I make no apologies for taking a look at another article by Atul Gawande, the Boston doctor who writes common sense. In a recent edition of the New Yorker he asked why doctors don’t have coaches.
When he turned 45 Gawande realised that his professional performance had stopped getting better. He’s a surgeon, so there are obvious performance measures; he assumed he had reached his peak. Then, at a conference, he had time for a game of tennis – he’s a keen player – and he took a lesson with a young coach. Gawande was amazed to find how much that one lesson improved his game. He went on to reflect that even Wimbledon champions have coaches, but surgeons don’t. He wondered whether a medical coach could improve his surgery. A senior surgeon agreed to observe him operating, and suggested some simple changes in his practice, such as the way he draped the patient. Gawande’s surgical performance started improving again.
Coaching, Gawande suggests, is an effective way to break entrenched habits – to teach an old dog new tricks. He quotes a study of teachers being taught new skills. After a workshop only 10% would take up a new skill. Practical demonstrations worked a little better. But when teachers had a coach watching as they tried out a new skill in the classroom, 90% of them absorbed it into their repertoire.
Students and registrars may sit in on our consultations, but as qualified GPs we are rarely observed by our peers. I recall my first two weeks of clinical training, spent in a rural GP practice sitting in with several partners. Each was incredibly curious about how the other partners consulted. They had no idea; they never saw them.
Yet there is so much to learn, both from observing and being observed. Some of the most useful ‘tricks of the trade’ I picked up from sitting in with other GPs - not ways of treating so much as ways of saying. For instance, how to divert patients from their long stories to possible action. Or finding vivid ways of illustrating risk. The oil that greases the wheels of the consultation makes the difference between a mechanical exchange and a relationship. I recall one GP giving a patient test results and saying “The results set my mind at rest; do you feel reassured?” I‘ve used his quote for years. You don’t find tips of that sort on GPnotebook. But how many GPs take part in a formal system for learning from each other in this way?
Recorded consultations are one way of observing. Trainers video consultations but I suspect that few of the rest of us do, and I’m not sure that it is the same as having someone in the room with you, experiencing the consultation first hand. It’s too easy for someone studying a video to think they would have done better, but the observer witnessing a live consultation is sharing the consulter’s dilemmas in real time. It’s the difference between watching a film and a live performance.
What might you learn from trying this out? Coaches are likely to pick up some things you are already aware of, like how much time you spend looking at the computer, but may also be able to analyse when and why you turn your attention away from patients, and to suggest ways of keeping your eyes on them. And they could contribute many new insights, things you are unaware of but which make your consultation less effective. It is hard to change entrenched behaviour patterns on your own, but having a coach watch you try out new techniques does seem to help the reprogramming process.
Appraisal and mentoring can be valuable, but appraisers and mentors don’t see us consulting. Maybe we could have a network of coaches – respected GPs nearing retirement or perhaps recently retired – who sit in on a surgery and talk with us about what we do well and where we could improve, whether it be the way we greet the patient, or how to consult more quickly, or improving our body language or ways of handling patients we find it hard to sympathise with. An extra bonus: they will be picking up tricks from you to pass on to others.
Do any NASGP members have experience of a system of this sort? If so, how does it work? Can you share your experience?
Judith Harvey was a research scientist, ran the VSO programme in Papua New Guinea and taught in a Liverpool comprehensive school before going to medical school. She has been a partner, a salaried GP and a locum, an LMC chair and a long-time supporter NASGP. Her charity, Cuba Medical Link, enables medical students to go to Cuba for their electives.
Judith has now published all her articles from the NASGP website as a new book Perspectives: A GP reflects on medical practice and, well, just about everything…