Can You Teach an Old Surgeon New Tricks?
Leaders of the Michigan Bariatric Surgery Collaborative have developed a way to teach practicing surgeons how to perform their operations better.
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The Oxford dictionary defines a coach as “an instructor or trainer in sport.” Atul Gawande, M.D., M.P.H., surgeon, writer and public health researcher at the Brigham and Women’s Hospital (BWH), provides a broader definition of coaching in his New Yorker article, “Personal Best”: “The concept of a coach is slippery. Coaches are not teachers, but they teach. They’re not your boss, but they can be bossy. They don’t even have to be good at the sport. The famous Olympic gymnastics coach Bela Karolyi couldn’t do a split if his life depended on it. Mainly, they observe, they judge and they guide.” Using Gawande’s description, the title of “coach” could apply to those practicing professions beyond sports—including surgery.
Justin Dimick, M.D., M.P.H., George D. Zuidema Professor of Surgery and Chief of the Division of Minimally Invasive Surgery at the University of Michigan (U-M) have been working with fellow surgeons in the Michigan Bariatric Surgery Collaborative (MBSC) to improve the quality of the operations they perform.
Currently, there are many programs in place that focus on improving care processes before and after the surgery, “but we thought it was time to start focusing on the surgery itself,” Dimick said.
The key question was: “For surgeons already in practice, already out there on their own, how do they learn new things, and how do they improve themselves?” Dimick and the other leaders of MBSC found that “what many [surgeons] recommend as the safest and the best way to learn things, and the things that they are actually doing aren’t the same.”
Before they could figure out how to improve surgery, they needed a method to measure the quality of an operation. Although measuring the skill of a surgeon seems simple enough, a study like this had never been performed before.
Dimick and the other MBSC leaders collected videos of bariatric surgeries around the state. The surgeons looked at each other’s videos and rated the other surgeons’ skills. Dimick then linked the rating to the outcomes of the surgeries, as well as the complications that arose during or after. When he analyzed the data, he was not surprised to find a strong correlation between the rating of the surgeons and the surgical outcomes: surgeons with higher skill rating had fewer complications and better outcomes.
Having discovered the bariatric surgeons with the best technical skills in the state was a strong start, but they still did not know how to—or if they could—improve the skills of other surgeons. Dimick was familiar with Gawande’s article. “[In it] he raised this issue of why is it that professional musicians and professional athletes who are the best in the world have coaches, but surgeons, who also rely on peak physical or technical performance, don’t have coaches,” Dimick said.
This idea formed the basis of their plan to improve surgical skill among MBSC surgeons. “We wrote a grant to the National Institute of Health and they funded it to develop a coaching program and have surgeons from around the state coach each other on their technical performance,” Dimick said. He compared it to a post-game video review for sports like football: “You video yourself operating, you sit down with somebody who’s one of the best performers in the state and you get feedback on your performance.”
Caprice Greenberg, M.D., M.P.H., Associate Professor of Surgery and Director of the Wisconsin Surgical Outcomes Research Program at the University of Wisconsin-Madison, launched a pilot that was tested at BWH, Gawande’s hospital, in Boston. The pilot program was a small group of surgeons focusing on the feasibility of a coaching program, trying to see how it would work and what it would look like. After the initial pilot at BWH, Greenberg tested the concept in Wisconsin in what she called the Wisconsin Surgical Coaching Program.
However, Dimick’s program in Michigan is the largest surgical coaching program to date. The 12 surgeons who had received the highest ratings in the original videos were trained to be coaches. “We didn’t train them in how to do the operation better, because they already knew how to do the operation well,” Dimick said. “We trained them on how to give feedback well and how to sit with a peer. You have two fully trained surgeons, these aren’t residents, these aren’t trainees, these are people that are all done, out on their own, and you have to give them feedback.”
At the start of each meeting, the coaches sit down with their “coachees” for two hours. During this time they go over the video that the coachee submitted, and the coach gives them tips, tricks and techniques for improvement.
There are two main things that Dimick is hoping to accomplish through the surgical coaching program. “One is to improve care for the patients that are undergoing bariatric surgery in our collaborative—improve the technical skills, up everybody’s game a little bit,” Dimick said. “But I think there’s a much bigger goal than that, and that is to develop a scientific understanding of how to do coaching like this so that other places in the country, and other procedures, can adopt it. I think that it’s a model that can be used for almost any procedure or intervention, and someone has to do the scientific work to figure out how it should be done and what it should look like.”
In other words, there is the short-term goal of improving the specific bariatric surgery that they are focusing on, but a long-term goal of fully understanding how to create a coaching program like this for other physicians around the world.
This program is right up Dimick’s alley. All of his projects focus on improving care for surgical patients in two ways. “One is to directly implement projects like this one that are innovative ways of improving care,” he said. Dimick’s other specialty is evaluating medical care public policies put in place to improve care. He tries to understand whether they lead to better outcomes or save money.
Although similar to many of the other projects he is involved in, the surgical coaching program is different in that “it’s an implementation project,” Dimick said. “We’re not just evaluating things, we’re not just analyzing data, we actually have to do something, put something into motion.”
It generated tremendous national attention in the scientific and mainstream press. Although the project has been successful, there have been challenges along the way. Surgeons were hesitant to join this program in the beginning because it is often challenging for them to come to terms with the fact that their technical skills are below that of their peers. Furthermore, accepting coaching from a peer is not easy for most people—let alone an accomplished surgeon.
Getting past this barrier “is really not an exercise in research, it’s an exercise in leadership—developing relationships with people and convincing them that it’s a worthwhile thing to participate in,” Dimick said.
Luckily, there have been no major setbacks. “I think the best way to overcome an obstacle is to see it coming and prevent it,” Dimick said. “We’ve been pretty good at preventing things, partly through paranoia, partly through the fact that we had a good leadership team.”
MBSC has been a great asset. “If I didn’t know them through the collaborative and if the team didn’t know them through the collaborative, this never would’ve happened,” Dimick said. “Those relationships, those preexisting relationships, enabled this.”
Relationships have played a central role in this program’s success. “We spent a lot of time developing relationships in a way that they feel like they’re going to get value out of it and that we’re not wasting their time,” Dimick said. “[That is] the biggest barrier in getting people to participate in anything: if you’re going to waste their time.”
Ultimately, surgeons and other physicians will accept peer coaching, even if it is hard, because they want to do what’s best for their patients. “You can do great things if you can convince people that you’re making the world a better place.”