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The Best Doctors Are Constantly Learning

Monday’s New Yorker has a story, Personal Best, by Atul Gawande. It’s about coaching, and the seemingly novel idea that doctors might engage coaches – individuals with relevant expertise and experience — to help them improve their usual work, i.e. how they practice medicine.

Dr. Gawande is a surgeon, now of eight years according to his article. His specialty is endocrine surgery – when he operates it’s most often on problematic glands like the thyroid, parathyroid or appendix. Results, and complications, are tracked. For a while after he completed his training he got better and better, in comparison to nation stats, by his accounting. And then things leveled off.

The surgeon-writer considered how coaches can help individuals get better at whatever they do, like playing a sport or singing. He writes:

The coaching model is different from the traditional conception of pedagogy, where there’s a presumption that, after a certain point, the student no longer needs instruction. You graduate. You’re done. You can go the rest of the way yourself…

He wonders about how this might apply in medicine:

…Knowledge of disease and the science of treatment are always evolving. We have to keep developing our capabilities and avoid falling behind. So the training inculcates an ethic of perfectionism. Expertise is thought to be not a static condition but one that doctors must build and sustain for themselves.

Gawande wondered if engaging a coach, a senior surgeon he knew and respected, to observe his moves in the O.R. and, perhaps, offer suggestions, might be beneficial to his operating skills. He tries it, and finds that perhaps by tweaking a few aspects of a procedure – like where he stands relative to the operating field and surgical light, how the drape is positioned relative to others assisting, and the position of his elbows – he might lessen some risks or reduce the duration of surgery.

from the New Yorker, Oct 3, 2011 issue

By reading the whole article, I gleaned a bit on the history of coaching in America (supposedly this dates back to Yale-Harvard football rivalries in 1875), and Gawande’s personal history of tennis playing at an Ohio high school. All interesting –

At the end of the piece, Gawande describes a patient awaiting anesthesia before surgery. She asks him about a man standing in the O.R. with a notebook in his hand, and Gawande responds that he’s a colleague, and eventually admits the man is “like a coach.”

He explains to the woman: “I asked him 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 writes. “She did not seem reassured.”

Her reaction is perfectly understandable. Who would want a doctor who still needs to learn what he’s doing?

This article interests me at several levels. First, it’s really about graduate medical education, and how doctors might continue to learn after they complete med school, residency and fellowship training. Although the term “coach” may seem strange as applied to medical practice, the concept of a doctor being observed, and even taped during a procedure or interview or physical examination of a patient, as part of a re-credentialing or boards certification process, is not so new.

Second, it’s curious how the coaching concept might apply to some medical specialties more than others. Surgery is a more physical activity than, say, the practice of hematology or oncology. Still, there are new facts constantly coming to light, and changing conventions, about which doctors in all fields should be aware. So I think it’s wise for all physicians to be actively learning – or perfecting their knowledge base. But this might be best accomplished in some areas by written, test-based evaluations, such as typically happens upon taking licensing exams and (more rigorously) specialty board exams.

As for coaching, we might call it something else, like “professional assessment” every few years. Sure, it’s disconcerting for patients to think that their selected surgeons or other doctors aren’t at the top of their skill-set, or think they aren’t. But what’s scarier is when their physicians think they can’t get better at their work (like performing colonoscopies, or spinal taps, or interpreting the readout of a new-model flow cytometer). Even when and if a doctor does a procedure flawlessly, details, like how he processes specimens — whether to place a fresh biopsy piece into formalin or normal saline solution, or into a new kind of tube — change over time. These small differences can affect the sensitivity and specificity of a diagnostic procedure, besides the complication rate.

I agree with Gawande that the best doctors are constantly learning, and choose to do so. They’re humble enough to ask a coach, or a colleague, or an examiner, to make sure they’re doing their daily work as best as they possibly can.

*This blog post was originally published at Medical Lessons*

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