Fall 2019 (Volume 29, Number 3)
CBD and You
By Lori Albert, MD, FRCPC
Many physicians are feeling overwhelmed by the changes that are taking place in medical education across the country. New frameworks have been developed, accompanied by new terminology, and seasoned clinicians don’t understand what was “wrong” with the way that they were trained as doctors. Wasn’t the introduction of CanMEDS enough? After all, the goals have not changed. Medical education systems aim to develop physicians who are competent, knowledgeable, caring, open-minded, patient-centred, and collaborative clinicians to whom we would entrust the care of our loved ones. But the CanMEDS initiative began in the 1990s, and just as our treatment of clinical conditions has evolved over time based on best evidence, the ways in which medical students and residents are educated also needs to evolve, based on evidence from research in the education sciences.
So, competency-based medical education (CBME) has arrived, and it is important that we ask ourselves how we can best engage with it. There are many aspects to CBME, but one of the key underpinnings is an emphasis on coaching.
The promotion of the concept of “coaching” in medical education is meant to stimulate a transition away from a system in which feedback was either not provided at all, or given in a way that was not particularly helpful. Statements like “you did a good job” and “you need to read more,” or the assignment of a numerical score out of 5, do not inform trainees of what they are doing right, and don’t give them specific suggestions for how to improve. “Coaching feedback” is the same thing that kids get when they take violin lessons or participate on the swim team. It is expected that the teacher or coach will watch them and tell them how to get better in a “teacherly” or coaching kind of way. Coaching feedback for medical trainees is no different. Observation of trainee performance is the key to coaching.
All assessment tools should have some consistency throughout the medical education continuum, and new models of education will emphasize “alignment” of these coaching principles as learners move from student to resident to fellow (and beyond). Undergraduate students are more likely to be receptive to coaching than residents who have established particular patterns of practice, and will benefit from coaching feedback as much or more than senior learners, although the coaching suggestions may be less complex at this level. Observation and coaching help to create links between current and future performance, and assist us in providing more meaningful and standardized ways of assessing trainees.
Longitudinal, consistent emphasis on coaching will improve the effectiveness of our interactions with all trainees, and will lead to a shift in the culture of the clinical environment. In fact, the benefits of effective coaching do not end when one becomes an independent practitioner. An extension of the “alignment” concept supports coaching in the continuing education phase. This idea has been effectively articulated by Atul Gawande. Gawande, himself an experienced surgeon, took on a coach and saw significant improvements in his performance and a drop in his complication rates. He reminds us that we all stand to benefit from a little coaching ourselves. As Gawande says, no matter how well-trained people are, it is difficult to sustain one’s best performance on one’s own. You can view the excellent TED talk by Gawande at www.ted.com/talks or read his article from the New Yorker at www.newyorker.com/magazine/2011/10/03/personal-best.
As established clinicians benefit from coaching and internally appreciate its value, our effectiveness as coaches will improve, and trainees will benefit as we share our coaching experiences with them. We can also model effective coaching techniques as trainees observe us in our day-to-day interactions. A discussion with a nurse, physiotherapist or assistant about a problem in the office might be much more productive when specific suggestions for improvement are made in a coaching style, based on specific observations.
I recently chatted with a younger friend, who works in the business world. She saw her supervisor as a bully, who called out people for mistakes in front of the whole group and offered no feedback, but only some loaded statements about how things should be done. The medical profession can be a leader in workplace-based training. The promotion of the value of coaching as a key concept in CBME is a welcome development that will help our trainees, and improve our own performance and professional relationships.
Lori Albert, MD, FRCPC
Professor of Medicine,
University of Toronto
Toronto Western Hospital