Coaching for Improving Clinical Performance of Surgeons: A Scoping Review

doi:10.21203/rs.3.rs-2977326/v1

Background

Like multiple successful coaching programs in many fields, surgical coaching has been developed and proven to be an effective way for clinical performance improvement. However, the strategy for surgical coaching implementation varied in a multitude of aspects, causing confusion for initializing new programs. The goal of our scoping review was to summarize the current literature about surgical coaching, which can help to direct future coaching programs.

Methods

We reviewed published articles in PubMed/Medline and suppletory manuscripts from reference lists. The protocol of our review was registered (osf.io, Z3S8H). Studies with a detailed description of structured surgical coaching programs for clinical performance improvement were included and research on mentoring, teaching, or other types of coaching not corresponding to our definition was excluded. Variable (authors, year of publication, region, etc.) were extracted and charted for further analysis.

Results

A total of 117 studies were screened, and 11 met our inclusion criteria. 5/11 articles (45%) used objective measurement to assess clinicians’ performance. One study described the overall complication rates within 30 days as an outcome. Surgeons were identified as coachees in 10 studies (91%), and training of a coach was regarded as necessary in 7 studies (64%). More research chose the expert coaching model (6/11, 55%), video-based coaching (9/11, 82%), and after-surgery timeline (7/11, 64%). Multiple coaching models were identified, including PRACTICE, GROW, and WISCONSIN.

Conclusions

As an effective education method, surgical coaching has been conducted in many regions with varied designs. Implementation of structured surgical coaching benefits trainers in an efficient way. Also, more high-level evidence, objective measurement, and combination with new technology, were needed in future investigations.

surgical coaching

scoping review

medical education

Coaches can be commonly identified in multiple fields, including music, business, and sports. By comparison, surgeons who are similar to outstanding musicians and athletes progressing through experiential learning rarely cooperate with coaches to improve their clinical performance. Unlike music or sports, surgical performance not only demonstrates the individual ability of surgeons but also significantly affects patients' short-term and long-term outcomes.(1) Studies demonstrated that patients' short-term and long-term outcomes were highly related to surgical technical skills.(2, 3) Therefore, the hope is that a coaching system may augment surgeons’ clinical performance to provide better healthcare and improve patient-care settings. The conception of surgical coaching was first mentioned by Atul Gwande.(4) In a review article, Louridas et al. firstly summarized the key elements of surgical coaching, including the goals set, the coach-coachee rapport, the criteria for a coach, and the requirement for the coachee, which contributed to the implementation of coaching and provided the reference for coaching system design.(5) Moreover, evidence suggests that surgical coaching by reviewing surgery videos or the in-person way in the operating room (OR) can provide a more effective way to improve surgical skills than traditional self-debriefing method(6, 7). Surgical coaching programs, however, varied in designs, strategies, timelines, coaching models, and implementation status,(8) which might confuse institutes planning to initiate surgical coaching programs.

To better estimate surgical coaching, we aim to identify currently implemented studies of surgical coaching on surgeons. Our scoping review aims to answer the following questions: what design is used for the current surgical coaching program; how can we design and implement a surgical coaching program?

Our scoping review was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Extension for Scoping Reviews (PRISMA-ScR)(9) and the Joanna Briggs Institute(10) to identify the types of current evidence and key characteristics or factors related to surgical coaching. We registered our study protocol in the Open Science Framework database (osf.io, Z3S8H).

Eligibility Criteria

We focused on practical surgeons, residents, or medical students who participated in surgical coaching programs (including multiple designs, strategies, timelines, and coaching models) to improve their clinical performance. Referring to the previous definition in other fields, coaching was defined as “…helping someone else expand and apply his/her skills, knowledge, and abilities.”(11) Primary studies that involved any description of surgical coaching (the goals set, the coach-coachee rapport, the criteria for coach, and the requirement for coachee) and the effect of the coaching program on coachees were identified. Specifically, because of the distinct concepts and aims of coaching, manuscripts discussing teaching, mentoring, or other types of “coaching” not corresponding to our definition were excluded. Editorials, review articles, invited commentaries, and case reports were excluded to reduce potential bias. (Table. 1)

Searching Strategy

According to the research librarian, we generated the search terms during the process of developing and refining our protocol by consensus of all authors, mostly based on the keywords and concepts with similar meanings of manuscripts. PICOS (Population, Intervention, Comparison, Outcome, Study Design) principles were used to direct our primary research. (Table 1). Then, an accurate search on PubMed/MEDLINE, using Medical Subject Heading (MeSH) and Title/Abstract terms, was conducted. Also, a manual search of the reference list of scoping manuscripts was conducted as a supplement. All full-text articles published between 1972 and July 2022 in English were screened using the search terms. The detailed searching formula can be found in the Appendix 1a.

Initial Screening

Two independent reviewers (S.W. and J.Z.) screened the titles/abstracts of included research, referring to our inclusion and exclusion criteria. (Table. 1) Disagreement was solved by consulting a third independent reviewer (X.W.).

Full-text Screening and Data Appraisal

Then, the full-text screen was implemented to confirm including research for further study. A handbook for the screening process was developed to reduce subjective bias. (Appendix 1b) Moreover, we constructed a standardized data extraction form to obtain critical information from including articles. (Appendix 1c) Reviewer (S.W.) extracted and charted the following variables: authors, year of publication, region, institution, title, article type, aims, population, coach training status, coaching description, coaching model, coaching type (video-based or others), the timeline of coaching, coaching specialty and surgery, main outcome measure, and important results. Another author (J.Z.) performed a final review of extracted data to ensure accuracy. Specifically, the coaching description was concluded by reviewer based on the varied information from the manuscripts. For example, some studies simply mention “coaching session” but no introduction of duration, frequency, or activity. Thus, all data helpful for the construction of coaching program were extracted as possible.

Results Synthesis

Summarizing and reporting the results were conducted following the research questions using both quantitative and qualitative analyses in the description of the studies.

For the aims of studies, we summarized and categorized articles with similar descriptions into three aspects: technical improvement, perception/agreement survey, both (technical improvement and perception/agreement survey). For specific, articles describing aiming to evaluate, assess or explore coaching program were identified as program assessment, and research about surgeons’ opinion, attitude, or perception were included in the perception/agreement survey part. Similarly, according to the measurement of outcomes, three categories were identified, including questionnaires or interviews, skill rating scale, and overall complication rates within 30 days.

According to Arksey and O’Malley’s framework(12) and Joanna Briggs Institute methodological guidance for scoping reviews(10), we didn’t conduct Formal risk-of-bias assessment.

Literature Search and Study Inclusion

We identified a total of 117 articles, including 115 from PubMed/Medline search and two from hand search. (Fig. 1) Eighty-eight articles were excluded during the initial screening of titles/abstracts for not meeting the inclusion criteria. The consultation of a third screener was required in 4 studies with an inter-rater reliability of 86%. Of the twenty-nine articles included for the full-text screen, 18 articles were excluded for the following reason: no description of surgical coaching, n=12; no clinical performance outcome, n=4; editorials, review articles, invited commentaries, and case reports, n=2.

Eleven articles were identified in the final review, including 9 non-randomized studies(1, 13, 14, 15, 16, 17, 18, 19, 20), 2 randomized control studies(6, 7). (Table 2) Studies were published between 2012 and 2022 and were conducted mainly by institutions in the US (7 of 11, 64%) or Canada (3 of 11, 27%). Multiple institutes or research programs were identified (Table 2). Among them, Wisconsin Surgical Outcomes Research Program conducted the most studies (3 of 11, 27%), followed by Brigham and Women’s Hospital (2 of 11, 18%). (Supplemental Figure 1) For the aims of 11 including research, 6 (55%) were for assessment on a structured-designed coaching program; 2 (18%) were to evaluate the perception/agreement survey of coaching; 3 (27%) were both included aforementioned goals. Only three studies used a control group (27%). Except for the two RCTs using conventional surgical training as a comparison, one non-RCT cohort study compared the results between participant and nonparticipant groups. As for the main measurement and important results, 6 studies demonstrated that the participants agreed on the effectiveness of the coaching program through a way of questionnaire or interviews. To assess the performance of surgeons, Fundamentals of Laparoscopic Surgery (FLS)(1 of 11) (1), Objective Structured Assessment of Technical Skills (OSATS)(3 of 11)(6, 7, 18), Generic Error Rating Tool (GERT) (1 of 11)(6), Global Operative Assessment of Laparoscopic Skills (GOALS)(1 of 11)(7), and Operative Performance Rating System (OPRS)(7) were used to evaluate surgical skill, and Non-Technical Skills for Surgeons (NOTSS)(16) were used for non-technical skills in articles, which all indicated that surgical coaching could improve clinical performance. Specifically, one study(17) used overall complication rates within 30 days as measurement, but no statistical significance was found between coaches, participants, and nonparticipants.

Conduction Status of Surgical Coaching As for details of coaching conduction, most participants were practical surgeons (10/11, 91%), while one included medical students. A multitude of specialties and surgeries were reported in surgical coaching. Among them, general surgery was mostly mentioned area. (7 studies) (Supplemental Figure 2). Pradarelli(16) et al. demonstrated that a surgical coaching workshop to learn the core principles and key behaviors was recommended in interviews with surgeons having coaching experiences. Similar results were found in seven studies (64%), which described the necessity of the training of coaches, such as training sessions about techniques for defining goals, collaborative analysis, active reflection, and constructive feedback. Additionally, one-on-one (5 of 11, 45%) and one-for-multitude (6 of 11, 55%) coach were both used in studies. (Table 3).

We define expert coaching as embracing a knowledge gap or technical skills differential between coachee and coach. In contrast, peer coaching involves participants with similar knowledge and technique levels.(21) The peer or expert model was mentioned in 5 (45%) and 6 (55%) manuscripts, respectively. Also, video-based coaching was implemented more (9 of 11, 82%), followed by coaching in the OR (2 of 11, 18%). Valanci-Aroesty et al. (13) conducted the coaching program with flexible locations (OR or Video-based), and all participants were satisfied with the program. The timeline of After-surgery was more identified (7 of 11, 64%). Tele-mentored coaching was only screened in one article. (1)

Two articles from Pradarelli et al. (16, 18) described an OR coaching structure consisting of a workshop to learn the core principles and key behaviors of surgical coaching and three sessions including preoperative goal setting, intraoperative observation, and postoperative debriefing. Two articles from Greenberg et al. (17, 19) introduced a video-based coaching strategy, which consists of an introductory session to establish rapport, set goals, and develop an action plan, a series of 1-hour video review sessions, and a quarterly goal session for one year. Pairs of participants were encouraged to refine their goals, analyze the participant's video-recorded surgery, identify changes to implement in practice, and develop a plan for the future. Interestingly, Zhu et al. (15) implemented a coaching program focused on surgeons who injured a bile duct during LC, including a review of videos of complicated gallbladder surgery and a video conference session to review the safe LC concept and analyze videos of the laparoscopic re-exploration. Miles et al. (1) conducted a tele-mentored program in which coaches could demonstrate refinement in techniques of Fundamentals of Laparoscopic Surgery (FLS) in a trainer box for residents. Esther et al. (6) developed a flexible approach to surgical coaching depending on the participant’s individual needs, using video reviewing to determine individual training needs and construct a future plan for the subsequent surgery. Summerized workflow of surgical coahcing was presentted in Figure 2.

This systematic scoping review of conducted coaching programs for surgery revealed the strategy currently used for surgical coaching and provided the consideration for our future coaching program implementation. According to a previous reviewing study(5), the definition and structure of surgical coaching, including the goals set, the coach-coachee rapport, the coach requirement, and the coachee aspect, were established to guide our screening. Since the first mention of surgical coaching in 2011, few studies aiming to develop a methodology and validate its efficiency were conducted and formed the basic workflow and principles for surgical coaching.(6, 7, 19, 20)

Outcome Measurement and Study Design

In recent years, surgical coaching was gradually accepted and implemented in hospitals or programs, for example, Wisconsin Surgical Outcomes Research Program (3 studies identified based on our data) (17, 19, 20), mostly reported between 2020 and 2022 (7 of 11, 64%). Most studies aim to enhance surgeons’ performance in surgery (9 of 11, 82%). However, objective assessment index was not used so much. (5 of 9, 56%)(1, 6, 7, 17, 18) Considering the inevitable bias from subjective measurement methods (for example, questionnaire interviews for self-evaluation), more objective evaluation, such as OSATS, and GOALS, would be needed in the future study. Especially, our team explored a new instrument, Surgesture, to evaluate surgical skills objectively in laparoscopic cholecystectomy (LC), which is the atomic functional unit of surgical actions such as hook, grasp, and dissection. This tool might help in the assessment of surgical coaching.(22) Interestingly, one manuscript(17) used patients’ complication rates as an outcome measurement in bariatric surgery. According to previous evidence that proved the association between surgeries technique and patient (bariatric surgery and laparoscopic right hemicolectomy) complication rate or survival (2, 3), short-term or long-term outcome evaluation of patients could be recommended for objective measurement in some specific surgeries.

Only two of the eleven included studies conducted RCT, which indicated the need for more high-level evidence for multiple surgical coaching programs. Because of the barriers caused by baseline variety and the daily duty of participants for coaching, performing an RCT requires a structured design, high-quality implementation, and supervision. The combination of convincible outcome measurement and study design might provide high-quality evidence in future research.

Coachee Population

In terms of the strategy of surgical coaching implementation, multiple specialties and surgeries were identified in coaching. Theoretically, all surgeries could be coached. However, considering some barriers in the clinical workflow (for example, time limitations and lack of cases), strategies should be specially constructed in different surgeries according to coaching principles. A comprehensive program should contain a variety of workflows to conduct training activities for different specialties and surgeries.

As for trainers, life-long learning would be necessary for all surgeons. Hu et al. showed a higher acceptance in senior clinicians for coaching.(20) Considering the differences in knowledge, working experience, and hierarchical issues, a categorized coaching design for surgeons with different levels (medical students, residents, practical surgeons, and attendings) would be proper. For example, junior surgeons will emphasize their improvement in technical skills, while senior experts think the strategy and decision-making in surgery are more significant. Also, in a cohort study, the design of coaching focused on surgeons who injured a bile duct during LC, which indicated a new strategy to coach the problem-based population.

Coach Aspect

Coach Training is regarded as a necessity for most researchers (64%). Multiple coaching models(8) emphasize the importance of Coach Training to perform coaching effectively. The core principles and key behaviors of a coach could be learned from the Pre-coaching workshop. Additionally, Kara et al. (23) demonstrated that surgeons of all personalities and thinking styles could become qualified coaches through coach-training sessions. Thus, formal training and inclusion criteria for surgical coach would be necessary in the future.

Two coaching models were commonly used, including peer and expert, and both were proved effective according to our review.(21) Additionally, 1-on-1 and one-for-multitude coach numbers were both employed and showed acceptable results. Thus, what type of model and coach number we should use for future research could base on the staff allocation of hospitals.

Coaching Content

We concluded the coaching workflow based on our screening in Fig. 3. Most studies (82%) were video-based coaching, while OR coaching was also feasible. With the development of minimally invasive techniques, the recording of surgical videos is convenient and regularly conducted in many institutes.(7) Although video-based and in OR are both acceptable, considering the heavy clinical work and research missions, video-based coaching in a more flexible time and location would be more proper. Furthermore, surgical videos can be watched repeatedly by surgeons, providing a more objective view to reflect on themselves. However, OR coaching is still indispensable for surgeries that cannot be recorded as videos. In addition, some non-technical assessment scales can only be evaluated intraoperatively such as NOTSS, for the lack of audio recording in video-based mode.

As for timelines of coaching, a meta-analysis of video-based coaching showed that the preoperative coaching style was preferable.(8) According to the time point to provide coaching sessions, we categorized timelines into Before surgery (lessons or video learning before surgery), After surgery (sessions after surgery), During surgery (instructions during surgery), and Before and After surgery (instructions before and after surgery). In our review, we identified After-surgery as the most conducted (64%) because of the stricter inclusion criteria of the surgical coaching definition. After-surgery coaching will fit in the process of establishing rapport, setting goals by analyzing, and developing an action plan better. In particular, a cohort study(1) described a live streaming platform for tele-mentored coaching, which might have great significance during the COVID-19 pandemic wave. In a technology description, doctors showed the feasibility of 5G-assisted tele-mentored surgery. (24) The constriction of time and geography of coaching would be minimized if face-to-face communication was not necessary. Also, large and developed coaching programs could be expanded globally without location limits to promote surgical education and communication and eventually, improving patient-care settings. With the development of artificial intelligence and big data, computer algorithm can perform some tasks to assist medical practice, including computer vision analysis.(25) These new technologies own the potential to output objective data, such as surgical steps, anatomy identification and movement of surgical tools, based on surgical videos to help coaching in goal setting and plan making process.(26)

Some models were tailored to instruct the design of surgical coaching programs, including the PRACTICE, GROW, and WISCONSIN models.(6, 7, 17) Two main categories were identified in our study. In the Surgical Coaching for Operative Performance Enhancement (SCOPE) study, Pradarelli et al(16) detailed the process of preoperative goal setting, intraoperative observation, and postoperative debriefing for OR surgical coaching. In addition, Greenberg et al(19) described their video-based coaching strategy based on the WISCONSIN model, including setting goals, developing an action plan, a series of 1-hour video review sessions, and a goal quarterly session for 1 year.

Additionally, we compared three most commonly used models and identified generality among them, which including: 1) Goals;2༉Discussion, Feedback and Solution, and 3༉Plan and Action. (Fig. 3) These strategies above can provide an eminent guidance for new program designers. Furthermore, we summarize our findings in Table. 4.

Limitations and Future Direction

We acknowledge the limitations of this review that only English articles were included and some research presented at conference lists that were not accessible for full-text screening were not included. Secondly, some conducted programs might not be published, and some surgical coaching programs could be skipped because they didn’t have the word “coaching” in the titles/abstracts in the initial screening. Besides, some research might not appear on PubMed. Thus, data extracted in our scoping review is a representative sample of surgical coaching. Thirdly, multiple papers did not show all the critical components of programs.

Our plan for the following studies is to implement a structured surgical coaching program with objective assessment in our institution according to the scoping review results. In the future, coaching program standardization and multi-centric consensus will be needed for better improvement in surgical education. The evidence synthesis by this review provides us with a better understanding of surgical coaching and an indication for future studies necessary to improve surgical quality further.

Our scoping review provides an overview of the current status of surgical coaching programs implementation and references for designing of newly started coaching projects. Coaching of various surgeries can effectively promote performance of clinicians. Surgeons could maximize their gain from structurally-designed coaching. Future investigation should focus on more high-level evidence like RCT, more objective assessment for clinical improvement, and combination with novel technology.

Operating Room OR

the Preferred Reporting Items for Systematic Review and Meta-Analysis Extension for Scoping Reviews PRISMA-ScR

Population, Intervention, Comparison, Outcome, Study Design PICOS

Medical Subject Heading MeSH

Randomized Control Ttrail RCT

Fundamentals of Laparoscopic Surgery FLS

Objective Structured Assessment of Technical Skills OSATS

Generic Error Rating Tool GERT

Global Operative Assessment of Laparoscopic Skills GOALS

Operative Performance Rating System OPRS

Non-Technical Skills for Surgeons NOTSS

Laparoscopic Cholecystectomy LC

Surgical Coaching for Operative Performance Enhancement SCOPE

Ethics approval and consent to participate

Not applicale because the research didn’t involve human subjects.

Consent for publication

All authors agree with the manuscript's contents and have consented for publication.

Availability of data and materials

All data generated or analysed during this study are included in this published article (and its Additional supplementary Information files)

Competing interests

Drs. Shangdi Wu, Jing Zhang, Bing Peng, Yunqiang Cai, Ang Li, Linxun Liu, Jie Liu, Chunlan Deng, Chunrong Wang and Xin Wang declare no conflicts of interest.

Funding

This work was supported by the Fund of the High-Quality Development of Guang’an People’s Hospital (21FZ001), Key Project of Science & Technology Department of Sichuan Province (2022YFS0024), Regional Innovation Cooperation in Sichuan Province (2022YFQ0068).

Author’s contributions

WX, CW, and WS conceived and designed the study. YC, JZ, and AL performed the research. LL and LJ did the statistical analysis. WS, DC, and JZ wrote the first draft of the Article, which was critically revised and approved by all authors.

Acknowledgements

Not applicable.

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Table 1. Population, Intervention, Control, Outcome, Study Design (PICOS) Inclusion Criteria and Exclusion Criteria for Article Review
Inclusion Criteria
	Population	Surgeons, residents or medical students
	Intervention	Surgical coaching program
	Control	Comparators were optional
	Outcome	Differs among studies
	Study Design	All retrospective and prospective studies
Exclusion Criteria
	Manuscripts discussing teaching, mentoring, or other types of “coaching”
	Editorials, review articles, invited commentaries, and case reports
No detailed surgical coaching description
Outcome not related with clinical performance (e.g., Relationship construction among surgeons, Coach training, and Coach character)

Table 2. Summary of Surgical Coaching Strategy (N=11)
Variable	n (%)
Article type
RCT	2 (18%)
Non-RCT Cohort	9 (82%)
Region
The US	7 (64%)
Canada	3 (27%)
The UK	1 (9%)
Institute
Wisconsin Surgical Outcomes Research Program	3 (27%)
Brigham and Women’s Hospital	2 (18%)
Others	6 (55%)
Aims
Program Assessment	6 (55%)
Perception/Agreement survey	2 (18%)
Both	3 (27%)
Population
Surgeons	10 (91%)
Medical students	1 (9%)
Comparison
Yes	3 (27%)
No	8 (73%)
Measurement
Questionnaire or interviews	6 (55%)
Skill rating scale	4 (36%)
Overall complication rates within 30 days	1 (9%)

Table 3. Conduction Status of Surgical Coaching (N=11)
Variable	n (%)
Coach training
Yes	7 (64%)
No	4 (36%)
Coach number
1-on-1	5 (45%)
One for multitude	6 (55%)
Coaching model
Peer	5 (45%)
Expert	6 (55%)
Coaching type
Video-based	9 (82%)
OR*	2 (18%)
Timeline
Before surgery	0
After surgery	7 (64%)
During surgery	0
Before and after surgery	3 (27%)
N/A*	1 (9%)
*Abbreviations: N/A, not applicable, data can’t be identified; OR, operating room.

Table. 4 Conclusion from Scoping Review

Objective skill assessments are needed in the future. (OSATS, GOALS, Surgesture, Patients’ outcome)

High-level evidence (e.g., RCT) should be conducted more with structured design, high-quality implementation, and supervision.

All specialties and surgeries could be coached, and multiple workflows should be set for specific surgery.

Coaching should be specially designed for doctors with different levels. (Medical students, residents, practical surgeons, and attendings)

Coach training is essential, and having an inclusion criterion for coaches will be proper.

Peer and expert models are both feasible, and implementation could be based on staff and facility conditions.

After-surgery method fits in coaching logic better.

Novel technologies (Tele-mentored devices, AI, and 5G et al.) contribute to overcoming time and location obstacles.

Multiple coaching models can be referred to design a new program.

Standardized coaching programs with multi-dimensional assessment for surgeons and multi-centric consensus directing program implementation will be necessary for the future.

No competing interests reported.

Coaching for Improving Clinical Performance of Surgeons: A Scoping Review

Status:

Version 1

Abstract

Background

Methods

Results

Conclusions

Figures

Background

Methods

Eligibility Criteria

Searching Strategy

Initial Screening

Full-text Screening and Data Appraisal

Results Synthesis

Results

Literature Search and Study Inclusion

Discussion

Outcome Measurement and Study Design

Coachee Population

Coach Aspect

Coaching Content

Limitations and Future Direction

Conclusion

Abbreviations

Declarations

References

Tables

Additional Declarations

Supplementary Files

Status:

Version 1