Should physicians have coaches?

Atul Gawande asks—and tries to answer—the question

Dan Diamond, Managing Editor

Atul Gawande—surgeon at Brigham and Women's Hospital, best-selling author, and apparently a one-time tennis prodigy—doesn't seem like the type who needs a coach. But writing in the Oct. 3 issue of The New Yorker, Gawande relays how the quest to achieve his "personal best" as a surgeon ultimately raised the question: Why don't we have coaches for physicians?

Coaches in many professions

In his piece, Gawande connects a pair of unrelated developments: the inability to cut his surgical complications rate and the decline of his tennis game.

Focusing first on his surgical career, Gawande discusses how he has performed more than 2,000 operations since becoming a surgeon eight years ago. Mastering the craft has involved a simultaneous mix of building knowledge of risks and confidence in his abilities, he writes.

But Gawande's growing skill eventually produced a surprising result. Based solely on complications rate, his operating room performance seemingly "reached a plateau."

"As I went along, I compared my results against national data, and I began beating the averages," Gawande writes. He adds that "my rates of complications moved steadily lower and lower. And then, a couple of years ago, they didn’t."

At about the same time, Gawande found himself with a spare afternoon at a tennis club and signed up for a lesson simply to get in a workout. Although Gawande was years past his peak as a high school tennis star, the club pro's basic tips soon had him "serving harder than I ever had in my life."

Curious about the power of coaches, Gawande investigated the presence—and effectiveness—of personal instruction across a diverse set of performers, like elite musicians and top-performing teachers. Intrigued by the results, Gawande made an unusual professional decision: "I decided to try a coach."

Finding his Yoda

For Gawande's surgical coach, he sought out Robert Osteen, a retired general surgeon who had been a favorite of Brigham and Women's residents. Osteen's teaching style, according to Gawande, was less didactic and more observational; his reticence allowed residents to make choices and learn as they went.

In his new role as coach, Osteen first observes a surgery that Gawande believed "went beautifully"—an efficient, 86-minute thyroidectomy. Yet Osteen had a long list of post-surgery critiques for Gawande: Pay more attention to how you drape the patient, because Gawande's choices trapped the surgical assistant in place; avoid reliance on magnifying loupes, which restrict peripheral vision; and so on.

"That one twenty-minute discussion gave me more to consider and work on than I'd had in the past five years," Gawande writes.

That initial experience also raised broader questions about how coaches might be perceived in medicine.

First, it had been awkward for Gawande to explain to others why, as a tenured surgeon, he had invited a coach along for the morning.

Yet "the stranger thing" that occurred to Gawande, "was that no senior colleague had come to observe me" since he'd established his professional practice. Physicians, he concludes, are left with little day-to-day scrutiny—and a set of outside eyes and ears can only help the push toward quality improvement.

Is this a model for others?

Gawande's thought-provoking piece has generated considerable comment, both inside and out of health care this week. Having stuck with Osteen for months, Gawande reports that his complications rate is falling once more and "I know that I'm learning again." 

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."

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