Why Don’t Surgeons Have Coaches?

Wednesday, October 12th, 2011

After receiving some good tennis coaching, surgeon Atul Gawande wondered, why don’t surgeons have coaches?

Good coaches know how to break down performance into its critical individual components. In sports, coaches focus on mechanics, conditioning, and strategy, and have ways to break each of those down, in turn. The U.C.L.A. basketball coach John Wooden, at the first squad meeting each season, even had his players practice putting their socks on. He demonstrated just how to do it: he carefully rolled each sock over his toes, up his foot, around the heel, and pulled it up snug, then went back to his toes and smoothed out the material along the sock’s length, making sure there were no wrinkles or creases. He had two purposes in doing this. First, wrinkles cause blisters. Blisters cost games. Second, he wanted his players to learn how crucial seemingly trivial details could be. “Details create success” was the creed of a coach who won ten N.C.A.A. men’s basketball championships.
Élite performers, researchers say, must engage in “deliberate practice” — sustained, mindful efforts to develop the full range of abilities that success requires. You have to work at what you’re not good at. In theory, people can do this themselves. But most people do not know where to start or how to proceed. Expertise, as the formula goes, requires going from unconscious incompetence to conscious incompetence to conscious competence and finally to unconscious competence. The coach provides the outside eyes and ears, and makes you aware of where you’re falling short. This is tricky. Human beings resist exposure and critique; our brains are well defended. So coaches use a variety of approaches — showing what other, respected colleagues do, for instance, or reviewing videos of the subject’s performance. The most common, however, is just conversation.

Gawande brought in a retired general surgeon, under whom he’d trained during his residency, as his coach:

He saw only small things, he said, but, if I were trying to keep a problem from happening even once in my next hundred operations, it’s the small things I had to worry about. He noticed that I’d positioned and draped the patient perfectly for me, standing on his left side, but not for anyone else. The draping hemmed in the surgical assistant across the table on the patient’s right side, restricting his left arm, and hampering his ability to pull the wound upward. At one point in the operation, we found ourselves struggling to see up high enough in the neck on that side. The draping also pushed the medical student off to the surgical assistant’s right, where he couldn’t help at all. I should have made more room to the left, which would have allowed the student to hold the retractor and freed the surgical assistant’s left hand.

Osteen also asked me to pay more attention to my elbows. At various points during the operation, he observed, my right elbow rose to the level of my shoulder, on occasion higher. “You cannot achieve precision with your elbow in the air,” he said. A surgeon’s elbows should be loose and down by his sides. “When you are tempted to raise your elbow, that means you need to either move your feet” — because you’re standing in the wrong position — “or choose a different instrument.”

He had a whole list of observations like this. His notepad was dense with small print. I operate with magnifying loupes and wasn’t aware how much this restricted my peripheral vision. I never noticed, for example, that at one point the patient had blood-pressure problems, which the anesthesiologist was monitoring. Nor did I realize that, for about half an hour, the operating light drifted out of the wound; I was operating with light from reflected surfaces. Osteen pointed out that the instruments I’d chosen for holding the incision open had got tangled up, wasting time.

That one twenty-minute discussion gave me more to consider and work on than I’d had in the past five years. It had been strange and more than a little awkward having to explain to the surgical team why Osteen was spending the morning with us. “He’s here to coach me,” I’d said. Yet the stranger thing, it occurred to me, was that no senior colleague had come to observe me in the eight years since I’d established my surgical practice. Like most work, medical practice is largely unseen by anyone who might raise one’s sights. I’d had no outside ears and eyes.

Osteen has continued to coach me in the months since that experiment. I take his observations, work on them for a few weeks, and then get together with him again. The mechanics of the interaction are still evolving. Surgical performance begins well before the operating room, with the choice made in the clinic of whether to operate in the first place. Osteen and I have spent time examining the way I plan before surgery. I’ve also begun taking time to do something I’d rarely done before — watch other colleagues operate in order to gather ideas about what I could do.

A former colleague at my hospital, the cancer surgeon Caprice Greenberg, has become a pioneer in using video in the operating room. She had the idea that routine, high-quality video recordings of operations could enable us to figure out why some patients fare better than others. If we learned what techniques made the difference, we could even try to coach for them. The work is still in its early stages. So far, a handful of surgeons have had their operations taped, and begun reviewing them with a colleague.

I was one of the surgeons who got to try it. It was like going over a game tape. One rainy afternoon, I brought my laptop to Osteen’s kitchen, and we watched a recording of another thyroidectomy I’d performed. Three video pictures of the operation streamed on the screen — one from a camera in the operating light, one from a wide-angle room camera, and one with the feed from the anesthesia monitor. A boom microphone picked up the sound.

Osteen liked how I’d changed the patient’s positioning and draping. “See? Right there!” He pointed at the screen. “The assistant is able to help you now.” At one point, the light drifted out of the wound and we watched to see how long it took me to realize I’d lost direct illumination: four minutes, instead of half an hour.

“Good,” he said. “You’re paying more attention.”

He had new pointers for me. He wanted me to let the residents struggle thirty seconds more when I asked them to help with a task. I tended to give them precise instructions as soon as progress slowed. “No, use the DeBakey forceps,” I’d say, or “Move the retractor first.” Osteen’s advice: “Get them to think.” It’s the only way people learn.

And together we identified a critical step in a thyroidectomy to work on: finding and preserving the parathyroid glands — four fatty glands the size of a yellow split pea that sit on the surface of the thyroid gland and are crucial for regulating a person’s calcium levels. The rate at which my patients suffered permanent injury to those little organs had been hovering at two per cent. He wanted me to try lowering the risk further by finding the glands earlier in the operation.

Since I have taken on a coach, my complication rate has gone down. It’s too soon to know for sure whether that’s not random, but it seems real. I know that I’m learning again. I can’t say that every surgeon needs a coach to do his or her best work, but I’ve discovered that I do.

Eventually he does answer his original question, by explaining what happened after a lapse in his professional judgment:

My cheeks burned; I was mortified. I wished I’d never asked him along. I tried to be rational about the situation — the patient did fine. But I had let Osteen see my judgment fail; I’d let him see that I may not be who I want to be.

This is why it will never be easy to submit to coaching, especially for those who are well along in their career. I’m ostensibly an expert. I’d finished long ago with the days of being tested and observed. I am supposed to be past needing such things. Why should I expose myself to scrutiny and fault-finding?

I have spoken to other surgeons about the idea. “Oh, I can think of a few people who could use some coaching” has been a common reaction. Not many say, “Man, could I use a coach!” Once, I wouldn’t have, either.
I knew that he could drive me to make smarter decisions, but that afternoon I recognized the price: exposure.

For society, too, there are uncomfortable difficulties: we may not be ready to accept — or pay for — a cadre of people who identify the flaws in the professionals upon whom we rely, and yet hold in confidence what they see. Coaching done well may be the most effective intervention designed for human performance. Yet the allegiance of coaches is to the people they work with; their success depends on it. And the existence of a coach requires an acknowledgment that even expert practitioners have significant room for improvement. Are we ready to confront this fact when we’re in their care?

“Who’s that?” a patient asked me as she awaited anesthesia and noticed Osteen standing off to the side of the operating room, notebook in hand.

I was flummoxed for a moment. He wasn’t a student or a visiting professor. Calling him “an observer” didn’t sound quite right, either.

“He’s a colleague,” I said. “I asked him along to observe and see if he saw things I could improve.”

The patient gave me a look that was somewhere between puzzlement and alarm.

“He’s like a coach,” I finally said.

She did not seem reassured.

Leave a Reply