support, and empower you to be your best.
If you already know or now realize why you would receive coaching, you need to ask yourself the “how” questions. How do you do what you do? How do you get better? How would you be coached best? At present, how surgeons are best coached is the least researched area, and subject mostly to personal opinion. One could be coached in any of the 8 practices of highly successful surgeons using my methodology. Alternatively, a surgeon could look at the best practices of being coached. At a personal coachee level, the key attitudes for optimizing the coaching relationship are to be self-directed, be accountable, listen carefully, be curious, avoid defensiveness, focus on learning, and inquire for understanding. A coach helps move ideas, plans and creates opportunities to move forward through a process of reflection, and creates goal setting and incremental adjustments in behavior to accomplish the self-defined goals.
In professional endeavors outside of medicine, coaching has proven to be an effective tool for individuals to manage “performance/skills, well-being, coping, work attitudes, and goal-directed self-regulation” within an organizational structure.9 Although research on coaching for individual surgeons, and teams or organizations, is lagging behind other disciplines, early returns are promising. Burnout is associated with increased medical errors, malpractice risk, and physician turnover.10,11 An August 2019 study found that <1 hour of coaching per month reduced symptoms associated with burnout.7 I would then hypothesize that if coaching can decrease burnout, improve well-being, and many of these other parameters, then coaching would likely have many benefits that are unrepresented in evidence-based literature in patient satisfaction and safety, and surgical outcomes.
It is also important to note that most successful professionals and coaches focus on “best performance” more than “worst performance.” Coaching is not typically remedial, though there can be benefits in addressing “bad habits.” We can use coaching to address physician satisfaction and well-being, a part of the Quadruple Aim, by providing a number of positive strategies for performance improvement that are not traditionally part of surgical training or the health care system that focuses on remedial strategies. As surgeons we are leaders, and as such, we owe it to ourselves to improve physician wellness in our health care settings.
When a medical professional is looking to explore a coaching relationship or start offering physician coaching within a department, group, or organization, there are a few important things to keep in mind. Start by determining the reason for the coaching. What is the purpose? If you are seeking guidance with a family health history of premature cardiac mortality, you might start with a cardiologist. If you do not know where to start, look for a general practitioner with a good reputation. Check to see whether your insurance or employer covers some of the expense and, if so, start with a doctor covered by the plan. When it comes to finding a coach, the sequence of steps might look analogous to selecting a doctor or something like Figure 1, Initiating a Surgeon Coaching Relationship. During the online research, one usually starts to notice things that attract you to one coach or another. Many have bios, blogs, podcasts, or testimonials that convey what topics they frequently address or other things in their background that communicate why they coach and what type of coaching they provide. Abide by the old adage—buyer beware. Although I am not aware of any quack physician coaches, one still should do the appropriate homework before hiring. What if you want to offer coaching as an initiative or benefit program to your group? Coaching can be particularly helpful in burnout management and surgeon wellness, including physical, mental, and emotional practices. If you want to create a highly successful program, look at Figure 2. Establishing a Surgeon Coaching Program to see best practices group coaching programs. Most of these key elements can be outsourced, except one—creating buy-in from the stakeholders. For example, it is best not to create or purchase an EMR before hearing from all stakeholders. You would not be able to wait for everyone to be on board, or you will be far behind the curve. You need other leaders, champions, early adopters, and others to play a critical internal role in creating forward momentum and making positive change. However, you do not have to wait for the perfect program to get started with many of the key elements.
There are endless opportunities for coaching and coaches. I envision coaching skills being taught in medical school and residency to ensure our future physicians are able to maintain their commitment to the field of medicine. Leaders will rely on coaching skills to bring out the best in their surgical team, while doctors will use these skills to improve resilience in their patients during recovery. Surgeons will also continue to have an empathic peer listener when they want to reach out to process difficult outcomes, other challenges, or to address burnout. Perhaps a form of peer coaching will be a means to decrease the moral injury of physicians providing the care to our patients and their families.
There are many reasons to engage in coaching. Some surgeons might turn to coaching to improve a “soft” skill deficiency with benefit to their employers, team, or patients. Other surgeons may seek guidance with struggles in their daily life with benefits more directly to the surgeon. However, coaching is much more than that. High-performance surgeons engage in coaching to maintain or reinvigorate that passion for performance improvement in anything and everything. Coaching usually involves an external dialogue to challenge our thinking, provide constructive feedback, and function as an active listener. Coaching helps provide the stimulus to self-inquiry and self-directed learning. Any way you look at it, coaching can be a positive avenue for surgeons to take in their life and career.
As teaching is a profession, a skill, and an action, coaching can be each of these. There are professional coaches who will work with physicians and surgeons in many different capacities. Coaching is also a skill to be practiced and refined. Peer-to-peer coaching is a classic example of learning the skill of coaching while practicing the act of coaching in a collaborative group of peers. Finally, any one of us can perform the act of coaching on others, such as a colleague, a patient, or even on ourselves. Coaching can be provided in person, online, and remotely; one-on-one, in groups, or any audience. Coaching models can come in all shapes and sizes from informal to formal, unstructured to structured, or in between. Although coaching can be remedial, the “best practices” shared in this article lean toward either a positive approach or one that is agnostic to positive and negative.
Within medicine, coaching has been applied in leadership training and some smaller scale experiments, but the research into best practices of coaching is in its infancy. Much research still needs to be done to adapt coaching to the unique characteristics of surgeons and surgery. Additional research and creativity will be required to offer a spectrum of options for cost and effectiveness to demonstrate the value.
When we circle back to the theme of wellness, surgeon coaching seems to have significant potential for creating surgeon wellness. It does not matter whether you are seeking coaching for juggling the many priorities in your life and practice; dealing with difficult outcomes, litigation, or personal stress; refining a technique or skill; addressing burnout; climbing to the next level of your career; training for or sustaining the marathon of a surgical career; implementing incremental steps or changes; or practicing wellness in your own way. Think about it. What if your ability to improve is unique to you? What if your ability to improve is through coaching? What if the answer to reaching your goals or working through your challenges is coaching? What if reaching your goals and working through your challenges is wellness?