Optimizing the Implementation of Surgical Coaching Through Feedback From Practicing Surgeons

This qualitative study identifies surgeon-derived recommendations for implementation of surgical coaching programs from participants’ exit interviews and ratings of their coaching interactions.

Key Points

Question

How can surgical coaching programs be implemented in a way that aligns with the professional culture of surgeons?

Findings

In this qualitative analysis of interviews with 23 practicing surgeons in a peer surgical coaching program, coaches and coachees agreed on key implementation recommendations, such as how to optimize coach-coachee relationships and facilitate productive coaching sessions. Despite consensus on their recommendations, surgeons tended to rate their coaching sessions positively if their own sessions aligned with these factors but negatively if their experiences were misaligned.

Meaning

These findings can help organizations implement effective coaching programs that enable meaningful continuous professional development for surgeons.

Abstract

Importance

Surgical coaching is maturing as a tangible strategy for surgeons’ continuing professional development. Resources to spread this innovation are not yet widely available.

Objective

To identify surgeon-derived implementation recommendations for surgical coaching programs from participants’ exit interviews and ratings of their coaching interactions.

Design, Setting, and Participants

This qualitative analysis of the Surgical Coaching for Operative Performance Enhancement (SCOPE) program, a quality improvement intervention, was conducted at 4 US academic medical centers. Participants included 46 practicing surgeons. The SCOPE program ran from December 7, 2018, to October 31, 2019. Data were analyzed from November 1, 2019, to January 31, 2020.

Interventions

Surgeons were assigned as either a coach or a coachee, and each coach was paired with 1 coachee by a local champion who knew the surgeons professionally. Coaching pairs underwent training and were instructed to complete 3 coaching sessions—consisting of preoperative goal setting, intraoperative observation, and postoperative debriefing—focused on intraoperative performance.

Main Outcomes and Measures

Themes from the participants’ exit interviews covering 3 major domains: (1) describing the experience, (2) coach-coachee relationship, and (3) facilitators and barriers to implementing surgical coaching. Surgeons’ responses were stratified by the net promoter score (NPS), a scale ranging from 0 to 10 points, indicating how likely they were to recommend their coaching session to others, with 9 to 10 indicating promoters; 7 to 8, passives; and 0 to 6, detractors.

Results

Among the 46 participants (36 men [78.3%]), 23 were interviewed (50.0%); thematic saturation was reached with 5 coach-coachee pairs (10 interviews). Overall, coaches and coachees agreed on key implementation recommendations for surgical coaching, including how to optimize coach-coachee relationships and facilitate productive coaching sessions. The NPS categories were associated with how participants experienced their own coaching sessions. Specifically, participants who reported excellent first sessions, had a coaching partner in the same clinical specialty, and were transparent about each other’s intentions in the program tended to be promoters. Participants who described suboptimal first sessions, less clinical overlap, and unclear goals with their partner were more likely detractors.

Conclusions and Relevance

These exit interviews with practicing surgeons offer critical insights for addressing cultural barriers and practical challenges for successful implementation of peer coaching programs focused on surgical performance improvement. With empirical evidence on optimizing coach-coachee relationships and facilitating participants’ experience, organizations can establish effective coaching programs that enable meaningful continuous professional development for surgeons and ultimately enhance patient care.

Introduction

Surgical coaching is maturing as a tangible strategy for surgeons’ continuous professional development, although resources to spread this innovation are not yet widely available. Early coaching programs for practicing surgeons have demonstrated that, in small pockets across the United States,^1,2,3 coaching is feasible and perceived as high value for surgeons who participate. From these pilot studies and interviews with additional surgeons, several barriers to implementing surgical coaching programs have also been identified, notably cultural resistance from surgeons.^1,4

It remains unclear how to implement coaching programs in a way that aligns with surgical culture. To be adopted widely, surgical coaching must integrate with surgeons’ priorities and simultaneously address their professional concerns. Known cultural barriers to surgical coaching include surgeons’ prominent concerns about maintaining an authoritative image and fears of losing autonomy.^4,5 Furthermore, in fields that regularly use coaching for performance improvement—including business and athletics—optimal coach-coachee matching is recognized as critical for gaining buy-in from the coachee.⁶ Despite having strategies for how coaches can build trusting relationships with peer surgeons,^7,8 evidence that specifically addresses the broader cultural concerns is lacking, hindering the ability of surgical coaching programs to gain widespread traction.

We studied a new surgical coaching program to identify implementation recommendations from themes of surgeons’ exit interviews and ratings of their own coaching interactions. Through this qualitative analysis of the Surgical Coaching for Operative Performance Enhancement (SCOPE) program, we aimed to generate empirical evidence that addresses key implementation challenges for surgical coaching. Armed with this evidence, surgical organizations may establish effective coaching programs to enable meaningful performance improvement throughout surgeons’ careers.

Methods

Setting

This qualitative study evaluated implementation of the inaugural SCOPE program, a professional development initiative for practicing surgeons, which ran from December 7, 2018, to October 31, 2019, at 4 academic medical centers in Boston, Massachusetts. Ethics approval was granted by Partners Human Subjects Research Committee, the governing institutional review board for all study sites, and all participants provided written informed consent.

Participants

One faculty surgeon at each institution was invited to be a coaching champion based on their expressed interest in coaching and previous involvement in local quality improvement and professional development initiatives. Champions were responsible for recruiting participants and encouraging coaching activities among their colleagues.

Study participants included practicing surgeons who were recruited by the champion and who agreed to participate in the SCOPE program. Champions were instructed to recruit surgeons—agnostic to their eventual role in the program—who aligned with the ideal characteristics of surgical coaches: excellent communication skills, emotional intelligence, and respect among their peers.^2,9,10 Because the champions professionally knew the surgeons, recruitment was conducted by the champions’ judgment of the aforementioned characteristics. No selection criteria regarding surgeons’ clinical specialty, clinical experience level, academic appointment, or leadership positions were imposed. Some surgeons were eligible for a malpractice premium reduction by attending the Surgical Coaching Workshop; however, none of the coaching sessions or research activities were incentivized.

Preparation

In SCOPE, surgeons were assigned to a single coaching role—either coach or coachee—by their institutions’ coaching champion. Champions then paired coaches 1:1 with coachees for the duration of the program. The coach-coachee matching process was not standardized, and no explicit recommendations were provided beforehand. Four champions were included, 1 at each institution. Two champions solicited their surgeons’ preferences to be either a coach or coachee and with whom they would like to be matched. The other 2 champions relied on their professional familiarity with each of their surgeon colleagues, pairing coaches and coachees based on seniority, specialty alignment, perceived personality compatibility, and reputation for receptiveness to feedback.

The SCOPE Program

All coaches and coachees were required to attend a 3-hour, in-person surgical coaching workshop at the start of the SCOPE program to learn the core principles and key behaviors of surgical coaching.¹¹ This workshop was followed by weekly emails reminding them of coaching tips from the workshop. Assigned coaching pairs were instructed to follow a defined coaching structure: preoperative goal setting, intraoperative observation, and postoperative debriefing. Together, these phases are considered a single coaching session.

Preoperative goal setting could occur either immediately before the observed case or in the days preceding the operation. Intraoperatively, the coach was expected to directly observe the coachee without scrubbing in or otherwise interacting with the coachee (ie, as a “fly on the wall”), paying attention to the coachee’s goals. The debrief occurred after the case was completed—either immediately after the observed case or within 3 days after the operation—and was intended for the coach and coachee to discuss the coachee’s intraoperative performance. The goal was for each pair to conduct 3 coaching sessions throughout the program. Coaching pairs were advised to focus their coaching sessions on technical skills (respect for tissue, exposure, instrument handling, time and motion, flow of operation),¹² nontechnical skills (situation awareness, decision-making, communication and teamwork, leadership),¹³ or intraoperative teaching skills (teaching the operation, teaching new surgical knowledge, assessing comprehension).

Net Promoter Scores

Within 24 hours after each debrief, a postcoaching survey was emailed individually to the coach and coachee to capture their immediate reactions on their coaching session. This survey included the Net Promoter Score (NPS), a 1-question rating used in business to measure customer experience and predict the growth of a company.¹⁴ The question asks, on a scale of 0 to 10, how likely participants are to recommend a product, brand, or company to another person. Those giving a 9 or 10 are promoters of the product, brand, or company; 7 and 8, passive; and 0 through 6, detractors.¹⁴ Asked immediately after a postoperative debrief, surgeons’ NPS responses were interpreted as their rating for the preceding coaching session.

Because surgeons could give an NPS rating after each coaching session, we categorized individual participants as promoters, passive, or detractors based on their most extreme rating provided, expecting their feedback to be driven by that rating. For example, if a surgeon rated their first coaching session as a 4 and their second session a 7, they would be categorized a detractor. If another surgeon rated their first coaching session a 10 and their second session a 7, they would be categorized a promoter. Only surgeons who rated all their sessions as 7 or 8 were categorized as passive. No surgeons provided ratings in both the promoter and detractor ranges.

Exit Interviews

To evaluate the quality improvement initiative, on program completion, 1 author (J.C.P.) conducted one-on-one semistructured interviews with surgeons to understand their experience as a participant and to solicit their recommendations for implementing surgical coaching programs. Interviews lasted approximately 30 minutes and were conducted in person or via telephone when in-person was not possible. Interview questions were grouped into 3 domains for subsequent analysis: (1) describing the experience, (2) coach-coachee relationship, and (3) facilitators and barriers to implementing surgical coaching. The full interview guide is included in eAppendixes 1 and 2 in the Supplement.

Interviews were conducted first for coaches and coachees who completed the program’s goal of 3 coaching sessions. At the end of the study period, a convenience sample of remaining coaches and coachees who completed fewer than 3 coaching sessions was selected for exit interviews to provide a diverse range of perspectives on program implementation. Surgeons who did not complete any sessions did not reply to program requests and could not be interviewed.

Analysis

Interviews were audio-recorded, transcribed, and deidentified before analysis. We then conducted a phenomenology-based thematic analysis on interview transcripts to categorize participants’ feedback into themes. Phenomenology is a qualitative research method aimed at describing the meaning of the lived experience of a phenomenon from the participants’ perspectives.¹⁵ Transcripts were first analyzed and coded independently by 2 study team members (J.C.P. and N.P.), both surgical residents and research fellows at Ariadne Labs, Boston, with experience in qualitative research. We conducted line-by-line coding for each interview transcript, using inductive reasoning to extract themes that developed from participants’ responses to each interview question. We then performed a second round of coding to consolidate the initial themes into a final representative model. Both qualitative analysts agreed on the final representative model for responses to each question.

To interpret implementation recommendations in the appropriate context, we stratified participants’ responses by their NPS category, specifically comparing responses between promoters and detractors. Representative quotes were selected for presentation. We used χ² tests to compare participants’ characteristics across NPS categories, with 2-sided α = .05 indicating significance.

Results

Participants’ Demographics

Of the 50 surgeons who completed the surgical coaching workshop, 4 left the program, and 46 were subsequently eligible for coaching sessions. During the study period, more male surgeons (36 [78%]) than female surgeons (10 [22%]) participated in SCOPE (Table 1), which varied by specialty. Surgeons across all levels of clinical experience and academic positions participated. Of the clinical specialties represented, general, colorectal, and bariatric/minimally invasive surgery were the most common specialties (7 [15%] each). Twenty-three of the 46 participants (50%) were interviewed; thematic saturation was reached with 5 pairs of coaches and coachees (10 interviews).

Table 1. Demographics of Surgeon Participants, Stratified by Net Promoter Score Category.

Characteristic	NPS group, No. (%) of participantsa				P valueb
	Promoters (n = 7)	Passive (n = 11)	Detractors (n = 10)	No response (n = 18)
Sex
Female	2 (28.6)	2 (18.2)	2 (20.0)	4 (22.2)	.96
Male	5 (71.4)	9 (81.8)	8 (80.0)	14 (77.8)
Time in practice, y
1-10	5 (71.4)	3 (27.3)	5 (50.0)	6 (33.3)	.54
11-20	1 (14.3)	3 (27.3)	3 (30.0)	6 (33.3)
≥21	1 (14.3)	5 (45.5)	2 (20.0)	6 (33.3)
Clinical specialty
Bariatric/MIS	0	2 (18.2)	1 (10.0)	4 (22.2)	.44
Breast	1 (14.3)	0	0	0
Colorectal	1 (14.3)	2 (18.2)	0	4 (22.2)
Endocrine	1 (14.3)	2 (18.2)	3 (30.0)	0
General	1 (14.3)	2 (18.2)	2 (20.0)	2 (11.1)
HPB	0	0	1 (10.0)	2 (11.1)
Neurosurgery	0	0	1 (10.0)	0
Orthopedics	2 (28.6)	1 (9.1)	2 (20.0)	1 (5.6)
Otolaryngology	0	0	0	2 (11.1)
Thoracic	0	1 (9.1)	0	0
Trauma/ACS	0	0	0	1 (5.6)
Urology	1 (14.3)	0	0	2 (11.1)
Vascular	0	1 (9.1)	0	0
Academic position
Clinical instructor	1 (14.3)	1 (9.1)	0	6 (33.3)	.56
Assistant professor	3 (42.9)	3 (27.3)	5 (50.0)	4 (22.2)
Associate professor	2 (28.6)	3 (27.3)	3 (30.0)	5 (27.8)
Professor	1 (14.3)	4 (36.4)	2 (20.0)	2 (11.1)
Other	0	0	0	1 (5.6)
Coaching role
Coach	3 (42.9)	8 (72.7)	4 (40.0)	8 (44.4)	.39
Coachee	4 (57.1)	3 (27.3)	6 (60.0)	10 (55.6)
No. of coaching sessions completed
0	0	0	0	6 (33.3)	.001
1	1 (14.3)	2 (18.2)	2 (20.0)	7 (38.9)
2	0	5 (45.5)	1 (10.0)	0
3	6 (85.7)	4 (36.4)	7 (70.0)	5 (27.8)

Abbreviations: ACS, acute care surgery; HPB, hepatopancreaticobiliary; MIS, minimally invasive surgery.

^aPercentages have been rounded and may not total 100.

^bCalculated using χ² analysis.

There were no systematic differences in surgeons’ demographic characteristics across NPS categories. Differences in coaching sessions completed across NPS categories were driven by surgeons who did not submit any NPS rating. Specifically, surgeons who did not complete any sessions also did not submit an NPS rating. Six of 7 promoters (85.7%) completed all 3 coaching sessions, but 1 promoter (14.3%) completed only 1 session. Most detractors (7 of 10 [70.0%]) also completed all 3 coaching sessions.

How Surgeons Experienced the Coaching Sessions

Themes from surgeons’ responses to describing the experience are presented in Table 2. Key themes included the impact of the first coaching session, the perception that coaching quality improved and that coaching interactions became more comfortable over time, and the importance of surgeons’ clinical backgrounds when assigning coach-coachee pairs.

Table 2. Themes and Quotations From the Interview Domain Describing the Experience.

Theme	Sample quotations
Impact of the first coaching sessiona	“So, I think that–so, the most that I got, the first session, I got by far the most out of it. The other sessions were still good. I still would have done them. They were still good. But the first one was by far the highest yield … Well, after I did it, I was like this is amazing. I was like I want to do this forever.” (coachee, promoter)
	“Well, I think the first coaching session was that I felt like there was nothing to coach him on, but if he just, he, ya know he’s such a teacher and commanding the room and a nice person, I'm like, why can I not find areas of improvement. Then what we said, well you know, what do you really want to focus on, so then we kind of identified then the teaching, the focus on the teaching. Um, and then I think I could give more feedback the second time around.” (coach, detractor)
Perception that coaching quality improved over timea	“And I think that changed with the second [coaching case] where there was much more observation and also seeing what happens to the resident or the fellow. So I think we became better at it and more focused on what we were supposed to do.” (coachee, detractor)
Coaching interactions became more comfortable over timea	“I think that there was an element of the Hawthorne effect in the beginning, but you know what? It was more towards the beginning of the procedure in a 2-and-a-half hour case because, after about 30 minutes, it’s almost like you kind of fade into the woodwork. And so I felt though the operation was much more natural at that point. And then by the time we did a second and third coaching session, I felt personally, though not measurable, that there was less of that Hawthorne effect.” (coach, no response to NPS)
Importance of clinical background in coach-coachee pairingsa	“I found having somebody outside of my specialty to be probably the least useful thing about the process because… it’s very hard for a [surgeon of a different specialty] to come in who doesn’t know the disease process, who doesn’t know the steps, who doesn’t know the surgery, who doesn’t even know the instruments I’m using to come in and start commenting on those things.” (coachee, detractor)
Applying coaching feedback	“Biggest takeaways I had [from my coaching sessions] were… I communicate out loud a lot… Sometimes when you’re about to say something that’s more important than what you’ve been saying, and the room can’t differentiate what’s going on because your body language is the same… For me, since I talk a lot and project a lot, [my coach] said, ‘You can probably still do something like that where you step away, patients in lithotomy, step away, get people’s attention, you’re stepping away from the field. And that will alert them to this is more important than everything else I’ve been saying.’ So, that was 1 thing that I found very helpful… I don’t always do it because it’s going to take a little while to figure it out. But once in a while, it’s a good way to do it.” (coachee, promoter)
Benefits to the coach in addition to the coachee	“Well, (1), I’ve tried different things based on what I’ve seen in the [coachee’s] OR; (2), I have redoubled my efforts to make sure that everything is that is needed—everything that can be possibly anticipated for the operation will be there at the beginning of the case. And I’ve done that before, but [before observing my coachee’s case] I just didn’t recognize that it’s a big thing when it comes to efficiency [in the OR].” (coach, no response to NPS)

Abbreviations: NPS, Net Promoter Score; OR, operating room.

^aIndicates differences in how promoters and detractors experienced their coaching sessions.

These themes differed in how promoters experienced their coaching sessions compared with how detractors experienced theirs. For example, promoters tended to have excellent first sessions, which may have led them to trust the coaching process and rate the coaching session highly. Detractors, who rated their coaching sessions less favorably, described suboptimal first sessions, despite noting that the interactions improved in subsequent sessions. Promoters had coaching partners who aligned with their own clinical backgrounds, whereas detractors reported less of a clinical overlap with their partners.

Regardless of their category as promoter or detractor, participants frequently described how they applied intraoperative performance feedback in subsequent cases. Similarly, a recurring theme was how the coaches gained valuable perspective as a neutral observer in the coachee’s operating room (OR).

Optimizing the Coach/Coachee Relationship

Table 3 reports themes from participants’ responses about the coach-coachee relationship. Generally, all surgeons agreed that the most important characteristics for a productive coach-coachee relationship were mutual respect and trust, transparent communication about each surgeon’s intentions, established rapport between the 2 surgeons, compatibility with communication styles, and mutual commitment to the partnership. Although all agreed on these recommendations, promoters experienced these characteristics in their coaching relationship, whereas detractors tended to report certain factors missing. Specifically, promoters reported clear transparency and previously established good rapport with their coaching partner. In contrast, detractors described a lack of transparency or preexisting rapport.

Table 3. Themes and Quotations From the Interview Domain Coach-Coachee Relationship.

Question	Theme	Sample quotation
What are the most important characteristics for a productive coach-coachee relationship?	Mutual respect and trust	I think with mutual respect for each other, so I think honestly he… respects me clinically and I certainly respect his opinion. So I think if you have someone who is just a whack job and trying to give you feedback, that I think is not going to be too, well, super helpful. So I think that the mutual respect and I mean so I think commitment, mutual respect for each other but also having someone who is clinically competent.” (coachee, detractor)
	Transparent communication about each surgeon’s intentionsa	“I think transparency about probably what you’re both trying to get out of this—which would probably we did not have—and understanding where each of us are coming from would be the main things.” (coachee, detractor)
	Good rapport should be established between coach and coacheea	I have a good rapport with him to begin with. So, I think that, and he and I, over the years, we’ve had either patients or clinical things where we’ve dealt with scenarios where things didn’t go right and we’ve–together, we’d worked through those issues before. So, I just think I had a good relationship with him where whatever he was going to tell me, since knowing him and knowing what his style was, I think that I was going to be receptive to whatever he was going to tell me.” (coachee, promoter)
	Compatibility with communication styles and personalities	No quotation provided
	Mutual commitment to the coaching partnership	No quotation provided
How should coach and coachee be matched up?	Match coachee’s goals with coach’s strengthsa	“I think probably the thing that we didn’t do well was really sit down and establish what those [goals] were on each end. But I think, we didn’t do it intentionally, but it just didn’t work out that way. I think we both went in there just as this was observing and sort of whatever we got out of it, we got out of it…I wasn’t clear on what it was I wanted [my coach] to focus on.” (coachee, detractor)
	Similar clinical specialty (although benefits to different subspecialty)a	“And I think it also is helpful—[coach] and I are both orthopedic surgeons, but [coach is] a hand surgeon and I'm a sports surgeon. So we don’t exactly do the same things. And I think it was helpful to have somebody a little bit outside of what my specialty is. I think if one of my colleagues that also did sports medicine was in the room with me, I think then you tend to be like, ‘Oh, well, I would use that screw instead of this.’” (coachee, promoter)
	Peer coaching: similar level of clinical experience, flat/no hierarchy. Expert coaching: coach has more expertise, and coachee has less expertise in selected performance topic, with increased risk for hierarchy	“I think for young surgeons—and by young, I mean the first 5 years—[the coach] probably should be someone more senior. So I always think of surgeons at 5 years, 15 years, and above, those are my blocks. So I think if someone in the first 5 years, it’d be nice if there was someone maybe around the 10-year mark. And then for people in advanced stage, maybe someone more senior. I do think sometimes it’s good to be coached by someone younger but depending on what your coaching objectives are.” (coachee, detractor)
How should surgical coaches ideally be selected?	Solicit coachee’s preferences in coach selectiona	No quotation provided
	Selection process by local leadership based on known expertise, reputation among peers, coaching ability	“I think it's important to have people who are invested in this because I think if you have people who aren’t invested, I think it’s going to feel like another one of the things you have to do. So I think, really, some interest in doing it I think is going to be key… I do think people in leadership positions might be able to pick some folks out. And I think if you queried some reliable people in the OR, frankly, you might get some interesting opinions about who would be good at this.” (coachee, promoter)
	Commitment/buy-in from the coach

Abbreviation: OR, operating room.

^aIndicates differences in how promoters and detractors experienced their coaching sessions.

Participants agreed that surgeons should be matched so that the coach’s strengths complemented the coachee’s goals and that the interactions were more valuable when the coach and coachee were in similar clinical specialties. Promoters, who reported positive interactions, conveyed alignment of the coachee’s goals with the content of their coaching discussions and a shared perspective by being in the same specialty. Detractors often acknowledged not setting goals or not having postoperative debriefs that focused on their intended goals. In this cohort, more detractors than promoters were in cross-specialty coaching pairs.

Facilitators and Barriers to Implementing Surgical Coaching

Beyond the one-on-one coach-coachee relationship, important facilitators for surgical coaching included selecting cases for observation that were appropriate for the coachee’s learning goals and having buy-in of the local work environment (Table 4). Promoters reported that their observed coaching cases provided valuable substrate for debriefing about the stated performance goal. For example, if coachees wanted to improve their intraoperative teaching skills, the observed case should involve a resident or fellow. Detractors tended to report that nothing remarkable happened in their observed cases and that there was little to debrief afterwards.

Table 4. Themes and Quotes From the Interview Domain Facilitators and Barriers to Implementing Surgical Coaching.

Questions	Themes	Sample quotes
Facilitators: Beyond the coach-coachee relationship, what factors made for a successful coaching experience?	Individual receptiveness to coaching	No quotation provided
	Selecting a case appropriate for the coachee’s learning goalsa	“I didn’t see anything glaring. It looked like [coachee] did a good job. I did mention that I thought he had very good control of the room… The first case was with the junior resident, so [coachee] basically did the case, I think it was just to be able to work with someone who’s not very …experienced… and do it smoothly and safely. The second case–I think [coachee] was hopeful that he could help the fellow be more adept at dissecting out the cystic artery and duct. And on the last case, it was to… [keep] the fellow in the preperitoneal plane on this hernia repair. Because the fellow had not a lot of experience with it.” (coach, passive)
	Buy-in of local work environment (eg, OR staff, leaders, institutional culture)a	“I think having the staff in the room understand what’s going on… I think having my assistant and [coach’s] assistant connecting helped the process, so I didn’t feel like the burden was on me to get everything set.” (coachee, promoter)
	Leadership of program locally (eg, champion, department chair, program director)	“I think departmental leadership was definitely behind it, so that was helpful. OR, I feel they'll go along with whatever we want to do, so they were fine with it.” (coachee, promoter)
	Coaching education for participants	No quotation provided
Barriers: Beyond the coach-coachee relationship, what factors negatively contributed to your coaching experience?	Stigma of surgeons having a coacha	“[Coachee] told me, ‘I think there’s some stigma assigned with having a coach a negative stigma, right?’... We didn’t really come out and say, oh, that’s [Dr X] and she’s here to observe a thyroidectomy, he didn’t call me a coach and I think there’s some stigma and he actually told me a story…like a friend of a friend of a friend poke him like, oh…she said ‘oh surgeon so and so must be a really bad surgeon because he has a coach coming in all of the time’… So I think there's just some, you know, there's just some stigma, a negative stigma with needing a coach.” (coach, detractor)
	Forgetting material from the coach traininga	No quotation provided
	Lack of protected time	No quotation provided
	Logistical challenges	No quotation provided

Abbreviation: OR, operating room.

^aIndicates differences in how promoters and detractors experienced their coaching sessions.

Buy-in of the local work environment was an important theme for both facilitators and barriers to coaching. Operating room staff welcomed the presence of a coach during cases described by promoters, whereas some detractors conveyed a stigma associated with surgeons having a coach, reporting comments from OR staff that surgeons “needing a coach” must be bad surgeons. Furthermore, promoters reported referencing their training material from the surgical coaching workshop, whereas those who mentioned forgetting coaching material previously learned were more likely detractors. Lack of protected time and scheduling challenges were reported as implementation barriers for all participants.

Discussion

In this qualitative analysis of the inaugural SCOPE program, we presented surgeons’ recommendations for implementing surgical coaching by interpreting their interview responses in the context of how they rated their own coaching sessions. Coaches and coachees generally agreed on key implementation factors for surgical coaching programs, including how to optimize coach-coachee relationships and facilitate productive coaching sessions that respect surgeons’ priorities and culture. Importantly, NPS ratings were associated with how participants actually experienced their coaching sessions, with promoters experiencing the program aligned with their recommendations and detractors experiencing it differently than they would have recommended.

Despite promising potential for surgical coaching to enhance intraoperative performance, widespread adoption has been stymied by persistent concerns from the surgical profession.^4,5 Few studies have directly investigated these cultural barriers to implementing coaching in surgery. In a survey of practicing surgeons, Mutabdzic et al⁴ identified key cultural concerns that surgeons have about coaching, including concerns about appearing incompetent and losing autonomy if they were to have a coach. In contrast, in Wisconsin’s video-based peer coaching program, Greenberg et al¹ identified programmatic logistics and technological capabilities—but not resistance to the fundamental concepts of coaching—as implementation barriers. This discrepancy might be explained by selection bias of the 20 surgeons in the Wisconsin study who volunteered to participate in a statewide coaching initiative and had already bought in to the concept of coaching. In the Carolinas’ paper, Stefanidis et al³ discussed a critical unknown for surgical coaching programs—how to select coaches and pair them with coachees—although their study was not designed to answer that question. In addition, a qualitative analysis of Michigan’s coaching program in bariatrics² found that coaches and coachees frequently alternated roles and provided bidirectional feedback, but it did not evaluate whether participants found that role change to be beneficial or not. In this analysis of the SCOPE program, we sought surgeons’ direct input on how to structure and implement surgical coaching. By understanding how they rated their own coaching sessions, we directly investigated key cultural barriers to surgical coaching.

These results have important implications for implementing successful surgical coaching programs and other quality improvement initiatives. To overcome cultural barriers of coaching for practicing surgeons, coaching programs need to incorporate recommendations from surgeon participants themselves (Table 5 and eFigure in the Supplement). Herein, we highlighted how critical the first coaching session seems to be for setting the tone in a coaching partnership. Coaching programs should focus efforts on pairing coachees with the appropriate coach and facilitating as smooth a start to their partnership as possible. In the early phases of surgical coaching, pairing surgeons in the same specialty appears to be well accepted. Creating an environment in which coaches and coachees can become acquainted personally—that is, through introductory social events—will be important for them to establish rapport and transparently communicate goals before coaching sessions begin. When possible, coaching program leaders should solicit preferences from the coachees about whom they would like to coach them and on which skills. Implementing these surgeons’ recommendations should facilitate buy-in and commitment from both coaches and coachees. Future program evaluations should investigate the perceptions of OR staff to address the reported stigma that OR team members may have about surgeons who use coaching. Creative solutions, such as departmental leaders permitting surgeons to dedicate time to coaching, regulatory bodies offering continuing medical education credit, and assistants coordinating coach-coachee calendars, will be necessary for addressing the inevitable challenges of protected time and scheduling difficulties for surgeons.

Table 5. Key Implementation Recommendations for Surgical Coaching Programs.

Set expectations for individual surgeons’ experiences	Optimize the coach-coachee relationships	Create an environment that invites surgical coaching
Meaningful first coaching session is critical Coach-coachee pairings can “make” or “break” the experience	Match coachee’s goals with coach’s strengths Match within similar clinical specialty Establish transparency and good rapport before coaching	Normalize coaching with leaders and OR staff Select cases appropriate for coachee’s goals Reinforce lessons from coach training

Abbreviation: OR, operating room.

Limitations

There are several limitations to this analysis. First, there was great heterogeneity of surgical specialties in the SCOPE program. Although the core principles of coaching are agnostic to clinical specialty, there are likely nuances to running successful coaching programs within each specialty that we were unable to detect with certainty owing to the wide variety of surgeons. Second, selection bias potentially influenced this analysis. Although coaching champions recruited participants at their own institutions and perhaps exerted unmeasured social influence for surgeons to participate, these surgeons ultimately volunteered to participate in SCOPE and thus might be more likely to promote coaching. Nonetheless, despite this self-selected cohort, many surgeons gave critical feedback, and several rated their coaching sessions unfavorably. Third, selection bias was also inherent for surgeons who did not complete any coaching sessions and did not respond to requests for exit interviews. We were, however, able to interview surgeons who only completed 1 or 2 coaching sessions, and their recommendations paralleled those of surgeons who completed all 3 sessions. Fourth, female surgeons were underrepresented in this study; intentional recruitment for personal diversity will be necessary in future coaching programs. Last, although using the NPS is a strength for measuring surgeons’ buy-in, asking participants to provide their NPS responses immediately after each coaching session may not represent surgeons’ attitudes toward the coaching program as a whole. Future evaluations might administer the NPS after the program has been completed entirely, after surgeons have had time to reflect on the program’s impact on their practice.

Conclusions

As surgical coaching continues to mature as a performance improvement strategy for surgeons, coaching programs will need to address the profession’s cultural concerns to achieve widespread adoption. The themes identified from surgeons in the SCOPE program offer critical insights into the successful implementation of surgical coaching programs. With empirical evidence on optimizing coach-coachee relationships and facilitating participants’ experience, organizations may establish effective coaching programs that enable meaningful continuous professional development for surgeons and ultimately enhance patient care.

Supplement.

eAppendix 1. Semistructured Exit Interview-Coach Version

eAppendix 2. Semistructured Exit Interview-Coachee Version

eFigure. Key Implementation Recommendations for Surgical Coaching Programs