25. The role of coaching in residency education

Introduction

Feedback has been long recognized as an essential component of medical training, and it’s something you will rely heavily on as a program director. However, the delivery feedback is often poorly executed, decreasing its effectiveness and meaningfulness. The challenges associated with providing feedback in medical training are many. There is a complex interplay between the individual learner and teacher that influences the content of feedback as well as how the feedback is delivered and how receptive the learner is to receiving it. Cultural norms, both within the local learning environment and more broadly within medical education, also influence the effectiveness of feedback.

In Competence by Design (CBD), the role of the clinical teacher is evolving from clinical supervision to a role that includes more observation and coaching of learners. When clinical teachers directly observe the work residents do or gather other data indirectly about the work that is done, these observations provide the teacher with the opportunity to move beyond traditional approaches to feedback and engage in coaching. Coaching provides actionable steps or suggestions for improvement and is beneficial for anyone who is pursuing optimal performance. Coaches can help an individual to do a task better, develop a skill they don’t yet possess or achieve a specific goal. Coaching helps a learner understand what adjustments and modifications will allow them to progress to the next level of capability or proficiency.

Coaching is meant to guide learners through a growth process that leads to performance improvement. Traditionally, feedback alone simply provides information to learners about what was observed compared with an expected standard, whereas coaching not only informs them what was noted during an observation but also, more importantly, focuses on specific actionable steps or suggestions for improvement (Figure 22.1). To use a sports analogy: a tennis coach would not simply describe how a forehand swing was incorrect. The coach would ask if the athlete had tried a body position correction before or might give specific suggestions for improvement such as an adjustment to the position of the body during the forehand swing.

It is notable, however, that over the last decade the definition of feedback has been evolving. In 2019, Ajjawi and Regehr suggested that feedback is a “dynamic and co‐constructive interaction in the context of a safe and mutually respectful relationship for the purpose of challenging a learner’s (and educator’s) ways of thinking, acting or being to support growth.”¹ Thus, overlap exists between modern conceptualizations of coaching and feedback in the medical education literature. For the purposes of CBD, coaching is the preferred term.

Key educational principles of successful coaching

The following principles are key to the success of the CBD coaching model. These principles could form the backbone of your local faculty development initiatives. There are a number of resources available on the Royal College website, and your local postgraduate medical education office will also have faculty development resources for this very important skill.

Principle 1: Building an educational alliance

In recent years, there has been a move away from the use of prescriptive structured feedback techniques. This change in thinking around feedback is related to an increased awareness that feedback is a process involving a bidirectional relationship between the person giving the feedback and the person hearing the feedback. This relationship or “educational alliance” has been proposed to be a key determinant of the effectiveness of feedback in improving resident performance. Effective coaching establishes an educational alliance and confirms, for the resident, the clinical teacher’s engagement in the educational process and commitment to providing guidance for the growth and development of the resident. Having such an educational relationship allows the two parties to mutually agree on the goals and expectations of the interaction and contributes to psychological safety for resident learning.

Principle 2: Growth mindset versus fixed mindset

The terms “growth mindset” and “fixed mindset” were coined by psychologist Carol Dweck and can be used to describe an individual’s approach to learning. People who possess a growth mindset believe that their abilities can be developed through dedication and hard work. As a result, they are very receptive to high-quality feedback and coaching. Individuals with a growth mindset take advantage of learning opportunities and seek input from others on their work. This mindset creates a desire and drive for learning and a resilience that is essential for the development of successful coaching relationships.

In contrast, people with a fixed mindset approach situations with a judgment lens. ‘Fixed Mindset’ individuals believe you are good at something or you are not.  Such individuals may want to hide weaknesses or mistakes and do not value challenging situations as learning opportunities. They also often respond negatively to feedback and suggestions for improvement, believing that they imply failure.

For coaching in CBD to be successful, both residents and clinical teachers must work toward developing and fostering a growth mindset. To achieve this goal, it is important that residents and faculty shift their thinking to embrace the view that the primary purpose of residency education is learning. Clinical teachers and residents both need to recognize the value of coaching in the learning process as it facilitates performance improvement and progressive development of expertise.

Principle 3: Assessment of learning versus observation for learning

In traditional residency education, the primary form of assessment was assessment of learning (summative assessment). The purpose of assessment of learning is to form a judgment or an evaluation and formally record what a resident knows or can do at that particular instant in time. Assessment of learning can create unease for residents and often puts them in a position of performing — in other words, doing what they believe is on a checklist as opposed to doing what they would normally do, as they feel appropriate, in the real clinical environment.

In CBD, we need to shift our thinking toward observation for learning (formative assessment). Observation for learning emphasizes observation of residents doing their daily work, rather than performing in a testing environment or situation. Observation is essential to the coaching process, as it allows the clinical teacher to guide the resident on what they can do to improve their current understanding or practice. These formative observations are lower stakes and should be frequent and ongoing. They should be embedded throughout the learning process rather than taking place only at the end of a rotation.

Understanding the Competence by Design coaching model

The Royal College’s CBD coaching model supports resident learning. It is part of an important philosophical shift in thinking about workplace-based learning and its purpose. It is important that you ensure that your faculty understand this model, so that they can incorporate it into their interactions with residents. There are many resources available on the Royal College website to help with coaching.

The emphasis of the CBD coaching model is on assessment for resident learning and competency development. This model defines two distinct coaching roles: coaching in the moment and coaching over time (Figure 22.2). However, both of these coaching roles rely on the use of observed work in the clinical environment as learning opportunities.

 

Coaching in the moment

Coaching in the moment is coaching that occurs in the clinical environment between a clinical teacher and resident. It follows a step-by-step process known as RX-OCR (Table 22.1). Use of the RX-OCR process promotes coaching irrespective of the duration of the clinical learning experience. Observations done as part of coaching in the moment are low-stakes observations of daily work, and the coaching provided facilitates development toward competent practice. Acquisition of the competencies needed for coaching in the moment should be a focus of broad faculty development in your program.

Coaching over time

Coaching over time requires a more longitudinal relationship between a designated coach and resident. In many cases, you as a program director will be in this coaching role, as will academic advisors and even some faculty members. This educational partnership lasts longer than any one clinical experience. It requires regularly scheduled face-to-face discussions about the resident’s progression toward competence. These coaching encounters follow the same step-by-step process as coaching in the moment, RX-OCR (Table 22.1). However, the observations that inform these coaching encounters are those recorded in the learning portfolio. Learning opportunities are planned to address any identified performance patterns. For an “educational alliance” to develop and work well, residents must feel confident that the coach has their best learning interests in mind. Coaching over time focuses on helping the resident to become an independent, competent clinician who is prepared for a career as a self-regulated learner. To facilitate coaching over time in your program, you will probably need to provide some targeted faculty development for the smaller group of faculty who are providing this type of coaching to your residents.

Table 22.1 RX-OCR process

Rapport	Establish educational Rapport between the resident and the clinician (“educational alliance”)
Expectations	Set eXpectations for an encounter (discuss learning goals and roles, and foster a safe learning environment)
Observe	Observe the resident (directly or indirectly)
Coach	Coach the resident for the purpose of improvement of that work
Record	Record a summary of the encounter

Resident progression

As a resident moves through their residency program, many documented observations and coaching encounters, involving multiple observers, build a representation of daily performance that is collected in a learning portfolio. The observations create an illustration of a resident’s progress over time. As part of a program of assessment, your program’s competence committee will monitor each resident’s developmental progress and make recommendations to your residency program committee about entrustment for specific activities, resident promotion, and residents’ readiness for challenging their final examinations (Figure 22.3).

The importance of observation in coaching

Observation is a key ingredient for successful coaching. Within CBD, observations are defined as either direct or indirect.

Direct observation

Direct observation refers to the process of watching residents perform a task to develop an understanding of how they apply their knowledge and skills to clinical practice. There are countless examples. They include observations of residents performing a physical examination, completing a procedure, leading a resuscitation, giving patient handover, communicating with a family, managing a ward rounds or running a meeting, to name just a few.

Indirect observation

Indirect observation comprises observations that an individual makes without having directly watched the resident perform the task. Indirect observation could include information gathered from surrogate data such as a resident’s oral case presentation, clinical documentation or reports from other health care providers, patients or families.

Observation in the Competence by Design coaching model

Ideally, most coaching in the moment should occur following a direct observation of clinical activities. Direct observations can increase the value of coaching encounters as they make it easier for the coach to suggest actionable steps for performance improvement. Indirect observation is a valuable alternative to direct observation for coaching in the moment, as it enables the coach to assess different skills, such as clinical reasoning. Given that coaching over time occurs longitudinally and outside of the clinical environment, the foundation of these coaching encounters will be review of and reflection on recorded observations in a learner’s portfolio.

Challenges to observation and coaching

Recent work has identified barriers to direct observation that can make coaching more challenging. Resident-identified barriers include concerns relating to overburdening their clinical teachers and the potential for residents to view direct observation as a form of summative assessment, leading to anxiety and avoidance behaviours. Teachers, on the other hand, have expressed fears about decreased resident autonomy and resident–supervisor trust. A barrier identified by both residents and teachers is the amount of time required to perform direct observation and the impact on efficiency of clinical care.

Given the emphasis on observation, feedback and coaching in CBD, these challenges make it is clear that education for both faculty and residents is an important part of building regular direct observation and coaching into the medical education culture, and specifically the culture of your program. It is important to ensure that the teachers in your program are provided with opportunities to develop competencies that will enable them to effectively engage with your program’s residents as coaches. In addition, it is important that residents are well oriented to the coaching process in CBD, to encourage them to engage in the process. Education also needs to be provided to everyone about the growth mindset and how to incorporate it into practice and about the importance of psychological safety in a learning context and how to foster it.

The next section introduces the acronym RX-OCR, which represents a process that both residents and faculty can use to facilitate coaching encounters. This process incorporates key steps necessary for successful coaching interactions and can address some of the challenges discussed above.

RX-OCR process to facilitate coaching encounters

Coaches can follow the step-by-step process known as RX-OCR to facilitate any coaching encounter. The five steps are described in Table 22.1. The Royal College offers Coaching to Competence interactive activities that you and your faculty can use to practise applying the RX-OCR coaching process (https://www.royalcollege.ca/mssites/rxocr/en/story.html). The activities will help you to identify gaps in knowledge and skills related to coaching so that you can work to help close these gaps through further practice, reflection and other learning opportunities.

Tips

• Build an educational alliance by explicitly stating your role as a coach.
• Use the RX-OCR process when you engage in coaching encounters.
• Ensure that actionable steps or suggestions for improvement are the result of coaching encounters.
• Coaching in the moment works best when it is based on direct observations.
• Ensure your program has dedicated someone to provide coaching over time for each resident.

Conclusion

While coaching in CBD may seem like a new concept, you and your faculty members have been probably been engaging in some form of coaching for years. This chapter highlights the importance of coaching in CBD and introduces the educational principles that are key to successful coaching. The coaching model presented in this chapter, along with the RX-OCR process, will help you, your faculty and your residents to incorporate coaching into your program and ensure that residents achieve peak performance. Development of your faculty’s coaching capacity, skill and competence will require a faculty improvement program. Similarly, residents will require orientation and education to ensure that they take full advantage of coaching interactions. Effective coaching can only exist in a system that supports it.

Further reading

Archer JC. State of the science in health professional education: effective feedback. Med Educ. 2010;44(1):101–108.

Bing-You R, Hayes V, Varaklis K, Trowbridge R, Kemp H, McKelvy D. Feedback for learners in medical education: What is known? A scoping review. Acad Med. 2017;92(9):1346–1354.

Bing-You R, Varaklis K, Hayes V, Trowbridge R, Kemp H, McKelvy D. The feedback tango: an integrative review and analysis of the content of the teacher–learner feedback exchange. Acad Med. 2018;93(4):657–663.

Cheung W, Patey A, Frank J, Mackay M, Boet S. Barriers and enablers to direct observation of trainees’ clinical performance: a qualitative study using the theoretical domains framework. Acad Med. 2019;94(1):101–114.

Constance L, Sherbino J. 2010. Coaching in emergency medicine. Can J Emerg Med. 2010;12(6):520–524.

Deiorio NM, Carney PA, Kahl LE, Bonura EM, Juve AM. Coaching: a new model for academic and career achievement. Med Educ Online. 2016;21(1):33480.

Gauthier S, Melvin L, Mylopoulos M, Abdullah N. Resident and attending perceptions of direct observation in internal medicine: a qualitative study. Med Educ. 2018;52(12):1249–1258.

Gifford KA, Fall LH. Doctor coach: a deliberate practice approach to teaching and learning clinical skills. Acad Med. 2014;89(2):272–276.

LaDonna K, Hatala R, Lingard L, Voyer S, Watling C. Staging a performance: learners’ perceptions about direct observation during residency. Med Educ. 2017;51(5):498–510.

Landreville JM, Cheung WJ, Frank JR, Richardson D. A definition for coaching in medical education. Can Med Educ J. 2019;10(4):e109.

Landreville JM, Cheung WJ, Hamelin A, Frank JR. Entrustment checkpoint: clinical supervisors’ perceptions of the emergency department oral case presentation. Teach Learn Med. 2019;31(3):250–257.

Madan R, Conn D, Dubo E, Voore P, Wiesenfeld L. The enablers and barriers to the use of direct observation of trainee clinical skills by supervising faculty in a psychiatry residency program. Can J Psychiatry. 2012;57(4):269–272.

Ross S, Dudek N, Halman S, Humphrey-Murto S. Context, time, and building relationships: bringing in situ feedback into the conversation. Med Educ. 2016;50(9):893–895.

Telio S, Ajjawi R, Regehr G. The “educational alliance” as a framework for reconceptualizing feedback in medical education. Acad Med. 2015;90(5):609–614.

Telio S, Regehr G, Ajjawi R. Feedback and the educational alliance: examining credibility judgements and their consequences. Med Educ. 2016;50(9):933–942.

Van De Ridder JM, Stokking KM, McGaghie WC, Ten Cate O. T. What is feedback in clinical education? Med Educ. 2008;42(2):189–197.

Watling C, Driessen E, van der Vleuten DPM, Lingard L. Learning culture and feedback: an international study of medical athletes and musicians. Medical Education. 2014;48 (7):713–723.

Watling C, Driessen E, van der Vleuten CP, Lingard L. Learning culture and feedback: an international study of medical athletes and musicians. Med Educ. 2014;48(7):713–723.

Watling C, LaDonna KA, Lingard L, Voyer S, Hatala R. ‘Sometimes the work just needs to be done’: socio‐cultural influences on direct observation in medical training. Med Educ. 2016;50(10):1054–1064.

Reference

1. Ajjawi R, Regehr G. When I say…Feedback. Med Educ.2019;53(7):652–654.