I flash a smile as I look up from my notes. “Do it again,” I say, encouraged by his progress, “but this time start with the physical exam.” I am the internal medicine resident leading our “twilight” admitting team, and Vikram, a student on the first day of his medicine clerkship, sits across from me. It is his third time practicing the presentation of Ms. R, a 56-year-old woman with pancreatitis who was recently admitted to our hospital.
When I first met Vikram earlier that day, I explained that I viewed my role as both his evaluator and coach as a conflict of interest and admitted that I could only choose one — I had chosen to be his coach.
Atul Gawande discussed the concept of a medical coach in his New Yorker article “Personal Best,” where he describes the experience of enlisting a former surgical mentor to observe him in the operating room. In the article, he raises the question of why elite performers often have coaches but physicians rarely do and makes the compelling case that dedicated coaching can lead to significant improvement in clinical skills. But what about young physicians, like Vikram or myself, who are still in training? Some would argue that we are surrounded by coaches — our program directors, clinic preceptors and hospital attendings amongst others. However, I would contest that these individuals play the dual role of coach and judge — a task that on the surface seems plausible but contains within it a set of opposing responsibilities.
Although coaches and judges are similar in some ways — they assess performance, provide feedback and possess domain expertise — their differences are more notable. Coaches carry us forward while judges assess us how far we’ve come. Coaches feel like they’re on our team, while judges feel impartial. Coaches see mistakes as opportunities for improvement, while judges see them as opportunities for evaluation. In clinical training, is it fair to ask one person to play both roles? And what is it about coaches that make them more effective in helping us improve?
My hypothesis to Vikram is that coaching allows clinical skills to flourish because trainees feel safe in discussing their weaknesses, and the trainer feels longitudinally invested in the trainee’s success. I suggest that medical education needs fewer judges and more coaches — and most importantly, that the two roles be separate.
Especially early in my training, I often concealed my clinical weaknesses to attendings because I feared their evaluations of me could have an adverse effect on my career aspirations. During my fourth-year subinternship, I rounded one morning with one of our school’s prominent teaching faculty. He leaned in to listen to the heart of a young man with meningitis and upon removing his stethoscope whispered to me, “A classic systolic flow murmur, you should have a listen.” I hurried to take his spot and leaned in myself. But I heard nothing besides the normal sounds of the heart. I stepped back, unsure of what to say, but eventually nodded in agreement, “I hear it as well.” At the time, it was an innocent lie about an innocent murmur, but the repercussions now seem much larger. Maybe I was listening with the wrong side of the stethoscope or in the wrong part of his chest? Maybe I needed to push harder with the stethoscope or palpate the pulse at the same time? What was a flow murmur and why couldn’t I hear it? I tabled these questions at the time, electing to search for the answers myself rather than learning from the expert before me, for what if my questions caused him to doubt my abilities — “A fourth-year medical student who cannot appreciate a simple murmur…” I imagined him telling our clerkship coordinator. On many occasions such as this, my desire to impress a judge overwhelmed my desire to improve.
Coaching is built upon a mutually beneficial relationship in which an individual’s success motivates both the trainer and the trainee. The opposite is true for judges; by common ethical standards, they must not be invested in the success of those they judge for doing so would be a conflict of interest. By asking our medical teachers to serve as both coach and judge, we place upon them an unsolvable contradiction — want what is best for the trainee but be prepared to evaluate them in a way that may hinder their success, whether by rating them poorly at the end of a rotation or recommending them less strongly to a future employer. In contrast to judges, effective coaches are allowed to be deeply invested in the learner’s success.
There are many barriers to implementing a coaching model in medical training. Coaching thrives when a coach can focus on a small cohort of learners, which is challenging in the resource-constrained environment of medical education. Coaching also requires longitudinal investment, but in medical training, we are frequently introduced to teachers who work with us for only a few days or weeks. These individuals parachute into our training without an understanding of where we started or how far we have come, and their impending departure makes them poorly suited to invest in our long-term success. These barriers may be difficult to overcome, but an acknowledgment of their existence is the first step toward change.
By the end of our week together, I am impressed by Vikram’s growth. His first few presentations were riddled with filler words and lack of structure, but within a few days, his presentations are almost indistinguishable from those of an intern.
A few days after our experiment, I receive an email request to evaluate Vikram’s performance. As promised, I kindly refuse to complete the evaluation; I will reserve this role for someone else. Meanwhile, I return to my place on his sideline, eager to offer my support when he needs me next.
Muthu Alagappan is an internal medicine resident who blogs at his self-titled site, Muthu Alagappan.
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