Sunday, March 30, 2014

No coaches for doctors?

I was re-reading a portion of Atul Gawnde's book Better: A Surgeon's Notes on Performance and was struck by a couple of sentences in the afterword:

Ours is a team sport, but with two key differences from the kinds with lighted scoreboards: the stakes are people's lives and we have no coaches.  The latter is no minor matter.  Doctors are expected to caoch themselves. We have no one but ourselves to lift us through the struggles.

I imagine this is a widely held view, as Atul is a gifted observer of the conditions within which doctors work.  But what a tragedy if the statement is true or if doctors believe it to be true.

If it is is true that doctors have no coaches, that represents an utter failure of the profession.  After all, there are people throughout a doctor's development and career who could serve as coaches--teachers, colleagues, chiefs of service.  Is Atul saying that none of these people view it in their role to be coaches for their students or colleagues?  If so, what a terrible indictment of the profession.

But there are also those in ancillary services like nursing and social work, and, yes, even administrators.  Beyond that, there are lay people who could often play this role--spouses, friends, clergy, and the like. Is Atul saying that doctors do not view it as possible that these people could serve as coaches? If so, what an unnecessarily lonely life must these people live.

All of this reminded me of a portion of this week's letter from my pal Gene Lindsey, in which he quotes a note to him from Rob Jandl, the CMO of Southboro Medical Group,

I have thought too about . . . the non-humane medical system we work in that does not support reflection, or personal growth, humility or even curiosity. Far too many physicians end up overvaluing their technical proficiency and under-valuing their wisdom, intuition, and compassion. I have concluded that while the system of care and even our training leads us in this direction, it will require significant personal growth not as a doctor but as a human being for the world to be different. A person such as this is frozen emotionally, is deeply disconnected from his feelings, and from what it means to be human. The best path I know of to pierce the fog of disconnection is to go right to our greatest fears and vulnerabilities: death, failure, loneliness.

Every day we have a choice. It is hard to see or feel sometimes but it is always there, and that is the choice to look for the opportunities, the potential good, the upside. But for physicians as individuals currently in practice I believe we must help them go inward, help them to grow as human beings, and the language we use as leaders and the work we do must support that journey which may have its dark moments and its losses.

This sure sounds like a profession in need of serious emotional counseling, or what I would call coaching.  After all, the key to good coaching is empathy.  In his afterword, Atul himself offers some good coaching about things doctors can do to make life better for themselves and their patients.  But both his words and Rob's comment left me deeply saddened.  Why should doctors be trained to believe that they are on their own?  While I understand the need for decisiveness and individual action and responsibility in the face of some clinical emergencies, I do not understand why the profession cruelly puts upon itself the expectation of isolation and a lack of support for the emotional well-being of its members.


Anonymous said...

Gawande is actually wrong. Big time. Young attendings are "mentored" throughout their career. At the early stages of their appointment a senior surgeon is assigned, usually informally, to operate with the new kid. This relationship then evolves and matures over time. In academics also many of us have several mentors that we use for different things: research, private life, operations, grant writing, career development. Mentors are chosen within the institution and also outside. One can have as many mentors he/she needs. In private practice it is common that 2 surgeons (senior and junior) scrub together as they have no residents and the team they form is much more cohesive in the long run. Of course there are exceptions as in everything

Petra Langer said...

While not coaching per se, the Schwartz Center Rounds program, which has been adopted by more than 350 hospitals and other healthcare institutions nationwide, provides a regular forum where physicians, nurses and other caregivers come together once a month to discuss the difficult emotional and psychosocial issues they face in caring for patients and families. The program has been found to enhance compassionate care, improve teamwork, and reduce caregiver stress and isolation. Each institution has a Rounds physician leader and an interdisciplinary planning committee, and the sessions provide tremendous support for not only physicians, but all members of the care team.

Jen said...

Excellent piece. So true. Thank you.

JasonGNewland said...

Thank you for an excellent provocative post. I think Atul Gawande must have been unsettled by this comment as well as he wrote a New Yorker article in 2011 on how doctors don't use professional coaches. It is a great article and in it he discusses bringing back one of his original mentors to give him pointers on his surgical techniques, years after his training was complete.

I do think we as physicians fail in many ways with our emotional help and we have a notion that we need to be the tough ones, the ones that can't or don't crack. We must do better to work as a team and to remember that all of us need one another. Caring for sick individuals has become so complex with so much information that the only way to do this is to incorporate everyone.

Thanks again

Dan Ford said...

From Facebook:

Very good observations, in total agreement! Unfortunate lack of introspection by too many physicians. Coaches would be of enormous benefit...if they take it seriously.

Anonymous said...

What I fail to see in all this is mention of educated patients. Some of do understand what is going on in health care. I've tried to go to bat for a doc, and another friend I know did, but were fired from practices for it. Neither of us were looking to sue but for the health and wellbeing of the doc and fellow patients. When you treat us like this, do you think that is helpful? If we can see the problems, it says your own profession is sorely lacking in doing things about this.

Today is Doctors Day. This past week, for every doctor that would allow it, I made sure they got doctors day/thank you cards and homemade goodies to say THANK YOU. I'll do the same for nurses week.

Did any one ever count that some of us patients may see problems in the system and we're willing to help? We see doctors as human and that is not a crime. I've certain changed my views once I had a doc who couldn't admit he was human. I certainly let my docs know verbally, their admin know, the ones who go the mile and are trying, how much it is appreciated. Don't overlook a very obvious form of help.

Martin in UK said...

I don't think it is as bleak as you are concerned about.

I have just re-read the afterward and I think the point Dr Gawande was making was that we should be coaching ourselves informally, or using peer groups positively for support and development.

He did go on to write in more detail about coaching in the October 3rd 2011 edition of the New Yorker.

But you are right. Everyone, even doctors, needs to develop their personal, emotional and spiritual lives as well as their technical skills. Without these we are not balanced. I think for surgeons more than physicians once you get to the consultant or attending level then an awful lot is expected of you. What I think is lacking is mentoring to help that development. However coaching itself is also helpful, and the New Yorker article goes in to some detail.

Don Sharpe said...

Replace the word 'Doctor' with 'Paramedic' and the article is still accurate.
Who would be the best coaches?
Retired or Senior Staff.
How would we formally Identify them?
Ideally (Hopefully) by their writing, speaking and interaction with the other members of the group.
Of course, they'd be the ones who 'survived' to become Senior Staff. It might be interesting to ask them to reflect on how they accomplished their longevity and become the mentors we need.

Bob said...

Good points. There are differences in a well-run group, which pays attention to the common needs of its members, and individual practices (far fewer now), and groups in name but not in fact, which are more cost-sharing than anything else. In my days as head of our large group, I took caring for our members as my most important task. It comes down to questions of leadership. Teach leadership, teach connection, teach caring, and show it by example.

I wonder how much leadership is taught with the "caring for your flock" image? I just don't know. But your post here clearly calls for just that paradigm. It should be natural for a doctor! But so many of them fall for the image of doctors as wanting to be independent, and the image of business people as cold-hearted rational bottom-line obsessed automaton.

Anonymous said...

I enjoyed Dr. Gawande's book and this is an excellent post. It was also timely for me, as i just attended a departmental quality meeting where we spent 15 minutes debating whether it was appropriate to send a letter to a physician who we felt acted outside the standard of care even though no harm was done. This to me is one of the more important aspects of acheiving quality - identifying the near misses and having the temerity to stand up to physicians and educate them. as a whole, we usually don't debate such things as much, but the particular physician is somewhat of a bully and the thought was that he wouldn't listen or be affected by such education.

but again, if we as physicians felt that it was just as much our job and our duty to continue to educate fellow docs even outside the formal training paradigm, this wouldn't have been a question. Educate, coach, mentor, whatever you want to call it, but do it in a respectful way and move on. This should be as ingrained in us as our reponsibility to our patients.

Patricia L. Hale said...

From Facebook:

We consider our CMO and medical directors office at the hospital as who should be the physician "coaches" ... but we are always understaffed and burdened by constant struggles with regulation requirements. We only get to reprimand bad behavior and have too few staff and tools to communicate directly with physicians for anything else. Recently our hospital started a clinical documentation initiative with a specific half time medical director and 6 member staff to work on rules!

Isabel C. Legarda said...

From Facebook:

"Why should doctors be trained to believe that they are on their own?" I could go on for hours about this. Buy me lunch! (Just kidding.) I had a physician teacher during med school actually explicitly say doctors should not be in the business of needing help. By residency, because anesthesiologists are obsessed with safety, it was a little different - you better darn well call for help if you need it because people lives are at stake. But still, it's help for a patient, ultimately, not for oneself.

"I do not understand why the profession cruelly puts upon itself the expectation of isolation and a lack of support for the emotional well-being of its members." We're supposed to be strong and to be able to function highly even under duress. We're supposed to know what to do when others don't. We are, in fact, on our own so much that it's almost irresponsible not to have SOME element of "you gotta be on your own" in the training process. Few have sympathy or patience for a doctor who shows weakness, even the barest HINT of so-called "weakness." It shows up in the lingo. What's the highest praise an attending and give a resident or med student? "Strong work."

Jeff said...

Very well said.... We can do better.....We will do better.