Strategies for Building Peer Surgical Coaching Relationships

Key Points

Question  What strategies are used by peer surgical coaches to develop effective peer-coaching relationships with their coachees?

Findings  In this qualitative study, peer surgical coaches used a range of concrete strategies to align role and process expectations about the coaching process, establish rapport, and cultivate mutual trust with their coachees during introductory meetings. Potential coaching pitfalls were identified that could interfere with each of the 3 relationship-building components.

Meaning  By identifying concrete strategies used by coaches to operationalize these concepts, we provide empirically based strategies to inform other surgical coaching programs.

Importance  Peer surgical coaching is a promising approach for continuing professional development. However, scant guidance is available for surgeons seeking to develop peer-coaching skills. Executive coaching research suggests that effective coaches first establish a positive relationship with their coachees by aligning role and process expectations, establishing rapport, and cultivating mutual trust.

Objective  To identify the strategies used by peer surgical coaches to develop effective peer-coaching relationships with their coachees.

Design, Setting, and Participants  Drawing on executive coaching literature, a 3-part framework was developed to examine the strategies peer surgical coaches (n = 8) used to initially cultivate a relationship with their coachees (n = 11). Eleven introductory 1-hour meetings between coaching pairs participating in a statewide surgical coaching program were audiorecorded, transcribed, and coded on the basis of 3 relationship-building components. Once coded, thematic analysis was used to organize coded strategies into thematic categories and subcategories. Data were collected from October 10, 2014, to March 20, 2015. Data analysis took place from May 26, 2015, to July 20, 2016.

Main Outcomes and Measures  Strategies and potentially counterproductive activities for building peer-coaching relationships in the surgical context to inform the future training of surgical coaches.

Results  Coaches used concrete strategies to align role and process expectations about the coaching process, to establish rapport, and to cultivate mutual trust with their coachees during introductory meetings. Potential coaching pitfalls are identified that could interfere with each of the 3 relationship-building components.

Conclusions and Relevance  Peer-nominated surgical coaches were provided with training on abstract concepts that underlie effective coaching practices in other fields. By identifying the strategies used by peer surgical coaches to operationalize these concepts, empirically based strategies to inform other surgical coaching programs are provided.

Surgical coaching is a promising approach for the training and continuing professional development of surgeons.^1-3 In a recent review article, Min et al⁴ concluded that surgical coaching is a “safe and effective way” to improve surgical performance for both trainees and practicing surgeons across a range of contexts, including simulation, real time in the operating room, and postoperative video-based coaching. For practicing surgeons who wish to continue to develop their skill, judgment, and leadership in the operating room, the particular approach of peer surgical coaching is aligned with principles of adult learning theories.^2,5,6 Compared with traditional forms of continuing medical education, in which surgeons are often passive participants, peer coaching is a learner-centered approach in which surgeon “coachees” are proactive. These coachees identify for themselves specific performance improvement goals in collaboration with a peer coach, who facilitates self-reflection, offers constructive feedback, guides action planning, and provides support for implementing and then self-evaluating changes in practice.⁷ Overwhelmingly, health care professionals in other nonsurgical disciplines participating in peer-coaching programs have been enthusiastic about these programs’ role in enhancing their continuous learning.⁶

Currently, scant guidance is available for surgeons seeking to develop the knowledge and skills necessary to serve as peer coaches. However, the literature base in the more established field of executive coaching provides useful insights regarding effective competencies and strategies that could be adapted. The International Coach Federation, the largest association of professional executive coaches, outlines several empirically based coach competencies, including “Co-creating the Relationship.”⁸ Executive coaching research suggests that building an effective peer-coaching relationship is a prerequisite for successful coaching outcomes^9-11 and has 3 interrelated components: (1) aligning role and process expectations, (2) establishing rapport, and (3) cultivating mutual trust (Table 1). Using this framework, we sought to examine the strategies peer surgical coaches used to develop a relationship with their coachees during an introductory meeting. Our aim was to identify promising strategies and potentially counterproductive activities for building peer relationships in the surgical context to inform future training for peer surgical coaches.

This qualitative research study was conducted as part of an ongoing, statewide peer surgical coaching program. The program identified, through a peer-nomination process, 8 surgeons to serve as coaches. Coaches received a half-day training that included interactive discussions of peer-coaching principles and role expectations. At the time of analyses, 12 surgeons had volunteered as coachees, and each was paired with a coach on the basis of shared surgical specialty or procedure as well as the coachee’s goals and preferences. Four of the 8 coaches were assigned 2 coachees each, while the other 4 coaches were paired with 1 coachee each. During an entire year, the coaching pairs were expected to meet quarterly to collaboratively review videorecorded surgical procedures to address the coachee’s performance improvement goals.

To acquaint the coaching pairs, we scheduled a 1-hour introductory meeting with 5 specified tasks: (1) facilitate introductions and share background information, (2) explore motivations to participate, (3) set specific goals, (4) establish a work plan and discuss logistics, and (5) attend to the coaching process. These tasks represent the core coaching components described in the existing literature on this approach in other fields. Coaches were provided with an overview of these tasks and a checklist as a real-time tool. We suggested that this meeting be conducted by telephone in recognition of participants’ busy schedules. However, 4 of the 12 coaching pairs opted to meet in person because they believed that doing so would be more conducive to establishing rapport. On average, the introductory meetings lasted approximately 40 minutes (range, 25-60 minutes). Coaching pairs spent the largest proportion of meeting time (42.5%) on the task of facilitating introductions and sharing background information, which is in line with program expectations for the first meeting.

This study was reviewed by the University of Wisconsin—Madison’s Health Sciences Institutional Review Board (HS-IRB). The HS-IRB determined the study to be exempt as a quality improvement project; as such, we were not required to obtain written or oral consent from our participants. However, per HS-IRB guidance, we provided all coaches and coachees with an information sheet outlining all aspects of the program and their roles.

We audiorecorded 11 introductory meetings. A professional transcriptionist transcribed and deidentified each recording, removing all personal identifiers to maintain participant anonymity. Two independent study team members then conducted a thematic analysis,¹² using the framework for building an effective peer-coaching relationship to code instances when coaches were attempting to align expectations, establish rapport, and cultivate trust with their coachees. The 2 team members met to resolve coding discrepancies and reach consensus, refining theme parameters and identifying additional subthemes. The entire multidisciplinary study team reviewed and revised codes at each stage of development. We used NVivo 10 (QSR International), a qualitative research software, for data management. Data were collected from October 10, 2014, to March 20, 2015. Data analysis took place from May 26, 2015, to July 20, 2016.

Coaches used a range of concrete strategies to align expectations about the coaching process, to establish rapport, and to cultivate trust with their coachees during introductory meetings (Table 1 and Table 2). In this section, these relationship-building strategies are described and organized into the thematic categories that emerged through data analysis; Tables 3, 4, and 5 provide detailed explanations and examples. We also identified potential coaching pitfalls that could interfere with each of the 3 components.

The majority of coaches framed the coaching relationship as a partnership between colearners, positioning themselves as professional peers rather than experts (Table 3). In some instances, they conveyed being an equal partner by clarifying the role of the coach, typically in response to a coachee expressing a misconception about the coach’s role. In addition, some coaches emphasized their expectation to provide constructive, nonevaluative feedback.

In other instances, coaches described the coaching process as an opportunity to learn together. These comments tended to be general, with coaches sharing expectations such as, “We can make it a valuable experience for both of us,” “We can have an exchange here,” or “We’re 2 surgeons; let’s look at this and see how we can learn from it.” A few coaches went further, specifying what they expected to learn from working together with their coachee. These comments reinforced the idea that the coach is a colearner and an equal partner in the coaching relationship.

Another way in which some coaches framed the coaching relationship as a partnership was by sharing anecdotes of themselves as learners. Several described how they improved their technique, ranging from observing other surgeons across different settings to scrubbing in with a colleague to watching a video online to visiting operating rooms with a traveling surgical club. One surgeon extended his anecdote by comparing his experience watching another surgeon with Tiger Woods analyzing his golf swing on video (Table 3). With such stories, coaches not only emphasized the value of reflecting critically on their performance, receiving constructive feedback, and maintaining a learning mind-set but also enabled themselves to be perceived by their coachees as peers or equals.

Coaches used strategies to emphasize that the coachees were in charge of directing the coaching agenda (Table 3). First, they conveyed their focus on their coachee’s development goals. Several coaches explicitly noted, for example, “We need to make sure that we’re really targeted on what we both feel is the important win-win for you…and what you’re most interested in.” Second, almost all of the coaches prompted coachees to specify their learning goals with questions such as, “When you volunteered for this coaching, what did you want to get out of it?” or “Do you have a sense of what you’d like to try to accomplish?” Several coaches even followed up with more specific questions, which allowed coachees to elaborate on and/or clarify their stated goals.

Third, coaches actively listened to and showed enthusiasm for those goals. A few coaches summarized their coachee’s goals before moving on to a new task, while another coach adopted his coachee’s language to discuss goals and commiserate about shared challenges. Fourth, some coaches communicated the expectation that coachees were responsible for directing the coaching process in other ways as well. A couple of coaches offered suggestions on how to proceed with coaching and expressed a willingness to follow their coachee’s lead. One coach, for example, recommended the type of case his coachee could videorecord but left him to make the decision, saying, “So that would be kind of what I would think, but I’m open to whatever you believe you would benefit most from.” This coach regularly followed his suggestions with phrases like, “if that makes sense to you” or “[does it] sound like that would be a good way to go?” The approach conveys the coach’s recognition that the coachee was responsible for determining the direction of coaching sessions. He also invited both of his coachees to give him feedback regarding his facilitation of their coaching sessions, tailoring these invitations to each individual.

Although the coaches used a range of strategies for aligning role and process expectations, they were not immune to using less effective approaches that could interfere with relationship building in the surgery field. In a few instances, the coaches offered premature advice. This may be a natural pitfall for coaches striving to be responsive and to be problem solvers, but it may hinder the establishment of a shared understanding of the surgical context and may interfere with coachees maintaining their “diagnostic initiative”—the responsibility for identifying their own areas for growth.¹⁸ Another pitfall is when coaches equate peer coaching with teaching residents or medical students, which in part occurs because some coaches draw on their previous experience as instructors. Some aspects of teaching are relevant to coaching. A coach’s allusion to hierarchical training relationships with residents or medical students could make the coachee feel like a subordinate rather than a peer.

A couple of coaches suggested an alternative coaching agenda based on their preferences. This pitfall seemed to reflect the coaches’ enthusiasm for a particular area or desire to stay in their comfort zone. In these instances, the coaches went beyond suggesting the range of goals possible for coaching sessions and toward being prescriptive. The former approach could help a coachee identify goals, while the latter runs counter to the principles of learner-directed professional development.

All but 1 coach conveyed an interest in developing a peer relationship by prompting coachees to talk about themselves to elicit information about their personal and professional background, surgical context, and/or motivations to participate in the coaching program (Table 4). Most coaches also asked responsive follow-up questions that built on what coachees shared. By encouraging coachees to talk in detail about these topics, coaches not only demonstrated interest in getting to know their coachees but also garnered information that could be useful for adapting to their coachees’ needs in subsequent coaching sessions.

Several coaches shared some personal information, which served to humanize them so that they could connect at an informal level with their coachees. This sharing included talking in brief about families, friends, outside interests and hobbies, and core personality traits. When coaches offered such personal information, their coachees often responded in kind, giving both parties an opportunity to discover commonalities with each other. In this way, coaches could relate to coachees as peers rather than as expert to learner, and establish a personal connection early in the coaching process.

Most coaches engaged with coachees in collegial exchanges about a variety of professional topics, including the current state of the profession, shifts in surgical culture over time, and the pros and cons of surgical techniques or technologies (Table 4). Coaches initiated most of these exchanges, but coachees initiated topics on occasion. During these exchanges, several coaches used the strategy of eliciting coachees’ perspectives and/or opinions with such questions as, “Have you found that the culture when you arrived…has begun to shift?” or “Tell me, is this whole minimally invasive thing kind of sorting out now?”

A few coaches used the strategy of identifying shared professional connections or interests. For example, some coaches mentioned familiarity with coachees’ colleagues or organizations, while others found camaraderie in discussing surgical techniques or approaches. Several coaching pairs identified with each other because they were members of the same professional culture and thus shared professional values, challenges, and experiences. “It’s just the nature of our being,” “It’s interesting because people [who] don’t go through it don’t get it,” and “We both trained in situations where I’m sure you’ve had somebody who lays into you pretty hard” were among the comments that reflected the commonalities these coaching pairs found.

With these strategies, coaches conveyed professional respect for coachees and leveled their relative positions, both of which contribute to the development of rapport.

In establishing rapport, potential pitfalls manifest as problems of omission rather than commission. A couple of coaches did not attempt to make a personal connection with their coachees, limiting the exchange of information to professional background and surgical expertise. When the professional aspect was the sole focus of introductions, the differences in experience between the coach and the coachee were accentuated and seemed to interfere with rapport development, although it is unclear if this would continue as the coaching progresses. Coaches who had this limited focus set the tone of the conversation, and coachees followed suit by avoiding to mention any personal information.

Occasionally, coaches missed opportunities to build on the topics initiated by coachees. This may have occurred because the coaches were too focused on efficient task completion, a core concern for surgeons, or the coaches were too enthusiastic about initiating topics themselves. Nevertheless, building on coachee-initiated topics could enable coaches to support a more equal exchange, especially given that they are likely to initiate topics frequently in their role as facilitator.

Cultivating trust for coaching depends in part on a mutual investment in the process and a willingness to work through difficulties (Table 5). Most coaching pairs demonstrated these 2 components by expressing their enthusiasm about being involved. These comments tended to be quite general (eg, “I think this is going to be great”), but several went further, touting the value of coaching as a form of continuing professional development. For example, one coach enthused, “I have a lot of hope that this may be a method for accelerated training for all surgeons and ongoing maintenance of certification for aging surgeons too. I can just see all kinds of benefits from this type of program.”

Another way in which the coaches conveyed their commitment to the program was by being willing to be accommodating. They volunteered to travel to their coachees’ institution for coaching sessions, offered to observe in the operating room or attend teaching conferences, and voiced their readiness to be accessible and flexible as needed to support the targeted work on coachees’ self-identified goals. A few coaches also demonstrated their commitment by being prepared for their introductory meeting. They referenced a range of resource materials provided by the program, including a checklist of tasks to be completed during the meeting and a pair-specific report comparing the communication styles of the coach and coachee.

To convey trustworthiness, coaches used a range of strategies (Table 5). First, they consistently demonstrated empathy when coachees made themselves vulnerable in conversations. They expressed an understanding of their peers’ concerns and commiserated about managing similar challenges, saying “that’s one of the things we all struggle with.” In some instances, when coachees shared stories of memorable technical complications, the coaches reciprocated by telling stories that were equally compelling. Sharing such stories allowed coaches to model trusting through self-disclosure. In this vein, a few coaches were forthcoming about their nervousness about the coaching process and/or their limited expertise in coaching. Still, others acknowledged their interpersonal shortcomings and gaffes, recognizing their interpersonal skills as an area for improvement. This willingness by both parties to be open and vulnerable contributed to the reciprocal intimacy that is a hallmark of mutual trust.

A few coaches recognized the risk to coachees in sharing video of their performance for analysis, especially when the video shows complications and situations of arrested development. One coach tactfully broached the subject by reassuring the coachee that video review is valuable for self-directed learning. The coach suggested a process for “backing off” if the coachee thought “this is way too much” in the first coaching session. A couple of coaches also acknowledged the vulnerable position coachees put themselves in and praised their willingness to do so with comments like, “I applaud you for saying, ‘Yeah, I want to show you this, and I want to learn from it. How can you help me?’”

All but 1 coach neglected to mention that all coaching conversations would remain completely confidential. Yet, arguably, the simplest strategy to help coachees feel at ease is to address the issue up front. Another pitfall is divulging other surgeons’ errors or complications and using their real names. While a coach’s intention could be to communicate to the coachee that mistakes are part of every physician’s practice, the sharing of this information could be interpreted as a breach of confidentiality. There were a few, rare instances in which a coach appeared ill prepared to facilitate the conversation. Such instances could inadvertently convey a lack of commitment on the part of the coach and thereby undermine trust.

Peer surgical coaching is a relatively new and developing field. Our study of introductory meetings facilitated by peer-nominated surgical coaches contributes to that development by identifying promising strategies for building effective peer-coaching relationships early in the process. We trained coaches on abstract concepts that underlie effective coaching practices in other fields. By identifying concrete strategies used spontaneously by our coaches to operationalize these concepts, we provide empirically based strategies to inform other surgical coaching programs.

Although the analytic framework used in this study was drawn from the executive coaching literature, each of its 3 components is highly relevant in the surgical coaching field. The potential is high for both surgical coaches and surgeon coachees to harbor misconceptions about the nature of a peer-coaching relationship. Mutabdzic et al¹⁹ reported that surgeons expressed concerns that participating as coachees in peer-coaching programs could undermine their autonomy or compromise their professional image. At the same time, surgeons who become coaches may be more accustomed to providing expert technical advice than facilitating learner-directed development. Therefore, it is critical to establish potentially countercultural expectations of the respective roles and responsibilities of both coach and coachee and the way in which they will work together. To reduce coachees’ concerns and to put them at ease, coaches must work to establish rapport. This practice involves conveying attentiveness and positivity and coordinating communication²⁰ so that coachees feel respected and thus willingly engage with their coaches. At a deeper level, coaches must cultivate mutual trust, instilling confidence in their coachees that feedback will be nonevaluative, that sensitive topics will be broached tactfully, and that coaching sessions will remain confidential. In these ways, the initial “small talk” between coaching pairs has the potential to influence how both parties will collaborate during subsequent coaching sessions and what coaching outcomes will be achieved.

Across a range of fields, effective coaches are recognized as good communicators. Too often, this finding is understood to imply that good coaching is primarily the result of personal style and therefore not a learnable skill. This study presents an alternative viewpoint. Coaching may not come naturally to surgeons who are accustomed to traditional didactic approaches to training residents and medical students and to working in organizational settings characterized by staunch individualism and hierarchical surgical culture. However, by identifying concrete strategies, such as those presented in this article, we can begin to specify the activities of surgical coaching to make coaching an acquirable skill. In addition, detailing a coach’s contribution to these processes makes it possible to recognize particular strategies and to study their effect on the coaching relationship.

As this was the pilot study, its limitations included the relatively small sample size used (8 coaches and 11 coachees). In addition, enrollment into the program was limited to the state of Wisconsin.

This study offers some initial insights into how the activities of peer surgical coaching can be operationalized at the level of relationship building during the introductory phase of the coaching process. Similar descriptive studies are needed to investigate other core elements of actual coaching sessions. As empirically based structures of effective peer-coaching activities emerge, future research will be able to empirically examine the effectiveness of surgical coaching interventions.

Corresponding Author: Caprice C. Greenberg, MD, MPH, Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin–Madison, 600 Highland Ave, BX 7375, Clinical Science Center, Madison, WI 53792 (greenberg@surgery.wisc.edu).

Accepted for Publication: November 12, 2016.

Published Online: February 1, 2017. doi:10.1001/jamasurg.2016.5540

Author Contributions: Dr Greenberg had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Beasley, Ghousseini, Wiegmann, Pavuluri Quamme, Greenberg.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Beasley.

Obtained funding: Greenberg.

Administrative, technical, or material support: Beasley, Pavuluri Quamme, Greenberg.

Study supervision: Wiegmann, Greenberg.

Conflict of Interest Disclosures: None reported.

Funding/Support: Funding was provided by the Wisconsin Partnership Program Education and Research Committee at the University of Wisconsin, School of Medicine and Public Health, and by grant number R01 DK101423-01 from the National Institute of Diabetes and Digestive and Kidney Disease of the National Institutes of Health.

Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: The authors acknowledge and thank the Wisconsin Surgical Society for their partnership in the development and execution of this project, particularly those surgeons who elected to participate as coaches and coachees in the Wisconsin Surgical Coaching Program (WSCP). The following individuals served as WSCP peer-nominated coaches: Louis Bernhardt, MD, Michael Garren, MD, and Layton Rikkers, MD, University of Wisconsin—Madison; Sigurd Gundersen III, MD, Shanu Kothari, MD, and Jeffrey Landercasper, MD, Gundersen Health System; Edward Quebbeman, MD, Froedtert Hospital; and Philip Vogt, MD, Fox Valley Surgical Associates. Each physician received a stipend.