Authors: Harry R. van Loren
Fayyadh R. Yusuf
Charles N. Paidas
The term "team", as an adjective for any collective working toward a common goal, is pervasive in our vernacular.1 We refer to teams in athletics, business, classrooms and medicine. It is especially salient in the operating theater where surgical teams engage in what is perhaps the ultimate contact sport: neurosurgical residency training. The similarities between athlete and surgeon are striking; whether on a field or in a hospital, both require trust in colleagues, technical proficiencies, positive interaction styles, the ability to be productive under pressure, and ease with competition. However, one major difference separates them strategically: In athletics, coaches are integral to develop team chemistry, player attitudes, and the overall culture.2,3 In academic medicine, such personnel are scarce.
In the fall of 2015, our office of Graduate Medical Education (GME) surmised that a mental conditioning coach could impact the performance of residents in a surgical training program. Subsequently, the vice-dean of Academic Affairs invited a consultant with specialized training in sports psychology (MEd) and leadership (PhD) to design and implement a pilot program that explored how coaching might benefit residents within the Department of Neurosurgery. In this paradigm, residents were considered athletes and their new coach was tasked with improving non-technical skills (professionalism, teamwork, communication, etc.). The following perspective piece describes the evolution of our coaching program from pilot to an in-demand, fulltime, faculty position.
Based on ACGME surveys and anecdotal evidence, the general perception of the Department of Neurosurgery (pre-coaching) was overwhelmingly positive in terms of leadership, competency, service, collegiality, and financial performance. It had the highest ranking in the university's survey of faculty satisfaction and confidence in departmental leadership. They were a hard-working, smart cohort within the hospital and medical school, and therefore were perceived to have more to teach a performance coach than the other way around. This department was chosen for the pilot study based upon its reputation, the willingness of the department chair and faculty to be critically observed, and its reasonable size. There was initial skepticism that a delta in performance could be achieved or measured. After discussion with the chair, an initial embedding process was undertaken for three months to establish credibility for the coach amongst the resident and faculty members of the team. This required full participation in the 80-hour work week, with complete immersion into the program, including rounds with residents, night call, clinics, observation in the operating theater, as well as attendance at all conferences, business meetings, and educational forums. This full "walk in my shoes before telling me what to do" approach turned out to be an essential ingredient to the success of the project.
During the first few weeks of immersion, every member of the team was aware their behavior, performance, and interpersonal interactions were being observed. Their performances were exceptional-a natural Hawthorne effect.4 Over time, however, they became numb to and nearly unaware of the continuous presence of the coach, who was generally in scrubs and often as fatigued as other team members. Thus, they reverted to more normal behaviors and interactions. To triangulate the coach's observations, individual interviews with hospital administrators, nurses, department staff, faculty, and residents at all levels were also conducted.
At the 30-day mark, the coach and chairman convened for an initial assessment. While individual efforts were impressive, it was the conclusion of the coach that the general culture of the department was not consistent with that described by faculty at the onset of the project, that the collegiality and collaboration were less than initially described, and that previous formal surveys of the program overestimated overall program happiness, satisfaction, and performance. Specifically, there was evolving unhealthy competition between some attendings that resulted in inappropriate personal interactions and created a toxic workplace environment that was spreading beyond those involved. Additionally, there was a general consensus among the residents that some faculty had solely focused upon their own career development or notoriety to the detriment of resident education. More poignant was the toxic relationship between some residents and hospital-based nursing staff. The lack of mutual appreciation was alarming because of potential adverse effects on nurse retention, quality patient care, and even the threat of restricted resident privileges.5
The embedding period continued for two more months, producing consistent findings. When presented the assessment, faculty were clearly disappointed but refreshingly committed to an improvement process. To create a high-performance team, the coach recommended that interventions focus on department culture, beginning with attending expectations and behaviors. In other words, if the leadership and faculty were not demonstrating elite habits, the residents had no model to follow.
Successfully changing the culture within an organization depends on multiple factors: leadership autonomy, size (number of people), existing mentality/willingness, systems in place, processes needed, external rules, and obstacles (known or unknown).6 In professional sports, there are often massive personnel changes when leadership determines a rebuild is necessary. Entire coaching staffs are fired and large roster makeovers are common. In these instances, culture change is implanted, not transformed. In academia, such overhauls are difficult because rules protecting employees are respected and financial resources are more stringent. Furthermore, hiring high-caliber surgeons is a time-consuming exercise that can take months, or years, to fulfill.
Within our neurosurgery program, we wanted existing faculty and staff to conform to a new cultural paradigm that would define all interpersonal interactions between faculty, faculty and residents, and all providers and patients. The coach leveled the challenge that if we could not agree to and record in writing our mission statement, our shared values, and our definitions of acceptable behaviors, then we would likely fail to achieve a specific culture. The coach also insisted that our values had to align with our departmental structure and be reflected in our compensation/incentive formula. In essence, if it's not part of your reward system, its not really a part of your culture.
Implementation came in three phases. First, after a series of facilitated group sessions and subsequent refinement process, the coach transcribed all aspects of our revised culture into a document that we now refer to as "The Playbook." Having a playbook meant that designated cultural ideas were tangible, observable, and measurable. A similar playbook was developed for the resident team detailing performance expectations and commitments. In our scientific tradition, all nuances of leadership expectations had to be clearly defined so that reliable data could verify assumptions. Second, the coach was empowered to implement new systems and hold participants accountable, whether it required participation, access, or funding. We agreed ahead of time this was the path we would take as a group in order to achieve the collective goals, and nonparticipation or obstruction would be taken as a desire to leave the department. Albeit a harsh position to take, it was felt the status quo, once elucidated, was no longer acceptable. Finally, the entire process was given time to assimilate.7 Short-term failures were acceptable as long as everyone gave a sincere effort. We were focused on long-term success, and therefore understood that measured improvements may not come for months, or even years.
Department mission and values preceded everything else in the playbook. The mission established priorities, while the values determined the manner in which we would achieve those goals. Our consensus mission statement reflected the core activity that brought the faculty together and informed all other decisions and initiatives.
Our mission statement: "We make neurosurgeons by modeling the very best practices in patient care, surgery, innovation, and research."
Our guiding values: "Commitment, humility, altruism, integrity, and respect." These values were specifically defined in application to the department of neurosurgery (Table 1).
Next, we wanted to address the major complaints or deficiencies within the program. In our context, we identified five key opportunities:
- High rate of negative "incidents" between residents and nursing staff
- Animosities between attending physicians
- Lack of structure in the resident education program
- General climate of individualism over cooperation
- Unfair compensation models
Our coach then linked each of these issues with recommendations for improvement. Key recommendations included the following:
- Chiefs' Leadership Dinner (hosted by chairman and coach)
- Conference participation (measured)
- Citizenship expectations (intra/inter departmental behaviors)
- Academic contributions (assigned non-clinical RVUs)
- Joint Journal Club (included all nursing + OR support staff)
- Nursing awards (determined by residents)
- Resident coaching (non-technical skills)
- Resident mentoring program (individual assignments with defined action plan)
- Revamped call schedule (night float system)
- Individual and focus group coaching (accountability and attitude)
The residents were fully engaged in all discussions regarding programmatic changes. They were encouraged to take ownership of their educational experience within the "guardrails" established by the ACGME and the RRC. This began with the mundane such as purchasing monogramed team jackets or providing snacks and exercise equipment in the call quarters. It expanded significantly in the form of conversion to a night-float call system, occasional "outings" with and without faculty, and the establishment of a series of new educational conferences. Examples of weekly teaching initiatives included: "Board Review" hosted by different faculty that tested residents' critical thinking; "Letters to Atticus," in which residents take 10 minutes to review the essential facts on a highly specific subject; and "Head's Up," where a member of the cranial team presents a detailed analysis of their plans and decision-making for upcoming cases.
Table 1: Values
Values drive our daily decisions and actions. These pillars are not up for debate or arbitrary application; rather, they embody how we treat others and what we hope others will recognize as our character. Faculty are expected to exemplify these values in all settings and enforce them amongst our residents.
Commitment: The need for care doesn't follow a set schedule or adjust to our convenience. People require our help at all hours of the day/night and even on holidays. While it may not be ideal, we embrace our responsibility by delivering the same quality care and service (to patients and colleagues) whenever or wherever it is demanded.
Humility: Many consider neurosurgery among the most demanding specialties in the world, and therefore, you are automatically considered to be the smartest, most hardworking, and talented doctors in the hospital. This level of respect can be intoxicating and potentially lead to behaviors that are perceived as arrogant. Consequently, on this service, we will go out of our way to always demonstrate a higher-than-expected level of inclusion, empathy, patience, and good manners.
Altruism: Going into medicine is an act of sacrifice, in itself requiring dedicated years of study and mountains of capital to pursue a vocation dedicated to the healing of others. Residents and attendings both work demanding hours under incredible stress; the only way to thrive under such circumstances is by looking out for one another and extending the protection to others beyond our inner circle.
Integrity: In medical science there is little room for creative interpretations. Time will always reveal the truth, whether it is a patient's condition or the readiness of team members. With consistent honesty, complications are minimized, and more trusting units are formed. Own up to mistakes and let team success drive your actions.
Respect: In matters of life and death, we cannot control how others will behave towards us. However, we will always remain professional, compassionate, patent, kind, and polite in our interactions with those seeking our help. Patients, their families, nurses, and colleagues throughout the hospital are deserving of our reverence, regardless of the place or time.
Prior to the pilot project, faculty insisted they were excellent mentors to the residents, but the coach failed to find documentation of an actual formal mentoring program, so one was established. Assignments are rotated every six months with explicit expectations. We mandated a formal evening dinner including spouses or significant others that focused on the resident's social adjustment to a new city and regimen. Informal follow-up meetings enabled continued dialogues that reinforced our commitment to each resident's personal well-being. And, perhaps most importantly, no academic production was expected from this specific mentoring relationship. By rotating through most of our faculty, residents should find a true mentor by their senior years. Consequently, chiefs are not assigned anyone, but do enjoy a private dinner at the chair's home every six months to discuss career plans, leadership, and opportunities to improve the resident experience.
An important responsibility thrust upon the chiefs is maintaining excellent relationships with our nursing teams through multiple programs the coach established. The quarterly nursing/faculty/ resident joint Journal Club requires a nurse and resident to copresent selected papers. These articles are germane to neuro- ICU or ward duties, with discussions focusing on best practices for improved patient care. The joint Journal Club is intentionally scheduled over a sit-down dinner (mixed, assigned seating) to encourage the social bonding that seems to have led to better interpersonal relationships, better interactions between residents and nursing staff at the hospital, and enhanced patient services. A monthly recognition program was instituted, with residents selecting members of the nursing team they believe represent the best in nursing care by going above duty to help residents succeed in providing excellent patient care. These nursing centric programs were funded by the hospital, including the gifts associated with nurse-of-the-month recognition.
The chair, prior to the project, claimed to develop leadership within the faculty but the faculty felt that all power and decision making was closely held. Therefore, the hierarchical structure of the department was revised, and division directors were appointed in five specific areas (cranial, spine, functional, pediatrics and research) with responsibilities and accountability in management, compensation, incentives, recruitment, and retention. Each division director receives specific structured leadership training that varies across a spectrum, from in-house courses to leadership programs provided at other universities, or a formal MBA program.
Table 2: ncRVU Allocation
|Prof. Hrs; QA; etc.
(+10 if hosting)
Summer Courses, etc.
Summer Courses, etc.
|CV's; Evaluations, etc.
Time, Talent, Treasure
National Committees, Grants, Honors etc.
Pre-pilot, the chair and faculty reported a strong commitment to academics, but the coach challenged the department to demonstrate alignment between compensation/incentives and academic obligations. Resolving this dilemma entailed a two-step process. First, we had to assign faculty into one of three categories. Gold faculty are in the core teaching program and held to higher standards of academic performance, green faculty are on a more clinically focused track and held to steeper expectations of clinical performance, and blue faculty are non-neurosurgical faculty within the department, critical to maintaining the mission, but again, held to adjusted academic and clinical performance metrics. With these differences in focus, faculty were measured based on their respective career tracks.
To align performance assessments with monetary incentives, we developed a new compensation formula that converts academic activities into non-clinical RVU's. An example of one of multiple tables utilized to quantify ncRVU's is presented (Table 2). An ncRVU's value is tagged to the value of a normal clinical RVU. When added to a faculty member's clinical RVU generation, the chair and directors have a quantifiable metric to determine overall productivity, compensation, bonuses, and incentives in accordance with individual goals and within the constraints imposed by our practice plan. This tool also allows faculty to compare their compensation to colleagues in a more transparent and transferable manner.
With respect to the didactic coaching sessions, the immersion phase was integral to building a trusting relationship because it provided the credibility that the coach was one of them. Consequently, we found people were willing to share details on a multitude of personally important topics. If something exceeded the coach's expertise, a more appropriate resource was found.
It should be noted that existing strengths were also highlighted in the playbook. The residents were a cohesive group that worked incredibly hard. Many faculty members were recognized as thought leaders in neurosurgery. And, our staff demonstrated tremendous loyalty despite comparatively lower pay than they might earn in the private sector.
There were some who embraced our coaching process while others remained aloof or skeptical. Those who saw the value gravitated towards our coach and gave all the initiatives an honest chance to succeed, while providing insight for improvements. One very influential member of the faculty who was initially dubious became a convert after an encounter with Peyton Manning, a keynote speaker at a meeting who highlighted the need for coaching even at his level of performance as an elite NFL quarterback. Manning stated that coaching was essential due to the inability to honestly assess one's own performance-regardless of level. Subsequently, that faculty member and others within the department were far more open to one-on-one performance coaching. In cases where coaching was not requested but leadership deemed it advisable, the coach was assigned to address specific performance or behavior concerns. Department members in the ambivalent category continued to function as normal but followed the new expectations or guidelines while remaining collegial citizens. For example, they made a more concerted effort to attend grand rounds and other educational forums.
To protect the process and culture, the coach insisted that faculty specify the thresholds and corresponding consequences for disruptive behavior. Resistors who were simply unable or unwilling to adapt to new expectations and new cultural norms were heard, counseled, and treated respectfully throughout the implementation phase. Meanwhile, in constantly "taking the pulse" of the residents and faculty, the coach encouraged the chair to have any necessary "difficult conversations" in a timely fashion. Unfortunately, but not unexpectedly, there were casualties. Two faculty members were no longer considered a good fit for the new organizational culture; one resigned and another was issued a non-renewal. Losing talented surgeons was difficult, but it reinforced our seriousness for the changing culture and sent a profound message to remaining personnel. Using a sports metaphor, the team sometimes performs at a higher level without a star player who is disruptive to the team's culture than with that player on the roster.
Internal surveys demonstrated a marked improvement in nursing perceptions of our physician engagement and professionalism. Our hospital partners were incredibly impressed with the turn around of attitudes and collegiality, recognizing our unit among the model intensive care units. Feedback from the residents was also markedly improved as demonstrated via the ACGME Resident Survey. Additionally, residents recognized the concerted effort of attending faculty who needed to change. From our standpoint, we appreciated how well our residents adapted to new expectations. Among the biggest shifts was the night float call system that imposed a different type of rigor than the Q4 schedule. The junior residents rose to the occasion and truly helped heal relations with the nursing staff. Formal metrics for improvement in faculty satisfaction with the program were more subdued because they ranked satisfaction high prior to the pilot program, and yet anecdotally, felt that remarkable improvements had occurred. Those who were in favor of the coaching program from the onset continued to be enthusiastic, resulting in some unforeseen consequences. One of our faculty members adapted so well to coaching that his professional reputation improved exponentially. He was promoted within the leadership ranks of multiple societies and then recruited to a position of national prominence with a leadership role. In his exit interview and farewell address, coaching and our culture were credited as key factors to his success.
A second major indicator of the pilot program's success was adoption of the program in various forms by the hospital, another surgical department, and a university institute. The coach was subsequently offered a joint faculty appointment with the Department of Neurosurgery under the title "Chief Cultural Officer," where he maintains regular coaching services to the chair, faculty, residents, and staff, both by assignment and upon request. He also participates in departmental leadership and program development.
We have established the benefit of professional "in-house" coaching to neurosurgical residency training and to the department that undertakes such training responsibilities. Although we do not contest the value of intermittent outside consultants for specific issues that might arise, we determined a unique value to the embedding of a coach within the program. As a faculty member, the coach better understands the subtle nuances of the program and activities at all levels, is familiar with all stakeholders (history, context, etc.), builds enhanced credibility over time, provides more immediate availability with a lower threshold for utilization, and reinforces a continuous improvement mentality.
We are developing methods to better quantify the impact of coaching, which we contend is one of consistent rather than episodic improvement. With the current expansion of our coaching program beyond residency training to improvement in overall departmental performance, we are also planning a transition from GME to Clinical Affairs. While coaching will remain an integral aspect of resident training, we believe that departmental coaching, beginning with all chairpersons, will help us establish the high-performance, collegial culture to which we aspire.
This pilot project has demonstrated the unique ability to benefit the training of our future surgeons, both at the individual level and collectively, with regard to patient care, academics, and quality of life. We thoroughly enjoy coming to work, interacting with colleagues, and struggling with daily battles to get better. We cherish our culture and believe that departmental culture should be intentional rather than accidental. It should be defined, implemented, and maintained in a continuous improvement model. In-house performance coaching is one investment that can facilitate this process. This paradigm has been adopted by other industries and we recommend it to all university resident training programs.
We have intentionally left out discussion of funding sources. Originally, the coaching program was sponsored by GME in full. We are now partially subsidized by GME with additional revenues generated from charges to those departments that utilize coaching services. Clinical Affairs believes that regardless of ability to pay, coaching must be available to all chairs and their respective resident programs and thus, intends to invest in this highly beneficial and in-demand resource.