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PRACTICAL ADVICE PAPER
Year : 2022 | Volume
: 35
| Issue : 3 | Page : 98-104
Developing a multi-departmental residency communication coaching program
Aussama K Nassar1, Marzena Sasnal2, Rebecca K Miller-Kuhlmann3, Rachel M Jensen1, Rebecca L Blankenburg4, Caroline E Rassbach4, Mystique Smith-Bentley5, Alpa Vyas5, James R Korndorffer1, Carl A Gold3
1 Department of Surgery, Stanford University School of Medicine, Stanford, California, USA
2 Department of Surgery, Stanford-Surgery Policy Improvement Research and Education Center, Stanford University School of Medicine, Stanford, California, USA
3 Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, California, USA
4 Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
5 Stanford Health Care, Stanford, California, USA
Correspondence Address:
Dr. Carl A Gold
Department of Neurology and Neurological Sciences, Center for Academic Medicine, 453 Quarry Road, Stanford, California 94305
USA
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/efh.efh_357_22
Background: Local needs assessments in our institution's surgery and neurology residency programs identified barriers to effective communication, such as no shared communication framework and limited feedback on nontechnical clinical skills. Residents identified faculty-led coaching as a desired educational intervention to improve communication skills. Three university departments (Surgery, Neurology, and Pediatrics) and health-care system leaders collaborated closely to develop an innovative communication coaching initiative generalizable to other residency programs. Innovation: Coaching program development involved several layers of collaboration between health-care system leaders, faculty educators, and departmental communication champions. The efforts included: (1) creating and delivering communication skills training to faculty and residents; (2) hosting frequent meetings among various stakeholders to develop program strategy, discuss opportunities and learnings, and engage other medical educators interested in coaching; (3) obtaining funding to implement the coaching initiative; (4) selecting coaches and providing salary and training support. Evaluation: A multi-phased mixed-methods study utilized online surveys and virtual semi-structured interviews to assess the program's quality and impact on the communication culture and the satisfaction and communication skills of residents. Quantitative and qualitative data have been integrated during data collection and analysis using embedding, building, and merging strategies. Discussion and Implications: Establishing a multi-departmental coaching program may be feasible and can be adapted by other programs if similar resources and focus are present. We found that stakeholders' buy-in, financial support, protected faculty time, flexible approach, and rigorous evaluation are crucial factors in successfully implementing and sustaining such an initiative.
Keywords: Communication coaching, communication skills training, faculty-led coaching, mixed-methods, multi-departmental collaboration, patient-provider communication, program evaluation, residency program, resident education
Deficiencies in physician communication skills have been linked to physician burnout, anxiety, and low confidence, particularly when encountering challenging clinical scenarios such as chronic pain, complex patients, or breaking bad news.[1],[2] In recognition of this, Interpersonal and Communication Skills (ICS) are highlighted by the Accreditation Council for Graduate Medical Education (ACGME) as a core competency for residents.[3] One of the challenges facing residency programs is how to teach and assess these nontechnical skills.[4] Many training programs lack curricula to address nontechnical skills acquisition.[5] Even for programs with such a curriculum, there may be limited curriculum reinforcement to create lasting behavioral change.[6]
Systematically engaging resident physicians in ICS training at our tertiary care academic medical center has proven challenging. For example, local needs assessments among the surgery and neurology residents revealed multiple barriers to effective communication, including perception that communication is difficult skill to learn, insufficient feedback from attendings, time constraints, and patient load.[7],[8] Residents desired direct observation at point-of-care and proposed communication coaching from faculty as a chosen educational strategy to help sustain behavior change.[8] Faculty coaching of residents, has been shown to improve the quality of feedback,[9] increase coping and relationship skills,[10] and reduce burnout,[11] and may be an effective strategy to engage resident physicians in ICS training.
As both the surgery and neurology residency programs at our institution encounter comparable challenges in the realm of ICS training and education, the leadership of these departments has expressed a willingness to develop faculty-led coaching for residents as an intervention. In response, our Institution's Service Excellence Program and the School of Medicine's Office of Graduate Medical Education have offered their support, contingent upon close collaboration between the two residency programs with the goal to create a program that can be easily adapted and implemented across other residency programs within our institution.
We describe a complex and innovative communication coaching education initiative, The Communication Coaching Program, offered to residents in two different specialties at our institution, focused on close multilayered collaboration to address overarching training needs and challenges. We share details on The Communication Coaching Program design, implementation, and evaluation strategies that may support the efforts of other institutions interested in implementing similar initiatives.
InnovationMultilayered collaboration
The Communication Coaching Program development has involved several layers of collaboration, as shown in [Figure 1].
Figure 1: Development of communication coaching program through multilayered collaboration effortsLayer 1: Building a collaborative environment with health-care system leaders and faculty educators. To improve patients' experience, leaders of the health-care system's Patient Experience program formed the Physician Partnership Program in 2015 with faculty physicians and experts in communication skills coaching to facilitate fundamental relationship-centered communication (RCC) skills workshops.[12] These workshops were delivered to nearly all faculty members and adapted and delivered annually to Surgery and Neurology, among other residency programs, starting in 2019.Layer 2: Fostering collaboration among faculty educators in different programs. Building upon the success from the first layer of collaboration, our GME hosted an executive strategic planning session with key communication skills champions and stakeholders. The goal of this meeting, held in March 2019, was to cross-pollinate ideas and develop strategic plans aligned with the health-care systems' academic leadership vision. Each departmental/specialty leader presented their work and progress. This meeting created the nidus for further collaborative efforts across the health-care system and medical school and was crucial to the next stepsLayer 3: Promoting interdepartmental collaboration efforts. Medical education leaders from Surgery and Neurology departments were interested in offering residents a platform to improve their nontechnical skills and decided to collaborate toward concrete actions. This prompted further collaboration with the Pediatrics department, which in 2013 launched its coaching program, focused on improving residents' clinical skill development rather than nontechnical skills, increasing residents' reflective practice, improving feedback, facilitating goal setting, and improving milestone assessment.[9] We built on the experiences of our colleagues from the Pediatrics department and adapted their approach to developing a program focusing specifically on residents' nontechnical skills development, including communication skillsLayer 4: Health-care system funding of collaborative communication coaching programs. Medical education leaders from the Surgery and Neurology departments submitted a grant proposal to and were approved by our institution's Patient Experience Department. Funding was obtained for (1) faculty-protected time for coaching residents and (2) research support to evaluate the implementation of The Communication Coaching ProgramLayer 5: Formation of multi-departmental coaching steering committee. Leaders of the coaching programs in Pediatrics, Neurology, and Surgery meet monthly to discuss opportunities and learnings and to engage other medical educators interested in coaching. Iterative improvements over time included aspects that remained aligned for all programs, such as the monthly faculty development to meet the trainee's needs for different specialties. While the overarching administration of the program was similar in the residencies, there was divergence in the implementation of individual resident coaching sessions. For example, it became clear that preoperative, intraoperative, and postoperative communication should be a major focus for surgery residents, while neurology residents benefitted from coaching in clinic visits, during hospital rounds, and in family meetings. In addition, coaching surgical residents presents its own set of challenges requiring substantial modification to the coaching process. This is largely due to their erratic schedules and availability. For example, residents might be in the operating room, attending to a trauma case, or treating a critically ill patient in the emergency department.Faculty coach's selection and training process
Nine surgery and neurology faculty coaches were selected after an application and interview process. They were given salary support to meet the time demands of coaching. Each coach was paired with 8–10 residents from all years of training. All coaches attended a half-day orientation session led by the directors of the Pediatrics Coaching Program. Before the first coaching session, coaches and residents also had a half-day training in RCC, the standard communication framework adopted by our institution. Each of these courses has been heavily adapted to meet the unique communication needs of surgery and neurology providers. Subsequently, surgery and neurology coaches attend monthly 90-min faculty development sessions with experienced pediatrics coaches, training on various topics related to coaching and feedback. Examples of sessions included: “Communication Coaching for Generation-Z Learners,” “Serious Illness Conversations,” and “Listening with Intention.”
Coaching sessions
Our coaching program is designed to be longitudinal, with each resident assigned a dedicated faculty coach who provides coaching throughout their entire residency period. Each resident is scheduled to meet with their coach to receive 5-8 30-90-min individual coaching sessions annually, depending on their postgraduate year level. Junior residents receive more coaching sessions, while senior residents receive fewer. Coaching sessions take place in all point-of-care settings in the hospital, including the operating room, emergency department, Intensive Care Units, and clinics, both in person and through video conferences. Participation in the coaching program is mandatory for residents and is a part of the residency program curriculum; however, to create a psychologically safe environment for coaching, the coaches are neither the attending of record nor should be included in their performance evaluation. There is no predefined checklist of behaviors for evaluation, as the coaching approach is tailored to residents' needs.
In this method, residents select a particular skill they want to enhance. The coach then observes their performance during real-time patient care and subsequently offers targeted coaching focused on the identified skill goal. The coaching encounters are based on the conceptual model for coaching in medicine developed by the Pediatrics Residency Coaching Program, emphasizing that the process of coaching creates an ongoing cycle of improvement in which the coach and residents both play an active role[9] and include four key elements: (1) goal setting by the resident, (2) direct observation of the resident by the faculty coach, (3) facilitated reflection and targeted feedback; and (4) future goal setting [Figure 2].
Figure 2: The scheme of the communication coaching sessions emphasizing coaching as an improvement process and active participation of coaches and residents.[9] (The permission to reprint the figure has been obtained under a CC-BY-NC-ND license number 5532890919076)The program design, implementation, and evaluation strategies are presented in [Figure 3].
Figure 3: Design, implementation, and evaluation strategies of the communication coaching program Evaluation Innovative medical education initiatives require rigorous evaluation to demonstrate outcomes and document added value to achieve acceptance, adoption, and scalability. Given the complexity of the presented longitudinal residency Communication Coaching Program, a mixed-methods evaluation approach was planned and implemented after 1–3 years of coaching.
Mixed-methods evaluation study
A multi-phased mixed-methods study[13] utilized online surveys and virtual semi-structured interviews to assess the program's quality and impact on the culture of communication and residents' satisfaction and communication skills.
The research project consisted of three phases, as depicted in [Figure 4]:
Figure 4: Communication coaching program mixed-methods evaluation designPhase 1: A convergent mixed-methods phase including an online baseline survey of residents and coaches with closed, Likert scale, and free-text questions to assess perceived baseline communication skills, communication culture, feedback quality and frequency, and expectations and concerns related to the program. Due to a lack of published surveys related to communication coaching needs, we designed our own survey, which was distributed in a baseline and follow-up setting. Survey questions were designed using medical education survey best practices and the questions were pilot tested and meticulously vetted by six educational leaders and stakeholders in the coaching program.[14] Further psychometric testing was conducted to assess validity and reliability. We examined the relationship between survey items and latent constructs by performing a principal components analysis combined with a factorial analysis based on the baseline survey results. Internal consistency was evaluated using Cronbach's alpha. The results demonstrated robust psychometric propertiesPhase 2: A qualitative phase including 35 virtual semi-structured interviews with key stakeholders (education leaders, coaches, programmatic sponsors, and residents) conducted by a research analyst on the team experienced in qualitative methods (M. S.), to understand factors leading to launching the program, barriers and facilitators to implementation, and strategies for improvement. We used a key informant sampling strategy to identify study participants[15]Phase 3: A convergent mixed-methods phase including an online follow-up survey of residents and coaches with closed, Likert scale, and free-text questions to evaluate the implementation efforts, communication skills, participants' reflections after 1-3 years of coaching, and ideas for improvement. We ensured the validity and reliability of the follow-up survey using the same approach as for the baseline survey.Quantitative and qualitative data have been integrated during data collection and analysis using various strategies such as embedding (supporting quantitative survey results with qualitative survey data), building (using the results of the baseline survey and interview study to develop the follow-up survey), and merging (bringing together and comparing results from all study phases to gain a comprehensive understanding of the research topic).[13] As of April 2023, data collection from all three study phases was completed. The complex analysis of the quantitative and qualitative data has been conducted and will be reported separately. The preliminary results suggest that an evaluation approach that engages broad representations of stakeholders may facilitate designing a genuinely community-driven initiative that meets residents' communication training needs.
Discussion and ImplicationsOur experience has taught us that establishing a multi-departmental coaching program may be feasible and successful and can be adopted by other programs if similar resources and focus are present.
The hospital and academic stakeholder buy-in and financial support for this unique collaboration have been essential. Protecting faculty time – both in FTE and ensuring they have time free of clinical responsibilities – has been critical. We have also learned that “not one size fits all.” A coaching program that suits one department may not work for another and requires some modifications and adjustments to meet the unique needs. This has been particularly relevant for procedural specialties, given the different workflows and emphases.
Moreover, given the logistical complexities of coordinating multi-departmental education initiatives and the unpredictability of the health-care environment, we have also learned to be flexible in our implementation and evaluation approach. The communication coaching program's launch in March 2020 coincided with the COVID-19 pandemic's shelter-in-place orders, and residents' clinic encounters shifted rapidly to telemedicine. We pivoted to provide virtual coaching and found this an opportunity to conduct an ad-hoc study to evaluate this new health-care format. Virtual coaching was shown to be acceptable and feasible by residents and coaches and perceived as a unique approach for resident education that will persist into the future.[16]
We strongly recommend planning a rigorous evaluation strategy and securing funding to cover program evaluation efforts to provide stakeholders with the necessary data to demonstrate program effectiveness and help maintain funding. We want to emphasize the importance of utilizing mixed methods and, most importantly, the qualitative interview component to reveal stakeholders' perspectives and make the initiative a genuinely community-driven effort that addresses pressing issues.
We are now in our 4th year and are constantly modifying and adapting our program to meet the needs of both coaches and trainees.
Limitations
Faculty-led coaching in medical education has proven effective, but it faces limitations. Time constraints due to faculty's multiple obligations can hinder regular, individualized sessions. Variations in coaching abilities may lead to inconsistent experiences, and a lack of standardized assessment methods may impede optimization efforts. In addition, trainee reluctance to engage in coaching could undermine its benefits. Moreover, securing sustained funding for similar programs can prove to be challenging.
ConclusionsOur study showcases the potential for a successful and adaptable multi-departmental coaching program. Key elements include flexibility, collaboration, rigorous evaluation strategies, and responsiveness to unique needs and changing health-care environments. Future research should address faculty-led coaching limitations to enhance the effectiveness of such programs in medical education.
Acknowledgments
The authors thank David Entwistle and Dr. Justin Ko for their innovative spirit and generous support of this initiative; Drs. Mary Leonard, Mary Hawn, and Frank Longo for their enthusiasm for communication skills training; Dr. Laurence Katznelson for encouraging collaboration among medical education leaders; Christopher D. Stave for providing support with the literature search; and the faculty coaches and residents for their dedication to this program.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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