What is Physician Coaching? Approaches in GME

As we close out the blog series What is Physician Coaching? I wanted to highlight the use of coaching in Graduated Medical Education (GME). Undergraduate Medical Education (UME) has more widely adopted coaching following the AMA’s Faculty and Student Guidebooks on Coaching. They have proactively recorded basic coaching videos and many medical schools host training for UME faculty.

I want to review a few important points to set the stage for this blog.

1. During training, physicians often solidify patterns such as a performance-based worth/identity, maladaptive perfectionism, and deprioritizing self-care that contribute to additional stressors on top of an already challenging career. These and similar habits contribute to the 20% of non-systems-based burnout causes. (i.e. burnout is an occupational issue and the various systems within the occupation account for about 80% of burnout.) Challenges unique to learners, impact their ability to learn, motivation, decision-making, quality of care and communication without having the necessary skills to navigate the stresssors. It’s noted that “physicians with lower resilience and who report lacking the skills to help them function well under stress are more likely to experience burnout. 
   According to the National Academy of Medicine, around 60% of medical students and residents have symptoms of burnout. Included in the National Academy of Medicine Health Workforce Well-being Plan is a positive culture within training institutions. Faculty help make up and set the culture. In one post-pandemic survey, 75.9% of faculty reported burnout. 
    
    

2. Our current burnout, mental health, and suicide rates are unacceptably high.

3. Physician coaching has demonstrated improved coping, relationship skills, resiliency, quality of life, engagement, psychological capital, self-compassion, increased job satisfaction/fulfillment, and overall well-being. It has also been shown to decrease imposter syndrome, emotional and work exhaustion, as well as burnout.

4. A growing primary care crisis is looming (along with many other subspecialty shortages).

5. There are 149,000+ trainees nationwide and countless more faculty. GME must be shored up to continue quality healthcare in our country.

6. Culture change to revolutionize the various systems can gain a foothold starting in the incubators of primary care – family medicine residencies, among others.

7. Each physician, especially those early in their careers, plays a role in the culture of medicine. Imagine what’s possible when these amazing humans can access coaching to optimize their personal and professional well-being, impact the system and communities, and truly flourish.

8. While coaches do not have to be physicians, physician coaches bring much contextual understanding and street credibility to the table. Many physicians, especially trainees, prefer physician coaches, in my experience. Many express having someone who really understands what it's like, makes the process of coaching feel easier, safer, and more helpful, and removes barriers from accessing coaching. 

And so, this is why I (and many others) feel that coaching will play a large role in improving the life of providers, which will improve healthcare overall. I believe it will take a multi-pronged approach to incorporate coaching into GME.

First, an overview of approaches, pros, and considerations. You can find more detail, including examples, following the overview below.

1. Internal coaching – physician coaches within the training program. Many leading universities, such as Duke, Harvard, Boston University, Stanford, and Johns Hopkins, have established programs to offer coaching to residents, fellows, and sometimes faculty. The approaches involve a mix of informal and formal coaching. Many have remediation-specific coaching. 

 Informal - faculty obtain coaching skills and employ them intentionally at appropriate times within their various roles of educator, advisor, mentor, and sponsor.

Considerations: include the learning curve of when to utilize a coaching approach which will vary on situations and individuals. The temptation will be to use leading questions to align with the faculty’s agenda and consider it coaching. Faculty can grow in their ability to know when the situation will best lend itself to really empowering the trainee to decide their own best answers. I wrote a blog on it.

Formal - faculty have coaching as part of their official job description in which they meet with residents or faculty individually or as a group to engage them in formal coaching. The ones that do this best separate out the remedial coach from the evaluative roles.

Considerations: Potential threats to internal coaching programs are less psychological safetyfor the trainee and more conflict of interest (COI) from the faculty coach. Confidentiality must be prioritized. (More on COI below that apply to all coaching approaches.)

These can be addressed by having faculty coaches out of specialty and/or faculty recusing themselves from serving on the CCC, resident evaluations, and certain discussions in faculty meetings to both protect the confidentiality and mitigate any related faculty bias.

 Community-based programs do not often have the luxury of multiple specialty faculty to train out of specialty. Also, family medicine residents interact with most specialties, which doesn’t necessarily offer solid psychological safety even in a university setting.

Lastly, as most faculty are already short on admin time and often work multiple hours outside of business hours, care needs to be given to FTE- time, pay, and support to avoid further donated work and/or work compression.

Coaching is so powerful, by limiting formal coaching to remediation, we are missing the preventative and flourishing opportunities. Plus remediation-only focused coaching, in some circles,, stigmatizes the reputation of physician coaching. 

2.  External coaching
   1. Individual – an individual external physician coach contracts with a training program to provide group and/or individual coaching to residents, fellows and/or faculty
   2. Organizations – an external organization contracts with the training program to offer group, individual, and/or hybrid coaching to residents, fellows, and/or faculty.

 Considerations for organizations – the continuity of the coaches may or may not be easily accessible.

 Considerations specific to both forms of external coaching:

1. The program needs a faculty liaison to bring the local contextual understanding and help coordinate schedules. In family medicine, this is often the behavioral health faculty, wellness faculty lead, APD, or PD. Having an assigned administrative assistant and a lead resident (chief or wellness leader) is also very beneficial in helping with communication and structuring.

I particularly believe in the strategic alliance that can happen between the behavioral health faculty and the physician coach. And I want to stress that external coaching does NOT negate the importance of having a trained behavioral scientist on faculty. That’s one of the benefits most family medicine residencies benefit from but have notoriously been on the chopping block in recent years to save money and designate physician faculty to the ABFM requirement of behavioral health faculty. (I’ll likely offer a blog on this subject in the coming weeks).

2. Local contacts and mental health resources should be communicated to the coach in the rare instance that someone is unstable or has suicidal ideation.

3. Unless local, most external coaches will run virtual programs.

 Considerations that apply to all GME coaching approaches.

1. The training program and coach need clear goals and processes to decrease COI. We know that directive coaching (i.e. coaching toward specific career outcomes such as Entrustable Professional Activities) is not as effective. So there needs to be a clear understanding on the part of the institution that the coach can partner with the groups and individuals on the areas they identify as the most important.
2. Faculty coaches will be tempted to go into mentor or advisor mode, feeling they have the best answers based on years of experience and conditioning. Strict attention must be given to staying in the role of coach – no agenda, holding space, with no judgments when in formal coaching sessions. Leading questions will not be as effective. While “code-switching” (i.e. “I’m taking off my coaching hat.”) may be called for in some instances, this should remain the exception and not the rule.
3. Finances and budgeting. Being proactive in setting up the budget for the AY, asking for an allocation for coaching from wellness funds, applying for grants, designating faculty development or CME funds, and identifying donors, trusts, and foundations can be useful.
4. Structure I invite you to consider this as a PDSA cycle until we have clear studies showing the “ideal” manner. There is no “perfect” way. Work with your coaches to decide what makes sense at this time for your program.
   1. Program-wide or identified individuals in difficulty or both? (This reminds me of preventative, chronic care management, and episodic care model)
   2. Group, Individual, or Both (Hybrid).
      1.  Group sessions offer connection, and shared humanity to normalize the struggles, and objectively see issues more clearly. PGY class-specific group coaching offers even more engagement. Do you want a mix of class-specific and trainee or program-wide groups or one type?
      2. Individual sessions offer the physician to coach on things for more time to make progress and offer more confidentiality on topics they may not feel comfortable discussing in the group.
      3. Hybrid brings the best of both
   3. Opt-in or Opt-out (I vote never mandating coaching as an unwilling participant will not likely reap the benefits).
   4. How many of each type of coaching session?
   5. Year-round or compressed?
   6. What is the process of scheduling? Self-scheduling or program-assisted? During business hours or after? As you may have experienced, trainees have difficulty scheduling their vacations, so deciding to assist via the scheduler, other admin staff, or faculty can increase success.
   7. Will it be for all class levels, senior residents, faculty, or all?
   8. A structured curriculum for the individual sessions or not? Some training programs have loosely set topics, such as goals, feedback, etc. to coach around at each session.
   9. A structured curriculum for group sessions or not? Do you want the session to be grounded in a professional topic or just coach on anything they bring up, or a co-created focus at the beginning of each session?

5. Lastly – what is the long-term goal? Do you want eventually to develop an internal program or do you enjoy the safe space and outsourcing? If you are thinking of a more robust approach down the line, perhaps you want to gain some traction by exposing trainees and faculty to coaching by
   1. Contracting with an external coach or organization with an established track record and program
   2. Taking advantage of the unique program out of CU noted below (#3).

That's the overview. I've recorded some examples of each type below with which I’m familiar, including a couple of unique approaches. I have first-hand experience with many of these since I coach with them (CFI, Better Together, AMWA) and others I know of from colleagues or presentations.

1. Internal, informal coaching in training programs.

Example: Dr. Riva Kamat, a pediatric faculty member at Inova Children's Hospital in Virginia, is just one of many examples. Although not a formal part of her department position, she weaves in coaching at appropriate times, such as during feedback sessions. Other times she may have a more formal coaching session with a trainee or colleague for which she makes time  She also uses her coaching skills when running peer support and debriefing meetings.

Pros: Depending on the manner of providing coaching skills, this can be scalable, quicker, and more cost-effective for hundreds of thousands of trainees and faculty.

Considerations: As above.

2. Internal, formal coaching roles and systems.

Examples: Mass General’s Physician Coach Program has been a role model, led by Dr. Kerri Palamara. She has dedicated time to set up and run the coaching program. They have also had many faculty attendings that are certified through Wellcoaches that coach across the institution for faculty members.

In addition, they have several faculty members that received novice coach training. Each year, volunteer faculty agree to 2-3 coach training sessions where they learn and practice. They are given a formal curriculum for each PGY year and assigned to 1-2 trainees They are paired with trainees outside their specialty to enhance the safe space and mitigate the tendency to advise. Over the course of 3 years, they have expanded their coaching tool kit and have a formalized curriculum for each PGY year. This has been replicated at 40 universities and through medical societies such as the Association of Women Surgeons and the American Academy of Pediatric Surgery. I understand that the faculty that receive the training are not necessarily allotted designated FTE to use their skillset but enjoy the process despite that. They are also available to train your faculty.

Dr. Bryant Murphy at UNC-Chapel Hill is leading coach training for some of the faculty (“Leader as Coach”) to the ICF-credentialled level by bringing in another external coach training program (Healthcare Coaching Institute). My understanding is that they, too, try to have coaching across specialties.

Next week, I will highlight yet another example, Dr. Marion McCrary and her formal role at Duke running their GME Coaching Program.

Pros: Having a cadre of internal physician coaches is more cost-effective than hiring external coaches routinely. They also understand many of the local contextual issues and are physically present.

Considerations: As above.

3. Hybrid, internal and external coaching program

 Sole Example: The unique approach is the brainchild of Dr. Adrienne Mann’s and Dr. Tyra Fainstad’s Better Together Coaching Program - from the University of Colorado who ran the study I mentioned a couple of weeks ago and just published their multi-center RCT.  They are currently enrolling UME, GME, Faculty, and APPs nationwide for this unique approach to bringing coaching into the medical education space (Deadline for AY 2023-2024 enrollment is June 1). 

They are internal faculty coaches within CU Internal Medicine program and external to the multiple other programs. They have a team of certified coaches (of which I’m one), both internal and external to CU, some of whom hold faculty appointments at various institutions. To date, we have been volunteering our time.

The sessions are virtual, focused group coaching sessions in a webinar format, so participants only see the person being coached, one at a time. Often, participants choose to receive coaching anonymously through the Q&A feature. The dates and coaches' names are published and are offered at various times throughout each week to opt into.

They also have anonymous, asynchronous coaching via a securely published portal to benefit others who read them in similar situations.

The amazing part of what they offer is unbelievably accessible pricing. $10 per trainee, $50 per faculty member for the group coaching throughout the academic year, and four of individual 1:1 sessions.

Pros: One of the most affordable and scalable ways to bring coaching into GME with little hassle.

They also have published proven results.

Hearing that other trainees and faculty in other institutions struggle with the same issues can be validating.

Considerations: While helping the psychological safety and shared humanity aspects, the webinar style doesn’t allow for participant interaction and connection. Continuity with a specific coach is a little more challenging. It doesn't necessarily enhance team cohesion if you program only has a small percentage that are involved. 

4. External coaching organization for sponsoring institutions. This is when an institution that sponsors training programs, not necessarily a university, contracts with an external coaching organization to coach those who opt in.

Example: Providence Health Systems Oregon contracted with Coaching for Institutions in this manner. They provided coaching for physicians and APPs statewide, which includes four primary care residency programs, allowing many faculty members to opt-in and take advantage of group and individual coaching.  

Coaching for Institutions hosts weekly CME didactic sessions, and biweekly small group sessions with individuals remaining in their assigned group for the duration, and each individual is afforded 6 individual coaching sessions. The pre-and post-surveys have shown such an incredible impact that Providence has had CFI run 4 different cohorts. Many of the individuals in small groups stay in touch afterward. 

Pros: The program's structure is paid by the organization and free to the individual, with the understanding that the individual will be fiscally responsible if they aren’t engaged in the coaching program they opted into. This builds accountability, which has been very helpful in those early weeks when the individuals are still uncertain of coaching before they begin to reap the rewards. Individuals within the institution gain connections and understanding across specialties.

Considerations: As above for external coaching.

5. External coaching organizations for Individual GME programs.

This is when a residency or fellowship program hires an external organization to come in and offer coaching.

Example: Coaching for Institutions has also offered external coaching to individual residency and fellowship programs. This uses a hybrid model to offer individual and group coaching.

Pros: They have a discount trainee package and offer several coaches for time convenience and fit with the flexibility of group, individual or hybrid models. They take care of most of the logistics. They provide a safe and confidential space with external coaches.

Considerations: As above.

6. External individual coach for residency and fellowship programs.

This is what I offer. I partner with family medicine residency programs to offer hybrid coaching. Groups for faculty and/or groups for each PGY year (or occasionally all classes combined), plus individual coaching sessions for each physician. I ground each group session in a professional development and fulfillment topic. These also offer CME for the faculty.

Other external coaches do the same, such as Dr. Jessie Mahoney, who partners with various fellowship training programs, including Stanford’s Anesthesiology Fellows and MUSC’s Cardiology Fellows. She offers both group and individual coaching for the small cohort.

Pros: It’s a more intimate group setting with an individual training program, and often broken into classes for group sessions. The coach is consistent and builds rapport over time with the individual trainees. There is no risk for the coaching to influence an evaluation which adds to extra psychological safety.

Cons: As above.

7.  Faculty Development coaching

I’ve had the unique ability to coach in one of the University of Washington’s Network of Family Medicine Residency’s Faculty development programs - The Hybrid UW/Madigan Longitudinal Faculty Development Program. Several community and university-based programs across the Pacific Northwest participate.

In it, I offer 4 group coaching sessions and individuals can opt into individual coaching sessions during the longitudinal program.

I plan to add in teaching some basic coaching skills that faculty can apply in their programs.

Pros: One faculty development network exposes many training programs to coaching. I hope this may lead to early adopters in each program finding what works best for them to bring coaching to their trainees and faculty. This is a scalable model to impact more individuals.

Cons: The physicians only have contact with the coach for the one year of their longitudinal faculty development program.

A note about para-training program coaching with which I’m familiar:

1. The American Medical Women’s Association (AMWA) runs coaching programs for both attendings (AMWA Elevate) and residents (AMWA Evolve). (AMWA Ignite for medical students is now Ignite Med).

2. The Society of Teachers in Family Medicine has a Virtual Coaching program. It lists coaches and mentors – but several trained coaches volunteer a session or two to members of STFM for free.

So, while you can see there is not one right way to bring coaching into GME, the good news is that many models exist. Find the one that makes the most sense for your program and start the PDSA cycle.

What other approaches have you seen? What ideas do you have - especially for the less resourced community family medicine programs?

(Wow, throwing in examples made for the longest blog post I’ve written to date! Sorry about the formatting - Kajabi was very temperamental with indented bullet points. 🤷‍♀️)

Next week, as part of my monthly Guest Blog Interview Series, I will highlight Duke’s Coaching Program and one of its leaders, Dr. Marion McCrary.

Until then, have a joy-filled week!  Tonya

I've given the talk to several audiences about coaching in GME. Reach out if you'd like me to present to your group.