Your forehand needs work

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.

Russell Saunders

Russell Saunders is the ridiculously flimsy pseudonym of a pediatrician in New England. He has a husband, three sons, daughter, cat and dog, though not in that order. He enjoys reading, running and cooking. He can be contacted at blindeddoc using his Gmail account. Twitter types can follow him @russellsaunder1.


  1. Thanks for the thought-provoking post. My Better Half RTod forwarded this link to me this morning and I got to be the first kid on my block (read, the first faculty member in my academic medical center) to read and share Atul Gawande’s latest with my colleagues.

    I really appreciate your candor about your own learning curve. I’m not a doctor (nor do I play one on TV) but I’ve been teaching communication skills and emotional intelligence to physicians, nurses and hospital administrators for a few years now, and I have come to have a sense of how deeply ingrained the socialization has been for physicians in particular to confidently communicate that they have “the answer.”

    Your reflections on the impact of coaching from your Better Half is now slated as an example for a workshop I’m teaching tomorrow night. We’re aiming to help participants in our course become aware when their emotions are “leaking” in a way that could have counter-productive impacts — and then, exactly the point you were making, find a way to communicate what is true for them without either harsh judgment or nicey-nice coverup. Your description of your own pendulum swing from the extreme of “brusque” to the opposite extreme of “treacly” and then back toward the middle path of “interested” and yet “concise” was exactly what we are seeking to teach in our course.

    I’m struck that it’s probably not a coincidence that your coach in this endeavor is your husband who loves you dearly, and that Itzhak Perlman’s coach is his wife. I don’t think that all of us are open to feedback from our spouses (I’m imagining mine having a good laugh at about this point), and, somehow I’m thinking that the foundation of deep love and acceptance some of us are fortunate enough to feel from our spouses might be part of what makes it safe enough to be open to accept the coaching and critique. Not to mention that for some of us our spouses are the ones who can read the smallest nuance in our voice and facial expressions and have a pretty good guess of what’s going on inside….

    Forgive my meandering. I continue to appreciate your self-aware reflections on your experience in the practice of medicine and I will continue to reflect on how we each might find others who we can trust to hold up a mirror and coach us into becoming better at our chosen vocations.

    • Thanks for reading and commenting, Niki. I’m gladdened to think my experience might be useful to other people.

      The Better Half would share your spouse’s amusement. As I mentioned above, I was not the most receptive person when he shared his impressions. What I now recognize as coaching I would probably have characterized as “hassling” at the time. I appreciate it now, but in those moments I was… less grateful.

      I concur that medical providers feel pressure to know “the answer.” This can be very challenging when there is no clear, simple or correct answer. As it happens, I’ve found that often (though certainly not always) patients/families have appreciated it when I’ve been candid about not being sure of the “right” answer.

  2. Thanks, Russell. That candor is what I value most when my kid is ill– and it’s exactly what I’m trying to coach for with the physicians and researchers who sign up for my classes. I find myself describing it as “confidently not-yet-knowing.” The confident (not to be confused with arrogant) part is important because I’m worried about my kid, and I am looking for reassurance that someone who knows quite a lot more than I do about risks to my kid’s health is on the job and fully engaged to figure out what’s going on. The “not-yet-knowing” part is harder– and, yet, as a parent, I can accept being told “we need to observe your child overnight to make sure it’s not encephalitis” (or appendicitis– the two “rule-outs” that have led to our younger son being hospitalized for observation).

    The part I’m still puzzling over is the emotional part– what emotions are brought up in the physician and in the patient, and where those are functional vs. dysfunctional. I was remembering this morning with my husband the feelings that were brought up in me when my on-call pediatrician said in an urgent voice on the phone “You need to bring your child in to the Emergency Dept right away– don’t stop to have breakfast, come right in.” Teasing out that the pediatrician may or may not have felt worried or panicky inside, but that this may have been a response to past parents’ level of denial that a low fever was really serious enough to warrant a trip to the ED– wanting to get me a little panicky. Remembering the very young ED resident’s response when my husband asked the reasonable question about the potential risks of the lumbar puncture– the resident responded in a harsh voice, “Death!” (I think trying to convey the urgency of doing the procedure, big-time overkill in that we were not considering refusing the procedure but simply trying to understand the risks of the treatment we had brought our son in for). In the first instance, the physician’s use of emotion was highly functional– we went straight to the ED– and in the second case the (far less experienced) physician’s use of emotion felt way over the top.

    What a dance we do as human beings… and how complex for you as a physician to be tracking not only the emotions aroused inside of you but also in the voices and faces of your patients and their parents, and reading those nuances to find the fine line that separates coaching from hassling, confident not-knowing from distant not-caring. What a tightrope….

    • “Death!”? Ugh. However, Lord knows how many dunderheaded interactions I had with parents as a resident (or new attending, for that matter). The more experience I get, the better I am at communicating well.

      Having a critter of my own has helped immensely, of course.

      • ““Death!”? Ugh.”

        Yes. I now just sit quietly and hope the doctor doesn’t yell at me. This has proved more calming.

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