Introduction

The field of obstetrics and gynecology is traditionally regarded as a field that is composed of the entirety of women’s reproductive health needs. The breadth of experience accrued in residency training prepares providers to advocate and care for patients across the reproductive life span. Furthermore, this structure limits the time available for dedicated surgical training during postgraduate medical education. Obstetrics and gynecology residents across the United States spend 18 to 24 months within a 4-year residency program rotating through gynecologic surgical specialties. This compares to approximately 60 months of surgical training among general surgery residents. Although these fields differ considerably in anatomic and procedural scope, residency graduates across surgical specialties are expected to be similarly prepared for independent practice despite marked variability in surgical volume and experience.

Because of restrictions on duty hours, changing technologies, and shifts in training culture, there are growing expectations for increased trainee supervision and the acquisition of a greater breadth of medical and procedural knowledge without increased length of training. As such, there is a critical need for innovation in the ways we conceptualize obstetrics and gynecology residency surgical training and continuing professional development. In their Continuing Board Certification: Vision for the Future Commission 2019 final report, the American Board of Medical Specialties (ABMS), of which the American Board of Obstetrics and Gynecology (ABOG) is a member, committed to reimagining mechanisms for regulating physician competency globally. The ABMS highlighted the importance of lifelong learning and individualized feedback that produces data-driven advances in clinical practice beyond training and board certification. In this article, we explored surgical autonomy and continued performance advancement and propose the implementation of surgical coaching to advance the visions of the ABMS and ABOG. Surgical coaching targets both technical and nontechnical skills and provides a framework for actualizing adult learning principles to create meaningful practice changes.

Determining Readiness for Independent Practice

We outlined several formal and informal steps involved in the process of attaining and maintaining high-level surgical skills. First, operative autonomy and the development of appropriate confidence are crucial components of preparing learners for independent practice. A recent nationwide survey demonstrated that a high proportion of graduating obstetrics and gynecology residents reported confidence in their abilities to perform most core surgical procedures. Conversely, fellowship program directors surveyed in 2014 believed that incoming fellows had lower surgical skills than their counterparts a decade earlier. Mutual trust between faculty and trainees is an important factor in increasing resident competency, developing necessary surgical autonomy, and improving patient outcomes in the long term.

It is critical to consider the role of clinical entrustment in surgical education and the transition to independent practice. Expert gynecologic surgeons use multiple inputs to determine appropriate resident autonomy, such as previous experiences with trainees, demonstrated medical knowledge, and intraoperative technical performance. A recent educational intervention to increase faculty entrustment of trainees’s difficult core general surgery procedures was associated with equivalent patient outcomes across more than 8800 surgical procedures. This suggested that efforts to increase autonomy during training are likely to benefit the surgeons’ development without negatively impacting patient care.

Furthermore, there are currently limited opportunities to demonstrate procedural competency before leaving obstetrics and gynecology residency and entering into practice. The Fundamentals of Laparoscopic Surgery examination was adopted from general surgery certification requirements and instituted in 2020 as a graduation requirement for obstetrics and gynecology residents. This decision was part of an initiative by the ABOG to standardize laparoscopic surgery training and knowledge on a national level using a reproducible and broadly accepted testing format. The Fundamentals of Laparoscopic Surgery examination consists of a computer-based cognitive assessment and laparoscopic skills test on a simulation trainer. After residency, national board certification functions as the principal metric for recognizing physicians’ abilities to provide high-quality patient care. The ABOG requires successful completion of written and oral examinations that evaluate medical knowledge and clinical decision-making. Direct procedural skills assessments are notably absent from the board certification process and limited in residency training.

Once in independent practice, obstetrics and gynecology physicians rarely receive formal surgical skills evaluation or feedback. After achieving board certification, the ABOG maintenance of certification programs for physicians in practice involves annual medical literature review, professionalism appraisal, and quality improvement or simulation courses selected by the individual practitioner. Practice improvement or maintenance of skills is largely dependent on self-evaluation, which presents significant limitations. Accurate self-assessment is critical to allow surgeons to act with appropriate confidence in areas of strength and seek improvement or limit practice in areas of weakness. Unfortunately, previous literature has revealed that trainee and faculty surgeons demonstrate inconsistent or inaccurate self-assessment, regardless of level of training, specialty, or self-assessment domain. Relying on physician self-assessment alone for continuing professional development likely limits opportunities for growth and performance improvement.

Defining and Assessing Surgical Performance

Surgical performance describes the implementation of multiple tasks and actions within interconnected domains to complete a patient’s operation safely and effectively. Performance domains include both technical and nontechnical components. Traditionally, technical skills are the most emphasized in graduate medical education training and involve the physical steps required to achieve visualization, tissue effect, and operative flow. A 2013 landmark study of bariatric surgery procedures demonstrated that increased level of technical skill of the operating surgeon, as assessed by peer surgeons, was associated with stepwise decreases in operative times, readmission rates, surgical complications, and mortality. These findings were strengthened by a subsequent study that used the validated Objective Structured Assessment of Technical Skills to rate surgeons’ technical performance during pancreaticoduodenectomy and showed that scores were predictive of postoperative outcomes.

Nontechnical skills are similarly essential to high-level surgical performance, although these are rarely emphasized in traditional surgical education. The primary nontechnical components of surgical performance include cognitive skills, such as situation awareness and intraoperative decision-making; interpersonal skills, such as communication, leadership, and teamwork; and self-regulatory abilities. ^{, ,} Breakdowns in communication have been linked to patient safety concerns and perioperative complications among surgical patients. Furthermore, deficiencies in surgeon-level nontechnical domains have been linked to adverse outcomes when controlling for patient-level factors. The Non-Technical Skills for Surgeons (NOTSS) framework is a structured process for rating cognitive and interpersonal skills. Of note, 1 study examined NOTSS scores for trainees and surgeons in practice during a simulated scenario and found that scores peaked in fellowship and declined thereafter, particularly in the areas of establishing a shared understanding, implementing and reviewing decisions, and coping with pressure. Although training and culture differences may account for some of the observed effects, this study highlighted the need for ongoing learning and dedicated practice in all elements of operative performance throughout the surgeons’ careers.

Innovations in the area of surgical performance assessment are active and ongoing in response to the ABMS Vision for the Future Commission, with obstetrics and gynecology transitioning to a continuous certification model. It is important to consider the goals of evaluation tools aimed at assessing surgical performance. Specifically, formative assessments seek to promote self-reflection and improvement through ongoing feedback, whereas summative assessments are designed to formally and globally evaluate competency against prespecified standards. Moreover, procedural assessments can be designed to broadly evaluate surgical performance or focus on factors specific to a given task or operation. The Society of American Gastrointestinal and Endoscopic Surgeons has undertaken the process of identifying index procedures for which to create video-based assessment tools, which are currently undergoing content validity testing. These tools may serve as examples for corresponding procedure-specific assessments in obstetrics and gynecology.

As tracking of patient outcomes becomes integrated into hospital policies and reimbursement models, questions arise regarding the impact of reporting on surgical performance. Multiple recent studies have demonstrated that hospital participation in quality reporting, such as enrollment in the American College of Surgeons National Surgical Quality Improvement Program, is not associated with improved surgical outcomes or decreased complication rates. ^, Although tracking of surgical outcomes plays an important role in patient care and quality improvement, this is likely not sufficient to yield meaningful practice changes. We proposed that effective surgical performance assessments should incorporate surgical outcomes reporting, video-based assessment, and individualized opportunities for reflection, inquiry, and feedback to drive sustainable performance improvement.

Surgical Coaching Frameworks

Coaching is the act of partnering in a creative and thought-provoking relationship that inspires individuals to maximize their personal and professional performance. Specifically, surgical coaching relies on the relationship between a surgeon (participant or coachee) and surgical colleague (coach) who has received formal training in the principles and philosophy of coaching. Surgical coaching differs from traditional medical educational relationships, such as teaching and mentoring ( Figure ) , in that coaching uses adult experiential learning whereby the participant drives the relationship and actively engages in the learning experience with individualized feedback guided by iterative reflection, inquiry, and critical analysis. ^, In contrast, teaching is traditionally carried out in a more directive fashion in which the learner acquires knowledge or skills from the teacher. Mentorship refers to a relationship with a broad scope in which the mentor has more knowledge, skill, or experience in a specific area and advises the mentee in these domains. Both of these relationships typically have a perceived hierarchy. ^,

Medical education relationships: the roles of coach, mentor, and teacher

Orlando. Surgical coaching in obstetrics and gynecology. Am J Obstet Gynecol 2022.

There are 2 major models for surgical coaching: peer and expert coaching. Expert coaching embraces an explicit differential in knowledge or technical skills between the participant and coach and can be particularly useful for surgeons aiming to acquire new skills or integrate new technology into the operating room. This may be especially beneficial when integrating new devices or technology into practice. A recent industry collaboration involving 23 practicing surgeons incorporated surgical coaching into a new product rollout. Following coaching, surgeons reported significantly improved confidence in using new technologies and made significant progress toward achieving their previously stated goals.

In contrast, peer coaching involves a participant and coach at similar knowledge and skill levels. Effective peer and expert coaching require faculty development to encourage participants to adhere to the principles of surgical coaching, rather than transitioning into relationships, such as teaching or mentorship, that are more prevalent in medical education and surgical culture. Coaching requires participants to shift from an expert to a learner mindset. Similarly, coaches must recognize their role in service to the participant and avoid potential pitfalls, such as alternative agenda-setting based on the coach’s preferences. Both peer and expert coaching models value collaboration rather than competition, establishment of goals, guided inquiry, constructive feedback, and self-evaluation. The focus of the coaching relationship remains on the participant’s strengths to improve performance.

Effective and longitudinal relationship building between the participant and coach is essential in surgical coaching. Relationship building can be conceptualized according to the following steps: aligning role and process expectations, establishing rapport, and cultivating mutual trust. Specific strategies have been identified in initiating successful participant-coach relationships. These include framing the coaching relationship as a partnership, positioning the participant as responsible for self-directed learning, conveying interest in developing an informal relationship, expressing a commitment to the coaching process, and modeling self-disclosure. Overall, the coach’s role is to empower the participant by allowing space and guiding self-reflection in all areas of surgical performance. This joint reflective process allows for more accurate identification of strengths and weaknesses than self-assessment alone. The mutual trust within the relationship may allow for insight into areas that are traditionally difficult to assess, including intraoperative decision-making, judgment, and leadership skills.

From Idea to Innovation

We presented our experience with the implementation of the aforementioned surgical coaching model according to the Idea, Development, Exploration, Assessment, and Long-term monitoring (IDEAL) framework, which provides a pathway for generating and analyzing data unique to surgical innovation to enhance safety and effectiveness during clinical integration. The IDEAL framework includes 5 stages: (1) Idea (describe the new treatment concept), (2) Development (pilot and iteration and observational intervention), (3) Exploration (comparative evaluation to achieve consensus among surgeons and determine benefits and harms), (4) Assessment (comparative effectiveness testing through controlled trials), and (5) Long-term monitoring (dissemination, surveillance, and quality assurance).

The initial report confirming proof of concept for video-based surgical coaching was published in 2012 (Idea). This was followed by the development of the Wisconsin Surgical Coaching Program, which was designed as a peer coaching program for practicing surgeons and allowed for the identification of logistical challenges and the perceived value of the intervention (Development and Exploration). Moreover, these concepts were applied to a 2015–2018 coaching program within the Michigan Surgery Bariatric Collaborative, which revealed that participants who underwent surgical coaching experienced statistically significant improvements in operative time, thereby demonstrating sustainable clinical practice improvements (Assessment). The Academy for Surgical Coaching, a not-for-profit service organization, was created to operationalize and disseminate a replicable framework for surgical coaching (Long-term monitoring).

Data-driven Impacts of Coaching

There is growing nationwide interest in the study and implementation of surgical coaching during the past decade. This is evidenced by a 2022 systematic review of articles examining the impact of surgical coaching on technical or nontechnical skills. The review identified 35 studies in total that met the criteria for inclusion, wherein all studies were published between 2010 and 2019. The authors found that coaching was associated with improved performance in the domain of interest in 97% of studies. Benefits of coaching have been demonstrated for both surgeons in training and surgeons in practice. Peer coaching has been investigated as a method for laparoscopic skills acquisition and compared favorably to both conventional residency training and online training and self-directed practice in randomized controlled trials (RCTs). ^, A 2020 systematic review and meta-analysis of 24 RCTs demonstrated that video-based coaching among surgical trainees improves technical performance compared with traditional master-apprentice models.

Surgical coaching supports continuous professional development with high acceptability and perceived value among participating faculty surgeons. In addition to benefits experienced by participants, surgical coaching has the potential to decrease physician burnout and improve well-being among coaches. ^, With increasing workplace loneliness and disconnection from peers, we believe that coaching may enhance physician retention and overall career satisfaction with increased surgeon engagement. In 2008, the Cleveland Clinic integrated a physician- and scientist-focused peer-based coaching program to promote well-being, with an estimated cost savings of at least $133 million in 2020 alone in physician retention. Opportunities afforded by surgical coaching include improvement during training and throughout a surgeon’s career.

Logistical challenges rather than issues related to the fundamental aspects of coaching seem to present the greatest barriers to participation. The use of surgical video review can remove competing intraoperative responsibilities and allow for coaching partnerships across institutions to overcome logistical challenges of distance and demanding schedules. In video-based coaching, the coach-participant pair reviews prerecorded operations to examine technical and nontechnical aspects of surgical performance, create participant-led goals, and design action plans through reflection and feedback. Video-based coaching can be performed in person or virtually with the use of surgical footage to supplement the coaching experience. Furthermore, coaching has been incorporated into simulation curricula with associated performance improvement in both technical and nontechnical skills. ^, Synergistic use of teaching, simulation, and coaching may be particularly useful in cases of new skills acquisition and to fit trainees at different skill levels.

Coaching in Obstetrics and Gynecology

Within the field of obstetrics and gynecology, current training models and requirements for graduation focus on surgical competency rather than mastery. In addition, there is significant variability in surgical volume across training programs, with approximately half of residency graduates unable to meet minimum case requirements for minimally invasive hysterectomy in 2017. ^, This coincides with decreasing rates of hysterectomy nationally as medical management of pelvic pain and abnormal uterine bleeding becomes more prevalent. Because of widespread difficulties in reaching case minimums, each surgical case should be viewed as an opportunity to maximize learning potential. Coaching can help to facilitate activities, such as postprocedure video review, self-reflection, and action planning to make subsequent learning opportunities more meaningful and allow for more advanced intraoperative teaching by expert surgeons.

Surgical coaching has the potential to bridge the gap from training to practice, which often involves an abrupt shift from limited surgical autonomy to minimal oversight or feedback. Unlike proposed initiatives, such as flexible residency curricula to improve surgical skills, surgical coaching can be integrated into existing training programs and institutions with minimal cost and limited resources. In addition, coaching may provide benefits in residency vs traditional teaching relationships in that trainees more frequently initiate teaching points and direct their educational needs. If surgical coaching can be normalized and incorporated into residency training, this may allow for a culture shift toward lifelong learning after graduation.

Surgical coaching can aid in achieving the goals of continuing professional development as outlined by the ABMS. The short-term and immediate recommendations by the ABMS include integration of activities grounded in adult learning principles. These activities should be frequent, goal oriented, and longitudinal, with individualized feedback that is repeated for reinforcement. We emphasized that surgical coaching is not intended to be used as a punitive action or for credentialing purposes. Preferably, the value of coaching comes from a relationship grounded in trust and safety devoid of penalty. In the field of obstetrics and gynecology, coaching can be considered for a wide range of procedures, from major surgery to office-based skills. Moreover, nontechnical skills, such as communication, leadership, or surgical education techniques, can be targeted through the incorporation of audio modalities.

As societies and institutions consider investing in coaching programs for surgeons in practice, best practice recommendations are emerging to guide successful implementation. These include optimizing coach-participant relationships, setting expectations through meaningful initial sessions, and normalizing coaching on an institutional level. Video-based case review rather than in-person live observation may allow for increased efficiency and scalability through national societies. Surgeons can upload operative footage to a secure online technology platform for review at an agreed time. Moreover, coaching sessions can be completed face to face with minimal use of financial or technological resources. Coaching programs can be tailored to individuals or organizations as desired. Establishing surgical coaching as an expectation for lifelong learning and improvement has the potential to elevate surgical performance and patient care across our field. With the enhanced virtual platforms available, surgical coaching also offers the opportunity to build coaching relationships worldwide.

Conclusion

With significant variations across obstetrics and gynecology training programs and an ever-changing landscape of new surgical challenges and technologies, there is a need for innovation to optimize surgical performance. The ABMS has created specific recommendations on how continuing certification must change. Surgical coaching offers an opportunity to help meet those recommendations by tailoring practice change to individual surgeons through goal setting, self-reflection, and ongoing feedback. We believe that the implementation of surgical coaching in obstetrics and gynecology has the potential to improve performance, provide lifelong learning, and promote excellence in patient care.