Surgical Coaching for Operative Performance Enhancement (SCOPE): skill ratings and impact on surgeons’ practice

Characteristics of Surgical Coaching Interventions: A Systematic Review

OBJECTIVE

Coaching is increasingly utilized as an educational intervention for performance improvement in surgeons and surgical trainees. Surgical coaching has been utilized across a broad range of specialties, experience levels and outcomes with generally positive results. Coaching interventions are often developed by individual institutions for their own context which has resulted in a heterogenous group of interventions. This review aims to investigate surgical coaching interventions to identify common characteristics that comprise an effective coaching intervention.

METHODS

A systematic review was conducted to identify studies investigating surgical coaching interventions up to July 2024. Studies were limited to English language peer-reviewed studies that adequately described the characteristics and outcomes of the surgical coaching intervention. Data on the primary and secondary outcomes, study objective and participants' demographics were also recorded.

RESULTS

The search across 4 electronic databases generated 9538 citations. Following screening and review of full text articles 28 studies were included in the review. Surgical coaching interventions were carried out in 8 separate countries with the majority (22/28) in North America. Studies involved between 3 and 107 participants. Coaching interventions were markedly heterogenous, and specific details of the methods used were inconsistently documented. Study length ranged from 1 (9/28) to 14 (1/28) sessions and duration from less than 15 minutes (1/29) to greater than 3 hours (3/28). The most common themes were goal setting (10/28), feedback (7/28) and reflection (7/28). Outcomes were generally positive with 47 of 55 identified outcomes demonstrating benefit from surgical coaching. There were 3 key domains and 13 sub-domains that comprised the majority of coaching interventions.

CONCLUSIONS

Surgical coaching has been shown to be a promising intervention that requires more rigorous research to develop the field. We have identified 3 key domains which can be utilized to analyses and develop coaching interventions in the future.

Nontechnical Coaching in Academic Surgical Practice-Where Do We Stand and What's Next?

OBJECTIVE

To evaluate the potential of nontechnical coaching (NC) as an intervention to enhance professional development, reduce burnout, and improve patient outcomes among attending academic surgeons (AS) in high-pressure surgical environments.

DESIGN

A narrative review was performed using PubMed to identify and assess studies focused on NC in academic surgery. We evaluated articles addressing the impact, benefits, risks, and barriers associated with NC, with particular attention to coaching frameworks, training programs, and participant feedback.

SETTING

The review encompasses research conducted in various academic surgical settings.

PARTICIPANTS

Studies primarily involved attending academic surgeons across diverse surgical specialties, especially those experiencing high levels of burnout and decreased job satisfaction.

RESULTS

Findings indicate that NC offers several benefits for AS. Pilot studies and qualitative surveys suggest that NC can reduce burnout, enhance intraoperative decision-making, and improve patient engagement. Surgeons who participated in NC reported better stress management, increased self-awareness, and improved leadership skills. Moreover, NC appears to foster enhanced team dynamics and, in some cases, may yield fiscal benefits by reducing surgical errors and increasing operational efficiency. However, significant barriers to NC adoption remain, including cultural resistance within surgical departments, time constraints, and concerns regarding the efficacy of NC compared to traditional technical coaching. Additionally, the current evidence is limited by small sample sizes, selection bias, and a lack of standardized, quantitative measures.

CONCLUSION

Preliminary evidence supports NC as a promising intervention for enhancing surgeon well-being and patient outcomes. Future research should focus on establishing standardized guidelines for coach training, addressing misconceptions about NC, and designing larger, methodologically robust studies using validated outcomes. Expanding NC could foster a more resilient surgical workforce, ultimately benefiting both surgeons and patients through improved engagement, satisfaction, and quality of care.

A Multicenter, Randomized Controlled Trial to Assess Video-based Surgical Coaching in Gynecology

STUDY OBJECTIVE

To evaluate the effect of video-based coaching on technical skill development in surgical education.

DESIGN

Randomized controlled trial with video-based coaching (intervention group) in addition to standard surgical curriculum or the standard surgical curriculum alone (control group).

SETTING

Laparoscopic vaginal vault closure in the operating room at 3 academic hospitals.

PARTICIPANTS

Senior Obstetrics and Gynecology residents (year 3-5) on their chief resident or gynecologic oncology rotation.

INTERVENTIONS

All residents were recorded performing laparoscopic closure of the vaginal cuff prior to randomization. Surgical coaching sessions followed the Wisconsin Surgical Coaching Framework over 30 minutes on Zoom with one surgical coach. All residents were recorded subsequently performing the same surgical technical skill. Blinded, expert surgeons performed the video assessment using the OSATS, GOALS, and global rating scale. The mean change in operative time and the mean change in video-assessment score between the 2 video-recorded attempts were compared between groups. Qualitative semi-structured interviews were conducted to understand the residents' perspective on video-based surgical coaching.

MEASUREMENTS AND MAIN RESULTS

Twenty residents participated with 10 in the coaching and 10 in the control group. Mean operative time to complete the suturing task was reduced by 32.8% (SD = 21.3%) in the coached group vs 7.2% (SD = 25.1%) in the control group (p = .025). There was no significant change in surgical assessment scores within the coached or control group. Residents identified the core components of a surgical coaching program to include: (1) the resident: focused skill development, (2) the coach: focused on feedback, (3) and the coaching program: a structured activity. Residents envisioned monthly coaching with the opportunity for deliberate practice, the importance of a positive relationship between the coach and coachee, and the importance of faculty development in surgical coaching.

CONCLUSION

Video-based surgical coaching is an effective tool to enhance technical skill development in surgical education.

Study of the performance of resident surgeon-in-training during distal fibula lateral plate placement according to 2 learning methods: naive practice versus deliberate practice

INTRODUCTION

Historically, surgical training has been primarily carried out in the operating theatre, using mentoring for the surgical resident to reach the appropriate skill level (3/5). Other surgical training methods also improve performance, but do not always lead to the highest level of expertise (5/5). Another training method, sometimes termed- deliberate practice, by setting objectives based on feedback, may be more effective. In this study we compared resident learning of osteosynthesis for a fibular fracture model between deliberate practice and traditional teaching or naive practice. The main hypothesis was that deliberate practice would result in better objective performance, better subjective performance and reduced stress levels.

MATERIALS AND METHODS

The study involved a level 3 expert and ten level 1 surgeon-in-training subjects divided into two groups naive practice and deliberate practice. Each subject placed 5 plates on a synthetic fibula model. The deliberate practice group received feedback from the expert after each trial. Stress level was measured using the Analgesia Nociception Index (ANI). Objective performance was assessed by OSATS and subjective performance by self-assessment.

RESULTS

Based on initial performance measurements, the two groups were comparable. The mean progression of objective performance over the five osteosynthesis was 10.3 in the naive practice group and 17.1 in the deliberate practice group, with a strong difference in favor of the deliberate practice group. Subjective performance and ANI improved in both groups, with no significant difference.

DISCUSSION

The main hypothesis was disproven: the improvement in objective performance was not significantly greater (< 97.5%) with deliberate practice. However, there was a substantial difference in favor of the deliberate practice group (93%). Secondary hypotheses were not proven too, as neither PS nor ANI were affected by deliberate practice. In conclusion, deliberate practice complements mentoring but must adhere to strict guidelines to be effective: level 5 expertise, precise criteria for defining OSATS, and the use of high- profile simulators.

How to be a Better Surgeon: The Evidence for Surgical Coaching

Surgical coaching has made a positive contribution to surgical training and practice; however, the otolaryngology-head and neck surgery literature is lacking. The operating environment for practicing surgeons, and specifically otolaryngologists, is continually changing due to advancements in technology and new practice patterns. These changes in practice, however, have not come with a coordinating system for operative feedback once surgical training is completed. In this commentary, we explore surgical coaching, its applicability to otolaryngology, and encourage its more widespread acceptance and implementation.

Coaching for improving clinical performance of surgeons: a scoping review

Surgical coaching has been proven to effectively enhance clinical performance. However, diverse implementation strategies present challenges when initiating new programs. Our scoping review aimed to synthesize the existing literature on surgical coaching, thereby informing the direction of future coaching initiatives. We reviewed published articles in PubMed/Medline and suppletory manuscripts from reference lists. The protocol of our review was registered (osf.io, Z3S8H). Inclusion criteria were studies that provided a detailed description of structured surgical coaching programs aimed at improving clinical performance. Excluded were studies focused on mentoring, teaching, or other forms of coaching that did not align with our specific definition of surgical coaching. We extracted and charted variables such as authors, publication year, geographic region, and others for subsequent analysis. A total of 117 studies were screened, and 11 met our inclusion criteria. Among these, five articles (45%) employed objective metrics to evaluate clinician performance. One study reported on the overall complication rates within 30 days as a measured outcome. Surgeons were the primary coachees in ten of the studies (91%), and the training of coaches was deemed necessary in seven studies (64%). The analyses revealed a preference for expert coaching models (6/11, 55%), video-based coaching (9/11, 82%), and postoperative timelines (7/11, 64%). Various coaching models were identified, including PRACTICE, GROW, and WISCONSIN. As an effective education method, surgical coaching has been conducted in many regions with varied designs. The implementation of structured surgical coaching programs offers substantial benefits for trainers, enhancing efficiency. Future research should focus on generating higher-level evidence, utilizing objective measurement tools, and integrating innovative technologies to further enhance the efficacy of surgical coaching programs.

Emotional Intelligence as a Component of Surgical Coaching: A Scoping Review

OBJECTIVE

Surgical coaching has become more widespread and involves both technical and nontechnical skills. Emotional Intelligence (EI) is an important nontechnical skill and is associated with leadership skills, increased job satisfaction and superior nontechnical skills. This scoping review aimed to explore the use of EI as a component of surgical coaching.

DESIGN AND SETTING

A scoping review was conducted to map the existing literature. Medline was searched from inception to May 2023. Eligible studies included surgical coaching, which incorporated aspects of emotional intelligence into the non-technical skills component.

RESULTS

3206 studies were identified in the initial search. A total of 2117 articles remained after duplicates were removed. 2117 articles were screened by 2 authors (DA and MR). 32 studies were included in the full-text review, and 8 studies were included in the final analysis. Coaching was predominantly delivered by practicing surgeons, although 1 study used external professional coaches. Training methods for coaches vary widely, from short courses to extensive workshops, highlighting the lack of standardized training protocols within the field. The outcomes measured across studies were diverse, encompassing both technical and non-technical skills, as well as emotional intelligence constructs. Non-technical skills were predominantly assessed using the Non-Technical Skills for Surgeons (NOTSS) assessment tool, whereas other outcomes included burnout, resilience, and technical skills. Notably, none of the studies incorporated formal measurements of emotional intelligence, although aspects such as motivation, empathy, self-knowledge, and social skills were addressed in the coaching sessions.

CONCLUSIONS

Standardization of coaching protocols and incorporation of emotional intelligence principles represent critical avenues for advancing the field and maximizing the benefits of coaching interventions in surgical practice.

Self-Assessment and Coaching Techniques Utilized in an Intraoperative Resident Peer Coaching Program

OBJECTIVES

To evaluate junior resident self-assessments and utilization of effective coaching principles by chief resident coaches in a resident peer surgical coaching program.

DESIGN

All residents underwent the Surgical Coaching for Operative Performance Enhancement (SCOPE) coaching curriculum. Junior residents ("coachees") were paired with chief resident coaches. A case was selected for coaching. The coaching structure was: 1) junior resident preoperative goal setting, 2) unscrubbed, intraoperative case observation by the coach, 3) postoperative coaching debrief. Debriefs were recorded to determine frequency of junior resident self-assessment and use of the effective coaching principles (goal setting, collaborative analysis, constructive feedback, action planning). Deductive thematic analysis was conducted.

SETTING

A general surgery residency at a single, large academic medical center.

PARTICIPANTS

16 junior resident (PGY1-3) coachees and 6 chief resident (PGY5) coaches.

RESULTS

There were 18 recorded coaching debrief sessions that lasted an average of 12.65 minutes (range 4-31 minutes). All debrief sessions included self-assessments by the junior resident coachees. There were numerous examples of the 4 effective coaching principles with all debriefs including use of at least 3. The most commonly used were collaborative analysis and constructive feedback. For technical skills, these highlighted body positioning, needle angles, and dissection techniques, including instrument choice, laparoscopic instrument technique, and use of electrocautery. Collaborative analysis of nontechnical skills emphasized communication with the attending surgeon, specifically operative decision-making and advocating for resident autonomy. Nontechnical constructive feedback addressed strategies the coaches themselves used for managing stress, interacting with attendings, and excelling in the operating room.

CONCLUSIONS

Self-assessments and use of effective coaching principles were frequent throughout peer coaching debriefs. Collaborative analysis and constructive feedback were employed to promote operative technical and nontechnical skill development. Within a peer coaching program, residents are able to employ high level teaching and coaching techniques to encourage operative performance enhancement.

Study of surgical performance during clavicle plate placements using 2 learning methods: naive practice versus deliberate practice

BACKGROUND

Companionship and simple experience or naive practice (NP) rarely lead to expert level surgery, in contrast to deliberate practice (DP) where an expert analyzes the learner's errors and sets goals to improve performance. The main hypothesis was that using DP for learning would result in faster and/or greater progress than using NP.

OBJECTIVES

The objective of this work was to compare the evolution of the learning curve for clavicle locking plate placement on a sawbone model of a clavicle fracture, by surgical trainees learning via two different methods; NP and DP.

PATIENTS AND METHODS

Ten surgical residents, divided into 2 groups of 5, each placed 6 plates. The 6 trials were filmed. The NP group saw an expert video before each placement. The DP group saw this video once and then received personalized advice from the expert for improvement, by analyzing their own video after each subsequent trial. Objective performance (OP) was measured by a standardized evaluation grid (OSATS, with a score ranging from 10 to 50 points per trial), self-evaluation of performance by a numerical scale (from 0 to 10) and stress by an analgesia-nociception index (ANI, calculated by heart rate recording, from 0 to 100).

RESULTS

The mean OP at the last trial of clavicle plate placement was 41.8 (NP group) and 48.2 (DP group), with a mean progression from the first to last trials of 0.8 in the NP group, and 5.1 in the DP group. The mean progression in self-evaluation between the first and last trials was 3.4 (NP group) and 4.6 (DP group). The mean progression of the ANI between the first and last trials was -4.5 (NP group) and +5 (DP group).

DISCUSSION

The results of learning a clavicle plate osteosynthesis technique measured by OSATS were better with deliberate practice than with naive practice. The progression in self-evaluated performance was better with deliberate practice, but with a higher stress level.

CONCLUSION

Deliberate practice is a technique for learning the surgical procedure which complements companionship and experience. It shortens the learning curve and improves the level of performance of surgical trainees.

LEVEL OF EVIDENCE

IV; non-interventional research.

Development and application of a non-technical skills coaching intervention framework for surgeons: A pilot quality improvement initiative

Non-technical skills (NTS) challenges experienced by surgeons may degrade performance, ultimately impacting the safety and quality of care delivered to patients. The objectives of this work were to develop a framework for NTS coaching for surgeons and implement a coaching program utilizing the developed NTS coaching framework. Leveraging adult learning and self-determination theories, a specialty-agnostic NTS coaching framework was developed for individual coaching sessions with robotic surgeons. The framework was used to deliver NTS coaching sessions to robotic surgeons. Surgeon's robotic procedures were recorded, and expert raters assessed their NTS using the Non-Technical Skills for Surgeons tool. Measures of surgeon satisfaction, learning outcomes, and performance improvement were determined. Cohen's d statistic was used to estimate the effect size of the coaching intervention. To pilot the program, ten robotic-assisted surgeries (five pre-coaching and five post-coaching) were observed from five practicing robotic surgeons who were recruited from a large academic healthcare system. Expert raters' assessment of surgeons' NTS revealed several exemplar and non-exemplar behaviors. Surgeons were satisfied with the coaching, rating its quality very highly on all NTS dimensions. On a Likert scale of 1 (strongly disagree) to 5 (strongly agree), surgeons had a stronger agreement that the coaching could improve their situation awareness (4.0±.5) and leadership (4.8±.2) skills compared to their decision making and communication (3.8±.7). From the post-coaching observations, coaching had medium-to-large effect on situation awareness (d = .65) and leadership (d = .41), small effect on communication and teamwork (d = .14), and no effect on decision-making. Overall, the coaching intervention had a medium effect on total NTS (d = .33). We presented a quality improvement initiative to enhance the NTS of surgeons by implementing a coaching program that leverages our developed NTS framework. Recognizing the importance of NTS in surgeries, our initiative shows a commitment to continuous improvement of patient safety and quality of care.

Adapting Surgical Coaching: Feasibility and Perceptions of Intraoperative Resident Peer Coaching

INTRODUCTION

Surgical coaching is utilized to enhance technical, nontechnical, and teaching skills. This study aims to evaluate the feasibility and benefit of a resident peer coaching program.

METHODS

Chief residents (postgraduate year 5) acted as coaches for junior residents (postgraduate year 1-3, "coachees"). All participants completed the Harvard Surgical Coaching for Operative Performance Enhancement curriculum. The coaching structure included 1) preoperative goal setting, 2) unscrubbed intraoperative observation, and 3) postoperative debrief. Upon completion, residents were surveyed to assess their experience. Descriptive and thematic analyses were performed.

RESULTS

There were 22 participants (6 coaches, 16 coachees). Five (83.3%) coaches and 14 (87.5%) coachees reported the program was useful, citing dedicated reflection outside the operating room, in-depth feedback, and structured self-assessment with increased accountability. Thirteen (81.3%) coachees reported perceived improvement in technical skills and 12 (75%) within nontechnical skills. All coaches felt they benefited and improved their ability to provide feedback. When asked how coaching compared to usual methods of operative feedback, 14 (87.5%) coachees and 5 (83.3%) coaches reported it was better, with only 1 coachee reporting it was worse. Benefits over typical operating room teaching included more feedback provided, more specific feedback, and the benefit of peer relationships. Twelve (54.5%) residents cited difficulty with coordinating sessions, but 21 (95.5%) reported that they would participate again.

CONCLUSIONS

Implementation of a resident peer surgical coaching program is feasible. Both coaches and coachees perceive significant benefit with improvement in technical, nontechnical, and feedback delivery skills. Given preference over other methods of operative feedback, expansion of peer coaching programs is warranted.

A pilot study of performance enhancement coaching for newly appointed urology registrars

OBJECTIVES

To assess the feasibility of performance enhancement coaching (PEC) for newly appointed Urology registrars (ST3s), specifically: whether the concept appealed, and which areas beyond technical skills acquisition were felt to be most relevant or useful.

SUBJECTS AND METHODS

All delegates on the Urology Bootcamp 2023 were invited to take part in an online survey before and after a 2-hour PEC workshop, collecting: basic demographic data, performance challenges, and the important aspects to include in, and consider with, a coaching programme. The workshop was delivered by a surgeon with a professional coaching qualification, to groups of four delegates at a time over 4 days. Ten pre-defined areas were offered during the session.

RESULTS

On a scale of 1 (poor) to 10 (excellent), the 62 participants' overall health was reported as a median of 8/10 (physical) and 7/10 (mental). Anxiety during performance was the most common concern (63%) and was accompanied by a tremor in 55%. The next most popular concerns, with 19% of responses each, were: sleep, insufficient operative skill or expertise, and worry about relationships with trainers. The commonest topics discussed were 'the inner critic' (100%), 'autonomic modulation' (69%), 'not working, well' (13%) and 'optimising study' (6%). Seventy-seven per cent were unaware of PEC for practising surgeons. All respondents felt that they would benefit from PEC to some extent (80% ≥8/10 where 10/10 was 'very useful'), ideally at the ST3 level. Sixty-two percent of respondents said there should be a fee for trainees, whereas 38% thought it should be free and paid for by their training authorities.

CONCLUSION

The concept of PEC is acceptable to ST3 Urology trainees, with particular interest in techniques to mitigate negative self-talk and autonomic modulation techniques. Existing barriers to coaching for the surgical community would need to be addressed in designing an acceptable coaching programme.

Putting the coach in the game: Current and future state of surgical coaching in pediatric urology

BACKGROUND

Surgical coaching has been proposed as a mechanism to fill gaps in proficiency and encourage continued growth following formal surgical training. Coaching benefits have been demonstrated in other surgical fields; however, have not been evaluated within pediatric urology. The aims of this study were to survey members of The Societies for Pediatric Urology (SPU) to assess the current understanding and utilization of surgical coaching while gauging interest, potential barriers and personal goals for participation in a coaching program.

METHODS

Following IRB approval, members of the SPU were invited to electronically complete an anonymous survey which assessed 4 domains: 1) understanding of surgical coaching principles, 2) current utilization, 3) interest and potential barriers to participation, and 4) personal surgical goals. To evaluate understanding, questions with predefined correct answers on the key principles of coaching were posed either in multiple choice or True/False format to the SPU membership.

RESULTS

Of the 674 pediatric urologists invited, 146 completed the survey (22%). Of those, 46% correctly responded the definition of surgical coaching. Coaching utilization was reported in 27% of respondents currently or having previously participated in a surgical coaching program. Despite current participation rates, only 6 surgeons (4%) have completed training in surgical coaching, despite 79% expressing interest to participate in a surgical coaching program. The most influential barrier to participating in a coaching program was time commitment. Respondents largely prioritized technical and cognitive skill improvement as their primary goals for coaching (see figure below).

CONCLUSIONS

While interest in surgical coaching is high among pediatric urologists, the principles of surgical coaching were not universally understood. Furthermore, formal coach training is markedly deficient, representing a gap in our profession and an opportunity for significant avenues for improvement, especially for technical and cognitive skills. Development of a coaching model based on these results would best suit the needs of pediatric urologists providing that the time commitment barrier for these endeavors can be mitigated and/or reconciled.

Data-driven coaching to improve statewide outcomes in CABG: before and after interventional study

BACKGROUND

The impact of quality improvement initiatives program (QIP) on coronary artery bypass grafting surgery (CABG) remains scarce, despite improved outcomes in other surgical areas. This study aims to evaluate the impact of a package of QIP on mortality rates among patients undergoing CABG.

MATERIALS AND METHODS

This prospective cohort study utilized data from the multicenter database Registro Paulista de Cirurgia Cardiovascular II (REPLICCAR II), spanning from July 2017 to June 2019. Data from 4018 isolated CABG adult patients were collected and analyzed in three phases: before-implementation, implementation, and after-implementation of the intervention (which comprised QIP training for the hospital team). Propensity Score Matching was used to balance the groups of 2170 patients each for a comparative analysis of the following outcomes: reoperation, deep sternal wound infection/mediastinitis ≤30 days, cerebrovascular accident, acute kidney injury, ventilation time >24 h, length of stay <6 days, length of stay >14 days, morbidity and mortality, and operative mortality. A multiple regression model was constructed to predict mortality outcomes.

RESULTS

Following implementation, there was a significant reduction of operative mortality (61.7%, P =0.046), as well as deep sternal wound infection/mediastinitis ( P <0.001), sepsis ( P =0.002), ventilation time in hours ( P <0.001), prolonged ventilation time ( P =0.009), postoperative peak blood glucose ( P <0.001), total length of hospital stay ( P <0.001). Additionally, there was a greater use of arterial grafts, including internal thoracic ( P <0.001) and radial ( P =0.038), along with a higher rate of skeletonized dissection of the internal thoracic artery.

CONCLUSIONS

QIP was associated with a 61.7% reduction in operative mortality following CABG. Although not all complications exhibited a decline, the reduction in mortality suggests a possible decrease in failure to rescue during the after-implementation period.

POSNA Leadership Program (PLP): Developing surgeon leaders for patients, organizations, and our society

The Pediatric Orthopaedic Society of North America (POSNA) initiated a Leadership Program in 2022. The POSNA Leadership Program (PLP) is designed to enhance emotional intelligence (social skills, empathy, communication, self-regulation, and self-awareness) and in-depth leadership skill development for selected participants in a year-long seminar. Disruptive behaviors detrimental to health care professionals, patients, and care delivery organizations can be identified and lessened through education. Most surgeons rightfully focus their learning intently on specific surgical knowledge and technical expertise, especially in the early and middle career stages. Despite this, surgical errors still occur secondary to limitations of nontechnical surgical skills: decision-making, communication, leadership, and teamwork. More senior surgeons are also prone to leadership and communication errors. By gaining education and expertise in nontechnical surgical skills, improved team building with more professional staff engagement, empowerment, and trust can result in lower risk.

Coaching your faculty and yourself

Surgical skills vary drastically among practicing surgeons. This variation in skill has been demonstrated to translate directly into patient outcomes, highlighting the importance of skill development. Despite this, directed efforts to improve surgical skills and performance among practicing surgeons remain limited. The development of surgical coaching programs offers an exciting opportunity for surgeon performance improvement and lifelong development. In this article, we will discuss the promise of surgical coaching programs, some of the challenges met when developing a program, and future avenues and opportunities for growth within the field.

Standardization and Implementation of a Surgical Coaching Model for Pediatric Urology

To bridge gaps in proficiency and encourage life-long learning following training, coaching models have been utilized in multiple surgical fields; however, not within pediatric urology. In this review of our methodology, we describe the development of a coaching model at a single institution. In our initial experience, the perceived most beneficial aspect of the program was the goal setting process with logistics around debriefs being the most challenging. With our proposed coaching study, we aim to develop a model based upon prior coaching frameworks,1,2 that is feasible and universally adaptable to allow for further advancement of surgical coaching, particularly within the field of pediatric urology.

Training for excellence: using a multimodal videoconferencing platform to coach surgeons and improve intraoperative performance

INTRODUCTION

Continuing Professional Development opportunities for lifelong learning are fundamental to the acquisition of surgical expertise. However, few opportunities exist for longitudinal and structured learning to support the educational needs of surgeons in practice. While peer-to-peer coaching has been proposed as a potential solution, there remains significant logistical constraints and a lack of evidence to support its effectiveness. The purpose of this study is to determine whether the use of remote videoconferencing for video-based coaching improves operative performance.

METHODS

Early career surgeon mentees participated in a remote coaching intervention with a surgeon coach of their choice and using a virtual telestration platform (Zoom Video Communications, San Jose, CA). Feedback was articulated through annotating videos. The coach evaluated mentee performance using a modified Intraoperative Performance Assessment Tool (IPAT). Participants completed a 5-point Likert scale on the educational value of the coaching program.

RESULTS

Eight surgeons were enrolled in the study, six of whom completed a total of two coaching sessions (baseline, 6-month). Subspecialties included endocrine, hepatopancreatobiliary, and surgical oncology. Mean age of participants was 39 (SD 3.3), with mean 5 (SD 4.1) years in independent practice. Total IPAT scores increased significantly from the first session (mean 47.0, SD 1.9) to the second session (mean 51.8, SD 2.1), p = 0.03. Sub-category analysis showed a significant improvement in the Advanced Cognitive Skills domain with a mean of 33.2 (SD 2.5) versus a mean of 37.0 (SD 2.4), p < 0.01. There was no improvement in the psychomotor skills category. Participants agreed or strongly agreed that the coaching programs can improve surgical performance and decision-making (coaches 85%; mentees 100%).

CONCLUSION

Remote surgical coaching is feasible and has educational value using ubiquitous commercially available virtual platforms. Logistical issues with scheduling and finding cases aligned with learning objectives continue to challenge program adoption and widespread dissemination.

Surgical Education

This paper summarizes the proceedings of the joint European Surgical Association ESA/American Surgical Association symposium on Surgical Education that took place in Bordeaux, France, as part of the celebrations for 30 years of ESA scientific meetings. Three presentations on the use of quantitative metrics to understand technical decisions, coaching during training and beyond, and entrustable professional activities were presented by American Surgical Association members and discussed by ESA members in a symposium attended by members of both associations.

Coaching with audiovisual technology in acute-care hospital settings: systematic review

BACKGROUND

Surgical coaching programmes are a means of improving surgeon performance. Embedded audiovisual technology has the potential to further enhance participant benefit and scalability of coaching. The objective of this systematic review was to evaluate how audiovisual technology has augmented coaching in the acute-care hospital setting and to characterize its impact on outcomes.

METHODS

A systematic review was conducted, searching PubMed, Ovid MEDLINE, Embase, PsycInfo, and CINAHL databases using PRISMA. Eligible studies described a coaching programme that utilized audiovisual technology, involved at least one coach-coachee interaction, and included healthcare professionals from the acute-care hospital environment. The risk of bias 2 tool and grading of recommendations, assessment, development, and evaluations (GRADE) framework were used to evaluate studies. Synthesis without meta-analysis was performed, creating harvest plots of three coaching outcomes: technical skills, self-assessment/feedback, and non-technical skills.

RESULTS

Of 10 458 abstracts screened, 135 full texts were reviewed, and 21 studies identified for inclusion. Seventeen studies were conducted within surgical specialties and six classes of audiovisual technology were utilized. An overall positive direction of effect was demonstrated for studies measuring improvement of either technical skills or non-technical skills. Direction of effect for self-assessment/feedback was weakly positive.

CONCLUSION

Audiovisual technology has been used successfully in coaching programmes within acute-care hospital settings to facilitate or assess coaching, with a positive impact on outcome measures. Future studies may address the additive benefits of video over in-person observation and enhance the certainty of evidence that coaching impacts on surgeon performance, surgeon well-being, and patient outcomes.

Residents as Medical Coaches

OBJECTIVES

With the recent implementation of Competency-based Medical Education (CBME) and emphasis on direct observation of learners, there is an increased interest in the concept of clinical coaching. While there is considerable literature on the role of attending physicians as coaches, little data is available on the role of residents as coaches, and residents' perceptions about effective coaching. We aimed to identify distinct characteristics of residents' coaching, to examine residents' perceptions on what they valued most in clinical coaches, and to explore trainees' ideas about how to optimize this role.

DESIGN

We performed an exploratory qualitative study, using 45 minutes semi-structured interviews. We did a thematic analysis of the interview transcripts using both inductive and deductive coding.

PARTICIPANTS

We invited and interviewed 5 surgical and 5 nonsurgical residents, and 3 surgical and 3 nonsurgical attending staff. Residents were recruited from all post graduate levels and from a variety of programs.

SETTING

Our study was done in a large tertiary teaching hospital.

RESULTS

Residents perceived that they have a significant role as coaches for junior learners, different from the attending's role. The proximity between the coach and the coaches leads to a different supervisor-learner rapport. This was of benefit as learners described feeling more comfortable making mistakes and seeking feedback, which potentiates effective coaching. Residents reported feeling that it was easier to coach their recently-acquired skills as the subtleties of the tasks and the troubleshooting were fresher in memory. Residents expressed appreciating a coach who values autonomy and does not intervene except when patient safety is at risk. Strategies identified to further optimize residents' role as coaches include placing coaching as a priority, ensuring dedicated time, and offering teaching sessions on coaching.

CONCLUSIONS

Residents have distinct roles as coaches, driven by their recent experience being coached and as near peers. More research is needed to evaluate concrete measures to optimize residents' role as coaches and to improve their coaching skills.

Surgical Coaching: Patient Perspectives Regarding Surgeon Coaches in the Operating Room

BACKGROUND

Surgical coaching programs have been introduced as platforms for ongoing professional development amongst independently practicing surgeons. While there is a plethora of evidence regarding the effectiveness of surgical coaching for practicing staff surgeons, patients' opinions regarding surgical coaching are largely unknown.

OBJECTIVES

To determine patients' baseline attitudes and opinions about the hypothetical situation of their treating surgeon having a surgical coach present during their upcoming operation, and to determine patients' baseline knowledge and prior exposure to surgical coaching.

DESIGN AND SETTING

This study was conducted at a tertiary hospital in Vancouver, Canada. Patients on the surgical waitlist of 2 independently practicing Otolaryngologists within the subspeciality of Neurotology were invited to participate in the study. Participants engaged in a semi-structured interview to discuss their opinions and knowledge of physician coaches and to learn about surgical coaching. The interview was conducted based on a pre-set script.

RESULTS

Of the 100 patients approached, 70 consented to participate. Forty-three (61%) participants identified as female, and the mean age was 56±15 years. Initially, 84% of participants (n = 59) consented to the hypothetical presence of a surgical coach. Post-discussion, this number increased to 95.7% (n = 67, p = 0.04). Prior participant exposure to coaching related to employment, education, athletics, or music was high (90%, n = 63). Younger participants between 25 and 45 years of age were more amenable to the presence of a surgical coach compared to participants >66 years of age (p = 0.01). After the interview, 55 (79%) participants were interested in learning more about surgical coaching.

CONCLUSION

Many patients were unaware of the rationale and importance of surgical coaching programs for practicing staff surgeons. Most patients, especially younger patients, were amenable to the presence of a surgical coach during their surgery, and this number increased in all age categories with patient education about surgical coaching.

Improving Surgical Excellence: Can Coaching Surgeons Improve Patient Engagement?

INTRODUCTION

Non-technical skills complement technical skills in surgeons to provide best possible care for patients. The former is essential to promote patient engagement. Coaching has been introduced to surgeons as a method to improve non-technical skills. We aimed to investigate the impact of coaching for surgeons on patient engagement in the outpatient consultation setting.

METHODS

This was a single-centre cohort study conducted in South Australia. Consultant surgeons, suitable coaches, and patients were recruited. Coaches underwent further training by a human factors psychologist on being an effective coach. Outpatient consultations were recorded in an audio-visual format and analysed by investigators. Patient talking time, mutual eye gaze between surgeon and patient, and number of questions asked by the patient were measured as outcomes for patient engagement.

RESULTS

182 patients, 12 surgeons, and 4 coaches participated in the study. Each surgeon underwent 3 coaching sessions, 5 to 6 weeks apart. There were 62 pre-coaching patient consultations, 63 patient consultations after one coaching session, and 57 patient consultations after two coaching sessions. The mean talking time of the patient increased significantly after a single coaching session (P < 0.05) without making significant difference to the total consultation time (p = 0.76). Coaching sessions did not have a significant effect on mutual eye gaze or mean number of questions asked by the patient.

CONCLUSION

Coaching of non-technical skills for surgeons appears to objectively improve patient engagement during the outpatient consultation. This would suggest that tailored coaching programs should be developed and delivered to surgeons to improve care delivery.

Stress in surgical educational environments: a systematic review

BACKGROUND

The effects of stress on surgical residents and how stress management training can prepare residents to effectively manage stressful situations is a relevant topic. This systematic review aimed to analyze the literature regarding (1) the current stress monitoring tools and their use in surgical environments, (2) the current methods in surgical stress management training, and (3) how stress affects surgical performance.

METHODS

A search strategy was implemented to retrieve relevant articles from Web of Science, Scopus, and PubMed. The 787 initially retrieved articles were reviewed for further evaluation according to the inclusion/exclusion criteria (Prospero registration number CRD42021252682).

RESULTS

Sixty-one articles were included in the review. The stress monitoring methods found in the articles showed heart rate analysis as the most used monitoring tool for physiological parameters while the STAI-6 scale was preferred for psychological parameters. The stress management methods found in the articles were mental-, simulation- and feedback-based training, with the mental-based training showing clear positive effects on participants. The studies analyzing the effects of stress on surgical performance showed both negative and positive effects on technical and non-technical performance.

CONCLUSIONS

The impact of stress responses presents an important factor in surgical environments, affecting residents' training and performance. This study identified the main methods used for monitoring stress parameters in surgical educational environments. The applied surgical stress management training methods were diverse and demonstrated positive effects on surgeons' stress levels and performance. There were negative and positive effects of stress on surgical performance, although a collective pattern on their effects was not clear.

Coaching for Surgeons: A Scoping Review of the Quantitative Evidence

To characterize quantitative studies on coaching interventions for professional surgeons to understand how surgical coaching is defined; examine how different coaching programs are designed, implemented, and evaluated; and identify any relevant research gaps.

Background

Surgical coaching is gaining attention as an approach that could help surgeons optimize performance and improve overall wellbeing. However, surgical coaching programs and definitions of coaching vary widely between studies.

Methods

A systematic literature search of PubMed, Scopus, Web of Science, CENTRAL, clinicaltrials.gov, and WHO ICTRP was conducted according to the PRISMA-ScR framework to identify studies and registered clinical trials written in English. Original quantitative studies on coaching interventions for professional surgeons were included. Characteristics of the coachees, coaching programs, study designs, outcomes, and findings were charted and analyzed.

Results

From 2589 references, 8 studies (6 published; 2 registered trials) met inclusion criteria. Published studies targeted technical or nontechnical skills, included 2-26 surgeons as coachees, and used coaches who were surgeons. Two studies demonstrated that surgeons react positively to coaching. Studies showed inconsistent effects on technical/nontechnical skills. Only two studies measured patient adverse events and reported no significant positive impacts. The registered randomized trials targeted surgeons' physiological parameters or wellbeing and used professional coaches. These trials measure surgeon and patient outcomes.

Conclusions

There is an emerging interest in coaching programs to improve surgeons' performance by targeting their professional skills and personal factors. However, more randomized trials are needed to evaluate the impact of coaching interventions on patient outcomes and surgeon wellness.

Operative Coaching for General Surgery Residents: Review of Implementation Requirements

Operative coaching offers a unique opportunity to strengthen surgery residents' skill sets and practice readiness. However, institutional organizational capacity may influence the ability to successfully implement and sustain a coaching program. This review concentrates on the implementation requirements as they relate to institutional organizational capacity to help evaluate and determine if adopting such a coaching model is feasible. We searched English-language, peer-reviewed articles concerning operative coaching of general surgery residents between 2000 and 2020 with the MEDLINE database. The abstracts of 267 identified articles were further screened based on the presence of 2 inclusion criteria: general surgery residents and operative coaching. Then we summarized the reported implementation requirements. Findings revealed the implementation requirements (ie people, processes, technology/support resources, physical resources, and organizational systems) of 3 major types of resident operative coaching models were different. Video-assisted coaching faces the most barriers to implementation followed by video-based coaching; in-person coaching encounters the least barriers. Six questions are generated helping residency education leaders assess their readiness for an operative coaching program. Evaluation of the implementation requirements of a desired coaching program using the 5 organizational capacity elements is recommended to ensure the residency's ability to achieve a successful and sustainable program.

Anterior plating technique for distal radius: comparing performance after learning through naive versus deliberate practice

BACKGROUND

Surgical teaching is most often carried out in the operating theatre through mentorship, and the performance of surgical procedures is rarely measured. The objective of this article is to compare the progression in learning curves of junior surgeons trained in the anterior plating technique for the distal radius on a nonbiological model according to three different methods.

METHODS

The materials comprised 12 junior surgeons of level 1 or 2 (as per Tang and Giddins) divided into three groups: control (G1), naive practice (G2), and deliberate practice (G3). The three groups watched a demonstration video of a level 5 expert. The four G1 surgeons (two level 1 and two level 2) saw the video only once, and each inserted five plates. The four G2 surgeons (two level 1 and two level 2) inserted five plates and watched the video before each time. The four G3 surgeons (two level 1 and two level 2) saw the video before the first plate insertion. Before posing the subsequent four plates, the four G3 surgeons watched their own video, and the expert indicated their errors and how to avoid them next time. A 12-criteria OSATS defined on the basis of the 60 videos, each graded from one (min.) to five (max.), was used to measure the objective surgical performance per plating (min. 12; max. 60) and per series of five plate fixations (min. 60, max. 300).

RESULTS

The total average objective performance of G1 was 44.73, of G2 was 50.57 and of G3 was 54.35. Change in objective performance was better for G3 (13.25) than G2 (5) or G1 (3.75). For all groups, the progression in objective performance was better amongst level 1 surgeons (9) than level 2 surgeons (5.6).

CONCLUSION

Surgical teaching is based on mentorship and experience. However, since "see one, practice many, do one" has started to replace "see one, do one, teach one", learning techniques have increasingly relied on procedure simulators. Against this background, few studies have looked at measuring the performance of surgical procedures and improved learning curves. Our results appear to suggest that deliberate practice, when used in addition to mentorship, is the best option for shortening the growth phase of the learning curve and improving performance. Deliberate practice is a learning technique for surgical procedures that is complementary to mentorship and experience, which allows the growth phase of the learning curve to be shortened and the objective performance of junior surgeons to be improved.

Reciprocal peer coaching for practice improvement in surgery: a pilot study

BACKGROUND

Peer coaching has been associated with much higher rates of practice changes and new skill implementation compared to common used modalities but bilateral peer coaching structures where seniority is not a requirement to coach have not been studied. The purpose of this study was to implement and evaluate a reciprocal peer coaching pilot program for practicing surgeons to inform future coaching program design.

METHODS

A multicenter reciprocal peer surgical coaching program was designed according to the framework developed from previous studies by our group. The coach-coachee matching process was voluntary and autonomous. All participants received basic coaching skills training. Pairs were instructed to complete two coaching sessions, alternating between the coach or coachee role for each session. Data were collected through questionnaires and structured interviews.

RESULTS

Twenty-two participants enrolled in the pilot study and completed the coach training (88% enrollment rate). During the first wave of COVID-19, 12 participants withdrew. Of the five pairs that completed the program, three pairs were composed of general surgeons, one of orthopedic surgeons, and one ophthalmologic surgeon. Three sessions were conducted live in the OR, five virtually, and one involved an in-person discussion. Overall satisfaction with the program was high and all participants expectations were met. Participants were significantly more likely to predict "routinely" asking for feedback from their partner after study completion (6, 66%) compared to pre-intervention (p = 0.02).

CONCLUSION

This pilot study supports the feasibility of a peer coaching model for surgeons in practice that emphasized reciprocity and participant autonomy. These key elements should be considered when designing future coaching programs.

Coaching to enhance qualified surgeons' non-technical skills: a systematic review

INTRODUCTION

The lack of an effective continuing professional development programme for qualified surgeons, specifically one that enhances non-technical skills (NTS), is an issue receiving increased attention. Peer-based coaching, used in multiple professions, is a proposed method to deliver this. The aim of this study was to undertake a systematic review of the literature to summarize the quantity and quality of studies involving surgical coaching of NTS in qualified surgeons.

METHODS

A systematic search of the literature was performed through MEDLINE, EMBASE, Cochrane Collaboration and PsychINFO. Studies were selected based on predefined inclusion and exclusion criteria. Data for the included studies was independently extracted by two reviewers and the quality of the studies evaluated using the Medical Education and Research Study Quality Instrument (MERSQI).

RESULTS

Some 4319 articles were screened from which 19 met the inclusion criteria. Ten studies involved coaching of individual surgeons and nine looked at group coaching of surgeons as part of a team. Group coaching studies used non-surgeons as coaches, included objective assessment of NTS, and were of a higher quality (average MERSQI 13.58). Individual coaching studies focused on learner perception, used experienced surgeons as coaches and were of a lower quality (average MERSQI 11.58). Individual coaching did not show an objective improvement in NTS for qualified surgeons in any study.

CONCLUSION

Surgical coaching of qualified surgeons' NTS in a group setting was found to be effective. Coaching of individual surgeons revealed an overall positive learner perception but did not show an objective improvement in NTS for qualified surgeons.

Development of a laparoscopic surgical skills simulation curriculum: Enhancing resident training through directed coaching and closed-loop feedback

BACKGROUND

Performance feedback through peer coaching and rigorous self-assessment is a critical part of technical skills improvement. However, formal collaborative programs using operative video-based skills assessments to generate peer coaching feedback have only been validated among attending surgeons. In this study, we developed a unique longitudinal, simulation video-based laparoscopic skills resident curriculum using video-based peer coaching and evaluated its association with skills acquisition among surgical trainees.

METHODS

The laparoscopic simulation curriculum consists of a pre-practice laparoscopic skill video recording, followed by receipt of directed coaching and feedback on performance from a faculty coach, a peer coach, and self-coaching. Residents then completed 6 weeks of feedback-directed practice and submitted a second post-practice laparoscopic skill video recording of the same skill, which was evaluated by a minimally invasive surgery expert grader. All general surgery residents in a single institution were enrolled, with 107 residents completing the curriculum in its initial 2 years.

RESULTS

Overall, more than two-thirds of residents achieved skills proficiency on their expert assessments, with similar rates of residents achieving skills proficiency at all postgraduate year levels. Significant improvements between the pre-practice assessments and post-practice assessments were most frequently seen in the instrument handling, precision, and motion & flow categories (P < .05 each). Faculty provided the highest number and proportion of closed-loop comments; residents' self-coaching feedback had the lowest number of closed-loop comments, with 83% of self-assessments containing none.

CONCLUSION

In this study, we describe the successful implementation of a longitudinal laparoscopic skills video-based coaching curriculum designed to improve residents' laparoscopic technical abilities through iterative directed practice supplemented by formative closed-loop feedback. This feasible, reproducible, and low-cost simulation curriculum can be adapted to other training programs and skills acquisition endeavors. This program also prepares trainees for ongoing performance feedback after completion of residency through rigorous self-assessment and peer-to-peer coaching.