Peer coaching increases emergency medicine faculty ability to perform and teach awake fiberoptic intubation

Abstract

Objectives

This study sought to evaluate the impact of peer coaching as a continuing medical education (CME) modality to improve faculty performance and teaching of a low‐frequency, high‐complexity procedure, awake fiberoptic intubation (AFOI).

Methods

Academic emergency medicine faculty at a single tertiary care, Level I trauma center participated in a prospective pre‐/postinterventional assessment of a peer coaching educational intervention. Participants completed a preintervention online survey to identify comfort and previous experience with performing and teaching AFOI. The participants reviewed presession materials and then completed a 25‐min didactic session with a peer coach. Participants were then broken into dyads where they initially each practiced the procedure and then attempted to teach the procedure to their colleague. An institutional standardized checklist for AFOI was utilized to assess participants procedural competency. Postintervention online surveys were compared to the preintervention surveys.

Results

A total of 15 faculty members were recruited for the study and completed pre‐ and postintervention surveys. All participants showed ability to perform AFOI as proven by successful completion of the procedural checklist. There was a statistically significant increase for self‐perceived efficacy in performing (p < 0.001, 95% confidence interval [CI] = 1.34 to 3.06) and teaching AFOI (p < 0.001, 95% CI = 1.56 to 3.05). All participants felt more likely to attempt AFOI after a single peer coaching session and most (14/15, 93.3%) were more likely to teach AFOI. Participants identified peer coaching as more effective at instilling confidence to perform and teach the skill than other CME activities that they have experienced.

Conclusion

This study demonstrates that peer coaching increases practicing faculty's ability to perform and teach a low‐frequency, high‐complexity procedure, AFOI. Peer coaching may offer an opportunity to improve the utility of learning compared to more traditional didactic‐based CME initiatives.

INTRODUCTION

Emergency medicine faculty are responsible for the delivery of high‐quality care for patients as well as the education of junior physicians. The skills required for emergency medicine practice are introduced and improved during residency training, although independent learning after graduation is necessary for the mastery of learned techniques and adoption of novel practices. Continuing medical education (CME) provides faculty the opportunity for this ongoing professional development.

To be maximally effective, CME must align with best practices in adult learning. This involves active assessment of learning needs, adoption of new behaviors into clinical practice and evaluation of those behavior changes on patient outcomes. Barriers identified to effective CME include lack of accessibility and availability as well as poor relevance of CME curricula to the individual learner. ¹ Further, CME often is passive learning (conferences, workshops, rounds). ² CME efforts remain essential as they can improve subsequent patient outcomes. ³ Peer coaching is a novel approach to CME that may address the shortcomings of current CME.

Peer coaching allows learners to actively establish goals, observe a peer's performance, and provide feedback to improve task performance. ⁴ , ⁵ Additionally, peer coaching has the benefit of occurring in the local environment where the skill will need to be performed or taught. Peer coaching has been demonstrated as a feasible means of improving faculty surgeon performance of a new procedural skill. ⁶ Our study sought to evaluate the impact of peer coaching as a CME modality to improve emergency medicine faculty performance of a low‐frequency, high‐complexity procedure, awake fiberoptic intubation (AFOI).

METHODS

This is a prospective pre‐/postinterventional assessment of a peer coaching educational intervention. A needs assessment was performed a priori with both faculty and residents at a single large academic, suburban ED that is a Level I trauma center. Faculty were asked what procedures they struggled to perform, and residents were asked which procedural area faculty teaching was in need of improvement. AFOI was cited commonly by faculty and residents alike and thus was selected as the procedure to utilize as a model for peer coaching.

A convenience sample of academic emergency medicine faculty were recruited to participate in the peer coaching session. An invitation to participate was sent to all academic emergency faculty and those who responded positively were invited to participate. The institutional review board exempted the study because this was an educational initiative. Prior to the session, participants completed a preintervention online survey (www.surveymonkey.com). Questions included demographic information, clinical experience, self‐perceived efficacy with procedural performance, and self‐perceived efficacy of procedural teaching. Qualitative questions on barriers to AFOI performance and teaching were also included. The survey was sent to nonparticipating faculty for face validity. Participants also received presession resources ⁷ , ⁸ on the role of the procedure within emergency medicine as well as an open‐access video demonstrating the procedure.

The peer coach recruited was cofaculty who is dual boarded in emergency medicine and critical care and recognized as having local expertise in teaching and performing AFOI. The peer coaching session included a 25‐min didactic highlighting clinical indications, exclusions, and teaching physical manipulation of the intubating bronchoscope. The peer coach then performed an AFOI on a Laerdal ⁹ airway management trainer in a stepwise fashion, taught to a checklist that was agreed upon as the institutional standard by both emergency medicine and anesthesia. The checklist was developed specifically for the peer coaching sessions and is composed of 10 critical actions of which seven were required for acceptable completion. Participants, grouped in pairs, first had to perform an AFOI and then had to teach the procedure to their peer colleague. Formative feedback on performing the procedure was given to the participants based on the predefined checklist by the peer coach. Numbers of completed critical actions were recorded for each learner. Formative feedback on teaching the procedure was given based on a procedure objective structured teaching exercise (PrOSTE) modified to AFOI. Like the objective structured teaching exercise (OSTE), ¹⁰ this is a faculty development tool that allows objective and immediate feedback given on procedural teaching skills. ¹¹ The session, including the didactic and then serial performance and teaching of AFOI by the dyad, lasted approximately 1 h. Following the session, the participants were asked to complete a postintervention online survey. Pre‐ and postsurveys results were compared with a two‐sample t‐test assuming unequal variance, ¹² with p < 0.05 denoting significance. Microsoft Excel 2016 was used for statistical analysis.

RESULTS

We offered this training to 45 faculty members. Fifteen faculty members volunteered for the session and completed the pre‐ and postintervention survey. Clinical experience was distributed from 0 to 5 years of practice (6/15, 40%) through over 15 years of practice (5/15, 33.3%; Table 1). Most had performed between one and five awake fiberoptic intubations in a nonsimulated clinical setting (12/15, 80%), with the remainder not having performed the procedure as an attending physician. More than half had not supervised performance of AFOI by a junior learner (8/15, 53.3%).

TABLE 1.

Experience of attending physicians and baseline AFOIs performed and supervised

Years of attending physician experience
0–5	6/15	40.0%
6–10	2/15	13.3%
11–15	2/15	13.3%
>16	5/15	33.3%
Number of AFOIs performed clinically
0	3/15	20%
1–5	12/15	80%
Number of AFOIs supervised, performed by junior learners
0	8/15	53.3%
1–5	7/15	46.7%

Abbreviation: AFOI, awake fiberoptic intubation.

Self‐perceived comfort with performing AFOI was rated as 3.2/7 (±1.42) by participants. The most common cited barrier to performing AFOI was lack of experience with the intubating bronchoscope (13/15, 86.7%). Self‐perceived comfort with teaching AFOI was rated 2.7/7 (±1.59). The most commonly cited barrier to teaching AFOI was discomfort with performing the procedure oneself (14/15, 93.3%). Figure 1 demonstrates participants level of comfort performing and teaching AFOI (Figure 2).

FIGURE 1.

Comfort performing and teaching AFOI prior to peer coaching intervention. Mean performance Likert score = 3.2/7, mean teaching Likert score = 2.7/7. N = 15. AFOI, awake fiberoptic intubation

FIGURE 2.

Comfort performing and teaching AFOI after peer coaching intervention. Mean performance Likert score = 5.4/7, mean teaching Likert score = 5.2/7. N = 15. AFOI, awake fiberoptic intubation

Postintervention, all participants (n = 15) showed ability to perform AFOI as proven by successful completion of the procedural checklist (Appendix S1). Out of 29 critical actions, scores ranged from 23/29 (79.3%) to 27/29 (93.1%). Attending physician self‐perceived ability performing AFOI rose to 5.4/7 (±0.74). Attending physician comfort in teaching AFOI also rose to 5.2/7 (±0.86). This change was statistically significant for comfort in performing (p < 0.001, 95% confidence interval [CI] = 1.34 to 3.06) and teaching AFOI (p < 0.001, 95% CI = 1.56 to 3.05). Further, all participants felt that they were more likely to attempt AFOI after the session (15/15, 100%) and most felt that they were more likely to teach the skill (14/15, 93.3%). Additionally, the majority of participants (86.7%) felt that the peer coaching session was more effective in instilling confidence to perform and teach the skill than other CME activities they had attended in the past (Figure 3).

FIGURE 3.

Effectiveness of peer coaching compared to previous CME activities. Relative to previous CME, effectiveness of peer coaching. Mean performance of a skill, teaching of a skill Likert = 4.86/5. N = 15. CME, continuing medical education

DISCUSSION

A peer coaching educational intervention improved academic emergency physician self‐perceived ability to both perform and teach a low‐frequency, high‐complexity procedure. To our knowledge, our paper is the first to use peer coaching to instruct emergency medicine faculty to enhance their procedural skill and assess both the performance and the teaching of the peer‐coached task.

There is limited literature around the use of peer coaching in medicine. Peer coaching was originally described as facilitating the implementation of novel teaching techniques in classroom teachers. ¹³ However, Schwellnus and Carnahan ¹⁴ completed a scoping review of early peer coaching interventions within the medical field, finding its deployment in a variety of clinical settings with results suggesting its use. Sekerka and Chao ⁵ qualitatively examined the benefits of peer coaching within the realm of faculty development of family medicine faculty. Peer coaches within the faculty found benefit themselves from the exercise, reinforcing engagement in their own professional development via reflection and continued support of junior learners. Our data add to the efficacy of peer coaching as a legitimate modality in medical education through the study's prospective nature and by focusing on both performance and teaching of a single procedure.

Evidence for coaching of procedures in medical education is limited. A review showed 21 papers on the topic, with only seven reporting on coaching for technical skills. ¹⁵ The best evidence for peer coaching to date relates to surgical skill acquisition. Palter et al. ⁶ performed a randomized control trial investigating if peer coaching was more effective than conventional practice in improving laparoscopic suturing technique among inexperienced faculty surgeons. Postintervention testing found that the peer coaching group had statistically significant improvement in technical proficiency in laparoscopic suturing compared to their conventionally trained peers. Further, the peer coaching group reported that they also felt more comfortable using the acquired suture skill in the operating room than those who learned the skill conventionally. ⁵ Bonrath et al. ¹⁶ randomized surgical residents to either conventional training or comprehensive surgical coaching during a minimally invasive surgery rotation. The coaching group scored significantly higher on a procedure‐based skill score and made fewer technical errors than the conventional training group. ¹⁷ Our study expands the use of peer coaching for procedure‐based skill development to non‐surgically trained physicians. Additionally, our effort looked to improve academic faculty self‐perceived ability in teaching the skill of AFOI, which is a necessary attribute given the responsibility of educating junior learners. Finally, peer coaching has not been studied previously in the context of CME.

The theoretical roots of peer coaching as a model for CME adhere to best practices in adult learning and utilize an experiential learning construct to emphasize problem‐based experiences. ¹⁸ Peer coaching is a distinct type of coaching that contains key elements, including: (1) a voluntary relationship based on collaboration versus competition, (2) self‐evaluation, (3) the existence of a peer coach to offer feedback, (4) establishment of goals by the participants, and (5) the focus on participants strengths and increase in skill capacity. ¹⁷ , ¹⁹ Faculty volunteered their participation recognizing their limited experience with this low‐frequency, yet high‐complexity procedure. Prior to the session, participants identified barriers to their performance and teaching of AFOI through self‐reflection. Peer coaches were cofaculty who also had completed critical care training, giving them a greater procedural volume and context to inform the session. Using an established checklist and goals derived from the participants, capacity to perform AFOI was increased via formative feedback. The participants then had to teach the procedure to their peer, in which formative feedback on their teaching was guided via the PrOSTE, providing opportunity to reinforce the procedural learning. Our study confirmed the efficacy of this theoretical framework as our participants reported an increase in comfort both performing and teaching this procedure. Further, our participants felt that peer coaching was more effective than prior CME activities.

LIMITATIONS

While there was no comparative arm to our peer coaching initiative, participants have extensive experience with traditional CME teaching and believed the peer coaching approach to be superior. Our sample size was small, though on par with the numbers reported previously in the surgical literature. ⁶ , ¹⁶ Academic faculty by practice size are a smaller representative group relative to all practitioners in a particular field, but by nature have the highest opportunity to oversee trainees performing novel techniques. There is a chance of selection bias as participants volunteered for peer coaching; it is uncertain whether less motivated individuals would report similar benefits. The procedural checklist did allow evaluation of faculty ability to perform AFOI but we have no patient‐centered or learner‐centered outcome to demonstrate higher order outcomes. The PrOSTE did offer some ability to confirm ability to teach AFOI, but this was used for formative and not summative assessment given the lack of a standardized learner. It is uncertain whether our intervention increased the amount or success of AFOI attempts in the department by either the participants or the associated junior learners. However, given the low frequency of AFOI in daily emergency medicine practice, if there was an effect on actual performance or teaching of the procedure, it may not be seen. It is also uncertain whether our intervention led to sustained ability to perform AFOI. Further, sustainability of skills would likely be enhanced by serial peer coaching sessions. This is certainly achievable, because peer coaching involves only the time capital of local experts to serve as peer coaches and administration of the peer coaching curriculum. Our institution was fortunate to have a dual‐boarded physician with experience performing and teaching AFOI and who donated their time; other centers may not have this luxury. Future work in peer coaching should feature comparison to existing CME modalities, with longitudinal analysis of both learning retention and patient‐oriented outcomes.

CONCLUSIONS

In conclusion, peer coaching is an effective strategy for improving self‐perceived efficacy of academic emergency medicine faculty to both perform and teach a low‐frequency, high‐complexity procedure, such as awake fiberoptic intubation. More research is required to confirm whether this added comfort translates to successful performance in the clinical environment as well as impacts on the learner to whom the skill was taught. Given that the majority of continuing medical education experiences are didactic‐based, incorporating peer coaching more routinely into continuing medical education offerings creates an opportunity to enhance the learning of practicing physicians. It is a local and more learner‐oriented model for delivery of continuing medical education.

CONFLICT OF INTEREST

The authors have no potential conflicts to disclose.

AUTHOR CONTRIBUTIONS

Colin G. McCloskey contributed to study concept and design, acquisition of the data, analysis and interpretation of the data, drafting of the manuscript, critical revision of the manuscript for important intellectual content, and statistical expertise. Christopher T. Dimza contributed to acquisition of the data, analysis and interpretation of the data, drafting of the manuscript, and critical revision of the manuscript for important intellectual content. Matthew J. Stull contributed to study concept and design, analysis and interpretation of the data, drafting of the manuscript, and critical revision of the manuscript for important intellectual content

Supporting information

Appendix S1. Peer Coaching AFOI Critical Actions.

McCloskey CG, Dimza CT, Stull MJ. Peer coaching increases emergency medicine faculty ability to perform and teach awake fiberoptic intubation. AEM Educ Train. 2021;5:e10705. doi: 10.1002/aet2.10705