Comment on Greenberg et al. 2021 "Association of a Statewide Surgical Coaching Program With Clinical Outcomes and Surgeon Perceptions".

Abstract

To the Editor: We read with great interest Greenberg et al's article entitled, “Association of a Statewide Surgical Coaching Program with Clinical Outcomes and Surgeon Perceptions.”1 The study makes a considerable contribution to the literature by providing both quantitative and qualitative data on the influence of surgical coaching on post-operative patient outcomes, operative time, and changes in surgical practice. We would like to commend the authors for creating a coaching intervention that effectively addressed a frequently reported barrier to coaching, surgeons’ busy schedules.2 In the study, coaching sessions were held before quarterly Michigan Bariatric Surgery Collaborative meetings, thereby facilitating scheduling for both the coaches and coachees. There are, however, several remarks that we would like to make regarding the study's design and the coaching program's content. The authors used an interrupted time series design to examine pre-post differences in the coach, participant, and nonparticipant groups, and demonstrated that only the participant group reduced operative time. However, surgeons were not randomized, and these findings should be interpreted with caution as several factors could affect the groups’ comparability. Notably, the participant group's average operative time at baseline was considerably greater than in the coach or nonparticipant groups. Therefore, the possible margin of improvement of the participant group was larger than in the other groups, making any between group comparisons difficult. Additionally, the participant group was composed of surgeons who volunteered to take part in the coaching intervention. This self-selected group of coachees could confound the results as they may have been more intrinsically motivated to improve their performance than their non-participant counterparts, regardless of whether or not they were coached. Furthermore, the groups were not controlled for surgeons’ age, experience, or case volume. Although there were no significant differences between the groups, which were small in size, the participants were slightly younger, and had been in practice for approximately two years less than both the coaches and the non-participants. The participants also had a higher case volume than the non-participants. These factors should be taken into account as previous studies have shown that experience and case volume can play a role in determining a surgeon's performance in a variety of specialties across his or her career.3,4 When considering bariatric surgeons specifically, a surgeon's age alone does not appear to be a significant determinant of patient outcomes.5 However, the frequency of serious complications among individuals undergoing bariatric surgery has been shown to be inversely associated with surgeons’ procedure volume.6 Another factor worth considering is the type of hospital where the surgeons practiced. In Greenberg et al's study the large majority of coaches and participants worked in teaching hospitals, whereas approximately a third of the non-participants did. Teaching hospitals have been shown to be associated with lower mortality rates for general surgery compared to nonteaching hospitals.7 The final remark we would like to make is related to the study's coaching program, which targeted intraoperative skills. No detailed information was given about the specific goals identified by the individual surgeons during their coaching sessions. However, the interview data showed that most participants found that the coaching helped them modify their nontechnical and technical skills, and some even reported positive changes in their social and family lives. These findings highlight the potential for the goals and benefits of surgical coaching to extend beyond the operating room. In consequence, we would like to propose that this coaching format could be adapted to include other determinants of surgeons’ performance, such as fatigue, stress, and wellbeing. Studies have shown that fatigue has negative effects on surgeons’ motor skills8 and overall performance.9 Furthermore, both fatigue and stress, along with elevated workload, can contribute to burnout, which has been shown to be an independent predictor of medical error among surgeons.10 Therefore, it is possible that coaching interventions that aim to reduce fatigue and burnout could result in performance improvements. In conclusion, we would like to underline the need for additional cluster randomized trials to evaluate the impact of coaching on surgeon performance and patient outcomes. In addition, future studies could focus on integrating these factors into the surgical coaching framework to provide for a more holistic approach to performance improvement.