I have no disclosures related to this talk. I wanted to start off this talk with a quote from Atul Gawande, who is a general surgeon at the Brigham and Women's Hospital, and he wrote an article in the New Yorker called Personal Best in 2011. And he led off that article with this quote, I've been a surgeon for eight years. For the past couple of them, my performance in the operating room has reached a plateau. I'd like to think it's a good thing. I've arrived at my professional peak, but mainly it seems as if I've just stopped getting better. And so we wondered, was there an opportunity around this type of thing in our department? Certainly for some of our early career surgeons, there may be opportunities to continue to improve their surgical technique or operative skills, and even their leadership skills in leading an operating room. But we wondered, were there also opportunities for some of our mid-career surgeons in things like when new techniques are introduced, or could we help them improve their time, efficiency of time and of motion? Could we help improve our teaching skills? But there were some barriers to coaching when we thought about this idea. So surgeons had very prominent concerns about would this allow them to maintain an authoritative image if they had a coach in the room? Would they lose autonomy? And what about the time? Time required to learn to be a coach and also to do the coaching. But at Harvard, we did finally implement something called the SCOPE program, and this was developed by Atul Gawande, who I quoted earlier. And this SCOPE is short for Surgical Coaching for Operative Performance Enhancement. This consisted of a three-hour in-person surgical coaching workshop, and the workshop was based on evidence both from fields of surgery and overall adult education. This was originally done as an in-person training, but now is also available online on their website. The key tenets of this program are that it's non-hierarchical. So this is surgeons coaching surgeons in a peer-to-peer fashion, not a hierarchical structure where it's a senior person always coaching a junior person. The coachee is called on to identify the goals they would like to work on with the coach, and that's discussed in a preoperative discussion. And then there are also techniques given for how to provide constructive feedback that can be heard as part of this workshop. The key skills that are emphasized in this workshop are things both around technical skills and non-technical skills, and these are done using two formatting tools. The first one is a framework for how to assess operative skills, and it has five basic areas that you can look at. And one of these, for example, is respect for tissue or minimizing tissue injury. So it's scored on a grade from 1 to 3, where a performance of 1 is considered poor, where the surgeon is rough or tears tissue or has poor control, all the way to a 5, where they have appropriate tension with negligible injury on the tissue. This technical framework also includes things like flow of operation and smooth transition. So how does the surgeon control the room during each step and then transition from step to step, and is also scored from 1 to 5. There's also a non-technical skills assessment, or the NOTSS format, and this looks at things like situational awareness or leadership. So example, in leadership, things like how do they set and maintain the standards within the room? How do they support others in the room? How do they cope when situations get stressful? So all of these things are things that can be assessed and worked on. This program was instituted at Children's and also throughout the Harvard system in 2018. At Children's Hospital, we trained six mid-career surgeons as coaches, and the coachees all elected to work on various things, including OR efficiency, OR presence, economy of movement, and communication skills. The results of this program throughout Harvard were analyzed, and in particular, one paper looked at coachees who did more than one session and specifically looked at 11 of the 23 coachees who did three sessions. And what they found when they looked at the results was that the adjusted mean OSAT scores really didn't change over the three coaching sessions, and neither did the NOTSS ratings change. However, the surgeons that were involved reported that they felt that they had improved teamwork skills, improved communication skills, and improved awareness inside and outside of the operating room. However, there was a potential for coaching to improve burnout as well due to reduced intraoperative stress and enhanced peer support. But on the other hand, there was also felt by the participants that this may actually worsen burnout in some ways by adding to the chronic work overload due to the extra time now needed to do this type of a coaching program. And then COVID hit, and there really was no opportunity in our hospital to have coaches in the room anymore. So this formal type of coaching really had to take a hiatus during the pandemic. However, one place that mentoring did develop now during the pandemic was with our spine surgery team. So we had several spine surgeons that really were at high risk for COVID for various reasons. And so they were reluctant to be in the hospital unless absolutely necessary. But they had important operative skills that we really needed. So what the solution was that came up was we had them co-scrub with a junior partner. The junior partner benefited from the extra experience of the senior partner. The senior partner didn't have to come in to round on the inpatients after surgery so they could minimize their exposure in the hospital. And most importantly, the patients continued to get great care during the pandemic. This has since evolved into our physician mentors and teachers program at Children's. The key components of this program are we have to have a good match between the mentor and the mentee. We've developed specific credentialing classes for these folks. So credential is just a scrubbed mentor. They can do unscrubbed mentoring, and they can simply see patients in the clinic adjacent to a clinic with another partner. And all of those different classes then can warrant a different malpractice rate, which is nice for them. We also changed them from a productivity-based compensation model to a salary-based model, recognizing that their clinical productivity, we don't need it to be super high. What we need them to do is this teaching and mentoring job. We also provided benefits that were important to this group, including things like consultation with a finance advisor, consultation about Medicare and which plans to select, participation in a prepaid medical cost plan, as well as, interestingly, what they really wanted was money for parking and to travel to conferences and other centers. Easy enough, right? So our vision for the future is we'd love to continue with this approach to lifelong mentoring and coaching for those who want it. We want to normalize the concept and try to de-stigmatize the coaching and mentoring process. It's not a problem person who has a coach. It's somebody who wants to improve. And we hope that we can all help each other continue to grow and improve. And our goal always continues to be we think that this will help us provide the best care for our patients. So thank you very much.

Surgical Coaching for Operative Performance Enhancement

SCOPE program

peer-to-peer coaching

teamwork and communication skills

COVID-19 pandemic