Sudha R. Pavuluri Quamme

Surgical coaching for individual performance improvement.

T he technical skill of individual surgeons is an important determinant of surgical outcomes, at least for bariatric surgery. In a recent study in The New England Journal of Medicine, Birkmeyer and colleagues1 provide evidence that there is wide variation in technical skill among practicing surgeons and that this variation correlates with outcome. The authors conclude that new approaches to improving individual performance are needed and one-on-one coaching has potential to fill this role. The concept of coaching for performance improvement has been recently described in a variety of health care settings, but it is not well developed and experience is limited.2,3 Surgical coaching has the potential to address limitations in our current approach to continuing medical education, which does not incorporate the critical concepts of adult learning theory. Adults learn best as active participants in learning that builds on individual needs, is tailored to past experiences, and has direct applicability to their daily activities.4 Adult learners should participate in the identification of their own goals and have the opportunity to practice what is learned through self-reflection coupled with constructive feedback. The importance of self-reflection is emphasized by K. Anders Ericsson, who advocates for deliberate practice. Ericsson examines this concept for physicians, suggesting that most clinical practice does not include the critical aspects of deliberate practice, namely, the identification of areas for improvement by reflection on performance, followed by intentional adjustments in approach and evaluation of the resultant impact.5 This deficiency leads many practitioners to plateau in a state of proficiency. In contrast, professionals in other disciplines use coaches to facilitate deliberate practice and continued performance improvement, even among the most elite experts. To further develop the concept of surgical coaching, we examined features of coaching in other disciplines through literature review and observation and interviews of prominent coaches. In what follows, we outline main themes and provide a conceptual framework to synthesize the critical elements.

Strategies for Building Peer Surgical Coaching Relationships

Importance Peer surgical coaching is a promising approach for continuing professional development. However, scant guidance is available for surgeons seeking to develop peer-coaching skills. Executive coaching research suggests that effective coaches first establish a positive relationship with their coachees by aligning role and process expectations, establishing rapport, and cultivating mutual trust. Objective To identify the strategies used by peer surgical coaches to develop effective peer-coaching relationships with their coachees. Design, Setting, and Participants Drawing on executive coaching literature, a 3-part framework was developed to examine the strategies peer surgical coaches (n = 8) used to initially cultivate a relationship with their coachees (n = 11). Eleven introductory 1-hour meetings between coaching pairs participating in a statewide surgical coaching program were audiorecorded, transcribed, and coded on the basis of 3 relationship-building components. Once coded, thematic analysis was used to organize coded strategies into thematic categories and subcategories. Data were collected from October 10, 2014, to March 20, 2015. Data analysis took place from May 26, 2015, to July 20, 2016. Main Outcomes and Measures Strategies and potentially counterproductive activities for building peer-coaching relationships in the surgical context to inform the future training of surgical coaches. Results Coaches used concrete strategies to align role and process expectations about the coaching process, to establish rapport, and to cultivate mutual trust with their coachees during introductory meetings. Potential coaching pitfalls are identified that could interfere with each of the 3 relationship-building components. Conclusions and Relevance Peer-nominated surgical coaches were provided with training on abstract concepts that underlie effective coaching practices in other fields. By identifying the strategies used by peer surgical coaches to operationalize these concepts, empirically based strategies to inform other surgical coaching programs are provided.

Investigating Teamwork in the Operating Room: Engaging Stakeholders and Setting the Agenda

patients, followed closely by privately insured patients, but long-term post-ORYGB resolution did not vary further by insurance. Obesity hypoventilation syndrome varied only to 6 months and nearly disappeared in Medicaid, private, and self-pay patients but persisted at nearly 50% of preoperative rates in Medicare. Cholelithiasis increased in Medicaid and Medicare patients but did not change postoperatively in private and self-pay patients. Abdominal hernia resulted most frequently in Medicaid patients through 24 months at rates nearly double the other 3 groups. Abdominal panniculitis increased in self-pay patients to levels more than double the other groups by 24 months. Gastroesophigal reflux disease decreased in all insurance groups but remained higher in Medicaid and Medicare patients vs privately insured patients through 24 months. The significance of increased self-pay alcohol consumption at 24 months is not clear from the data. Private and self-pay patients benefited more from ORYGB than did Medicaid or Medicare patients. Postoperatively, privately insured patients had the lowest rates of 5 weightrelated comorbidities and highest in none. Self-pay patients were highest in 3 comorbidities but resolved 24 others to the lowest levels. Medicaid and Medicare patients were highest in 16 and 11 comorbidities, respectively. Medicare patients were lowest in abdominal hernia. Medicaid patients were lowest in none.

A structured, extended training program to facilitate adoption of new techniques for practicing surgeons

IntroductionLaparoscopic inguinal hernia repair has been shown to have significant benefits when compared to open inguinal hernia repair, yet remains underutilized in the United States. The traditional model of short, hands-on, cognitive courses to enhance the adoption of new techniques fails to lead to significant levels of practice implementation for most surgeons. We hypothesized that a comprehensive program would facilitate the adoption of laparoscopic inguinal hernia repair (TEP) for practicing surgeons.MethodsA team of experts in simulation, coaching, and hernia care created a comprehensive training program to facilitate the adoption of TEP. Three surgeons who routinely performed open inguinal hernia repair with greater than 50 cases annually were recruited to participate in the program. Coaches were selected based on their procedural expertise and underwent formal training in surgical coaching. Participants were required to evaluate all aspects of the educational program and were surveyed out to one year following completion of the program to assess for sustained adoption of TEP.ResultsAll three participants successfully completed the first three steps of the seven-step program. Two participants completed the full course, while the third dropped out of the program due to time constraints and low case volume. Participant surgeons rated Orientation (4.7/5), GlovesOn training (5/5), and Preceptored Cases (5/5) as highly important training activities that contributed to advancing their knowledge and technical performance of the TEP procedure. At one year, both participants were performing TEPs for “most of their cases” and were confident in their ability to perform the procedure. The total cost of the program including all travel, personal coaching, and simulation was

A Statewide Surgical Coaching Program Provides Opportunity for Continuous Professional Development

8638.60 per participant.DiscussionOur comprehensive educational program led to full and sustained adoption of TEP for those who completed the course. Time constraints, travel costs, and case volume are major considerations for successful completion; however, the program is feasible, acceptable, and affordable.