Learning from Surgeons

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Introduction

Back in 2010, I wrote about Paul Barach’s research and practice in creating, assessing and sustaining high performance in healthcare teams.

Just last week I wrote about Mandy Ruddock-Hudson and Sophie Knights’ research with 12 of the 18 senior Australian Rules coaches.

Both post were linked for me by a Radio National discussion led by Norman Swan on the Health Report earlier this week (17 March).

Surgeons’ Well-Being

In the program, Norman discussed Anna Pinto’s research work in the United Kingdom. Her PhD has explored the psychological impact of surgical complications on patients and surgeons. Her project had three aims:

  1. To investigate the consequences of serious medical incidents on patients and how patients cope with such incidents.
  2. To investigate the consequences of serious medical incidents on healthcare staff and how staff cope with such incidents.
  3. To investigate optimal pathways of managing serious medical incidents.

In a paper published in December 2013, Anna and her colleagues reported that:

Twenty-seven surgeons participated. Many were seriously affected by major surgical complications. Surgeons’ practice was also often affected, not always in the best interest of their patients. The surgeons’ reactions depended on the preventability of the complications, their personality and experience, patient outcomes and patients’ reactions, as well as colleagues’ reactions and the culture of the institution. Discussing complications, deconstructing the incidents and rationalizing were the most commonly quoted coping mechanisms. Institutional support was generally described as inadequate, and the participants often reported the existence of strong institutional blame cultures. Suggestions for supporting surgeons in managing the personal impact of complications included better mentoring, teamwork approaches, blame-free opportunities for the discussion of complications, and structures aimed at the human aspects of complications.

Anna and her colleagues concluded that “those involved in the management of surgical services need to consider how to improve support for surgeons in the aftermath of major surgical incidents”.

Professor Guy Maddern discussed some of the processes available in Australia to support surgeons after major surgical incidents.

There is a transcript of the discussions. I listened very carefully to this exchange between Norman and Guy:

Norman Swan: Let’s move on to the more telling story there which was Anna Pinto’s story on the emotional impact on surgeons of complications. It’s a difficult area, Guy, because you’ve got to get up out of bed in the morning and go and operate, and there’s got to be a bit of steel-belting around you that if you had a bad day in theatre through no fault of yours the day before, you’ve still got to get up in the morning and do it again.

Guy Maddern: Yes, you have to certainly perform week after week and month after month, despite having over a lifetime collected a collection of complications that you wish hadn’t occurred. Also of course there is always that concern that maybe the complication was due to a poor judgement or a technical error, and despite being meticulous and trying always to do the best, technical errors do occur. And it is often very hard to ever know whether it was the patient’s biology that let them down or your abilities.

Norman Swan: And the psychological impact? What have you seen in your colleagues when this has happened?

Guy Maddern: Well, I think what surgeons have had a habit of doing is keeping this all to themselves, that can really be very destructive and often lead to premature resignations and even changing careers. However, fortunately it is being more widely promulgated, the need to discuss these sorts of things with colleagues and to debrief. And what we are seeing now is more team-based care. Many hospitals treat their patients in surgical teams, and although the surgeon carries the ultimate responsibility for what he or she did, discussion and support from colleagues is becoming increasingly important.

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Guy’s mention of team-based care took me back to Paul Barach’s team-based approach and the development of the Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) program. I was very interested to learn about the quality control dimension of TeamSTEPPS, namely to:

  • Produce highly effective medical teams that optimize the use of information, people, and resources to achieve the best clinical outcomes for patients.
  • Increase team awareness and clarifying team roles and responsibilities.
  • Resolve conflicts and improving information sharing.
  • Eliminate barriers to quality and safety.

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Learning from Surgeons

Whilst listening to Norman, Guy and Anna, I was very conscious of Mandy Ruddock-Hudson and Sophie Knights’ research at La Trobe University. Mandy and Sophie interviewed 12 of the 18 senior AFL coaches.

Samantha Lane summarised some of their work in an article The Age. Her summary included these items:

While they (the coaches) reported having support services at their fingertips, a factor that appeared to deter one from using it was the sense that he is “tough and resilient … OK with anything that goes on at work.”

And:

One coach said the aspect of the job he struggled with most was his feeling of isolation. Another described how he commonly suffered physically and emotionally from stress, which caused him to “really struggle to sleep”.

These issues resonate strongly for me with Anna’s findings and Greg’s observations.

Without pushing the connections too far, I think there need to be very good processes in place in sport when coaches experience counter-intuitive game results or when a team does not perform as planned or hoped.

Sensitive formative monitoring of performance in training and competition is a key component of the processes for me.

I do regard these processes as fundamental to long-term coach development and employment. A TeamSTEPPS approach would make very effective use of quantitative and qualitative data.

I see the Boards of professional sport teams to be the leaders in the development of these processes. They would have to engage in the goal of Phase 1 of TeamSTEPPS ‘to determine an organization’s readiness for undertaking a TeamSTEPPS-based initiative’. It would be great to see a vision statement that included this goal:

  • To produce highly effective coaching teams that optimise the use of information, people, and resources to achieve the best sport outcomes for supporters.

Photo Credits

Reeve 40258 (Otis Historical Archives, CC BY 2.0)

Surgery Image 3 (UCD Medicine, CC BY-NC-ND 2.0)

The Mastermind (Kitt Foo, CC BY-SA 2.0)

Coaching as an Occupation

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Introduction

I received two excellent alerts today. Both helped me think more about coaching as an occupation.

I am feeling very reflective at the moment, more so than usual. The death of a coaching friend, Dean Bailey, is a significant part of this.

John’s Mum

In the first alert, John Kessel writes delightfully about why his Mom would have been a GREAT volleyball coach.

Why My Mom Would Picture 3John’s Mom taught first grade pupils for over thirty years. He writes about how the lessons he learned from her shaped his coaching. His Mom:

  • made sure every student knew how artistic and creative they were.
  • taught to 25 individuals, not making them be the same, but discovered quickly how each student learned best.
  • kept EVERY child active/hands on.
  • had high expectations of her class and students.
  • focused on leadership skills.
  • ALWAYS had a smile on and made class fun.

AFL Coaches

The second alert came from Mark Upton (a retweet from AFL Coaching).

Mark took me to Mandy Ruddock-Hudson and Sophie Knights’ research at La Trobe University. Mandy works with The AFL Coaches’ Association on coaches’ welfare and personal development. Their research was shared with the AFL Coaches’ Association Conference in Adelaide earlier this month.

Samantha Lane wrote about their work in The Age (9 March).

Mandy and Sophie interviewed 12 of the 18 senior AFL coaches. The Age summarises the study’s findings that:

collate the innermost thoughts of a driven and passionate group who love the game, innermost thoughts of a driven and passionate group who love the game, but it also highlights how the role of an AFL head coach is an ever-expanding, increasingly demanding brief involving more responsibility than ever.

Three points from The Age’s reporting of the study struck me forcefully.

  • Coaches are experiencing high levels of stress that lead to insomnia and feeling physically ill.
  • Some coaches do not always know who their true football allies are and whom they can trust.
  • Some coaches feel vulnerable, lonely and isolated.

These experiences take their toll on close family members.

The 2014 AFL season commences with a third of the senior coaches from 2013 no longer in the same posts.

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Balance?

I found the juxtaposition of the celebration of teaching and coaching in John’s post with Mandy and Sophie’s research to be very powerful.

I am a profound optimist and believe we can transform coaching as an occupational culture.

Most coaches spend most of their professional lives losing championships.

Accepting this reality and then coaching to develop performances that give supporters hope is my antidote to the pressures that are heaped upon coaches and their families.

I do believe that coaching is about developing athletes’ and teams’ performances of understanding.

We have to uncouple the financial imperatives placed on coaches by Boards from the opportunities that should be available to expert pedagogues.

Transforming and sustaining performance is a long-term undertaking. John’s Mom developed her practice over thirty years. Professional sports have decided that two years is too long for some coaches.

A 2013 paper from Italian football noted:

the firing of the manager has to be explained in relation to other reasons rather than for the expected improvement in team performance. For example, team boards may overestimate their own ability to undertake optimal replacement decisions, or as suggested by the scapegoating theory, firing the manager may represent a convenient tool for owners in order to placate frustrated stakeholders and supporters and displace blame for the poor performance away from themselves.
We can show with an unprecedented small statistical error for the German soccer league that dismissing the coach within the season has basically no effect on the subsequent performance of a team. Changing the coach between two seasons has no effect either.
I understand that all professional coaches accept a voluntary risk when they are appointed. But we can do much better to alleviate the stresses indicated in Mandy and Sophie’s research.

The Age article quotes Danny Frawley, the AFLCA’s Chief Executive:

We’ve just got to make sure that clubs understand that this job is becoming more difficult by the day. It is a great industry to be involved in, but I think we’re in an industry now where the pressures are becoming greater. Let’s not tip people over the edge just for the sake of it.
All edges need a fine sense of balance.

Photo Credits

Coach Wagner drenched by victorious Garnets (Eric Behrens, CC BY 2.0)

John and his Mom (John Kessel)

Melbourne, Australia (Betsy Weber, CC BY 2.0)