Recently, I had the pleasure of discussing video-based coaching with Dr. Caprice Greenberg, Associate Professor of Surgery and Director of the Wisconsin Surgical Outcomes Research Program at the University of Wisconsin, Madison. Our interview was based largely on her paper “Postgame Analysis: Using Video-based coaching for continuous professional development.”
Andrew Gonzalez: What motivated you to study post-game analysis?
Caprice Greenberg: We were conducting a different study to try to understand system performance in the OR and were videotaping operations. Because we already had the videotapes, we started talking about the idea of coaching. It was around the time that Atul Gawande was working on his New Yorker article on surgical coaching. We decided to see if video-based coaching was feasible.
AG: What was your major finding?
CG: Surgeons of all levels seem to benefit from coaching and find it rewarding and informative. There was a lot of focus on surgical technique. Further, because it was in an academic setting, there was also much attention paid to ways of optimizing the teaching of residents in the operating room.
AG: Did you have any surprising findings?
CG: We anticipated that people would find it really rewarding to watch themselves operate. As an exploratory study, we wanted to examine what factors surgeons would spend time discussing in post-game analysis. One thing that was interesting was the amount of time spent talking about the set-up — the patient’s positioning, the location of retractors, etc.
AG: As you laid out in your paper, one of the challenges was recruiting participants. How did you frame the project to get buy-in from potential participants?
CG: One of challenges with getting surgeons to use video for quality improvement and self-reflection is ensuring that the endeavor is perceived as positive — it can’t be seen as punitive. One of the things we did very early on was to engage the surgical leadership. We had departmental leaders be some of the first to participate in the study so that others understood it was not some sort of remediation.
AG: What was your operating room set-up for this project?
CG: For this particular study, we had two cameras. One was an in-light camera filming the operative field and one was a wide-angled, low-resolution wall camera. We used the wall-camera because one of the major goals of the study was to look at system performance. We also had multiple shotgun microphones and an omni-directional microphone that was placed at the OR table.
Right now, many institutions are investing a lot of money to install AV capture technology in the OR. There are lots of different ways to capture the field. For instance, in John Birkmeyer’s surgical skills and complications paper, they captured the laparoscopic feed. Our group is also exploring using cameras embedded into glasses such as those used in extreme sports or google glass. We have also explored the use of GoPro cameras to obtain a broader view..
The technology certainly exists to capture video in the operating room for review. The issues will be (A) being able to capture sound and (B) the medicolegal and HIPAA issues around capturing the whole room (as opposed to just the operative field).
AG: Was it challenging to consent patients for this study?
CG: Very few patients were unwilling to consent. The overwhelming majority of patients were happy that we were doing this study to improve performance. Patients tend to be incredibly supportive of this type of work.
AG: I noticed one of your coauthors, Sarah Peyré was from the educational psychology field. How did she add to this work?
CG: One of the problems in medical and surgical research is that we often reinvent the wheel. We tend not to look outside of our field to see what theoretical frameworks exist that could be applied to surgery. Within our coaching study, it was certainly helpful to have someone who was familiar with educational theory.
In our current work, we not only have people from the field of education, but also from cognitive psychology and systems engineering. Each member of our team brings a different knowledge of the literature from their fields and a different set of theories and framework that can be used to approach performance improvement.
AG: To explore that a bit more, how did you pitch the idea to get involved with this work? Did your non-physician team members have a pre-existing interested in medical education?
CG: Since finishing her doctorate, Sarah Peyré had always been employed in departments of surgery. Most of her work looks at applying cognitive task analysis to surgical procedures. Similarly, our current systems-factors expert, Douglas Wiegmann, has previously worked within a department of surgery and has numerous ongoing collaborations with surgeons. Our current education collaborator did not have a prior interest in healthcare but was very interested in the coaching of teachers. She was eager to apply what she learned from the teaching world to coaching in another profession.
AG: Your coaches were quite skillful at employing different techniques to impart feedback. How would you standardize coaching if this program were to be rolled out on a larger scale?
CG: Identifying characteristics of people who have the potential to be effective surgical coaches, along with training people to be effective coaches is an area of ongoing investigation. Obviously, the challenge is to train coaches within the time constraints of the average practicing surgeon. For coaches, it is paramount to have good communication skills and the ability to employ different approaches with different people based upon how receptive the surgeon is being.
Also, when we interviewed our coach at the Brigham after the conclusion of the study, he felt his experience at doing intraoperative consults was very valuable. It allowed him to rapidly assess a situation, and provide feedback on how the surgeon got into that situation in the first place.
AG: How much time was required from the coach and the surgeon’s day to participate in the program?
CG: Essentially, just the hour devoted to the feedback session. Major time savings is one of the big advantages of video review — you can fast-forward through all the uninteresting or irrelevant parts. In contrast, to coach in the OR, you really have to commit to several hours for feedback. We asked, “what would be feasible to a busy surgical practice if we rolled this [program] out on a larger level?” This is why we specifically limited our sessions to one hour.
AG: Are there any plans to expand the program?
CG: We are in the process of rolling out a study across the state of Wisconsin to see if we can implement a cross-institutional coaching program. It is being run through the Wisconsin Surgical Society as a way to engage people across a broad set of practice settings and institutions.
Within that study, the first aim is to look at how coaching is used in other settings such as sports, music, and education. We plan to look at the principal theories and conceptual frameworks that exist in these disciplines that can help us to develop a coaching program in surgery. We then aim to engage coaches, train them, and facilitate coaching sessions across institutions. Finally, we are also working with researchers at the University of Michigan on a proposal to employ coaching in their bariatric collaborative.