I have a pile of unread copies of The New Yorker that stares at me balefully when it catches my eye. When I lived in New York, I would read it cover-to-cover every week, having a lengthy subway/bus commute to work. I felt culturally attuned, well informed, and keenly aware of all the wonderful things going on around me that I couldn’t afford on a resident’s salary. Now that I drive to work (and have a toddler), they don’t get the attention they used to. Thus, I would likely have missed this fascinating article by Atul Gawande about improving the performance of surgeons had my best friend not brought it to my attention.
I’ve been a surgeon for eight years. For the past couple of them, my performance in the operating room has reached a plateau. I’d like to think it’s a good thing—I’ve arrived at my professional peak. But mainly it seems as if I’ve just stopped getting better.
Over time, you learn how to head off problems, and, when you can’t, you arrive at solutions with less fumbling and more assurance. After eight years, I’ve performed more than two thousand operations. Three-quarters have involved my specialty, endocrine surgery—surgery for endocrine organs such as the thyroid, the parathyroid, and the adrenal glands. The rest have involved everything from simple biopsies to colon cancer. For my specialized cases, I’ve come to know most of the serious difficulties that could arise, and have worked out solutions. For the others, I’ve gained confidence in my ability to handle a wide range of situations, and to improvise when necessary.
As I went along, I compared my results against national data, and I began beating the averages. My rates of complications moved steadily lower and lower. And then, a couple of years ago, they didn’t. It started to seem that the only direction things could go from here was the wrong one.
Gawande has an epiphany after getting a tennis lesson from a club pro while traveling on business.
I was dubious. My serve had always been the best part of my game. But I listened. He had me pay attention to my feet as I served, and I gradually recognized that my legs weren’t really underneath me when I swung my racquet up into the air. My right leg dragged a few inches behind my body, reducing my power. With a few minutes of tinkering, he’d added at least ten miles an hour to my serve. I was serving harder than I ever had in my life.
Not long afterward, I watched Rafael Nadal play a tournament match on the Tennis Channel. The camera flashed to his coach, and the obvious struck me as interesting: even Rafael Nadal has a coach. Nearly every élite tennis player in the world does. Professional athletes use coaches to make sure they are as good as they can be.
But doctors don’t. I’d paid to have a kid just out of college look at my serve. So why did I find it inconceivable to pay someone to come into my operating room and coach me on my surgical technique?
To summarize what follows, Gawande asks a former mentor to come and observe his technique, and finds that his skills improved with coaching. He wonders if a similar kind of coaching could lead to better surgeons, or better doctors in general.
I began reading the article with detached interest. Surgery is a procedure-based specialty, so it made sense to me that having someone observe and correct small flaws in technique would confer a benefit. By way of contrast, there are very few procedures that I do, and those are straightforward and uncomplicated. I didn’t see how much of Gawande’s experience could translate to my own. Then I got to this bit:
I asked [Itzhak Perlman] why concert violinists didn’t have coaches, the way top athletes did. He said that he didn’t know, but that it had always seemed a mistake to him. He had enjoyed the services of a coach all along.
He had a coach? “I was very, very lucky,” Perlman said. His wife, Toby, whom he’d known at Juilliard, was a concert-level violinist, and he’d relied on her for the past forty years. “The great challenge in performing is listening to yourself,” he said. “Your physicality, the sensation that you have as you play the violin, interferes with your accuracy of listening.” What violinists perceive is often quite different from what audiences perceive.
“My wife always says that I don’t really know how I play,” he told me. “She is an extra ear.” She’d tell him if a passage was too fast or too tight or too mechanical—if there was something that needed fixing. Sometimes she has had to puzzle out what might be wrong, asking another expert to describe what she heard as he played.
Her ear provided external judgment. “She is very tough, and that’s what I like about it,” Perlman says. He doesn’t always trust his response when he listens to recordings of his performances. He might think something sounds awful, and then realize he was mistaken: “There is a variation in the ability to listen, as well, I’ve found.” He didn’t know if other instrumentalists relied on coaching, but he suspected that many find help like he did. Vocalists, he pointed out, employ voice coaches throughout their careers.
Ton of bricks, meet my head. I have absolutely gotten coaching, though I didn’t recognize it as such (or necessarily request it). Hereabouts I refer to my coach as The Better Half.
Allow me to explain. My husband isn’t in medicine, and I don’t schlep him to the office with me. However, like many medical providers I take call from home. When it’s my turn to cover for our office, I get calls after hours from patients/parents with questions or concerns. Since these calls come at all times, I frequently answer them during dinner, in the car or in the dead of night. Though it’s not 100% HIPAA-compliant to admit this, sometimes it’s unavoidable that he overhears my end of the conversation (which hardly ever contains information that could be used to identify patients anyhow). Occasionally he gives me notes.
I know that my default setting is a little on the brusque side, certainly at 2 AM. Earlier in my (admittedly relatively young) career I struggled to keep irritation or frustration out of my voice when calls came at particularly inconvenient times, most especially when they concerned something that really could have waited the few hours for the office to open again. “You sounded kind of… annoyed,” The Better Half would try to say in as gentle a tone as possible. I bridled at hearing this, all the more for knowing that it had been true. Later coaching told me I’d overcompensated, and now sounded treacly. Over time and with sincere effort, I’m told I’ve gotten much, much better at communicating my interest without being cloying and while remaining concise.
This may seem like small potatoes, but any malpractice attorney can tell you that patients are far more apt to sue doctors they don’t like. Bedside manner (as I plan to discuss more in a later post) is an essential part of patient care. This was an area that truly needed improvement, and that really did improve with what Gawande would call coaching. And now I’m wondering if this is something I could really benefit from.
I wonder how this would look for my own practice. The article includes a lengthy passage that doesn’t lend itself to quotation, in which Gawande watches as a teacher is coached. Two teachers are brought in to observe her, and offer feedback on how she could improve. I wonder if I could invite a pediatrician (either from my own practice or from the area) to watch my interactions with patients and their families, maybe duplicate my exams, and tell me what I might have done better.
My interest is sincere enough to discuss with my colleagues. There are myriad external pressures on medical practices to improve the way they deliver care, and this seems like a novel and useful way of meeting those requirements. I have no idea if this is something that I could actually make happen, but I’m actually kind of eager to try. If it pans out, I’ll let you know how it goes.