ORIGINAL ARTICLE

Identifying Naturalistic Coaching Behavior Among Practicing

Surgeons in the Operating Room
Jason C. Pradarelli, MD, MS,  y Megan Delisle, MD,yz Alexandra Briggs, MD,§
Douglas S. Smink, MD, MPH,  yô and Steven Yule, PhD  yô
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Objective: The aim of this study was to identify examples of naturalistic

coaching behavior among practicing surgeons operating together by analyz-
ing their intraoperative discussion.
Background: Opportunities to improve surgical performance are limited for
practicing surgeons; surgical coaching is one strategy to address this need. To
develop peer coaching programs that integrate with surgical culture, a better
understanding is needed of how surgeons routinely discuss operative perfor-
mance.
Methods: As part of a ‘‘co-surgery’’ quality improvement program, 20
faculty surgeons were randomized into 10 dyads who performed an operation
together. Discourse analysis was conducted on transcribed intraoperative
discussions. Themes were coded using an existing framework of surgical
coaching principles (self-identified goals, collaborative analysis, constructive
feedback, peer learning support) and surgical coaching content (technical
skills, nontechnical skills). Coaching principles were cross-referenced with
coaching content; c-coefficient measured the strength of association between
pairs of themes.
Results: Overall, 44 unique coaching examples were identified in 10 oper-
ations. Of the 4 principles of surgical coaching, only self-identified goals and
collaborative analysis were identified consistently. Self-identified goals were
most associated with discussions regarding technical skills of ‘‘tissue expo-
sure,’’ ‘‘flow of operation,’’ and ‘‘instrument handling’’ and the nontechnical
skill ‘‘situation awareness.’’ Collaborative analysis was most associated with
discussions regarding technical skills of ‘‘respect for tissue’’ and ‘‘flow of
operation’’ and nontechnical skills of ‘‘communication and teamwork.’’
Conclusions: In naturalistic discussions between practicing surgeons in the
operating room, numerous examples of unprompted coaching behavior were
identified that target intraoperative performance. Prominent coaching gaps—
constructive feedback and peer learning support—were also observed. Surgi-
cal coach trainings should address these gaps.
Keywords: continuous professional development, intraoperative
performance, patient safety, surgeon behavior, surgical coaching
(Ann Surg 2021;273:181–186)
From the Department of Surgery, Brigham and Women’s Hospital, Boston, MA;
yAriadne Labs at Brigham and Women’s Hospital and the Harvard T.H. Chan
School of Public Health, Boston, MA; zDepartment of Surgery, University of
Manitoba, Winnipeg, MB; §Department of Surgery, Dartmouth-Hitchcock
Medical Center, Lebanon, NH; and ôSTRATUS Center for Medical Simula-
tion, Brigham and Women’s Hospital, Boston, MA.
Dr. Pradarelli is funded as a Safe Surgery Fellow at Ariadne Labs through a
research grant from the Risk Management Foundation of the Harvard Medical
Institutions, Inc., a part of CRICO (Controlled Risk Insurance Company).
Dr. Pradarelli participates in a research contract with Johnson & Johnson Medical
Devices and Global Diagnostic Services as a co-investigator for projects on
new device safety.
The authors report no conflicts of interest.
Reprints: Jason C. Pradarelli, MD, MS, Ariadne Labs, 401 Park Drive, 3rd Floor
East, Boston, MA 02215. E-mail: jpradarelli@partners.org.
Copyright ß 2019 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0003-4932/19/27301-0181
DOI: 10.1097/SLA.0000000000003368
C ontinuous professional development is a major challenge for
surgeons in practice.1 Surgical residency programs differ
from surgical practice by providing an educational environment
that supports the longitudinal learning of surgical knowledge and
skills. In contrast, once surgeons finish their formal training, they
are suddenly expected to improve performance and acquire new
skills on their own. Opportunities for surgeons’ continuous pro-
fessional development have traditionally been limited to short
didactic sessions, simulation courses, or self-study.2,3 Rarely do
practicing surgeons have a dedicated setting to learn from another
surgeon one-on-one as they had done throughout their training.
To address this gap within surgery, coaching has entered the field
as a strategy for individual performance improvement. Thus far,
pilot studies of video-based peer surgical coaching have demon-
strated feasibility,4 acceptability,1 and a perception of high
value1,4 among surgeon participants. In these early surgical coach-
ing programs, coaches have almost exclusively been surgeons
themselves.
In the search for meaningful methods of continuous profes-
sional development, ‘‘co-surgery’’ has been described as a setting
where 2 practicing surgeons operate together as partners and not as
consultants.5 Empirical research to support co-surgery for profes-
sional development is limited; the existing evidence for dual-surgeon
operations has focused primarily on operative efficiency and clinical
outcomes (eg, operative time, blood loss, complication rates).5 –7
However, several potential benefits exist for this approach to surgical
performance improvement. In contrast to video-based coaching on a
prior operation, co-surgery involves real-time interactions between 2
surgeons without relying on video. Although video may provide
objective data and be useful for studying intraoperative performance
in a coaching setting, most video equipment is restricted to laparo-
scopic surgery and does not routinely record audio. This limits the
ability to study open procedures and to learn from real-time dis-
cussions about a surgeon’s performance. Direct observation, such as
in co-surgery, offers the opportunity to study a broad range of
intraoperative performance metrics (eg, communication patterns,
decision-making) and types of operations (eg, open and minimally
invasive procedures). Thus, the co-surgery model offers a unique
perspective for studying and improving surgical performance as an
alternative to video-based coaching.
Whether surgeons innately possess the ability to coach their
peers is unknown. Contrary to traditional methods of surgical
teaching, ‘‘coaching’’ employs critical concepts of adult learning
and relies on a cooperative partnership between 2 professionals to
facilitate one’s pursuit of self-identified goals through collabora-
tive analysis, constructive feedback, and peer learning support.1
Coaching has the potential to enhance any aspect of surgical
performance, including technical and nontechnical (ie, cognitive
and social) skills.1,2 Although evidence remains limited, it is
believed that good surgical coaches need to have a high level of
emotional intelligence, excellent communication skills, and the
respect of their peers.8 Peer coaching requires that practicing

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Pradarelli et al
surgeons put aside their typical hierarchical roles to function as
equal partners with other practicing surgeons.9,10 To develop peer
coaching programs that integrate with surgical culture, a better
understanding is needed of how surgeons routinely discuss perfor-
mance in an operative context.
To characterize the baseline tendencies of surgeons to display
coaching behaviors with their peers in the operating room, we
analyzed intraoperative discussions from a co-surgery professional
development program. This consisted of 2 practicing surgeons
operating together as an ‘‘attending’’ and an ‘‘assistant’’ surgeon
without further instruction—that is, a naturalistic setting for sur-
geons. By categorizing intraoperative discussion using an existing
framework of coaching principles, we identified examples of natu-
ralistic coaching behavior among practicing surgeons in a real
operative setting.
METHODS
Study Population and Intervention
A division in a surgical department at a large US academic
medical center instituted a professional development program for
practicing surgeons to learn from one another through ‘‘co-surgery,’’
or performing an operation with another practicing surgeon. This was
presented to the division as an opportunity for the faculty to build
camaraderie, to learn from each other’s intraoperative skill sets, and
to improve their own skills. A total of 20 faculty surgeons volun-
teered to be randomized into 10 co-surgery dyads. Each dyad
comprised one surgeon assigned as the ‘‘attending’’ and the other
as the ‘‘assistant’’ surgeon; the patient was ultimately under the care
of the attending surgeon. The surgeons assigned to each other were
told simply to perform one operation together as normal, without
other explicit instructions. Operations selected were at the discretion
of the primary surgeon and were encouraged to be routine cases. To
ensure participants’ confidentiality, broad demographic information
was collected about participating surgeons and their operations
(Table 1).
This co-surgery program was developed at an academic
medical center where surgical residents train. Although a co-surgery
operation involves a practicing surgeon as the ‘‘assistant’’ instead of
a resident, these cases were relatively infrequent (eg, 1–2 cases per
surgeon per year). In addition, residents were not available for cases
at certain times (eg, during weekly protected education time), during
which it was feasible for an attending to schedule a co-surgery case
without interfering with residents’ operative education.
TABLE 1. Demographic Information on Co-Surgery Partici-
pants (n ¼ 20) and Operations
Characteristic Data
Mean duration in practice for participating surgeons, y 10.7
Standard deviation, y 7.5
Range, y 2–25
Surgeons who had previously participated in a co-surgery 15
operation (no.)
First time participants in a co-surgery operation (no.) 5 related to intraoperative performance and makes suggestions for
Operations observed (no.) 10
Breast 7 ‘‘Peer learning support’’ is a behavior demonstrated by a surgeon to
Melanoma 1 aid their peer surgeon in developing new goals, acquiring new
Thyroid 1 knowledge, and executing an action plan for improving their
Ventral hernia 1 intraoperative performance.
Mean operative time, min 75.5
Standard deviation, min 33.5
Range, min 35–140
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Annals of Surgery  Volume 273, Number 1, January 2021
Data Collection
Data were collected from 10 operations where 2 faculty
surgeons operated together as co-surgeons. An experienced surgical
observer (AB) transcribed the entirety of the surgeons’ discussions in
real time, from the time of entering the room until the time the
attending surgeon scrubbed out at the end of the case. The surgeons
did not wear microphones to maintain a naturalistic work environ-
ment; the observer moved actively around the room to ensure the
surgeons’ discussions were heard and recorded. Inaudible discussion
was infrequent, brief (seconds in duration), and did not occur in every
case. All transcripts were de-identified to maintain confidentiality
and preserve anonymity. The transcripts from each of the 10 oper-
ations reflect a different surgeon–surgeon dyad. Data collection
occurred during the 2014 to 2015 academic year.
Analysis
This observational study was analyzed qualitatively via dis-
course analysis. Discourse analysis is a well-described qualitative
research method that aims to understand how people use language to
create and enact identities and activities.11,12 Coding for a discourse
analysis entails identifying themes and roles as detected through
language use.12 In this study, coding was approached systematically
using an existing framework of surgical coaching principles,
described below. For the purpose of this analysis (ie, to understand
surgeons’ baseline communication behaviors regarding intraopera-
tive performance), the codes were identified agnostic to a surgeon’s
role as ‘‘attending’’ or ‘‘assistant.’’ Intraoperative transcripts were
first analyzed independently, then co-coded by 2 members of the
research team not involved with the program design or data collec-
tion process (JCP, MD).13,14 Surgeons’ discussions were categorized
into predefined surgical coaching themes (defined below), and
representative quotes were extracted (Table 2).
To identify examples of coaching behavior in the surgeons’
discussions, our approach employed deductive reasoning to catego-
rize data into 4 themes based on existing principles of surgical
coaching: (1) self-identified goals, (2) collaborative analysis, (3)
constructive feedback, and (4) peer learning support.1 These core
principles were derived from work performed by a surgical coaching
group at University of Wisconsin,1 and have been adopted by the
Surgical Coaching for Operative Performance Enhancement
(SCOPE) program at Ariadne Labs. The SCOPE program is a
professional development initiative for practicing surgeons at several
hospitals in Boston, MA.
For purposes of coding themes from intraoperative surgeon
conversations, the core principles of surgical coaching were defined a
priori as follows (Table 2). The principles of surgical coaching
describe how the surgeons communicate with each other, a critical
component of teaching coaching strategies to professionals.15,16
‘‘Self-identified goals’’ are topics that a surgeon verbalizes that they
desire to learn, improve on, or master. ‘‘Collaborative analysis’’
describes a give-and-take approach to identifying areas for improve-
ment, whereby a surgeon effectively uses inquiry to exchange ideas
and come to a joint conclusion about the other surgeon’s perfor-
mance. ‘‘Constructive feedback’’ describes communication from a
surgeon to their colleague in which that surgeon states observations
potential solutions/alternatives for the colleague to try out in practice.
Transcripts were also coded into themes of surgical coaching
content to determine what the surgeons communicate with each
other. Content included surgeons’ technical skills—such as respect
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Annals of Surgery  Volume 273, Number 1, January 2021
TABLE 2. Examples of Naturalistic Coaching Behavior From Intraoperative Discussions Between Pairs of Practicing Surgeons
Operating Together
Surgical Coaching
Principle Definition
Self-identified goals Topics that a surgeon verbalizes that
they desire to learn, improve on,
or master.
Collaborative analysis A give-and-take approach to
identifying areas for
improvement, whereby a
surgeon effectively uses inquiry
to exchange ideas and come to a
joint conclusion about the other
surgeon’s performance.
Constructive Communication from a surgeon to
feedback their colleague in which that
surgeon states observations
related to intraoperative
performance and makes
suggestions for potential
solutions/alternatives for the
colleague to try out in practice.
Peer learning Behavior demonstrated by a surgeon
support to aid their peer surgeon in
developing new goals, acquiring
new knowledge, and executing
an action plan for improving
their intraoperative performance.
for tissue, exposure, instrument handling, time and motion, and flow
of operation—and nontechnical skills—such as situation awareness,
decision-making, communication and teamwork, and leadership.
The individual technical skills17 and nontechnical skills18—and
their coding frameworks—have been defined and widely validated
elsewhere.
To map the associations between the 4 principles of surgical
coaching and coaching content, co-occurrence frequencies were
tabulated using Dedoose software (www.dedoose.com). From these
frequencies, a co-occurrence coefficient (c-coefficient) was
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Natural Coaching Behavior in Surgeons
Representative Quotes
Discussing retraction techniques:
Assistant: I like how you use the suction as a retractor. . .I need to do that with the
residents. That way you can see back there.
Discussing technique to label pathology specimen:
Attending: I often mark it while it’s still in situ, because it can be hard.
Assistant: For the circular tissue I do the same thing, because it can rotate around. But
that’s a good idea, I should do that.
Discussing situation awareness after dropping electrocautery device:
Assistant: The flex move [while retracting] made me drop it. I just need to pay attention
when [the cautery device] flexes.
Discussing suture placement and technique to suture in mesh:
Attending: So in terms of where this goes out here, you don’t want it bunched up. If you
put a stitch there, you want it way out. Why don’t you put a stitch there.
Assistant: Here?
Attending: Yeah. Fascia way out. Try to get way underneath it.
Assistant: How far?
Attending: Just guess at it, and we’ll see how it looks. Pop that off, pull it up, and we’ll
see how it lies. That’s not far enough.
Assistant: Not far enough?
Attending: See how it folds? You don’t want that. I think you gotta stitch here, right in
that.
Assistant: Oh, I see what you’re saying.
Discussing decision-making for a mastectomy and sentinel node biopsy:
Assistant: So let me get this straight. You’re going to get the node tissue from here as
well?
Attending: Yeah!
Assistant: Alright, that’s neat. You need to do the mastectomy and then the node then.
Attending: Yeah. But since we’re doing this side first, it doesn’t matter. Plus, she has
[ductal carcinoma in situ] so it’s not likely.
Assistant: So why do it?
Attending: So she’s getting a mastectomy, and there’s a chance that when they do the path
they find a cancer, and then I’d have to go back and do an [axillary] dissection.
Assistant: Oh I see.
Discussing situation awareness and operative planning during a thyroidectomy:
Assistant: Should I [dissect] right here? And is this parathyroid?
Attending: No, that’s more thyroid. The parathyroid is a little lower. Oh, there it goes.
Assistant: Ah, okay, so that’s going to be the superior.
Attending: And also, once you see the parathyroid, the nerve is usually anterior to it.
Discussing the assistant’s progress during a mastectomy:
Attending: This is feeling good here. You are definitely far enough along this area here—
that’s perfect. You have to get a little bit better over here.
No examples of peer learning support were identified in routine intraoperative discussions
between practicing surgeons in the operating room.
calculated for each of the pairs of surgical coaching principles
and content domains of surgeons’ technical and nontechnical skills
(Tables 3 and 4),19,20 using the formula c ¼ n12/(n1 þ n2 – n12), with
n1 ¼ number of occurrences of code A, n2 ¼ number of occurrences
of code B, and n12 ¼ number of co-occurrences between code A and
code B. The c-coefficient measures how consistently pairs of themes
co-occur or overlap (range 0 to 1, with 0 meaning no co-occurrence
of the coded themes in the dataset, and 1 meaning that the coded
themes always occurred together). To interpret the c-coefficient, it
should be noted that the greater the discrepancy between n1 and n2,
www.annalsofsurgery.com | 183
Pradarelli et al
TABLE 3. Heat Map of C-Coefficients for Surgical Coaching Principles and Technical Skills Coaching Content From the Surgical
Coaching Initiative
Respect for Tissue Time and Motion
Self-identified goals 0 0
Collaborative analysis 0.40 0 0.09
Constructive feedback 0 0
Peer learning support 0 —
The c-coefficient measures the strength of the association between pairs of themes (range 0–1, with 0 meaning no co-occurrence of the coded themes in the dataset, and 1 meaning
that the coded themes always occurred together).
TABLE 4. Heat Map of C-Coefficients for Surgical Coaching
Principles and Nontechnical Skills Coaching Content From
the Surgical Coaching Initiative
Situation Decision- Communication
Awareness Making and Teamwork Leadership
Self-identified goals 0.13 0 0.03 0
Collaborative analysis 0.22 0.16 0.52 0.09
Constructive feedback 0 0 0 0
Peer learning support 0 0 0 0
The c-coefficient measures the strength of the association between pairs of themes
(range 0–1, with 0 meaning no co-occurrence of the coded themes in the dataset, and
1 meaning that the coded themes always occurred together).
the smaller are the highest possible values of c. For example, say code
A occurs 10 times, and code B occurs 5 times. Even if code B
overlaps every time with code A, the maximum c-coefficient for this
pair of codes 0.5.20 The c-coefficient should be interpreted in context
and is useful for comparisons between pairs of codes in
qualitative research.
Dedoose qualitative research software (version 8.0.42) was
used for data management. This study was exempted from the
Partners Human Research Committee/Institutional Review Board.
RESULTS
Examples of Naturalistic Coaching Behavior Among
Practicing Surgeons
Demographic information about the participants and the co-
surgery operations are presented in Table 1. Overall, 44 unique
examples of surgical coaching were identified during the 10 proce-
dures in which practicing surgeons operated together, yielding an
average of 4.4 coaching examples per operation (range 1–8). Of the
4 principles of surgical coaching, only self-identified goals and
collaborative analysis were identified consistently in naturalistic
discussions between practicing surgeons in the operating room
(Table 2). Constructive feedback and peer learning support were
rarely, if at all, identified in the surgeons’ routine discussions.
Surgeons displayed evidence of self-identified goals when
they explicitly verbalized to their colleague that they desired to learn
or do a specific task (Table 2). For example, when discussing
retraction techniques, one surgeon stated, ‘‘I like how you use the
suction as a retractor. . .I need to do that with the residents. That way
you can see back there.’’ Another surgeon noted a desire to modify
their technique to label pathology specimens based on observations
of their peer surgeon. After one attending stated, ‘‘I often mark it
while it’s still in situ, because it can be hard,’’ the assistant surgeon
replied, ‘‘For the circular tissue I do the same thing, because it can
rotate around. But that’s a good idea, I should do that.’’ Surgeons also
identified nontechnical skills they wished to improve. After one
184 | www.annalsofsurgery.com
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Annals of Surgery  Volume 273, Number 1, January 2021
Instrument Handling Tissue Exposure Flow of Operation
0.14 0.17 0.15
0.06 0.39
0 0 0.07
0 0 0
surgeon dropped the electrocautery device during a mastectomy, they
recognized a need to improve on their situation awareness, saying,
‘‘The flex move [while retracting] made me drop it. I just need to pay
attention when [the cautery device] flexes.’’
When assessing their own intraoperative performance, sur-
geons frequently demonstrated collaborative analysis with each
other in the context of both technical and nontechnical skills
(Table 2). During a ventral hernia repair, 2 surgeons exhibited a
give-and-take exchange where they came to a joint conclusion about
the assistant surgeon’s suture placement and technique when sutur-
ing in the mesh.
Attending: So in terms of where this goes out here, you don’t want
it bunched up. If you put a stitch there, you want it way out. Why
don’t you put a stitch there.
Assistant: Here?
Attending: Yeah. Fascia way out. Try to get way underneath it.
Assistant: How far?
Attending: Just guess at it, and we’ll see how it looks. Pop that off,
pull it up, and we’ll see how it lies. That’s not far enough.
Assistant: Not far enough?
Attending: See how it folds? You don’t want that. I think you gotta
stitch here, right in that.
Assistant: Oh, I see what you’re saying.
Similarly, another pair of practicing surgeons collaboratively
came to an assessment regarding the decision-making for a mastec-
tomy and sentinel lymph node biopsy.
Assistant: So let me get this straight. You’re going to get the node
tissue from here as well?
Attending: Yeah!
Assistant: Alright, that’s neat. You need to do the mastectomy and
then the node then.
Attending: Yeah. But since we’re doing this side first, it doesn’t
matter. Plus, she has [ductal carcinoma in situ] so it’s not likely.
Assistant: So why do it?
Attending: So she’s getting a mastectomy, and there’s a chance
that when they do the path they find a cancer, and then I’d have to
go back and do an [axillary] dissection.
Assistant: Oh I see.
In contrast, the surgical coaching principles of constructive
feedback and peer learning support were rarely, if at all, identified in
routine intraoperative discussions between practicing surgeons. No
examples of peer learning support were identified in this study. The
single example of constructive feedback identified was during a
mastectomy (Table 2). The attending surgeon stated an observation
about the assistant’s progress in the mastectomy and immediately
followed up by suggesting an alternative for the assistant to try. The
attending said, ‘‘This is feeling good here. You are definitely far
enough along this area here—that’s perfect. You have to get a little bit
better over here.’’
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Annals of Surgery  Volume 273, Number 1, January 2021
Coaching Behavior and Surgeons’ Technical Skills
Associations between surgical coaching principles and tech-
nical skill coaching themes were most consistent for collaborative
analysis and least consistent for constructive feedback and peer
learning support (Table 3). Collaborative analysis was most consis-
tently associated with discussions about ‘‘respect for tissue’’ and
‘‘flow of operation’’ (c-coefficient: 0.40 and 0.39, respectively) for
technical skill content. Self-identified goals were most consistently
associated with technical skill themes, specifically with ‘‘tissue
exposure,’’ ‘‘flow of operation,’’ and ‘‘instrument handling’’
(c-coefficient: 0.17, 0.15, 0.14, respectively). Constructive feedback
had an inconsistent association with ‘‘flow of operation’’ (c-coeffi-
cient: 0.07). Because no examples of peer learning support were
identified in the intraoperative transcripts, there was no association
between this principle and technical skill coaching content.
Coaching Behavior and Surgeons’ Nontechnical
Skills
Associations between surgical coaching principles and non-
technical skill coaching themes were most consistent for collabora-
tive analysis but were absent for constructive feedback and peer
learning support (Table 4), in line with the pattern of results for
technical skills presented above. Collaborative analysis was most
consistently associated with discussions about ‘‘communication and
teamwork’’ (c-coefficient: 0.52); its associations with other nontech-
nical skill themes were less consistent. Self-identified goals were
most consistently associated with ‘‘situation awareness’’ (c-coeffi-
cient: 0.13); they were near absent from surgeons’ discussions of
other aspects of nontechnical skill. Neither constructive feedback nor
peer learning support had a quantifiable association with nontechni-
cal skill themes in these intraoperative discussions between
practicing surgeons.
DISCUSSION
In this qualitative study analyzing naturalistic discussions
between practicing surgeons in the operating room, numerous exam-
ples of coaching behavior were identified that target intraoperative
performance. Core surgical coaching principles of self-identified
goals and collaborative analysis were commonly identified in the
context of practicing surgeons discussing certain technical and
nontechnical skills. Interestingly, analysis of intraoperative tran-
scripts revealed prominent gaps in the natural coaching behavior
of surgeons in the operating room; surgeons did not routinely provide
constructive feedback or peer learning support in this study.
Although the current literature describes ideal characteristics
of surgical coaches, little empirical evidence exists to support
cultivating these behaviors in practicing surgeons. Other disciplines,
including business,21 athletics,22 and music,8,22 have shown the
meaningful and essential role that coaching plays in those industries.
Greenberg et al pioneered the way in surgery, paralleling these
professions by describing theoretical frameworks for coaching—
which this study utilizes—and by proposing characteristics of effec-
tive surgical coaches.8 The current analysis provides essential con-
text for surgical coaching practices by characterizing naturalistic
behaviors of practicing surgeons in a real operative context. Further-
more, it demonstrates the feasibility of direct observation as a
mechanism to facilitate surgeons’ professional development
throughout their careers. With a better understanding of how prac-
ticing surgeons routinely discuss intraoperative performance, surgi-
cal coaching programs can be designed to more smoothly integrate
with surgical culture.
How to train practicing surgeons to become effective surgical
coaches and what strategies to emphasize in their training remain
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Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Natural Coaching Behavior in Surgeons
important questions when developing a surgical coaching program.
From early observations of statewide surgical coaching programs,
surgeons that assume the coaching role have displayed certain
behaviors—including embodying a partnership mentality and
empowering the coachee—that seem to be critical for positive
coach–coachee relationships in surgery.9,10 For example, the Wis-
consin group studied its surgical coaches to operationalize behaviors
that surgeons may use to align role and process expectations,
establish rapport, and cultivate mutual trust in their coaching rela-
tionships.10 In Michigan, surgeons assigned as coaches and coachees
were found to frequently exchange roles.9 This observation may have
demonstrated evidence of a flattened hierarchy and partnership
approach; however, it may suggest instead that surgical coaches
need more structured training tailored to their innate coaching
strengths and natural abilities. The data have yet to reveal the
downstream effects of these surgeons’ alternating coaching behav-
iors on coaching effectiveness, participant satisfaction, or patient
outcomes. In considering how to train practicing surgeons to be
coaches, the present study is the first to investigate the unprompted
use of coaching strategies when surgeons interact in an
operative context.
The results of this analysis should be interpreted in the context
of several limitations. First, this was a single-institution study that
was limited to transcript data from 10 operations between 20
practicing surgeons in a quality improvement pilot program.
Although a larger sample size may improve the transferability of
these findings, this convenience sample represents surgeons that
would be expected to participate in early trials of a surgical coaching
professional development program within individual surgical depart-
ments. Furthermore, this is the only study known to the authors that
has evaluated the naturalistic coaching behavior among practicing
surgeons. Next, certain surgical coaching principles (eg, peer learn-
ing support) were not identified at all in routine discussions of these
practicing surgeons in the operating room. Although this could mean
that the surgeons did not have the innate capability to demonstrate
supportive learning behavior and action planning for their peers, it
more likely reflects that the operating room may not be the proper
setting to display these coaching actions (ie, that structured feedback
and action planning may be suited better for a postoperative—rather
than intraoperative—discussion). The setting of this study differs
from most published surgical coaching programs in that all discus-
sions occurred in the operating room, whereas both surgeons were
scrubbed. From a coach training perspective, the absence of certain
coaching principles might indicate a need for training workshops to
emphasize these principles for surgical coaches. Lastly, a critique of
this study may be that surgical coaching themes were applied to
surgeons who were never instructed in surgical coaching. However,
this may also be a core strength of the analysis. Although the
Hawthorne effect remains (ie, the potential that one’s behavior
may change simply because they are being observed), the fact that
surgeons were blinded to the specific research question likely
reduced potential bias due to the Hawthorne effect. That is, without
being told the principles of surgical coaching beforehand, surgeons
would be unlikely to modify their behavior toward surgical coaching
behaviors, thus strengthening the validity of the observational data.
Viewing the surgeons’ conversations through this lens provides an
invaluable perspective on the innate abilities of practicing surgeons
to demonstrate behavior characteristic of surgical coaches.
The findings from the present study provide critical insights to
designing effective surgical coaching programs. Major contemporary
questions for surgical coaching programs include (1) how to train
surgeons to be good coaches, (2) what content to emphasize in
coaching training, and (3) how to integrate coaching within surgical
culture. To better equip emerging surgical coaching programs to
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Pradarelli et al
address these obstacles, the present study characterizes the natural-
istic behaviors of practicing surgeons from a surgical coaching
perspective. The coaching behaviors identified routinely here—
self-identified goals and collaborative analysis—are encouraging
signs to suggest that practicing surgeons innately possess some
fundamental characteristics of effective surgical coaches. Coach
training workshops will need to focus on maturing these already-
existing skills that surgeons possess. This study also identified other
coaching behaviors—constructive feedback and peer learning sup-
port—that were scarce in routine conversations between practicing
surgeons in the operating room. Rather than view these as unfixable
deficits, coach training workshops might dedicate more time and
emphasis for surgeons to provide structured feedback and guidance
in action-planning for performance improvement. Surgical coaching
programs will need to address this behavioral variability to train
surgeons as effective surgical coaches.
CONCLUSIONS
In naturalistic discussions between practicing surgeons in the
operating room, numerous examples of innate coaching behavior
were identified that focus on intraoperative technical and nontechni-
cal performance, including self-identified goals and collaborative
analysis. However, prominent gaps were also observed in the natural
behavior of surgeons with respect to coaching principles. For exam-
ple, constructive feedback and peer learning support were rarely, if at
all, identified. As experience develops with surgical coaching pro-
grams, program leaders will have the opportunity to optimize the
peer coaching process; these results may help better prepare surgeons
to be effective surgical coaches and strengthen the culture of surgical
performance improvement.
ACKNOWLEDGMENTS
The authors are grateful for the collaboration of the research
team at Ariadne Labs and the general support of the surgical
leadership at the Harvard-affiliated hospitals for ongoing research
in surgical quality improvement.
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