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Figure.  Life Styles Inventory Cluster Score and First Session Overall Coach Performance Scatterplots
Life Styles Inventory Cluster Score and First Session Overall Coach Performance Scatterplots
Table 1.  Descriptive Statistics for Individual Coaches and Pairs
Descriptive Statistics for Individual Coaches and Pairs
Table 2.  Individual Coach Myers-Briggs Type Indicator Preferences and Overall Coach Performance in First Coaching Session
Individual Coach Myers-Briggs Type Indicator Preferences and Overall Coach Performance in First Coaching Session
Table 3.  Repeated-Measure Linear Regression Models for Individual Coach MBTI/LSI and Overall Coach Performance for All Coaching Sessions
Repeated-Measure Linear Regression Models for Individual Coach MBTI/LSI and Overall Coach Performance for All Coaching Sessions
Table 4.  Mixed Models for Coach and Coachee MBTI Similarity and Overall Coach Performance With Coach as Random Effect
Mixed Models for Coach and Coachee MBTI Similarity and Overall Coach Performance With Coach as Random Effect
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Shubeck  SP, Kanters  AE, Sandhu  G, Greenberg  CC, Dimick  JB.  Dynamics within peer-to-peer surgical coaching relationships: early evidence from the Michigan Bariatric Surgical Collaborative.   Surgery. 2018;164(2):185-188. doi:10.1016/j.surg.2018.03.009PubMedGoogle Scholar
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Singh  P, Aggarwal  R, Tahir  M, Pucher  PH, Darzi  A.  A randomized controlled study to evaluate the role of video-based coaching in training laparoscopic skills.   Ann Surg. 2015;261(5):862-869. doi:10.1097/SLA.0000000000000857PubMedGoogle Scholar
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Bonrath  EM, Dedy  NJ, Gordon  LE, Grantcharov  TP.  Comprehensive surgical coaching enhances surgical skill in the operating room: a randomized controlled trial.   Ann Surg. 2015;262(2):205-212. doi:10.1097/SLA.0000000000001214PubMedGoogle Scholar
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Alameddine  MB, Englesbe  MJ, Waits  SA.  A video-based coaching intervention to improve surgical skill in fourth-year medical students.   J Surg Educ. 2018;75(6):1475-1479. doi:10.1016/j.jsurg.2018.04.003PubMedGoogle Scholar
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Greenberg  CC, Ghousseini  HN, Pavuluri Quamme  SR, Beasley  HL, Wiegmann  DA.  Surgical coaching for individual performance improvement.   Ann Surg. 2015;261(1):32-34. doi:10.1097/SLA.0000000000000776PubMedGoogle Scholar
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Ware  M, Leak  G, Perry  N.  Life styles inventory: evidence for its factorial validity.   Psychol Rep. 1985;56(3):963-968. doi:10.2466/pr0.1985.56.3.963Google Scholar
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    Original Investigation
    April 1, 2020

    Association of Personality and Thinking Style With Effective Surgical Coaching

    Author Affiliations
    • 1Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin–Madison, Madison
    • 2Center for Healthcare Outcomes & Policy, Department of Surgery, University of Michigan, Ann Arbor
    • 3JCD Advisors LLC, Ann Arbor, Michigan
    • 4Department of Industrial and Systems Engineering, University of Wisconsin–Madison, Madison
    • 5Section Editor, JAMA Surgery
    JAMA Surg. 2020;155(6):480-485. doi:10.1001/jamasurg.2020.0234
    Key Points

    Question  How can an effective surgical coach be objectively identified?

    Findings  In this cohort study of 23 surgical coaches and 38 coachees, higher Life Styles Inventory constructive scores for coaches and increased similarity of Myers-Briggs Type Indicator judging/perceiving preferences for coaching pairs were associated with increased coach performance for the first coaching session. After multiple coaching sessions, these objective measures were no longer associated with effective coaching.

    Meaning  Surgeons with diverse personalities and styles can become effective coaches with experience and training.

    Abstract

    Importance  While interest in surgical coaching programs is rising, there is no objective method for selecting effective surgical coaches.

    Objective  To identify a quantitative measure to determine who will be an effective surgical coach.

    Design, Setting, and Participants  This prospective cohort study included coaches and coachees from 2 statewide peer surgical coaching programs: the Wisconsin Surgical Coaching Program and the Michigan Bariatric Surgical Collaborative coaching program. Data were collected from April 2014 to February 2018, and analysis began August 2018.

    Interventions  The Myers-Briggs Type Indicator was administered to coaches and coachees, and the Life Styles Inventory was administered to surgical coaches before their first coaching session.

    Main Outcomes and Measures  Coach performance in the first coaching session and all coaching sessions using the Wisconsin Surgical Coaching Rubric.

    Results  Twenty-three surgical coaches and 38 coachees combined for a total of 65 unique pairs and 106 coaching sessions. Overall, 22 of 23 coaches (96%) and 32 of 38 coachees (84%) were men. An increase in a coach’s Life Styles Inventory constructive style score correlated with an increase in overall coach performance for the first coaching session (r = 0.70; P = .002). Similarity in the coaching pair’s Myers-Briggs Type Indicator judging/perceiving dichotomy was also associated with an increase in overall coach performance for their first coaching session (β = 0.38; P = .02). When all sessions were included in the analysis, these objective measures were no longer associated with coach performance.

    Conclusions and Relevance  Surgeons of all personalities and thinking styles can become an effective coach with appropriate training and experience. Coach training can be tailored to support diverse behavioral styles and preferences to maximize coach effectiveness.

    Introduction

    Surgical coaching is a partnership between a trained surgeon coach and a surgeon coachee. Together, they use collaborative analysis and constructive feedback to set goals and make action plans to promote performance improvement in technical and nontechnical skills.1 Successful surgical coaching programs have been implemented for medical students, residents, and practicing surgeons.1-8 This success has added to the growing enthusiasm for creating surgical coaching programs for professional development.

    While there is rising interest in building surgical coaching programs, it remains unclear how to select effective surgical coaches. The selection of coaches is a crucial step in the creation of a coaching program as the program’s success relies on the effectiveness of its coaches.8 The Wisconsin Surgical Coaching Framework identifies important characteristics of coaches that include strong interpersonal and communication skills, adaptability, advanced experience and skill level, and the ability to get into the coaching mindset.1,8 While these qualities provide insight into basic coaching skills, there is no objective method to select effective surgical coaches.

    Consequently, the objective of this study was to identify an objective measure to determine who will be an effective surgical coach. Given that interpersonal and communication skills are important for surgical coaches, we hypothesized existing behavioral assessments, including the Myers-Briggs Type Indicator (MBTI) and the Life Styles Inventory (LSI), could be used to identify effective surgical coaches.9-14 We had the following specific hypotheses: (1) the MBTI profile for an individual coach would not be associated with coach performance as all types are considered equal, (2) higher LSI constructive cluster scores would be associated with increased coach performance, and (3) the similarity of the coach and coachee’s MBTI profiles would be associated with coach performance.

    Methods

    This study included surgical coaches from the Wisconsin Surgical Coaching Program (April 2014 to February 2015) and the Michigan Bariatric Surgery Collaborative coaching program (October 2015 to February 2018).1,2 These were peer coaching programs for practicing surgeons throughout each respective state. Coaches in the Wisconsin Surgical Coaching Program were peer nominated, while coaches in the Michigan Bariatric Surgery Collaborative coaching program were selected for their superior technical skills. Coaches received a half day of training on peer coaching roles and expectations. Each coach was paired with 1 or more coachees. Some pairs had a single session together, while others had multiple. Each coaching session was approximately 1 hour and included video review of an operative case from the coachee. Coaching sessions were audio recorded and transcribed. This study was approved by the University of Wisconsin–Madison Health Sciences institutional review board and the University of Michigan institutional review board. This study was considered a quality improvement project with a waiver of consent.

    Coaches and coachees were administered the MBTI before their first coaching session. The MBTI is a personality inventory that assesses differences in how individuals prefer to use perception and judgment.9 There are 4 dichotomies of preferences: extraversion/introversion, sensing/intuition, thinking/feeling, and judging/perceiving. No preference is considered superior; all are equally effective. For each dichotomy, MBTI results were reported as both the binary preference and on a continuous scale (−30 to 30).

    Coaches were also administered the LSI, a 240-item self-report assessment that evaluates an individual’s thinking and behavior styles.10-13 There are 12 styles grouped into 3 clusters: constructive (humanistic-encouraging, affiliative, achievement, self-actualizing), passive/defensive (approval, conventional, dependent, avoidance), and aggressive/defensive (oppositional, power, competitive, perfectionistic).12 Each style is measured on a scale from 0 to 100. The 4 style scores that comprise each cluster are averaged to create a cluster score.

    Coaching sessions were evaluated by raters using the transcribed recording. There were 12 raters, which included experts in surgery, human factors, education, and executive coaching. Each coaching session was rated by 2 raters with some sessions consensus coded by 8 raters. While sessions were rated in order, raters were unaware if this was a coach’s or pair’s first session. Raters used the Wisconsin Surgical Coaching Rubric to provide a score for coach performance during each coaching session. It consisted of 4 domains: shares responsibility, contributes to equal exchange; uses questions/prompts to guide coachee self-reflection/analysis; provides constructive feedback and encouragement; and guides goal setting and action planning. An overall coach performance score on a scale between 1 (counterproductive) and 5 (exemplary) is generated by the rater after considering the coach’s performance in each domain. The interrater reliability for the Wisconsin Surgical Coaching Rubric is 0.87 using Gwet weighted agreement coefficient. This measure was chosen because not all raters evaluated each session, and Gwet weighted agreement coefficient can account for missing data as well as nonindependent observations. Two coaching sessions were excluded from the analysis owing to poor audio quality.

    Separate analyses were done for the individual surgical coach and coaching pairs. Individual coaches were first analyzed using only their first coaching session. The association between the coach’s binary MBTI preferences and overall coach performance was evaluated using a Wilcoxon rank sum test. The association between the coach’s continuous MBTI preferences or LSI cluster score and overall coach performance was evaluated with a Pearson correlation coefficient. Next, the associations between an individual coach’s MBTI or LSI and overall coach performance were analyzed using all of a coach’s sessions. Given that coaches had multiple sessions included in the analysis, repeated-measures regression models were used to account for covariance. Two-sided P values had a significance threshold of .05.

    For coaching pairs, the similarity between the coach MBTI and the coachee MBTI was calculated. For the binary MBTI preferences, a pair had either the same preference (eg, both extraversion) or had different preferences (eg, 1 with extraversion and 1 with introversion). For the continuous MBTI preferences, the difference between the coach MBTI score and the coachee MBTI score was calculated for each dichotomy. Because the continuous MBTI scale includes negative values, the absolute value of this difference was taken to measure how close a pair’s MBTI preferences are. Coaching pairs were first analyzed using only a pair’s first coaching session. Mixed linear regression models were used to assess the association between coach and coachee MBTI similarity (binary and continuous) and overall coach performance. Given that some coaches had multiple coachees, the coach was included in the models as a random effect. The subsequent analysis included all of a pair’s coaching sessions. The association between MBTI similarity and overall coach performance was calculated using a mixed linear regression model including coach as a random effect and including repeated measures because the pairs had multiple sessions together.

    An additional analysis addressed whether overall coach performance varied with coachee sex. This analysis compared sessions with a male coach and a male coachee to sessions with a male coach and a female coachee. For a pair’s first session, mixed linear regression models including sex and the coach as a random effect was used. When all of a pair’s coaching sessions were used, repeated measures were added to the model to account for the multiple sessions pairs had together. All statistical analyses were performed in SAS, version 9.4 (SAS Institute). Analysis began August 2018.

    Results

    There were 23 surgical coaches and 38 coachees that combined for 65 unique pairs and 106 coaching sessions. All coaches except 1 were men and most pairs consisted of 2 men (Table 1). Most coaches had preferences for introversion, sensing, thinking, and judging. The LSI constructive and passive clusters had similar means that were higher than the mean aggressive cluster score. Pairs of coaches and coachees with the same MBTI preferences ranged from 46% (30 of 65) (extraversion/introversion) to 60% (39 of 65) (thinking/feeling). On the MBTI continuous scale, pairs had a mean (SD) difference ranging from 15.6 (13.2) (sensing/intuition) to 19.1 (13.9) (judging/perceiving). The mean (SD) overall coach performance score for all sessions was 3.32 (0.74).

    For an individual coach’s first session, binary coach MBTI preference was not associated with overall coach performance (Table 2). Coach MBTI on the continuous scale was also not associated with overall coach performance for the first session: extraversion/introversion (r = −0.38; 95% CI, −0.70 to 0.05; P = .09), sensing/intuition (r = 0.11; 95% CI, −0.34 to 0.52; P = .64), thinking/feeling (r = 0.19; 95% CI, −0.26 to 0.58; P = .40), and judging/perceiving (r = −0.27; 95% CI, −0.63 to 0.18; P = .23). Scatterplots of a coach’s LSI cluster score and overall coach performance for the first session are shown in the Figure. There was a positive correlation between the constructive style score and overall coach performance (r = 0.70; 95% CI, 0.33-0.88; P = .002). When the constructive style scores are split into tertiles, the highest constructive style tertile had an overall coach performance of 3.8 (95% CI, 3.4-4.23)and the lowest constructive style tertile had an overall coach performance of 2.8 (95% CI, 2.4-3.2; P = .01). There was no association between the passive style score or the aggressive style score and overall coach performance.

    Coaches participated in a minimum of 1 coaching session and a maximum of 8 coaching sessions (mean [SD], 4.7 [2.6]). Repeated-measures regression models for coach MBTI/LSI and overall coach performance are shown in Table 3. When all sessions were considered, there was a significant association of binary coach MBTI preference with overall coach performance for only the sensing/intuition dichotomy (−0.43; 95% CI, −0.29 to −0.28; P = .02) (Table 3). This model shows that coaches with a sensing preference have a lower overall coach performance by 0.43 (on a scale of 1 to 5) compared with coaches with an intuition preference. However, on a continuous scale, coach MBTI preference was not associated with overall coach performance for any dichotomy including sensing/intuition (0.003; 95% CI, −0.02 to 0.02; P = .77). When all sessions were included in the analysis, no LSI cluster was associated with overall coach performance (Table 3).

    Results of mixed linear regression models for a pair’s MBTI similarity and overall coach performance are shown in Table 4. For a pair’s first coaching session together, there was an association between similarity in the MBTI judging/perceiving dichotomy and overall coach performance on both the binary and continuous scales (0.38; 95% CI, 0.07-0.69; P = .02 and −0.013; 95% CI, −0.05 to −0.0003; P = .045) (Table 4). In the binary analysis, this means that coach and coachee pairs who were both judging-judging or perceiving-perceiving had a coach performance 0.38 points higher over those pairs who were different (judging-perceiving/perceiving-judging). When broken into 3 groups (perceiving-perceiving, judging-judging, and judging-perceiving/perceiving-judging), the perceiving-perceiving pairs had the highest overall coach performance (P = .04). The perceiving-perceiving group had an overall coach performance score 0.28 (95% CI, 0.34-0.93) points higher than the judging-judging group and 0.59 (95% CI, 0.01-1.18) points higher than the judging-perceiving/perceiving-judging group.

    Most pairs only had 1 (42 [65%]) or 2 sessions together (11 [17%]), while some pairs had up to 5 sessions together (2 [3%]). When all sessions were included in the analysis, a pair’s MBTI similarity was not associated with overall coach performance (Table 4).

    There were 52 pairs with a male coach and male coachee and 8 pairs with a male coach and female coachee. In the mixed linear regression model including only a pair’s first session, there was no difference in overall coach performance based on coachee sex with a male coachee parameter estimate of 0.21 (95% CI, −0.32 to 0.74; P = .43). This did not change when all sessions were included with a male coachee parameter estimate of 0.34 (95% CI, −0.38 to 1.06; P = .23).

    Discussion

    For the first coaching session, the findings of our study were consistent with our hypotheses. An individual coach’s LSI constructive score was positively associated with overall coach performance for the first coaching session. In addition, coaching pairs with similar preferences on the MBTI judging/perceiving dichotomy had increased coach performance for the pair’s first coaching session. However, these associations no longer existed when all of an individual coach’s or all of a pair’s sessions were included in the analysis. Lastly, individual coach MBTI preferences were not associated with coach performance for a coach’s first session. When all sessions were considered, the coach’s MBTI sensing/intuition dichotomy gave conflicting results between the binary and continuous measures.

    Our cohort of surgical coaches had a similar MBTI profile to what has been reported for surgical trainees; namely the majority of both groups prefer introversion, sensing, thinking, and judging.15 The preference for introversion is a change from the stereotypical depiction of the surgeon and older work that found surgeons prefer extraversion.15 Compared with the general population, surgical coaches are more likely to prefer thinking and judging. Those with a thinking preference put more weight on objective principles than personal concerns when making decisions, and those with a judging preference like a more structured life as opposed to remaining flexible.9

    With regard to the LSI, surgical coaches have slightly higher constructive and passive cluster scores and slightly lower aggressive scores than the general population, as the cluster scores represent percentiles in the population.10 Constructive styles involve self-enhancing thinking and behavior that contribute to satisfaction, healthy relationships, and accomplishing tasks. The passive styles include self-protecting thinking and behavior that fulfill security needs through people. Lastly, aggressive styles contain self-promoting thinking and behavior to maintain status and fulfill security needs through tasks.10 Because the constructive styles promote healthy relationships, as opposed to the passive and aggressive styles that focus on the self, we hypothesized that surgical coaches with higher constructive style scores would be more effective coaches. This was true for a coach’s first session but was no longer true after a coach had participated in multiple coaching sessions. This may be explained by coach training and experience, which helps those with lower constructive style scores to become effective coaches as well.

    The coach-coachee relationship is important to coaching success and can be described as the need for establishing rapport, trust, and expectations.16-20 While there is some evidence that personality similarity improves evaluations in student-teacher relationships, most studies of personality matching in executive coaching found it does not affect coach effectiveness.16-19,21 Boyce et al16 suggests that pairs with similar personalities may have better rapport initially, but over time the similarities in personalities may prevent a different perspective from emerging from which the coachee could benefit. These findings in executive coaching are consistent with our findings. We found surgical coaching pairs with more similar personalities in the MBTI judging/perceiving dichotomy initially had higher coach performance, but after a pair worked together for multiple sessions this effect was no longer present. While the coaching relationship remains important, personality measures do not appear to define the effectiveness of the relationship over time. This suggests that building a quality coaching relationship is a learnable skill.

    We also found that a coach’s sensing/intuition dichotomy and coach performance were associated with the binary analysis but not in the continuous analysis when including all sessions. Using the sensing preference involves paying attention to reality, facts, and details. On the other hand, using the intuition preference includes paying attention to meaning, possibilities, and the big picture.9 Both preferences are important for effective coaching. For example, the coaching principle of creating detailed and concrete goals reflects the sensing preference, while the principle of promoting in-depth analysis through understanding the deeper meaning reflects the intuition preference.1 Given our conflicting results, further investigation is needed.

    To our knowledge, this is the first study to propose an objective assessment to identify effective surgical coaches. While the MBTI and LSI may be able to select effective coaches and coaching pairs for their initial session, coach performance equalized over time regardless of type or style. Improvement may be due to the practical experience coaches gain as they continue coaching, group feedback given to the coaches on how to improve, as well as the ability of a coach to adapt. Given the ability of surgeons of all personalities and styles to become effective coaches, the use of a coach’s MBTI or LSI to identify coaches is not valuable; however, such assessments can help coaches develop more self-awareness, optimize their strengths, and mitigate the effect of their blindspots. Because coaches with higher constructive scores initially have higher coach performance, the coach training program could be adapted to strengthen coaches’ constructive styles and shorten the coaching learning curve. Furthermore, the coach and coachee can use their MBTI results to better understand each other’s preferences to enhance communication and optimize their coaching relationship. In the future, a randomized trial could be conducted to test whether coach performance improves with training to both bolster coach constructive style skills and to help coach and coachee pairs understand how to communicate in light of their different MBTI preferences. Another important future direction is to explore how adaptability, a core construct of coaching, influences performance over time. With regard to coach nomination, additional studies are necessary to determine the optimal approach to identifying the most effective coaches. Until that time, we recommend peer nomination as a way to identify coaches with the right skill set.

    Limitations

    There are several limitations to this study. First, the coaches in this study were nearly all men. In the Wisconsin Surgical Coaching Program, coaches were selected based on peer nomination. A woman was nominated but declined to serve as a coach owing to time constraints. In the Michigan Bariatric Surgery Collaborative coaching program, coaches were selected based on superior technical skills. Using this criteria, several women qualified as coaches. However, all but 1 did not participate as coaches owing to other time commitments or the perception that they were not qualified given their junior faculty status. It is critical that future coaching programs prioritize the recruitment of a diverse set of coaches. This study also only includes coaches from 2 Midwestern coaching programs. Consequently, our results may not extend to female coaches or coaching programs in other locations. These coaching programs were also peer coaching programs, and our results may not generalize to expert coaching programs, in which a surgeon coach imparts new skills or knowledge. The number of coaching sessions a coach or pair had was determined by logistics and the perceived value of the coaching program, which may have introduced selection bias into the results. Lastly, we intended to analyze if a coach’s constructive style score increased after they had completed the coaching program; however, there was poor compliance with postintervention LSI completion.

    Conclusions

    A surgical coach’s LSI constructive score and a coaching pair’s MBTI judging/perceiving similarity are associated with coach performance for the first coaching session. After multiple coaching sessions, these objective measures are no longer associated with effective coaching. Surgeons of all personalities and styles can become an effective coach with appropriate training and experience.

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    Article Information

    Corresponding Author: Caprice C. Greenberg, MD, MPH, Wisconsin Surgical Outcomes Research (WiSOR) Program, Department of Surgery, University of Wisconsin-Madison, 600 Highland Ave, K6/100 Clinical Science Center, Madison, WI 53792 (greenberg@surgery.wisc.edu).

    Accepted for Publication: January 26, 2020.

    Published Online: April 1, 2020. doi:10.1001/jamasurg.2020.0234

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

    Concept and design: Vande Walle, Pavuluri Quamme, Engler, Dombrowski, Wiegmann, Dimick, Greenberg.

    Acquisition, analysis, or interpretation of data: Vande Walle, Pavuluri Quamme, Leverson, Engler, Wiegmann, Dimick, Greenberg.

    Drafting of the manuscript: Vande Walle, Pavuluri Quamme, Wiegmann, Dimick, Greenberg.

    Critical revision of the manuscript for important intellectual content: Vande Walle, Pavuluri Quamme, Leverson, Engler, Dombrowski, Greenberg.

    Statistical analysis: Vande Walle, Pavuluri Quamme, Leverson, Wiegmann, Greenberg.

    Obtained funding: Pavuluri Quamme, Wiegmann, Dimick, Greenberg.

    Administrative, technical, or material support: Pavuluri Quamme, Engler, Dombrowski, Greenberg.

    Supervision: Pavuluri Quamme, Wiegmann, Dimick, Greenberg.

    Conflict of Interest Disclosures: Dr Dimick is a cofounder of ArborMetrix Inc. Dr Greenberg reports grants from National Institutes of Health and Wisconsin Partnership Program during the conduct of the study; consults for Johnson & Johnson on the Global Education Council outside the submitted work; and serves as founder and president (unpaid) of the Academy for Surgical Coaching. No other disclosures were reported.

    Funding/Support: Funding was provided by the National Institutes of Health/National Institute of Diabetes and Digestive and Kidney Diseases (grant R01 DK101423-01) and the Wisconsin Partnership Program Education and Research Committee (grant 2357). Dr Vande Walle was supported by the National Institutes of Health (training grant T32 CA090217).

    Role of the Funder/Sponsor: The funder 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.

    Disclaimer: Dr Dimick is the Surgical Innovation Editor of JAMA Surgery, but he was not involved in any of the decisions regarding review of the manuscript or its acceptance.

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    2.
    Shubeck  SP, Kanters  AE, Sandhu  G, Greenberg  CC, Dimick  JB.  Dynamics within peer-to-peer surgical coaching relationships: early evidence from the Michigan Bariatric Surgical Collaborative.   Surgery. 2018;164(2):185-188. doi:10.1016/j.surg.2018.03.009PubMedGoogle Scholar
    3.
    Singh  P, Aggarwal  R, Tahir  M, Pucher  PH, Darzi  A.  A randomized controlled study to evaluate the role of video-based coaching in training laparoscopic skills.   Ann Surg. 2015;261(5):862-869. doi:10.1097/SLA.0000000000000857PubMedGoogle Scholar
    4.
    Bonrath  EM, Dedy  NJ, Gordon  LE, Grantcharov  TP.  Comprehensive surgical coaching enhances surgical skill in the operating room: a randomized controlled trial.   Ann Surg. 2015;262(2):205-212. doi:10.1097/SLA.0000000000001214PubMedGoogle Scholar
    5.
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